Diversity Assignment 5

The purpose of this paper is to conduct a cultural self-assessment.

1. You will read each of the boxes in Chapter 2 of your textbook (one for each domain of the Purnell Model for Cultural Competence), answer these questions as they relate to you.
2. Remember to answer these questions from your personal perspective. At all times, explain why you do or do not adhere to the dominant cultural practices and beliefs of the ethnic group(s) with which you primarily identify.
3. If you do not wish to self-disclose a specific area from the Organizing Framework, indicate so instead of just not addressing it; of course, this should not happen very often.
   Your paper should be formatted per APA and references should be current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions)

Submission Instructions:

• The paper is to be clear and concise and students will lose points for improper grammar, punctuation and misspelling.
• The paper is to be no shorter than 3 pages; nor longer than 5 pages in length, excluding the title, abstract and references page.
• Incorporate a minimum of 3 current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style (the library has a copy of the APA Manual).

TRANSCULTURAL
HEALTH C ARE
2780_FM_i-xx 16/07/12 12:22 PM Page i

2780_FM_i-xx 16/07/12 12:22 PM Page ii
Davis’s success series
Q&A Course Review and NCLEX Prep
9Thousands of NCLEX-style questions
9Alternate-item-format questions
9Rationales for correct and incorrect answers
9Test-taking tips
Visit www.fadavis.com
Keyword: Success Series to learn more.
Ready. Set. Go Mobile
9iPhone
9iPod Touch
Davis Mobile aPPs
9iPad
9Android
Visit www.fadavis.com
Keyword: Davis Mobile to learn more.

TRANSCULTURAL
HEALTH C ARE
A Culturally Competent Approach
4th Edition
Larry D. Purnell
Phd, RN, FAAN
2780_FM_i-xx 16/07/12 12:22 PM Page iii

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2013 by F. A. Davis Company
Copyright © 2013 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
without written permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Publisher, Nursing: Robert G. Martone
Director of Content Development: Darlene D. Pedersen
Project Editor: Victoria White
Electronic Project Manager: Tyler Baber
Design and Illustrations Manager: Carolyn O’Brien
As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo
changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted
standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences
from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described
in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances
that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new infor-
mation regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently
ordered drugs.
Library of Congress Cataloging-in-Publication Data
Transcultural health care : a culturally competent approach / [edited by] Larry D. Purnell. — 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-3705-4
I. Purnell, Larry D.
[DNLM: 1. Cultural Competency—United States. 2. Delivery of Health Care—United States. 3. Cultural Diversity—United States.
4. Ethnic Groups—United States. W 84 AA1]
362.1089—dc23
2012016099
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis
Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25
per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy
license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is:
978-0-8036-3705-4/12 0 + $.25.
2780_FM_i-xx 16/07/12 12:22 PM Page iv

v
Foreword
Knowing is not enough, we must apply.
Willing is not enough, we must do.
Goethe
Goethe’s quote is considered a call to action by organ-
izations as prestigious as the Institute of Medicine,
and it remains one of my favorite quotes today. It has
such incredible implications for health care, particu-
larly as we struggle with the extended time it takes to
translate research into practice. In fact, oftentimes, de-
spite strong evidence, we are slow in enacting the
changes we need to improve the health care and nurs-
ing we deliver. In some cases we are waiting for the
“indisputable” evidence, and in other cases we are sim-
ply being resistant to change. But occasionally the
need for change is thrust upon us, momentum builds,
and the realization emerges that there isn’t a need to
prove the obvious before acting but a need to act as
the obvious is all around us. This has become the case
with cultural competence in health care.
My knowing about the importance of cultural com-
petence developed as I grew up in my bilingual, bicul-
tural Puerto Rican family, where perspectives about
health and health care were incredibly varied, and at
times at odds with Western medicine. My knowing
grew, as I trained to be a health-care professional in
underserved and diverse settings such as Newark,
New Jersey, and New York City, where we saw pa-
tients from all cultures, classes, and racial/ethnic back-
grounds. What became crystal clear to me was that
while we were learning the best medications to treat
hypertension or the most advanced algorithms for di-
agnosing and treating disease, if we couldn’t commu-
nicate effectively with our patients or get them to buy
into, agree with, and cooperate with what we were try-
ing to accomplish, then all that medical knowledge
was worth nothing. Whether a doctor, a nurse, or
other health professional, caring for patients required
an understanding of the sociocultural factors that
might impact their health beliefs and behaviors, rang-
ing from how they presented their symptoms, to how
they viewed disease and illness, to what informed their
health care, diagnostic, and treatment choices. Cases
where we couldn’t bring our knowledge to bear to ease
suffering or cure disease because of “cultural differ-
ences” with patients were the ones that kept us up at
night and were the most frustrating and disappointing
of all. Along the way I also learned to appreciate that
we all have culture and that the tools and skills I
needed to learn to communicate clearly with patients
wouldn’t just be helpful in the care of those who were
culturally different from me, but to any patient with
whom I interacted. For at the end of the day, there
were always three cultures in the room—my culture;
the patient’s culture; and the cultures of medicine,
nursing, and other health professions—making every
encounter cross-cultural in one way or another.
Despite these almost daily epiphanies during my
training, there were few resources available that might
provide me with guidance on how to become an effec-
tive communicator and caregiver in this new world I
was entering. Fortunately, this has changed. New
models have been developed, leaders have emerged,
and health-care professionals no longer need to go
blindly into cross-cultural encounters without guid-
ance, as there are real and practical approaches that
facilitate improved understanding, communication,
and care. Knowing is not enough, we must apply.
Transcultural Health Care: A Culturally Compe-
tent Approach builds on a framework for cultural
competence—which is essential in the care of the
individual—by bringing together health-care providers
of various backgrounds and disciplines to share their
knowledge, expertise, and experiences in the field
with particulars about different populations. This
information is presented to provide details about the
social and cultural fabric of different cultural groups,
with the important caveat that it is not to be used to
stereotype patients within these groups, as each pa-
tient is an individual and diversity can be as extensive
within groups as it is among groups. It is from this
principle—that learning background information
about cultural groups can help health-care providers
both develop a “radar” for potential pitfalls when
caring for them and serve as a springboard for in-
quiry with the individual patient—that Transcultural
Health Care emerges.
Why is this book, and this edition, so timely? In the
past, arguments about the importance of cultural
competence were based primarily on making the case
that our nation was becoming increasingly diverse and
that as health-care professionals we need to be pre-
pared to care for patients of different sociocultural
backgrounds. This is an important argument, no
2780_FM_i-xx 16/07/12 12:22 PM Page v

doubt. Shortly thereafter, research began to emerge
demonstrating that being inattentive to cultural issues
in the clinical setting leads to lower quality of care
for specific populations, such as racial and ethnic
minorities—a term that became known as disparities
in health care. Yet what has evolved more recently is a
burgeoning literature documenting the impact of cul-
tural factors on health-care quality, cost, and safety.
New research demonstrates that when we are not
skilled or prepared to care for patients from diverse
backgrounds, they may, when compared to their Cau-
casian counterparts, suffer more medical errors with
greater clinical consequences; have longer hospital
stays for the same common clinical conditions; and
may have more unnecessary tests ordered—all due to
language or cultural barriers between health-care
providers and patients. With health-care reform and
payment reform on the horizon, we literally can no
longer afford to be ill prepared to meet the needs of
an increasingly diverse nation.
As we look toward the future, we see signs of a
breakthrough occurring. More and more is being writ-
ten about the topic of cultural competence. Students
who years ago had to be convinced of the importance
of this issue are now arriving more sensitized about
cultural competence than ever before and are demand-
ing to build their skills in the field. More research is
being conducted on cultural competence and its im-
pact on quality, safety, and cost. Additional areas are
being cross-linked to cultural competence, such as
patient-centeredness and health literacy. New quality
measures and accreditation standards are being devel-
oped, and in some states cultural competence training
has become a condition of health professional licen-
sure. There is little doubt that the field of cultural
competence is moving from the margin to the main-
stream and from a luxury to a necessity. As individual
providers, we must all do our part to ensure that we
are delivering high-quality care to any patient we see,
regardless of her or his race, ethnicity, culture, socio –
economic class, or language proficiency. Transcultural
Health Care: A Culturally Competent Approach helps
us build the radar to identify and understand key
cross-cultural issues among diverse populations and,
when applied with the tools and skills that are essen-
tial for exploring the sociocultural perspectives of the
individual patient, positions us for success. Now it is
time for us to learn the lessons and skills so gracefully
shared with us in this book to make a difference in pa-
tients’ lives. Willing is not enough, we must do.
Joseph R. Betancourt, MD, MPH
Director, The Disparities Solutions Center and
Director of Multicultural Education,
Massachusetts General Hospital
Associate Professor of Medicine,
Harvard Medical School
Cofounder, Manhattan Cross-Cultural Group
vi Foreword
2780_FM_i-xx 16/07/12 12:22 PM Page vi

vii
Preface
The Purnell Model for Cultural Competence and its
accompanying organizing framework continue to be
used in education, clinical practice, administration,
and research. The Model and selected chapters have
been translated into Arabic, Flemish, French, Korean,
Portuguese, Spanish, Turkish, and Korean, attesting
to its value on a worldwide basis. In addition, many
health-care organizations have adapted the organizing
framework as a cultural assessment tool, and numer-
ous students in the United States and overseas
have used the Model to guide research for theses and
dissertations. The Model is increasingly being used
as a guide to help ensure organizational cultural
competence.
This fourth edition of Transcultural Health Care:
A Culturally Competent Approach has been revised
based upon responses from students, faculty, and
practicing health-care professionals such as nurses,
physicians, emergency medical technicians, nutrition-
ists, and people in noetic sciences. In addition, this edi-
tion is divided into two units. Unit 1, Foundations for
Cultural Competence: Individual and Organizational,
has the following features:
• An expanded chapter on the overview of transcul-
tural diversity and health care
• A separate chapter on the Purnell Model for
Cultural Competence, with specific questions in the
organizing framework instead of objectives
• A separate chapter on individual competence and
evidence-based practice
• A separate chapter on organizational cultural
competence
• A separate chapter on global health
Unit 2 is entitled Aggregate Data for Cultural-
Specific Groups. As in previous editions, we have made
a concerted effort to use nonstereotypical language
when describing cultural attributes of specific cultures,
recognizing that there are exceptions to every descrip-
tion provided and that the differences within a cultural
group are determined by variant cultural characteris-
tics. One important change on the Model is that the pri-
mary and secondary characteristics of culture are now
called “variant cultural characteristics” at the sugges-
tion of gay, lesbian, and transgendered communities.
The first time a cultural term is used in a chapter, it
is in boldface type and is defined in the glossary.
Because faculty and clinical practitioners have found
the Appendix—Cultural, Ethnic, and Racial Diseases
and Illnesses—valuable, it remains in the book.
Abstracts are included in the main textbook for each
culturally specific full chapter located on Davis Plus.
Space and cost concerns limit the number of chapters
that are included in the book; therefore, additional cul-
tural groups are on Davis Plus. Also on Davis Plus are
student resources such as review questions, Web sites of
interest, case studies, and reflective exercises. Additional
faculty resources on Davis Plus include PowerPoint
slides with clicker check questions for each chapter and
a question bank.
Specific criteria were used for identifying the groups
represented in the book and those included in elec-
tronic format. Groups included in the book were
selected based on any of the following six criteria:
• The group has a large population in North
America, such as people of Appalachian, Mexican,
German, and African American heritage.
• The group is relatively new in its migration status,
such as people of Haitian, Somali, and Arab
heritage.
• The group is widely dispersed throughout
North America, such as people of Iranian,
Korean, Hindu, and Filipino heritage.
• The group is of particular interest to readers, such
as people from Amish heritage.
• The group is of particular interest to students and
staff from other countries, such as European
Americans.
A particular strength of each chapter is that it has
been written by individuals who are intimately famil-
iar with the specific culture. Again, we have strived to
portray each culture comprehensively, positively, and
without stereotyping. We hope you enjoy the book.
Larry D. Purnell
2780_FM_i-xx 16/07/12 12:22 PM Page vii

2780_FM_i-xx 16/07/12 12:22 PM Page viii

ix
Contributors
Richard Adair, MD
Adjunct Professor of Medicine
University of Minnesota
Minneapolis, Minnesota
Karen Aroian, PhD, RN, FAAN
Director of Research and Chatlos Endowed Professor
University of Florida College of Nursing
Orlando, Florida
Linda Ciofu Baumann, PhD, RN, FAAN
University of Wisconsin-Madison
Madison, Wisconsin
Joseph R. Betancourt, MD, MPH
Director of Disparities Solutions Center
Massachusetts General Hospital
Boston, Massachusetts
Josepha Campinha-Bacote, PhD, MAR,
PMHCNS-BC, CTN-A, FAAN
Transcultural Healthcare Consultant
Transcultural C.A.R.E. Associates
Blue Ash, Ohio
Marga Simon Coler, EdD, Dr. Causa Honoris,
FAAN, APRN-BC
Professor Emeritus
University of Connecticut
South Hadley, Massachusetts
Jessie M. Colin, PhD, RN, FAAN
Professor and Director of Nursing PhD, Nursing
Administration and Nursing Education Programs
Barry University
Miami Shores, Florida
Tina A. Ellis, RN, MSN, CTN
Nursing Instructor
Florida Gulf Coast University
Fort Myers, Florida
Myriam Gauthier, MSN
Graduate Student in Nursing
Faculté des sciences infirmières, Université Laval
Pavillon Ferdinand-Vandry, Québec
Rauda Gelazis, RN, PhD
Retired, Associate Professor
Ursuline College
Pepper Pike, Ohio
Homeyra Hafizi, MSN, RN, COHN/S, LHRM
Coordinator, Employee Health and Workers’
Compensation
Wuesthoff Health System/HMA
Rockledge, Florida
Laurie B. Hartjes, PhD, RN, PNP-BC
Educational Design Consultant
Lodestone Safety International
Beverly, Massachusetts
Keiko Hattori, RN, PhD
Assistant Professor
Kawasaki University of Medical Welfare
Kurashiki, Okayama, Japan
Sandra M. Hillman, PhD, MS, BS, RN
Associate Professor
College of Mount Saint Vincent
Bronx, New York
David Hodgins, MSN, RN, CEN
Indian Health Service
Shiprock, New Mexico
Olivia Hodgins, RN, PhD, MSA, BSN
Map Instructor and Nurse Executive
Indian Health Service
San Fidel, New Mexico
Kathleen Huttlinger, PhD, RN
Associate Director for Graduate Programs
New Mexico State University
Las Cruces, New Mexico
Eun-Ok Im, PhD, MPH, RN, CNS, FAAN
Professor and Marjorie O. Rendell Endowed
Professor
University of Pennsylvania
Philadelphia, Pennsylvania
Misae Ito, RN, MW, MSN, PhD
Professor
Kawasaki University of Medical Welfare
Kurashiki, Okayama, Japan
2780_FM_i-xx 16/07/12 12:22 PM Page ix

Jayalakshmi Jambunathan, PhD, MSN, BSN,
MA BSc
Professor, CON UW Oshkosh
Director, Research and Evaluation and Assistant
Dean
UW Oshkosh
Oshkosh, Wisconsin
Galina Khatutsky, MS
Research Analyst
RTI International
Waltham, Massachusetts
Sema Kuguoglu, PhD, BSN, RN
Professor Emeritus, University of Mamara
Funded Professor, University of Gazikent
Istanbul and Gaziantep, Turkey
Anahid Kulwicki, PhD, RN, FAAN
Professor and Associate Dean for Research
Director of the PhD in Nursing Program
Florida International University
Miami, Florida
Ginette Lazure, PhD
Professeure titulaire
Université Laval
Pavillon Ferdinand-Vandry
Médecine, Québec
Stephen R. Marrone, EdD, RN-BC, CTN-A
Deputy Nursing Director
State University of New York
SUNY Downstate Medical Center
Brooklyn, New York
Susan Mattson, RNC-OB, CTN-OB, PhD, FAAN
Professor Emerita
Arizona State University College of Nursing and
Health Innovation
Scottsdale, Arizona
Afaf Ibrahim Meleis, PhD, DrPS (hon), FAAN
Margaret Bond Simon Dean of Nursing
University of Pennsylvania School of Nursing
Philadelphia, Pennsylvania
Mahmoud Hanafi Meleis, PhD, PE
Retired Nuclear Engineer
Philadelphia, Pennsylvania
Cora Munoz, PhD, RN
Professor Emerita/Adjunct Professor
Capital University
Columbus, Ohio
Irena Papadopoulos, PhD, MA (Ed), BA, RN, RM,
NDN, FHEA
Professor
Middlesex University
Highgate Hill, London, UK
Ghislaine Paperwalla, BSN, RN
Research Nurse in Immunology
Veterans Administration Medical Center
Miami, Florida
Jeffrey R. Ross, MAT, MA, BFA
ESL Teacher and Tutor
Springfield School System and the University
of Akron
Akron, Ohio
Ratchneewan Ross, PhD, MSc (Public Health), RN
Associate Professor and Director of International
Activities
Kent State University
Kent, Ohio
Susan W. Salmond, EdD, RN, CNE, CTN
Dean and Professor
University of Medicine and Dentistry of New Jersey
Newark, New Jersey
Stephanie Myers Schim, PhD, RN, PHCNS-BC
Associate Professor
Wayne State University College of Nursing
Detroit, Michigan
Janice Selekman, DNSc, RN
Professor Nursing
University of Delaware
Newark, DE
Jessica A. Steckler, MS, RN-BC
CEO
The Firm of Jessica A. Steckler
Erie, Pennsylvania
Marshelle Thobaben, RN, PHN, MS, FNP, PMHNP
Department Chair, Professor
Humboldt State University
Arcata, California
Hsiu-Min Tsai, RN, PhD
Dean of Academic Affairs and Associate Professor
Chang Gung University of Science and Technology
Tao-Yuan, Taiwan
x Contributors
2780_FM_i-xx 16/07/12 12:22 PM Page x

Anna Frances Z. Wenger, PhD, RN, FAAN
Professor and Director Emeritus of Nursing
Goshen College
Goshen, Indiana
Marion R. Wenger, PhD
Professor of Linguistics and Foreign Languages
Goshen College
Goshen, Indiana
Cecilia A. Zamarripa, RN, CWON
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Rick Zoucha, APRN, BC, DNSc, CTN
Associate Professor
Duquesne University School of Nursing
Pittsburgh, Pennsylvania
Contributors xi
2780_FM_i-xx 16/07/12 12:22 PM Page xi

2780_FM_i-xx 16/07/12 12:22 PM Page xii

xiii
Reviewers
Kristie Berkstresser, MSN, RN, CNE, BC
Assistant Professor of Nursing
HAAC—Central Pennsylvania’s Community College
Lancaster, Pennsylvania
Judy Shockey Carter, MSN Ed, RN
Assistant Professor
Anderson University
Anderson, Indiana
Sabrina L. Dickey, RN, BSN, MSN
Assistant Faculty in Nursing
Florida State University
Tallahassee, Florida
David N. Ekstrom, PhD, RN
Associate Professor
Pace University, College of Health Professions
Lienhard School of Nursing
New York, New York
Mary L. Padden, RNC,APN-C, FN-CSA
Assistant Professor, Nursing
Cumberland County College
Vineland, New Jersey
Priscilla L. Sagar, EdD, RN, ACNS-BC, CTN
Professor of Nursing
Mount Saint Mary College
Newburgh, New York
Lisabeth M. Searing, PhD, MSN, RN
Assistant Professor
Illinois Wesleyan University, School of Nursing
Bloomington, Illinois
Gale Sewell, RN, MSN, CNE
Assistant Professor
Indiana Wesleyan University
Marion, Indiana
Jeanine Tweedie, MSN, RN, CNE
Nursing Faculty
Hawaii Pacific University
Kaneohe, Hawaii
Mai-Neng Lee Xiong, BSN
Director of Nursing
People Incorporated Mental Health Services
St. Paul, Minnesota
2780_FM_i-xx 16/07/12 12:22 PM Page xiii

2780_FM_i-xx 16/07/12 12:22 PM Page xiv

xv
Table of Contents
UNIT 1: FOUNDATIONS FOR CULTURAL COMPETENCE:
INDIVIDUAL AND ORGANIZATIONAL 1
Chapter 1 Transcultural Diversity and Health Care 3
Chapter 2 The Purnell Model for Cultural Competence 15
Chapter 3 Individual Competence and Evidence-Based Practice
(with inclusion of the International Standards) 45
Chapter 4 Organizational Cultural Competence 60
Chapter 5 Perspectives on Nursing in a Global Context 74
UNIT 2: AGGREGATE DATA FOR CULTURAL-SPECIFIC GROUPS 89
Chapter 6 People of African American Heritage 91
Chapter 7 The Amish 115
Chapter 8 People of Appalachian Heritage 137
Chapter 9 People of Arab Heritage 159
Chapter 10 People of Chinese Heritage 178
Chapter 11 People of Cuban Heritage 197
Chapter 12 People of European American Heritage 214
Chapter 13 People of Filipino Heritage 228
Chapter 14 People of German Heritage 250
Chapter 15 People of Haitian Heritage 269
Chapter 16 People of Hindu Heritage 288
Chapter 17 People of Hmong Heritage 310
Chapter 18 People of Japanese Heritage 319
Chapter 19 People of Jewish Heritage 339
Chapter 20 People of Korean Heritage 357
Chapter 21 People of Mexican Heritage 374
Chapter 22 People of Polish Heritage 391
Chapter 23 People of Puerto Rican Heritage 407
Chapter 24 People of Russian Heritage 426
Appendix Cultural, Ethnic, and Racial Diseases and Illnesses 441
ABSTRACTS
American Indians and Alaska Natives 449
People of Baltic Heritage: Estonians, Latvians, and Lithuanians 452
People of Brazilian Heritage 454
2780_FM_i-xx 16/07/12 12:22 PM Page xv

People of Egyptian Heritage 456
People of French Canadian Heritage 459
People of Greek Ancestry 462
People of Guatemalan Heritage 464
People of Iranian Heritage 466
People of Irish Heritage 469
People of Italian Heritage 471
People of Somali Heritage 473
People of Thai Heritage 475
People of Turkish Heritage 477
People of Vietnamese Heritage 479
GLOSSARY 481
INDEX 489
xvi Table of Contents
2780_FM_i-xx 16/07/12 12:22 PM Page xvi

xvii
Contents – DavisPlus
American Indians and Alaska Natives
People of Baltic Heritage: Estonians, Latvians, and Lithuanians
People of Brazilian Heritage
People of Egyptian Heritage
People of French Canadian Heritage
People of Greek Ancestry
People of Guatemalan Heritage
People of Iranian Heritage
People of Irish Heritage
People of Italian Heritage
People of Somali Heritage
People of Thai Heritage
People of Turkish Heritage
People of Vietnamese Heritage
2780_FM_i-xx 16/07/12 12:23 PM Page xvii

2780_FM_i-xx 16/07/12 12:23 PM Page xviii

xix
Introduction
The Purnell Model for Cultural Competence and its
organizing framework continue to be used in educa-
tion, clinical practice, administration, and research by
nurses, physicians, and other health-care providers.
The Model has been translated into Arabic, Flemish,
French, German, Korean, Portuguese, Spanish, and
Turkish. Health-care organizations have adapted the
organizing framework as a cultural assessment tool
and to guide research for theses and dissertations in
the United States and overseas. The Model’s useful-
ness has been established in the global arena, recog-
nizing and including the client’s culture in assessments,
health-care planning, interventions, and evaluations.
The Model has proven useful with organizational
cultural competence as well.
Transcultural Health Care: A Culturally Competent
Approach continues to be revised based upon feedback
from students and clinical health-care providers, as
well as educators from associate degree, baccalaureate,
master’s, and doctoral programs. Their reviews and
suggestions are appreciated.
This edition has been divided into two units. Unit 1
contains five chapters. Chapter 1, Transcultural Diver-
sity and Health Care, gives an overview of transcultural
health and nursing care along with essential terminology
related to culture. Chapter 2 is an extensive description
the Purnell Model for Cultural Competence, along with
recommended questions to ask and observations to
make when doing a cultural assessment or formulating
questions for qualitative research. Chapter 3, Individual
Competence and Evidence-Based Practice, includes in-
ternational standards on culturally competent care and
an extensive section on searching literature for evidence-
based cultural research. Chapter 4, Organizational Cul-
tural Competence, provides a crosswalk with the Purnell
Model and CLAS Standards. Chapter 5, Perspectives
on Nursing in a Global Context, addresses health-care
organizations that have a global context, the forces that
shape global health and nursing, and international
migration.
Unit 2 consists of aggregate data on culturally spe-
cific groups, 18 of which are covered in the book and
an additional 14 on DavisPlus. We continue to make
a concerted effort to use nonstereotypical language
when describing cultural attributes of specific cultures,
recognizing that there are exceptions to every descrip-
tion provided. Aggregate data are true for the group
but not necessarily for the individual. Therefore,
readers are encouraged to look at the variant cultural
characteristics when viewing aggregate data on any
population. An attempt has been made to include
both the sociological and anthropological perspectives
of culture.
Given the world diversity and the diversity within
cultural groups, it is impossible to cover each group
more extensively. Space and cost concerns limit the
number of chapters that are included in the book;
therefore, additional cultural groups, PowerPoint slides,
interactive exercises, test banks, useful Web sites, and
additional case studies are included on DavisPlus.
Specific criteria were used for identifying the groups
represented in the book and those included in elec-
tronic format. Groups included in the book were
selected based on any of the following six criteria:
• The group has a large population in North
America, such as people of African American,
Appalachian, Chinese, German, Irish, and
Mexican heritage.
• The group is relatively new in its migration status,
such as people of Arab, Haitian, and Cuban
heritage.
• The group is widely dispersed throughout North
America, such as people of Filipino, Hindu,
Iranian, and Korean heritage.
• The group has little written about it in the health-
care literature, such as people of Guatemalan,
Russian, Somali, and Thai heritage.
• The group holds significant disenfranchised status,
such as American Indians.
• The group was of particular interest to readers in
previous editions, such as people from Amish
heritage.
We have strived to portray each culture positively
and without stereotyping. Individual chapter authors
made every attempt to incorporate the latest research
at the time of writing.
Larry D. Purnell
2780_FM_i-xx 16/07/12 12:23 PM Page xix

2780_FM_i-xx 16/07/12 12:23 PM Page xx

UNIT 1
FOUNDATIONS FOR
CULTURAL COMPETENCE
Individual and Organizational
2780_Ch01_001-014 16/07/12 11:35 AM Page 1

2780_Ch01_001-014 16/07/12 11:35 AM Page 2

3
Chapter 1
Transcultural Diversity and
Health Care
Larry D. Purnell
The Need for Culturally
Competent Health Care
Cultural competence has become one of the most im-
portant initiatives in health care in the United States
and throughout most of the world. Diversity has in-
creased in many countries due to wars, discrimination,
political strife, worldwide socioeconomic conditions,
and the creation of the European Union. Some of the
diversity is driven by actual numbers of immigrants,
but other dimensions come from the visibility of the
“new ethnics” and the waning of the social ideology
of the “melting pot” (O’Neil, 2008). Instead of the
term melting pot, meaning everyone is expected to
blend, many believe the term salad bowl is more ap-
propriate because people can stand out and be seen as
individuals. Health ideology and health-care providers
have learned that it is just as important to understand
the patient’s culture as it is to understand the physio-
logical responses in illness, disease, and injury. The
health-care provider may be very knowledgeable
about laboratory values and standard treatments and
interventions for diabetes mellitus, heart disease, and
asthma, but if the recommendations are not compat-
ible with the patient’s own health beliefs, dietary prac-
tices, and views toward wellness, the treatment plan is
less likely to be followed (Giger et al., 2007). To this
end, a number of worldwide initiatives have addressed
cultural competence as a means for improving health
and health care, decreasing disparities, and increasing
patient satisfaction. These initiatives come from the
U.S. Office of Minority Health, the Institute of Med-
icine, Healthy People 2020, the National Quality
Forum, the Joint Commission, The American Medical
Association, the American Association of Colleges
of Nursing, and other professional organizations.
Educational institutions—from elementary schools to
colleges and universities—are also addressing cultural
diversity and cultural competency as they relate to
disparities; health promotion and wellness; illness, dis-
ease, and injury prevention; and health maintenance
and restoration.
Many countries are now recognizing the need for
addressing the diversity of their societies. Societies
that used to be rather homogeneous, such as Portugal,
Norway, Sweden, Korea, and selected areas in the
United States and the United Kingdom, are now fac-
ing significant internal and external migration, result-
ing in ethnic and cultural diversities that did not
previously exist, at least not to the degree they do
now. Several European countries, such as Denmark,
Italy, Poland, the Czech Republic, Latvia, the United
Kingdom, Sweden, Norway, Finland, Italy, Spain,
Portugal, Hungary, Belgium, Greece, Germany, the
Netherlands, and France, either have in place or are
developing national programs to address the value of
cultural competence in reducing health disparities
(Judge, Platt, Costongs, & Jurczak, 2005).
Whether people are internal migrants, immigrants,
or vacationers, they have the right to expect the
health-care system to respect their personal beliefs,
values, and health-care practices. Culturally compe-
tent health care from providers and the system,
regardless of the setting in which care is delivered, is
becoming a concern and expectation among con-
sumers. Diversity also includes having a diverse
workforce that more closely represents the popula-
tion the organization serves. Health-care personnel
provide care to people of diverse cultures in long-
term-care facilities, acute-care facilities, clinics,
communities, and patients’ homes. All health-care
providers—physicians, nurses, nutritionists, thera-
pists, technicians, home health aides, and other
caregivers—need similar culturally specific information.
For example, all health-care providers communicate,
2780_Ch01_001-014 16/07/12 11:35 AM Page 3

both verbally and nonverbally; therefore, all health-
care providers and ancillary staff need to have
similar information and skill development to com-
municate effectively with diverse populations. The
manner in which the information is used may differ
significantly based on the discipline, individual expe-
riences, and specific circumstances of the patient,
provider, and organization. If providers and the
system are competent, most patients will access the
health-care system when problems are first recog-
nized, thereby reducing the length of stay, decreasing
complications, and reducing overall costs.
A lack of knowledge of patients’ language abilities
and cultural beliefs and values can result in serious
threats to life and quality of care for all individuals
(Joint Commission, 2010). Organizations and indi-
viduals who understand their patients’ cultural val-
ues, beliefs, and practices are in a better position to
be co-participants with their patients in providing
culturally acceptable care. Having ethnocultural-
specific knowledge, understanding, and assessment
skills to work with culturally diverse patients ensures
that the health-care provider can conduct a more tar-
geted assessment. Providers who know culturally
specific aggregate data are less likely to demonstrate
negative attitudes, behaviors, ethnocentrism, stereo-
typing, and racism. The onus for cultural compe-
tence is on the health-care provider and the delivery
system in which care is provided. To this end, health-
care providers need both general and specific cultural
knowledge when conducting assessments, planning
care, and teaching patients about their treatments
and prescriptions.
World Diversity and Migration
As of January 2011, the world’s population estimate
reached 6.8 billion people, with a median age of
27.7 years. The population is expected to approach
7.6 billion by 2020 and 9.3 billion by 2050. The esti-
mated population growth rate remains relatively stable
at 1.13 percent, with 19.86 births per 1000 population;
8.7 deaths per 1000 population; and an infant mortal-
ity rate of 44.13 per 1000 population, down from
48.87 in 2005. Worldwide life expectancy at birth is
currently 66.12 years, up from 64.77 years in 2005
(CIA World Factbook, 2011). The ten largest urban pop-
ulations where significant migration occurs are Tokyo,
Japan with 36.7 million; Delhi, India with 22.2 million;
São Paulo, Brazil with 20.3 million; Mexico City,
Mexico with 19 million; New York–Newark, United States
with 19.4 million; Shanghai, China with 16.6 million;
Kolata, India with 15.6 million; Dhaka, Bangladesh
with 14.7 million; and Karachi, Pakistan with 13.1 million
(CIA World Factbook, 2011).
As a first language, Mandarin Chinese is the most
popular, spoken by 12.65 percent of the world’s pop-
ulation, followed by Spanish at 4.93 percent, English
at 4.91 percent, Arabic at 3.1 percent, Hindi at 2.73
percent, Portuguese at 2.67 percent, Bengali at
2.71 percent, Russian at 2.16 percent, Japanese at
1.83 percent, and Standard German at 1.35 percent.
Only 82 percent of the world population is literate.
When technology is examined, more people have
a cell phone than a landline—with a ratio of 3:1.
Over 1.6 billion people are Internet users, up by
62 percent from 2005 (CIA World Factbook, 2011).
Language literacy has serious implications for im-
migration. Over two-thirds of the world’s 785 million
illiterate adults are found in only eight countries:
Bangladesh, China, Egypt, Ethiopia, India, Indonesia,
Nigeria, and Pakistan. Of all the illiterate adults
in the world, two-thirds are women; extremely low
literacy rates are concentrated in three regions: the
Arab states, South and West Asia, and Sub-Saharan
Africa, where around one-third of the men and half
of all women are illiterate (2005 est.) (CIA World
Factbook, 2011).
The United Nations High Commissioner for Refugees
estimated in December 2006, the latest year for
which figures are available, a global population of
8.8 million registered refugees, the lowest number in
30 years, and as many as 24.5 million internally dis-
placed persons in more than 50 countries. The actual
global population of refugees is probably closer
to 10 million given the estimated 1.5 million Iraqi
refugees displaced throughout the Middle East.
Migrants represent approximately 190 million people
or 2.9 percent of the world population, up from
175 million in the year 2000. Moreover, international
migration is decreasing, while internal migration is
increasing, especially in Asian countries (U.N.
Refugee Agency, 2009).
In 1997, the International Organization for Migra-
tion studied the costs and benefits of international
migration. A comprehensive update has not been un-
dertaken since that time. According to the report,
ample evidence exists that migration brings both costs
and benefits for sending and receiving countries, al-
though these are not shared equally. Trends suggest a
greater movement toward circular migration with sub-
stantial benefits to both home and host countries. The
perception that migrants are more of a burden on
than a benefit to the host country is not substantiated
by research. For example, in the Home Office Study
(2002) in the United Kingdom, migrants contributed
US$4 billion more in taxes than they received in ben-
efits. In the United States, the National Research
Council (1998) estimated that national income had
expanded by US$8 billion because of immigration.
Thus, because migrants pay taxes, they are not likely
to put a greater burden on health and welfare services
than the host population. However, undocumented
migrants run the highest health risks because they are
less likely to seek health care. This not only poses risks
4 Foundations for Cultural Competence
2780_Ch01_001-014 16/07/12 11:35 AM Page 4

for migrants but also fuels sentiments of xenophobia
and discrimination against all migrants.
◗ What evidence do you see in your community
that migrants have added to the economic base
of the community? Who would be doing their
work if they were not available? If migrants
(legal or undocumented) were not picking veg-
etables (just one example), how much more do
you think you would pay for the vegetables?
U.S. Population and Census Data
As of 2010, the U.S. population was over 308 million,
an increase of 16 million since the 2000 census. The
2010 census data include changes designed to more
clearly distinguish Hispanic ethnicity as not being a
race. In addition, the Hispanic terms have been mod-
ified to include Hispanic (used more heavily on the
East Coast), Latino (used more heavily in California
and the West Coast), and Spanish. The most recent
census data estimate that 65.1 percent of the U.S.
population are white, 15.8 percent are Hispanic/
Latino, 12.9 percent are black, 4.6 percent are Asian,
1.0 percent are American Indian or Alaskan Native,
and 0.2 percent are Native Hawaiian or other Pacific
Islander. These groupings will be more specifically re-
ported as the census data are analyzed. The categories
as used in the 2010 U.S. Census are as follows:
1. White refers to people having origins in any of the
original peoples of Europe and includes Middle
Easterners, Irish, German, Italian, Lebanese,
Turkish, Arab, and Polish.
2. Black, or African American, refers to people hav-
ing origins in any of the black racial groups of
Africa and includes Nigerians and Haitians or
any person who self-designates this category
regardless of origin.
3. American Indian and Alaskan Native refer to
people having origins in any of the original peo-
ples of North, South, or Central America and
who maintain tribal affiliation or community
attachment.
4. 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 terms Asian Indian, Chinese, Filipino,
Korean, Japanese, Vietnamese, Burmese, Hmong,
Pakistani, and Thai.
5. Native Hawaiian and other Pacific Islander refer
to people having origins in any of the original
peoples of Hawaii, Guam, Samoa, Tahiti, the
Mariana Islands, and Chuuk.
6. Some other race was included for people who are
unable to identify with the other categories.
7. In addition, the respondent could identify, as
a write-in, with two races (U.S. Census Bureau,
2010).
The Hispanic/Latino and Asian populations con-
tinue to rise in numbers and in percentage of the
overall population; however, although the black/
African American, Native Hawaiian and Pacific
Islanders, and American Indian and Alaskan Natives
groups continue to increase in overall numbers, their
percentage of the population has decreased. Of the
Hispanic/Latino population, most are Mexicans, fol-
lowed by Puerto Ricans, Cubans, Central Americans,
South Americans, and Dominicans. Salvadorans
are the largest group from Central America. Three-
quarters of Hispanics live in the West or South, with
50 percent of the Hispanics living in just two states:
California and Texas. The median age for the entire
U.S. population is 41.8 years, and the median age for
Hispanics is 27.2 years (U.S. Census Bureau, 2010).
The young age of Hispanics in the United States
makes them ideal candidates for recruitment into the
health professions, an area with crisis-level shortages
of personnel, especially of minority representation.
Before 1940, most immigrants to the United States
came from Europe, especially Germany, the United
Kingdom, Ireland, the former Union of Soviet Social-
ist Republics, Latvia, Austria, and Hungary. Since
1940, immigration patterns to the United States have
changed: Most are from Mexico, the Philippines,
China, India, Brazil, Russia, Pakistan, Japan, Turkey,
Egypt, and Thailand. People from each of these coun-
tries bring their own culture with them and increase
the cultural mosaic of the United States. Many of
these groups have strong ethnic identities and main-
tain their values, beliefs, practices, and languages long
after their arrival. Individuals who speak only their
indigenous language are more likely to adhere to
traditional practices and live in ethnic enclaves and
are less likely to assimilate into their new society. The
inability of immigrants to speak the language of their
new country creates additional challenges for health-
care providers working with these populations. Other
countries in the world face similar immigration chal-
lenges and opportunities for diversity enrichment.
However, space does not permit a comprehensive
analysis of migration patterns.
◗ What changes in ethnic and cultural diversity
have you seen in your community over the last
5 years? Over the last 10 years? Have you had
the opportunity to interact with these newer
groups?
Racial and Ethnic Disparities
in Health Care
A number of organizations have developed docu-
ments addressing the need for cultural competence
as one strategy for eliminating racial and ethnic dis-
parities. In 2005, the Agency for Healthcare Research
and Quality (AHRQ) released the “Third National
Transcultural Diversity and Health Care 5
2780_Ch01_001-014 16/07/12 11:35 AM Page 5

Healthcare Disparities Report” (AHRQ, 2005), which
provided a comprehensive overview of health dispar-
ities in ethnic, racial, and socioeconomic groups in
the United States. This report was a companion doc-
ument to the “National Healthcare Quality Report”
(2006), which was an overview of quality health care
in the United States. Healthy People 2010’s (www.
healthypeople.gov) goals were to increase the quality
and the length of a healthy life and to eliminate
health disparities. Healthy People provided science-
based, 10-year national objectives for improving
the health of all Americans. For 3 decades, Healthy
People has established benchmarks and monitored
progress over time in order to (1) encourage collabo-
rations across communities and sectors, (2) empower
individuals toward making informed health decisions,
and (3) measure the impact of prevention activities
( h t t p : / / w w w. h e a l t hy p e o p l e. g ov / 2 0 2 0 / ab o u t /
default.aspx).
The Healthy People 2020 (www.healthypeople2020.
gov) report had a renewed focus on identifying,
measuring, tracking, and reducing health disparities
through determinants of health such as the social
and economic environment, the physical environ-
ment, and the person’s individual characteristics and
behaviors.
Although the term disparities is often interpreted
to mean racial or ethnic disparities, many dimensions
of disparity exist in the United States, particularly in
health. If a health outcome is seen in a greater or
lesser extent among different populations, a disparity
exists. Race or ethnicity, sex, sexual identity, age, dis-
ability, socioeconomic status, and geographic location
all contribute to an individual’s ability to achieve good
health. During the past two decades, one of Healthy
People’s overarching goals focused on disparities. In-
deed, in Healthy People 2000, the goal was to reduce
health disparities among Americans; in Healthy Peo-
ple 2010, it was to completely eliminate, not just
reduce, health disparities; and in Healthy People
2020, the goal was expanded to achieve health equity,
eliminate disparities, and improve the health of all
groups.
Healthy People 2020 defines a health disparity as
“a particular type of health difference that is closely
linked with social, economic, and/or environmental
disadvantage.” Health disparities adversely affect
groups of people who have systematically experi-
enced greater obstacles to health based on their
racial or ethnic group; religion; socioeconomic
status; gender; age; mental health; cognitive, sen-
sory, or physical disability; sexual orientation or
gender identity; geographic location; or other char-
acteristics historically linked to discrimination or
exclusion. In addition, powerful, complex relation-
ships exist among health and biology, genetics,
and individual behavior, and among health and
health services, socioeconomic status, the physical
envi ronment, discrimination, racism, literacy levels,
and legislative policies. These factors, which influ-
ence an individual’s or population’s health, are
known as determinants of health (Healthy People
2020).
◗ What health disparities have you observed in
your community? To what do you attribute these
disparities? What can you do as a professional to
help decrease these disparities?
More specific data on ethnic and cultural groups
are included in individual chapters. As can be seen
by the overwhelming data, much more work needs to
be done to improve the health of the nation. Space
does not permit an extensive discourse on racial and
ethnic disparities in other countries, but documents
with frequent updates that include other countries,
conditions, and policies are listed as a resource on
DavisPlus.
Culture and Essential Terminology
Culture Defined
Anthropologists and sociologists have proposed many
definitions of culture. For the purposes of this book,
which is primarily focused on individual cultural com-
petence instead of the culturally competent organiza-
tion, culture is defined as the totality of socially
transmitted behavioral patterns, arts, beliefs, values,
customs, lifeways, and all other products of human
work and thought characteristics of a population of
people that guide their worldview and decision mak-
ing. Health and health-care beliefs and values are as-
sumed in this definition. These patterns may be
explicit or implicit, are primarily learned and trans-
mitted within the family, are shared by most
(but not all) members of the culture, and are emergent
phenomena that change in response to global phe-
nomena. Culture, a combined anthropological and
social construct, can be seen as having three levels:
(1) a tertiary level that is visible to outsiders, such as
things that can be seen, worn, or otherwise observed;
(2) a secondary level, in which only members know
the rules of behavior and can articulate them; and
(3) a primary level that represents the deepest level in
which rules are known by all, observed by all, implicit,
and taken for granted (Koffman, 2006). Culture is
largely unconscious and has powerful influences on
health and illness.
An important concept to understand is that
cultural beliefs, values, and practices are learned
from birth: first at home, then in the church and
other places where people congregate, and then
in educational settings. Therefore, a 3-month-old
female child from Russian Ashkenazi Jewish heri –
tage who is adopted by a European American
6 Foundations for Cultural Competence
2780_Ch01_001-014 16/07/12 11:35 AM Page 6

family and reared in a dominant European American
environment will have a European American world-
view. However, if that child’s heritage has a tendency
toward genetic/hereditary conditions, they would
come from her Russian Jewish ancestry, not from
European American genetics.
◗ Who in your family had the most influence in
teaching you cultural values and practices? Out-
side the family, where else did you learn about
your cultural values and beliefs? What cultural
practices did you learn in your family that you
no longer practice?
When individuals of dissimilar cultural orienta-
tions meet in a work or a therapeutic environment,
the likelihood for developing a mutually satisfying
relationship is improved if both parties attempt to
learn about one another’s culture. Moreover, race
and culture are not synonymous and should not
be confused. For example, most people who self-
identify as African American have varying degrees
of dark skin, but some may have white skin. How-
ever, as a cultural term, African American means
that the person takes pride in having ancestry from
both Africa and the United States; thus, a person
with white skin could self-identify as African
American.
Important Terms Related to Culture
Attitude is a state of mind or feeling about some as-
pect of a culture. Attitudes are learned; for example,
some people think that one culture is better than
another. No one culture is “better” than another;
they are just different, and many different cultures
share the same customs. A belief is something that
is accepted as true, especially as a tenet or a body
of tenets accepted by people in an ethnocultural
group. A belief among some cultures is that if you
go outside in the cold weather with wet hair, you
will catch a cold. Attitudes and beliefs do not have
to be proven; they are unconsciously accepted as
truths. Ideology consists of the thoughts and beliefs
that reflect the social needs and aspirations of an in-
dividual or an ethnocultural group. For example,
some people believe that health care is the right
of all people, whereas others see health care as a
privilege.
The literature reports many definitions of the terms
cultural awareness, cultural sensitivity, and cultural
competence. Sometimes, these definitions are used in-
terchangeably, but each has a distinct meaning. Cul-
tural awareness has to do with an appreciation of the
external signs of diversity, such as the arts, music,
dress, foods, and physical characteristics. Cultural sen-
sitivity has to do with personal attitudes and not say-
ing things that might be offensive to someone from a
cultural or ethnic background different from the
health-care provider’s. Cultural competence in health
care is having the knowledge, abilities, and skills
to deliver care congruent with the patient’s cultural
beliefs and practices. Increasing one’s consciousness
of cultural diversity improves the possibilities for
health-care practitioners to provide culturally compe-
tent care.
◗ What activities have you done to increase your
cultural awareness and competence? How do you
demonstrate that you are culturally sensitive?
One progresses from unconscious incompetence
(not being aware that one is lacking knowledge
about another culture), to conscious incompetence
(being aware that one is lacking knowledge about
another culture), to conscious competence (learning
about the patient’s culture, verifying generalizations
about the patient’s culture, and providing cultural-
specific interventions), and, finally, to unconscious
competence (automatically providing culturally
congruent care to patients of diverse cultures). Un-
conscious competence is difficult to accomplish
and potentially dangerous because individual differ-
ences exist within cultural groups. To be even mini-
mally effective, culturally competent care must have
the assurance of continuation after the original im-
petus is withdrawn; it must be integrated into, and
valued by, the culture that is to benefit from the
interventions.
Developing mutually satisfying relationships with
diverse cultural groups involves good interpersonal
skills and the application of knowledge and tech-
niques learned from the physical, biological, and
social sciences as well as the humanities. An under-
standing of one’s own culture and personal values
and the ability to detach oneself from “excess bag-
gage” associated with personal views are essential
for cultural competence. Even then, traces of ethno-
centrism may unconsciously pervade one’s attitudes
and behavior. Ethnocentrism—the universal ten-
dency of human beings to think that their ways of
thinking, acting, and believing are the only right,
proper, and natural ways (which most people prac-
tice to some degree)—can be a major barrier to pro-
viding culturally competent care. Ethnocentrism
perpetuates an attitude in which beliefs that differ
greatly from one’s own are strange, bizarre, or unen-
lightened and, therefore, wrong. Values are princi-
ples and standards that are important and have
meaning and worth to an individual, family, group,
or community. For example, the dominant U.S. cul-
ture places high value on youth, technology, and
money. The extent to which one’s cultural values
are internalized influences the tendency toward
ethnocentrism. The more one’s values are internal-
ized, the more difficult it is to avoid the tendency
toward ethnocentrism.
Transcultural Diversity and Health Care 7
2780_Ch01_001-014 16/07/12 11:35 AM Page 7

◗ Given that everyone is ethnocentric to some de-
gree, what do you do to become less ethnocentric?
With which groups are you more ethnocentric?
If you were to rate yourself on a scale of 1 to
10, with 1 being only a little ethnocentric and
10 being very ethnocentric, what score would
you give yourself ? What score would your
friends give you? What score would you give
your closest friends?
The Human Genome Project (2003) determined
that 99.9 percent of all humans share the same genes.
One-tenth percent of genetic variations account for the
differences among humans, although these diff erences
may be significant when conducting health assessments
and prescribing medications and treatments. Ignoring
this small difference, however, is ignoring the beliefs,
practices, and values of a small ethnic or cultural
population to whom one provides care. However, the
controversial term race must still be addressed when
learning about culture. Race is genetic in origin and in-
cludes physical characteristics that are similar among
members of the group, such as skin color, blood type,
and hair and eye color (Giger et al., 2007). People from
a given racial group may, but do not necessarily, share
a common culture. Race as a social concept is some-
times more important than race as a biological con-
cept. Race has social meaning, assigns status, limits or
increases opportunities, and influences interactions be-
tween patients and clinicians. Some believe that race
terminology was invented to assign low status to some
and privilege, power, and wealth to others (American
Anthropological Association, 1998). Thus, perhaps the
most significant aspect of race is social in origin.
Moreover, one must remember that even though one
might have a racist attitude, it is not always recognized
because it is ingrained during socialization and leads
to ethnocentrism.
◗ How do you define race? What other terms do
you use besides race to describe people? In what
category did you classify yourself on the last
census? What categories would you add to the
current census classifications?
Worldview is the way individuals or groups of peo-
ple look at the universe to form basic assumptions and
values about their lives and the world around them.
Worldview includes cosmology, relationships with na-
ture, moral and ethical reasoning, social relationships,
magicoreligious beliefs, and aesthetics.
Any generalization—reducing numerous character-
istics of an individual or group of people to a general
form that renders them indistinguishable—made
about the behaviors of any individual or large group
of people is almost certain to be an oversimplification.
When a generalization relates less to the actual
observed behavior than to the motives thought to
underlie the behavior (i.e., the why of the behavior), it
is likely to be oversimplified. However, generalizations
can lead to stereotyping, an oversimplified concep-
tion, opinion, or belief about some aspect of an indi-
vidual or group. Although generalization and
stereotyping are similar, functionally, they are very dif-
ferent. Generalization is a starting point, whereas
stereotyping is an endpoint. The health-care provider
must specifically ask questions to determine these
values and avoid stereotypical views of patients. See
the section on Variant Characteristics of Culture in
this chapter.
◗ Everyone engages in stereotypical behavior to
some degree. We could not function otherwise. If
someone asks you to think of a nurse, what
image do you have? Is the nurse male or female?
How old is the nurse? How is the nurse dressed?
Is the nurse wearing a hat? How do you distin-
guish a stereotype from a generalization?
Within all cultures are subcultures and ethnic
groups whose values/experiences differ from those
of the dominant culture with which they identify.
Indeed, subcultures share beliefs according to the
variant characteristics of culture, as described later in
this chapter. In sociology, anthropology, and cultural
studies, a subculture is defined as a group of people
with a culture that differentiates them from the larger
culture of which they are a part. Subcultures may be
distinct or hidden (e.g., gay, lesbian, bisexual, and
transgendered populations). If the subculture is char-
acterized by a systematic opposition to the dominant
culture, then it may be described as a counterculture.
Examples of subcultures are Goths, punks, and ston-
ers, although popular lay literature might call these
groups cultures instead of subcultures. A countercul-
ture would include cults (Merriam Webster Online
Dictionary, 2010).
The terms transcultural versus cross-cultural have
been hotly debated among experts in several countries
but especially in the United States. Specific definitions
of these terms vary. Some attest that they are the
same, whereas others say they are different. Histori-
cally, nursing seems to favor the word transcultural.
Indeed, the term has been credited to a nurse anthro-
pologist, Madeleine Leininger, in the 1950s (Leininger
& McFarland, 2006), and it continues to be popular
in the United States, the United Kingdom, and many
European countries. The term cross-cultural can be
traced to anthropologist George Murdock in the
1930s and is still a popular term used in the social
sciences, although the health sciences have used it as
well. The term implies comparative interactivity
among cultures.
Cultural humility, another term found in cultural
literature, focuses on the process of intercultural
exchange, paying explicit attention to clarifying
8 Foundations for Cultural Competence
2780_Ch01_001-014 16/07/12 11:35 AM Page 8

the professional’s values and beliefs through self-
reflection and incorporating the cultural characteris-
tics of the professional and the patient into a mutually
beneficial and balanced relationship (Trevalon &
Murray-Garcia, 1998). This term appears to be most
popular with physicians and some professionals from
the social sciences.
Cultural safety is a popular term in Australia,
New Zealand, and Canada, although it is used else-
where. Cultural safety expresses the diversity that
exists within cultural groups and includes the social
determinants of health, religion, and gender, in ad-
dition to ethnicity (Guidelines for Cultural Safety,
2005). Cultural leverage is a process whereby the
principles of cultural competence are deliberately
invoked to develop interventions. It is a focused
strategy for improving the health of racial and eth-
nic communities by using their cultural practices,
products, philosophies, or environments to facilitate
behavioral changes of the patient and professional
(Fisher et al., 2007).
Acculturation occurs when a person gives up the
traits of his or her culture of origin as a result of con-
tact with another culture. Acculturation is not an ab-
solute, and it has varying degrees. Traditional people
hold onto the majority of cultural traits from their
culture of origin, which is frequently seen when people
live in ethnic enclaves and can get most of their needs
met without mixing with the outside world. Bicultural
acculturation occurs when an individual is able to
function equally in the dominant culture and in one’s
own culture. People who are comfortable working in
the dominant culture and return to their ethnic en-
clave without taking on most of the dominant cul-
ture’s traits are usually bicultural. Marginalized
individuals are not comfortable in their new culture or
their culture of origin. Assimilation is the gradual
adoption and incorporation of characteristics of the
prevailing culture (Portes, 2007).
Enculturation is a natural conscious and uncon-
scious conditioning process of learning accepted cul-
tural norms, values, and roles in society and achieving
competence in one’s culture through socialization.
Enculturation is facilitated by growing up in a partic-
ular culture, and it can be through formal education,
apprenticeships, mentorships, and role modeling
(Clarke & Hofsess, 1998).
Individualism, Collectivism,
and Individuality
All cultures worldwide vary along an individualism
and collectivism scale and are subsets of broad world-
views. A continuum of values for individualistic and
collectivistic cultures includes orientation to self
or group, decision making, knowledge transmission,
individual choice and personal responsibility, the
concept of progress, competitiveness, shame and guilt,
help-seeking, expression of identity, and interaction/
communication style (Hofstede, 1991; Hofstede &
Hofstede, 2005).
Elements and the degree of individualism and col-
lectivism exist in every culture. People from an indi-
vidualist culture will more strongly identify with the
values at the individualistic end of the scale. More-
over, individualism and collectivism fall along a con-
tinuum, and some people from an individualistic
culture will, to some degree, align themselves toward
the collectivistic end of the scale. Some people from a
collectivist culture will, to some degree, hold values
along the individualistic end of the scale. Accultura-
tion is a key component of adopting individualistic
and collectivistic values. Those who live in ethnic en-
claves usually, but not always, adhere more strongly to
their dominant cultural values, sometimes to such a
degree that they are more traditional than people in
their home country. Acculturation and the variant
characteristics of culture determine the degree of ad-
herence to traditional individualistic and collectivist
cultural values, beliefs, and practices (Hofstede, 1991;
Hofstede & Hofstede, 2005).
Communicating, assessing, counseling, and educat-
ing a person from an individualistic culture, where the
most important person in society is the individual,
may require different techniques than for a person in
a collectivist culture where the group is seen as more
important than the individual (Hofstede & Hofstede,
2005). The professional must not confuse individual-
ism with individuality—the degree that varies by cul-
ture and is usually more prevalent in individualistic
countries. Individuality is the sense that each person
has a separate and equal place in the community and
where individuals who are considered “eccentrics or
local characters” are tolerated (Purnell, 2010).
Some highly individualistic cultures include tradi-
tional European American (in the United States),
British, Canadian, German, Norwegian, and Swedish,
to name a few. Some examples of collectivist cultures
include traditional Arabic, Amish, Chinese, Filipino,
Korean, Japanese, Latin American, Mexican, Ameri-
can Indians (and most other indigenous Indian
groups), Taiwanese, Thai, Turkish, and Vietnamese.
Far more world cultures are collectivistic than are in-
dividualistic. It may be difficult for a nurse who is
from a highly collectivist culture to communicate with
patients and staff in highly individualistic cultures,
such as the United States and Germany (Hofstede &
Hofstede, 2005).
Cultures differ in the extent to which health and in-
formation are explicit or implicit. In low-context cul-
tures, great emphasis is placed on the verbal mode,
and many words are used to express a thought. Low-
context cultures are individualistic. In high-context
cultures, much of the information is implicit where
Transcultural Diversity and Health Care 9
2780_Ch01_001-014 16/07/12 11:35 AM Page 9

fewer words are used to express a thought, resulting
in more of the message being in the nonverbal mode.
Great emphasis is placed on personal relationships.
High-context cultures are collectivistic (Hofstede,
1991; 2001).
Consistent with individualism, individualistic cul-
tures encourage self-expression. Adherents to individ-
ualism freely express personal opinions, share many
personal issues, and ask personal questions of others
to a degree that may be seen as offensive to those who
come from a collectivistic culture. Direct, straight
forward questioning is usually appreciated with indi-
vidualism. However, the professional should take cues
from the patient before this intrusive approach is ini-
tiated. Small talk before getting down to business is
not always appreciated. Individualistic cultures usu-
ally tend to be more informal and frequently use first
names. Ask the patient by what name he or she prefers
to be called. Questions that require a “yes” or “no”
answer are usually answered truthfully from the pa-
tient’s perspective. In individualistic cultures that value
autonomy and productivity, one is expected to be a
productive member of society. Among collectivistic
cultures, people with a mental or physical disability
are more likely to be hidden from society to “save
face,” and the cultural norms and values of the family
unit mean that the family provides care in the home
(Purnell, 2001).
Indeed, it is absolutely imperative to include the
family, and sometimes the community, in health care
for effective counseling; otherwise, the treatment plan
may falter. However, among many Middle Eastern
and other collectivistic cultures, family members with
mental or physical disabilities are hidden from the
community for fear that children in the family might
not be able to obtain a spouse if the condition is
known. For other impairments, such as HIV, the con-
dition may be kept from public view, not because of
confidentiality rights but for fear that news of the con-
dition will spread to other family members and the
community.
The greater the perceived cultural stigma, the
more likely the delay in seeking counseling, resulting
in the condition being more severe at the time of
treatment. Individualistic cultures socialize their
members to view themselves as independent, separate,
distinct individuals, where the most important per-
son in society is self. A person feels free to change
alliances and not feel bound by any particular group
(shared identity). Although they are part of a group,
they are still free to act independently within the
group and less likely to engage in “groupthink.” In
individualism, competition, whether individual or
group, permeates every aspect of life. Separateness,
independence, and the capacity to express one’s own
views and opinions are both explicitly valued and
implicitly assumed.
In individualistic cultures, a person’s identity is
based mainly on one’s personal accomplishments,
career, and challenges. A high standard of living
supports self-efficiency, self-direction, self-advocacy,
and independent living. Decisions made by elders and
people in hierarchal positions may be questioned or
not followed because the ideal is that all people expect
to, and are expected to, make their own decisions
about their lives. Moreover, people are personally re-
sponsible and held accountable for their decisions.
Improving self, doing “better” than others (frequently
focused on material gains), and making progress on
a community or national level are expected. If one
fails, the blame and shame are on the individual
alone.
In collectivistic cultures, people are socialized to
view themselves as members of a larger group, family,
school, church, educational setting, workplace, and so
on. They are bound through the expectations of loy-
alty and personal and familial lifetime protective ties.
Children are socialized where priority is given to con-
nections and interrelationship with others as the basis
of psychological well-being. Older people and those
in hierarchical positions are respected, and people are
less likely to openly disagree with them. Parents and
elders may have the final say in their children’s careers
and life partners. The focus is not on the individual
but on the group.
Collectivism is characterized by not drawing atten-
tion to oneself, and people are not encouraged to ask
controversial questions about themselves or others.
When one fails, shame may be extended to the family,
and external explanations, spiritual, superiors, or fate
may be given. To avoid offending someone, people are
expected to practice smooth interpersonal communi-
cation by not openly disagreeing with anyone and
being evasive about negative issues. Among most col-
lectivist cultures, disagreeing with or saying “no” to a
health-care professional is considered rude. In fact, in
some languages, there is no word for “no.” If you ask
a collectivist patient if she knows what you are asking,
if she understands you, and if she knows how to do
something, she will always answer “yes.” But “yes”
could mean (a) I hear you, but I do not understand
you; (b) I understand you, but I do not agree with
what you are saying; and (c) I know how to do that,
but I might not do it. Repeating what has been pre-
scribed does not ensure understanding; instead, ask
for a demonstration or some other response that is
more likely to determine understanding.
Variant Characteristics of Culture
Great diversity exists within a cultural group. Major
influences that shape people’s worldviews and the de-
gree to which they identify with their cultural group
of origin are called the “variant characteristics of
culture.” Some variant characteristics cannot be
10 Foundations for Cultural Competence
2780_Ch01_001-014 16/07/12 11:35 AM Page 10

• Urban versus rural residence: People can change
their residence with concomitant changes in ideology
with different health risks and access to health care.
• Enclave identity: For people who primarily live and
work in an ethnic enclave where they can get their
needs met without mixing with the world outside,
they may be more traditional than people in their
home country.
• Marital status: Married people and people with
partners frequently have a different worldview than
those without partners.
• Parental status: Often, when people become
parents—having children, adopting, or taking
responsibility for raising a child—their worldview
changes, and they usually become more futuristic.
• Sexual orientation: Sexual orientation is usually
stable over time, but some people are bisexual. In
addition, people who are incarcerated may engage
in same-sex activity but return to a heterosexual
lifestyle when released from prison. Gender reas-
signment is now a possibility for some, although a
significant stigma may occur.
• Gender issues: Men and women may have different
concerns in regards to type of work and work
hours, pay scales, and health inequalities.
• Physical characteristics: One’s physical characteris-
tics may have an effect on how people see them-
selves and how others see them and can include
such characteristics as height, weight, hair color
and style, and skin color.
• Immigration status (sojourner, immigrant, or undoc-
umented status): Immigration status and length of
time away from the country of origin also affect
one’s worldview. People who voluntarily immigrate
generally acculturate and assimilate more easily.
Sojourners who immigrate with the intention of
remaining in their new homeland for only a short
time on work assignments or refugees who think
they may return to their home country may not
have the need or desire to acculturate or assimilate.
Additionally, undocumented individuals (illegal
immigrants) may have a different worldview from
those who have arrived legally. Many in this group
remained hidden in society so they will not be
discovered and returned to their home country.
• Length of time away from the country of origin: Usu-
ally, the longer people are away from their culture
of origin, the less traditional they become as they
acculturate and assimilate into their new culture.
Transcultural Diversity and Health Care 11
changed, while others can. They include but are not
limited to the following:
• Nationality: One cannot change his or her nation-
ality, but over time many people have changed
their names to better fit into society or to decrease
discrimination. For example, many Jews changed
the spelling of their last names during and after
World War II to avoid discrimination.
• Race: Race cannot be changed, but people can and
do make changes in their appearance, such as with
of cosmetic surgery.
• Color: Skin color cannot usually be changed on a
permanent basis.
• Age: Age cannot be changed, but many people
go to extensive lengths to make themselves look
younger. One’s worldview changes with age. In
some cultures, older people are looked upon with
reverence and increased respect. Age difference
with the accompanying worldview is frequently
called the generation gap.
• Religious affiliation: People can and do change
their religious affiliations or self-identify as atheists.
However, if someone changes his or her religious
affiliation—for example, from Judaism to Pente-
costal or Baptist to Islam—a significant stigma
may occur within their family or community.
• Educational status: As education increases, people’s
worldview changes and increases their knowledge
base for decision making.
• Socioeconomic status: Socioeconomic status can
change either up or down and can be a major de-
terminant for access to and use of health care.
• Occupation: One’s occupation can change. Of
course, an occupation can be a health risk if
employment is in a coal mine, on a farm, or in a
high-stress position. In addition, someone who is
educated in the health professions would not have
as much difficulty with health literacy.
• Military experience: People who have military ex-
perience may be more accustomed to hierarchical
decision making and rules of authority.
• Political beliefs: Political affiliation can change ac-
cording to one’s ideology. One of the major reasons
for migration is ideological and political beliefs.
R E F L E C T I V E E X E R C I S E 1 . 1
Does your cultural heritage primarily have a collectivistic or in-
dividualistic cultural worldview? Rate your culture on a scale of
1 to 10 with 1 = collectivistic and 10 = individualistic. Is your
culture tolerant of individuality? Are you consistent with your
cultural heritage? Provide some specific behaviors to support
your answer.
Collectivism Individualism
1 2 3 4 5 6 7 8 9 10
R E F L E C T I V E E X E R C I S E 1 . 2
What are your variant characteristics of culture? How has
each one influenced you and your worldview? How has your
worldview changed as your variant characteristics have
changed? How is each of these a culture or a subculture?
2780_Ch01_001-014 16/07/12 11:35 AM Page 11

Some examples of how variant cultural character-
istics change one’s worldview follow.
Consider two people with the following variant
characteristics. One is a 75-year-old devout Islamic
female from Saudi Arabia, and the other is a 19-year-
old African American fundamentalist Baptist male
from Louisiana. Obviously, the two do not look alike,
and they probably have very different worldviews and
beliefs, many of which come from their religious tenets
and country of origin.
The variant cultural characteristics of being a single
transsexual urban business executive will most likely
have a different worldview from that of a married het-
erosexual rural secretary who has two teenagers. In
another case, a migrant farm worker from the high-
lands of Guatemala with an undocumented status
has a different perspective than an immigrant from
Mexico who has lived in New York City for 10 years.
Ethics Across Cultures
As globalization grows and population diversity with
nations increases, health-care providers are increas-
ingly confronted with ethical issues related to cultural
diversity. At the extremes stand those who favor mul-
ticulturalism and postmodernism versus those who
favor humanism. Internationally, multiculturalism as-
serts that no common moral principles are shared by
all cultures. Postmodernism asserts a similar claim
against all universal standards, both moral and im-
moral. The concern is that universal standards provide
a disguise, whereas dominant cultures destroy or erad-
icate traditional cultures.
Humanism asserts that all human beings are equal
in worth, that they have common resources and prob-
lems, and that they are alike in fundamental ways
(Macklin, 1999). Humanism does not put aside the
many circumstances that make individuals’ lives dif-
ferent around the world. Many similarities exist as to
what people need to live well. Humanism says that cer-
tain human rights should not be violated. Macklin
(1998) asserts that universal applicability of moral
principles is required, not universal acceptability.
Beaucamp (1998) concurs that fundamental principles
of morality and human rights allow for cross-cultural
judgments of immoral conduct. Of course, there is a
middle ground.
Throughout the world, practices are claimed to be
cultural, traditional, and beneficial, even when they
are exploitative and harmful. For example, female cir-
cumcision, a traditional cultural practice, is seen by
some as exploiting women. In many cases, the practice
is harmful and can even lead to death. Although
empirical, anthropological research has shown that
different cultures and historical eras contain different
moral beliefs and practices, it is far from certain that
what is right or wrong can be determined only by
the beliefs and practices within a particular culture or
subculture. Slavery and apartheid are examples of civil
rights violations.
Accordingly, codes of ethics are open to interpre-
tation and are not value-free. Furthermore, ethics be-
long to the society, not to professional groups. Ethics
and ethical decision making are culturally bound. The
Western ethical principles of patient autonomy, self-
determination, justice, do no harm, truth telling,
and promise-keeping are highly valued, but not all
cultures—non-Western societies—place such high
regard on these values. For example, in Russia, the
truth is optional, people are expected to break their
promises, and most students cheat on examinations.
Cheating on a business deal is not necessarily considered
dishonorable (Birch, 2006).
In health organizations in the United States, ad-
vance directives give patients the opportunity to de-
cide about their care, and staff members are required
to ask patients about this upon admission to a health-
care facility. Western ethics, with its stress on individ-
ualism, asks this question directly of the patient.
However, in collectivist societies, such as among some
ethnic Chinese and Japanese, the preferred person to
ask may be a family member. In addition, translating
health forms into other languages can be troublesome
because a direct translation can be confusing. For ex-
ample, “informed consent” may be translated to mean
that the person relinquishes his or her right to decision
making.
Some cultural situations occur that raise legal is-
sues. For instance, in Western societies, a competent
person (or an alternative such as the spouse, if the
person is married) is supposed to sign her or his own
consent for medical procedures. However, in some cul-
tures, the eldest son is expected to sign consent forms,
not the spouse. In this case, both the organization and
the family can be satisfied if both the spouse and the
son sign the informed consent.
Instead of Western ethics prevailing, some author-
ities advocate for universal ethics. Each culture has its
own definition of what is right or wrong and what is
good or bad. Accordingly, some health-care providers
encourage international codes of ethics, such as those
developed by the International Council of Nurses
(2010). These codes are intended to reflect the
patient’s culture and whether the value is placed on
individualism or collectivism. Most Western codes of
ethics have interpretative statements based on the
Western value of individualism. International codes
of ethics do not contain interpretative statements but,
rather, let each society interpret them according to its
culture. As our multicultural society increases its di-
versity, health-care providers need to rely upon ethics
committees that include members from the cultures
they serve.
As the globalization of health-care services increases,
providers must also address very crucial issues, such as
12 Foundations for Cultural Competence
2780_Ch01_001-014 16/07/12 11:35 AM Page 12

cultural imperialism, cultural relativism, and cultural
imposition. Cultural imperialism is the practice of ex-
tending the policies and practices of one group (usually
the dominant one) to disenfranchised and minority
groups. An example is the U.S. government’s forced mi-
gration of Native American tribes to reservations with
individual allotments of lands (instead of group own-
ership), as well as forced attendance of their children at
boarding schools attended by white people. Proponents
of cultural imperialism appeal to universal human rights
values and standards (Purnell, 2001).
Cultural relativism is the belief that the behaviors
and practices of people should be judged only from
the context of their cultural system. Proponents of
cultural relativism argue that issues such as abortion,
euthanasia, female circumcision, and physical punish-
ment in child rearing should be accepted as cultural
values without judgment from the outside world.
Opponents argue that cultural relativism may under-
mine condemnation of human rights violations, and
family violence cannot be justified or excused on a cul-
tural basis (Purnell, 2001).
Cultural imposition is the intrusive application of the
majority group’s cultural view upon individuals and
families (Universal Declaration of Human Rights,
2001). Prescription of special diets without regard to
patients’ cultures and limiting visitors to immediate
family, a practice of many acute-care facilities, border
on cultural imposition (Purnell, 2001).
◗ What practices have you seen that might be
considered a cultural imposition?
What practices have you seen that might be
considered cultural imperialism?
What practices have you seen that might be
considered cultural relativism?
What have you done to address them when you
have seen them occurring?
Health-care providers must be cautious about
forcefully imposing their values regarding genetic test-
ing and counseling. No group is spared from genetic
disease. Advances in technology and genetics have
found that many diseases, such as Huntington‘s
chorea, have a genetic basis. Some forms of breast and
colon cancers, adult-onset diabetes, Alzheimer’s dis-
ease, and hypertension are some of the newest addi-
tions. Currently, only the well-to-do can afford broad
testing. Advances in technology will provide the
means for access to screening that will challenge
genetic testing and counseling. The relationship of ge-
netics to disability, individuals with a disability, and
those with a potential disability will create moral
dilemmas of new complexity and magnitude.
Many questions surround genetic testing. Should
health-care providers encourage genetic testing? What
is, or should be, done with the results? How do we
approach testing for genes that lead to disease or
disability? How do we maximize health and well-being
without creating a eugenic devaluation of those who
have a disability? Should employers and third-party
payers be allowed to discriminate based on genetic
potential for illness? What is the purpose of prenatal
screening and genetic testing? What are the assump-
tions for state-mandated testing programs? Should
parents and individuals be allowed to “opt out” of
testing? What if the individual does not want to know
the results? What if the results could have a deleterious
outcome to the infant or the mother? What if the re-
sults got into the hands of insurance companies that
then denied payment or refused to provide coverage?
Should public policy support genetic testing, which
may improve health and health care for the masses of
society? Should multiple births from fertility drugs be
restricted because of the burden of cost, education,
and health of the family? Should public policy encour-
age limiting family size in the contexts of the mother’s
health, religious and personal preferences, and the
availability of sufficient natural resources (such as
water and food) for future survival? What effect do
these issues have on a nation with an aging popula-
tion, a decrease in family size, and decreases in the
numbers and percentages of younger people? What ef-
fect will these issues have on the ability of countries
to provide health care for their citizens? Health-care
providers must understand these three concepts and
the ethical issues involved because they will increasingly
encounter situations in which they must balance the
patient’s cultural practices and behaviors with health
promotion and wellness, as well as illness, disease, and
injury prevention activities for the good of the patient,
the family, and society. Other international issues that
may be less controversial include sustainable environ-
ments, pacification, and poverty (Purnell, 2001).
R E F E R E N C E S
Agency for Healthcare Research and Quality (AHRQ). (2005).
Third national healthcare disparities report. U.S. Department
of Health and Human Services. AHRQ Publication No. 060.
Retrieved from http://health-equity.pitt.edu/371/
Agency for Healthcare Research and Quality (AHRQ). (2006).
National healthcare quality report. Retrieved from http://www.
ahrq.gov/
American Anthropological Association. (1998). Statement on
race: Position paper. Retrieved from http://www.aaanet.org/
stmts/racepp.htm
Beaucamp, T. (1998). The mettle of moral fundamentalism: A
reply to Robert Baker. Kennedy Institute of Ethics Journal, 8(4),
389–401.
Birch, D. (2006, October 27). In Russia, the truth is optional.
Baltimore Sun, pp. 2F, 6F.
Centers for Disease Control. (1985). Perspectives on disease pre-
vention and health promotion. Retrieved from www.cdc.gov/
mmwr/preview/mmwrthml/00000688.htm
CIA World Factbook. (2011). World. Retrieved from https://www.
cia.gov/library/publications/the-world-factbook/geos/xx.html
Transcultural Diversity and Health Care 13
2780_Ch01_001-014 16/07/12 11:35 AM Page 13

Clarke, L., & Hofsess, L. (1998). Acculturation. In S. Loue (Ed.),
Handbook of immigrant health (pp. 37–59). New York: Plenum
Press.
Council of New Zealand. (2005). Guidelines for cultural safety:
The treaty of Waitangi and Maori health. Retrieved from
http://www.nursingcouncil.org.nz
Fisher, T.L., Burnet, D.L., Huang, E.S., Chin, T.L., & Cagney,
K.A. (2007). Cultural leverage: Interventions using culture to
narrow racial disparities in health care. Medical Care Research
Review, 64 (5 suppl. 243S–282S).
Giger, J., Davidhizar, R., Purnell, L., Taylor Harden, J., Phillips,
J., & Strickland, O. (2007). American Academy of Nursing Ex-
pert Panel Report: Developing cultural competence to elimi-
nate health disparities in ethnic minorities and other vulnerable
populations. Journal of Transcultural Nursing, 18(2), 95-102.
Healthy People 2010. (2005). Retrieved from http://www.healthy-
people.gov
Healthy People 2010. (2001). Companion document for lesbian, gay,
bisexual, and transgender health. Retrieved from http://
www.lgbthealth.net
Healthy People 2020. Retrieved from www.healthypeople2020.gov
Hofstede, G. (1991). Cultures and organizations: Software of the
mind. New York: McGraw-Hill.
Hofstede, G. (2001). Culture’s consequences: Comparing values, be-
haviors, institutions, and organizations across nations (2nd ed.).
Thousand Oaks, CA: Sage.
Hofstede, G., & Hofstede, J. (2005). Cultures and organizations:
Software of the mind (2nd ed.). New York: McGraw-Hill.
Home Office Study. (2002). Retrieved from http://news.google.
com/news?q=Home+Office+Study++United+Kingdom&hl=
en&lr=&sa=Xoi=news&ct=title
Human Genome Project. (2003). Retrieved from http://www.ornl.
gov/sci/techresources/Human_Genome/home.shtml
International Council of Nurses. (2010). Ethics. Retrieved from
http://www.icn.ch/publications/ethics/
Joint Commission. (2010). Effective Communication, Cultural
Competence and Family Centered Care: A Roadmap for
Hospitals.
Judge, K., Platt, S., Costongs, C., & Jurczak, K. (2005). Health
inequalities: A challenge for Europe. Retrieved from http://
eurohealthnet.eu/sites/eurohealthnet.eu/files/publications/pu_2
Koffman, J. (2006). Transcultural and ethical issues at the end
of life. In J. Cooper (Ed.), Stepping into palliative care
(pp. 171–186). Abington, UK: Radcliffe Publishing Ltd.
Leininger, M., & McFarland, M. (2006). Culture care diversity
and universality: A worldwide theory. Burlington, MA: Jones and
Bartlett.
Macklin, R. (1998). A defense of fundamental principles and
human rights: A reply to Robert Baker. Kennedy Institute of
Ethics Journal, 8(4), 389–401.
Macklin, R. (1999). Against relativism: Cultural diversity and the
search for ethical universals in medicine. New York: Oxford
University Press.
Merriam Webster Online Dictionary: Subculture versus counter-
culture. (2010). Retrieved from http://www.merriam-webster.
com/dictionary/counterculture
National Research Council. (1998). Retrieved from www.nation-
alacademies.org/news.nsf/isbn/0309063566?OpenDocument
National Standards of Cultural and Linguistic Services. (2007).
Retrieved from http://minorityhealth.hhs.gov/templates/
browse.aspx?lvl=2&lvlID=15
O’Neil, E. (2008). Preface. In L. Purnell & B. Paulanka, Transcul-
tural health care: A culturally competent approach (3rd ed.).
Philadelphia: F.A. Davis Co.
Portes, A. (2007). Migration, development and segmented assim-
ilation: A conceptual review of evidence. Annals of American
Academy of Political and Social Science, 610, 73–97.
Purnell, L. (2001). Cultural competence in a changing health-care
environment. In N. L. Chaska (Ed.), The nursing profession:
Tomorrow and beyond (pp. 451–461). Thousand Oaks, CA:
Sage Publications.
Purnell, L. (2010). Cultural rituals in health and nursing care. In
P. Esterhuizen & A. Kuckert (Eds.), Diversiteit in de verpleeg-
kunde [Diversity in nursing] (pp. 130–196). Amsterdam: Bohn
Stafleu van Loghum.
Trevalon, M., & Murray-Garcia, J. (1998). Cultural humility
versus cultural competence. Journal of Health Care for the Poor
and Underserved, 9(2), 117–125.
U.N. Refugee Agency. (2009). Retrieved from http://www.unhcr.org
Universal Declaration of Human Rights. (2001). Retrieved from
www.amnesty.org
U.S. Census Bureau. (2010). Demographic profiles. Retrieved from
2010.census.gov/news/press-kits/demographic-profiles.html
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
14 Foundations for Cultural Competence
2780_Ch01_001-014 16/07/12 11:35 AM Page 14

15
Chapter 2
The Purnell Model for
Cultural Competence
Larry D. Purnell
This chapter presents the Purnell Model for Cultural
Competence, its organizing framework, and the as-
sumptions upon which the model is based. The model
provides a comprehensive, systematic, and concise
framework for learning and understanding culture.
The empirical framework of the model provides a
basis for health-care providers, educators, researchers,
managers, and administrators in all health disciplines
to provide holistic, culturally competent, therapeutic
interventions; health promotion and wellness; illness,
disease, and injury prevention; health maintenance
and restoration; and health teaching across educa-
tional and practice settings.
The purposes of this model are the following:
• Provide a framework for all health-care providers
to learn concepts and characteristics of culture.
Define circumstances that affect a person’s cultural
worldview in the context of historical perspectives.
• Provide a model that links the most central rela-
tionships of culture.
• Interrelate characteristics of culture to promote
congruence and to facilitate the delivery of con-
sciously sensitive and competent health care.
• Provide a framework that reflects such human
characteristics as motivation, intentionality, and
meaning.
• Provide a structure for analyzing cultural data.
• View the individual, family, or group within their
unique ethnocultural environment.
Assumptions Upon Which
the Model Is Based
The major explicit assumptions upon which the model
is based are as follows:
• All health-care professions need similar
information about cultural diversity.
• All health-care professions share the meta –
paradigm concepts of global society, family,
person, and health.
• One culture is not better than another culture; they
are just different.
• Core similarities are shared by all cultures.
• Differences exist within, between, and among
cultures.
• Cultures change slowly over time.
• The variant cultural characteristics (see Chapter 1)
determine the degree to which one varies from the
dominant culture.
• If patients are coparticipants in their care and have
a choice in health-related goals, plans, and inter-
ventions, their compliance and health outcomes
will be improved.
• Culture has a powerful influence on one’s
interpretation of and responses to health care.
• Individuals and families belong to several
subcultures.
• Each individual has the right to be respected for
his or her uniqueness and cultural heritage.
• Caregivers need both culture-general and culture-
specific information in order to provide culturally
sensitive and culturally competent care.
• Caregivers who can assess, plan, intervene, and
evaluate in a culturally competent manner will
improve the care of patients for whom they care.
• Learning culture is an ongoing process that
increases by working with diverse encounters.
• Prejudices and biases can be minimized with
cultural understanding.
• To be effective, health care must reflect the unique
understanding of the values, beliefs, attitudes, life-
ways, and worldviews of diverse populations and
individual acculturation patterns.
• Differences in race and culture often require
adaptations to standard interventions.
2780_Ch02_015-044 16/07/12 11:37 AM Page 15

• Cultural awareness improves the caregiver’s self-
awareness.
• Professions, organizations, and associations have
their own culture, which can be analyzed using a
grand theory of culture.
• Every patient contact is a cultural encounter.
Overview of the Theory, the Model,
and the Organizing Framework
The Purnell Model has been classified as holographic
and complexity theory because it includes a model and
organizing framework that can be used by all health-
care providers in various disciplines and settings. The
model is a circle: the outer rim represents global soci-
ety, the second rim represents community, the third rim
represents family, and the inner rim represents the per-
son (Fig. 2-1). The interior of the circle is divided into
12 pie-shaped wedges depicting cultural domains and
their concepts. The dark center of the circle represents
unknown phenomena. Along the bottom of the
model, a jagged line represents the nonlinear concept
of cultural consciousness. The 12 cultural domains
(constructs) provide the organizing framework of the
model. Following the discussion of each domain, a
table provides statements that can be adapted as a
guide for assessing patients in various settings. Accord-
ingly, health-care providers can use these same ques-
tions to better understand their own cultural beliefs,
attitudes, values, practices, and behaviors.
Macro Aspects of the Model
The macro aspects of this interactional model include
the metaparadigm concepts of a global society, com-
munity, family, person, and conscious competence.
The theory and model are conceptualized from biol-
ogy, anthropology, sociology, economics, geography,
history, ecology, physiology, psychology, political
science, pharmacology, and nutrition, as well as theo-
ries from communication, family development, and
social support. The model can be used in clinical
practice, education, research, and the administration
and management of health-care services or to analyze
organizational culture.
Phenomena related to a global society include
world communication and politics; conflicts and war-
fare; natural disasters and famines; international
exchanges in education, business, commerce, and in-
formation technology; advances in health science;
space exploration; and the expanded opportunities for
people to travel around the world and interact with
diverse societies. Global events that are widely dissem-
inated by television, radio, satellite transmission,
newsprint, and information technology affect all so-
cieties, either directly or indirectly. Such events create
chaos while consciously and unconsciously forcing
people to alter their lifeways and worldviews.
◗ Think of a recent event that has affected global
society, such as a conflict or war, health
advances in technology, possible environmental
exposure to health problems, or volcanic
eruptions. How did you become aware of this
event? How has this event altered your views and
other people’s views of worldwide cultures?
In the broadest definition, community is a group of
people who have a common interest or identity that goes
beyond the physical environment. Community includes
the physical, social, and symbolic characteristics that
cause people to connect. Bodies of water, mountains,
rural versus urban living, and even railroad tracks help
people define their physical concept of community.
Today, however, technology and the Internet allow
people to expand their community beyond physical
boundaries through social and professional networking
sites. Economics, religion, politics, age, generation, and
marital status delineate the social concepts of commu-
nity. Symbolic characteristics of a community include
sharing a specific language or dialect, lifestyle, history,
dress, art, or musical interest. People actively and pas-
sively interact with the community, necessitating adap-
tation and assimilation for equilibrium and homeostasis
in their worldview. Individuals may willingly change
their physical, social, and symbolic community when it
no longer meets their needs.
◗ How do you define your community in terms
of objective and subjective cultural characteris-
tics? How has your community changed over
the last 5 to 10 years? The last 15 years?
The last 20 years? If you have changed
communities, think of the community in
which you were raised.
A family is two or more people who are emotionally
connected. They may, but do not necessarily, live in close
proximity to one another. Family may include physically
and emotionally close and distant consanguineous rel-
atives, as well as physically and emotionally connected
and distant non–blood-related significant others. Family
structure and roles change according to age, generation,
marital status, relocation or immigration, and socioeco-
nomic status, requiring each person to rethink individ-
ual beliefs and lifeways.
◗ Whom do you consider family? Are they all
blood related? How have they influenced your
culture and worldview? Who else has helped
instill your cultural values?
A person is a biopsychosociocultural being who
is constantly adapting to her or his community.
Human beings adapt biologically and physiologi-
cally with the aging process; psychologically in the
context of social relationships, stress, and relax-
ation; socially as they interact with the changing
16 Foundations for Cultural Competence
2780_Ch02_015-044 16/07/12 11:37 AM Page 16

community; and culturally within the broader global so-
ciety. In highly individualistic cultures (see Chapter 1),
a person is a separate physical and unique psycho-
logical being and a singular member of society. The
self is separate from others. However, in highly col-
lectivistic cultures, the individual is defined in rela-
tion to the family or other group rather than a basic
unit of nature.
◗ In what ways have you adapted (1) biologically
and physiologically to the aging process,
(2) psychologically in the context of social
relationships, (3) socially in your community,
and (4) culturally within the broader society?
Health, as used in this book, is a state of wellness
as defined by the individual within his or her cultural
The Purnell Model for Cultural Competence 17
Community
Person
Person
Person
Person
P
erson
P
erson
P
e
rs
o
n
Pe
rso
n
Pe
rso
n
P
er
so
n
P
er
so
n
Family
Family
Fam
ily
Fam
ily
F
a
m
ily
F
a
m
ily
Fami
ly
Fami
ly
Fa
m
ily
Fa
m
ily
F
a
m
ily
F
a
m
ily
Gl
ob
al
S
oc
ie
ty
Global Society Gl
ob
al
S
oc
ie
ty
Global Society
C
o
m
m
u
n
it
y
Community
C
o
m
m
u
n
ityP
e
rs
o
n
Unconsciously
incompetent
Consciously
incompetent
Consciously
competent
Unconsciously
competent
Over
view
/heri
tage
Origi
ns
Resid
ence
Topo
graph
y
Econ
omic
s
Politi
cs
Educ
ation
Occu
patio
n
Nutri
tion
Mean
ing o
f food
Com
mon
foods
Ritua
ls
Defic
ienci
es
Limit
ation
s
Heal
th pro
motio
n
Communication
Dominant languageDialectsContextual useVolume/toneSpatial distancingEye contactFacial expressionsGreetingsTemporalityTime
Names
Touch
PregnancyFertility practices
Views toward pregnancy
Pregnancy beliefsBirthingPostpartum
Fam
ily roles and
organization
Head of household
G
ender roles
G
oals & priorities
Developm
ental tasks
Roles of aged
Extended fam
ily
Social status
Alternative
lifestyles
Death rituals
Death rituals
Bereavem
ent
W
o
rk
fo
rc
e
is
s
u
e
s
A
ccu
ltu
ra
tio
n
A
u
to
n
o
m
y
L
a
n
g
u
a
g
e
b
a
rrie
rs
S
p
iritu
a
lity
R
e
lig
io
u
s
p
ra
ctice
s
U
se
o
f p
ra
ye
r
M
e
a
n
in
g
o
f life
In
d
ivid
u
a
l stre
n
g
th
S
p
iritu
a
lity &
h
e
a
lth
He
al
th
-c
ar
e
pr
ov
id
er
s
Pe
rc
ep
tio
ns
o
f p
ro
vid
er
s
Fo
lk
pr
ac
tit
io
ne
rs
G
en
de
r &
h
ea
lth
c
ar
e
Hi
gh
-ri
sk
be
ha
vi
or
s
To
ba
cc
o
Al
co
ho
l
Re
cr
ea
tio
na
l d
ru
gs
Ph
ys
ica
l a
ct
ivi
ty
Sa
fe
ty
H
e
a
lt
h
-c
a
re
p
ra
c
ti
c
e
s
F
o
cu
s
o
n
h
e
a
lth
c
a
re
T
ra
d
iti
o
n
a
l p
ra
ct
ic
e
s
M
a
g
ic
o
re
lig
io
u
s
re
lig
io
u
s
b
e
lie
fs

R
es
po
ns
ib
ilt
y
fo
r
he
al
th
T
ra
n
sp
la
n
ta
tio
n
R
e
h
a
b
lil
ita
tio
n
/
ch
ro
n
ic
ity
S
e
lf-
m
e
d
ic
a
tio
n
P
a
in
/s
ic
k
ro
le
M
en
ta
l h
ea
lth
B
a
rr
ie
rs
B
io
c
u
lt
u
ra
l
e
c
o
lo
g
y
B
io
lo
g
ic
a
l v
a
ri
a
tio
n
s
S
ki
n
c
o
lo
r
H
e
re
d
ity
G
e
n
e
tic
s
E
co
lo
g
y
D
ru
g
m
e
ta
b
o
lis
m
Variant cultural characteristics: age, generation, nationality, race, color, gender, religion, educational status,
socioeconomic status, occupation, military status, political beliefs, urban versus rural residence, enclave
identity, marital status, parental status, physical characteristics, sexual orientation, gender issues, and reason
for migration (sojourner, immigrant, undocumented status).
Unconsciously incompetent: not being aware that one is lacking knowledge about another culture
Consciously incompetent: being aware that one is lacking knowledge about another culture
Consciously competent: learning about the client’s culture, verifying generalizations about the client’s culture,
and providing culturally specific interventions
Unconsciously competent: automatically providing culturally congruent care to clients of diverse cultures
The Purnell Model for Cultural Competence
Figure 2-1 The Purnell Model
for Cultural Competence.
(Adapted with permission from Larry
Purnell, Newark, DE.)
2780_Ch02_015-044 16/07/12 11:37 AM Page 17

group. Health generally includes physical, mental, and
spiritual states because group members interact with
the family, community, and global society. The con-
cept of health, which permeates all metaparadigm
concepts of culture, is defined globally, nationally, re-
gionally, locally, and individually. Thus, people can
speak about their personal health status or the health
status of the nation or community. Health can also be
subjective or objective in nature.
◗ How do you define health? Is health the
absence of illness, disease, injury, and/or
disability? How does your profession define
health? How does your nation or community
define health? How do these definitions compare
with your original cultural heritage?
Micro Aspects of the Model
On a micro level, the model’s organizing framework
consists of 12 domains and their concepts, which are
common to all cultures. These 12 domains are inter-
connected and have implications for health. The utility
of this organizing framework comes from its concise
structure, which can be used in any setting and applied
to a broad range of empirical experiences and can fos-
ter inductive and deductive reasoning in the assess-
ment of cultural domains. Once cultural data are
analyzed, the practitioner can fully adopt, modify, or
reject health-care interventions and treatment regi-
mens in a manner that respects the patient’s cultural
differences. Such adaptations improve the quality
of the patient’s health-care experiences and personal
existence.
The Twelve Domains of Culture
These are the 12 domains that are essential for assess-
ing the ethnocultural attributes of an individual, fam-
ily, or group:
1. Overview, inhabited localities, and topography
2. Communication
3. Family roles and organization
4. Workforce issues
5. Biocultural ecology
6. High-risk behaviors
7. Nutrition
8. Pregnancy and childbearing practices
9. Death rituals
10. Spirituality
11. Health-care practices
12. Health-care providers
Overview, Inhabited Localities, and
Topography
This domain includes concepts related to the country of
origin, the current residence, and the effects of the to-
pography of both the country of origin and the current
residence on health, economics, politics, reasons for
migration, educational status, and occupations. Learn-
ing about a culture includes becoming familiar with the
heritage of its people and understanding how discrimi-
nation, prejudice, and oppression influence value sys-
tems and beliefs used in everyday life.
Heritage and Residence
Heritage and residence includes ancestry as the coun-
try of origin; where they were born, if different from
the country of origin; and other places they have lived.
For example, one’s ancestry might be German as the
country of origin but born in the United States and
lived or worked in Asia or Central American, where
that person might have been exposed to tropical dis-
eases unknown in the United States. Likewise, the to-
pography and physical environment of one’s residence
may increase one’s chances of being inflicted with an
can we leave in disease? There is a difference between
a disease and an illness and we have both here. illness
such as malaria from swampy areas, asthma from pol-
luted inner-city environments, or cancer if exposed to
radioactive fallout. Regardless of one’s environment
and lifestyle, one heritage may be an increased risk for
genetic and hereditary diseases that are common
among French Canadians, the Amish, and Ashkenazi
Jews (see specific chapters on these cultural groups).
One’s occupation can also have deleterious effects
on health if exposed to asbestos, working in farming
with pesticides, or in textile factories with increased
risk for respiratory, eye, and ear infections. A complete
health history may be required because people might
have worked in several occupations over a lifetime.
Reasons for Migration and Associated
Economic Factors
The social, economic, religious, and political forces of
the country of origin play an important role in the de-
velopment of the ideologies and the worldview of indi-
viduals, families, and groups and are often a major
motivating force for emigration. People emigrate for bet-
ter economic opportunities; because of religious and po-
litical oppression and ethnic cleansing; as a result of
environmental disasters, such as earthquakes and hur-
ricanes in their home countries; and by forced reloca-
tion, such as with slaves and indentured servants. Others
have emigrated for educational opportunities and per-
sonal ideologies or a combination of factors. Most peo-
ple emigrate in the hope of a better life, but the
individual or group personally defines this ideology.
A common practice for many immigrants is to re-
locate to an area that has an established population
with similar ideologies that can provide initial sup-
port, serve as cultural brokers, and orient them to
their new culture and health-care system. When im-
migrants settle and work exclusively in predominantly
ethnic communities, primary social support is
18 Foundations for Cultural Competence
2780_Ch02_015-044 16/07/12 11:37 AM Page 18

enhanced, but acculturation and assimilation into the
wider society may be hindered. Although ethnic en-
claves assist them with acculturation (to an extent),
they may need extra help in adjusting to their new
homeland’s language as well as securing access to
health-care services, living accommodations, and em-
ployment opportunities. Further, people who move
voluntarily are likely to experience less difficulty with
acculturation than people who are forced to emigrate.
Some individuals immigrate with the intention of re-
maining in this country only a short time, making
money, continuing their education, and returning
home, whereas others immigrate with the intention of
relocating permanently.
◗ What is your cultural heritage? How might you
find out more about it? How does your cultural
heritage influence your current beliefs and values
about health and wellness? What brought
you/your ancestors to your current country of
residence? Why did you/your ancestors
emigrate?
Educational Status and Occupations
The value placed on formal education differs among
cultural and ethnic groups and is often related to their
socioeconomic status in their homeland and their abil-
ities and reasons for emigrating. Some people place a
high value on formal education; however, some do not
stress formal education because it is not needed for
employment in their homeland. Consequently, they
may become engulfed in poverty, isolation, and en-
clave identity, which may further limit their potential
for formal educational opportunities and planning for
the future.
In regard to learning styles, the Western system
places a high value on the student’s ability to catego-
rize information using linear, sequential thought
processes. However, not everyone adheres to this pat-
tern of thinking. Others have spiral and circular
thought patterns that move from concept to concept
without being linear or sequential; therefore, they may
have difficulty placing information in a stepwise
methodology, which is common in individualistic cul-
tures. When someone is unaware of the value given to
such behaviors, the person may seem disorganized,
scattered, and faulty in their cognitive patterns, result-
ing in increased difficulty with written and verbal
communications.
Some educational systems stress application of con-
tent over theory. Most European educational programs
emphasize theory over practical application, and Arab
education emphasizes theory with little attention given
to practical application. As a result, Arab students are
more proficient at tests requiring rote learning than at
those requiring conceptualization and analysis. Being
familiar with the individual’s personal educational
values and learning modes allows health-care providers,
educators, and employers to adjust teaching strategies
for patients, students, and employees. Educational ma-
terials and explanations must be presented at a level
consistent with the patient’s educational capabilities
and within their cultural framework and beliefs (see
Chapter 3).
◗ How strongly do you believe in the value of
education? Who in your life is responsible for
instilling this value? Do you consider yourself
to be a more linear/sequential learner or a
random-patterned learner?
Immigrants bring job skills from their homelands
and traditionally seek employment in the same or sim-
ilar trades. Sometimes, these job skills are inadequate
for the available jobs in the new society; thus, immi-
grants are forced to take low-paying jobs and join the
ranks of the working poor and economically disadvan-
taged. Immigrants to America are employed in a broad
variety of occupations and professions; however, lim-
ited experiential, educational, and language abilities of
more recent immigrants often restrict employment
possibilities. More importantly, experiential back-
grounds sometimes encourage employment choices
that are identified as high risk for chronic diseases, such
as exposure to pesticides and chemicals. Others may
work in factories that manufacture hepatotoxic chem-
icals, in industries with pollutants that increase the risk
for pulmonary diseases, and in crowded conditions
with poor ventilation that increase the risk for tuber-
culosis or other respiratory diseases.
Understanding patients’ current and previous work
background is essential for health screening. For
example, newer immigrants who worked in malaria-
infested areas in their native country, such as Egypt,
Italy, Turkey, and Vietnam, may need health screening
for malaria. Those who worked in mining, such as in
Ireland and Poland, may need screening for respira-
tory diseases. Those who lived in overcrowded and un-
sanitary conditions, such as with refugees and migrant
workers, may need to be screened for such infectious
diseases as tuberculosis, parasitosis, and respiratory
diseases. Table 2-1 identifies guidelines for assessing
the cultural domain overview, inhabited localities, and
topography.
Communication
Perhaps no other domain has the complexities as that
of communication. Communication is interrelated with
all other domains and depends on verbal language
skills that include the dominant language, dialects, and
contextual use of the language, as well as paralanguage
variations such as voice volume, tone, intonations,
reflections, and willingness to share thoughts and feel-
ings. Other important communication characteristics
include nonverbal communications, such as eye
The Purnell Model for Cultural Competence 19
2780_Ch02_015-044 16/07/12 11:37 AM Page 19

contact, facial expressions, use of touch, body lan-
guage, spatial distancing practices, and acceptable
greetings; temporality in terms of past, present, or fu-
ture orientation of worldview; clock versus social time;
and the name format and the degree of formality in the
use of names. Communication styles may vary among
insiders (family and close friends) and outsiders
(strangers and unknown health-care providers). Hier-
archical relationships, gender, and some religious beliefs
affect communication.
Dominant Language and Dialects
The health-care provider must be aware of the domi-
nant language and the difficulties that dialects may
cause when communicating in the patient’s native lan-
guage. For example, English is a monochromic, low-
contextual language in which most of the message is
in the verbal mode, and verbal communication is fre-
quently seen as being more important than nonverbal
communication. Thus, people for whom English is the
dominant language are more likely to miss the more
subtle nuances of communication. Accordingly, if a
misunderstanding occurs, both the sender and the
receiver of the message take responsibility for the
miscommunication.
English differs somewhat in its pronunciation,
spelling, and choice of words from English spoken in
Great Britain, Australia, and other English-speaking
20 Foundations for Cultural Competence
❙❙◗ Table 2-1 Overview and Heritage
Suggested Question Sample Rationale/Example
1. Where do you currently live?
2. What is your ancestry?
3. Where were you born?
4. How many years have you lived in the
United States (or other country, as appropriate)?
5. Were your parents born in the United States
(or other country, as appropriate)?
6. What brought you (your parents/ancestors)
to the United States (or other country,
as appropriate)?
7. Describe the land or countryside where you
live. Is it mountainous, swampy, etc.?
8. Have you lived in other places in the
United States/world?
9. What is your income level?
10. Does your income allow you to afford the
essentials of life?
11. Do you have health insurance?
12. Are you able to afford health insurance
on your salary?
13. What is your educational level (formal/
informal/self-taught)?
14. What is your current occupation? If retired,
ask about previous occupations.
15. Are there (were there) any particular health
hazards associated with your job(s)?
16. Have you been in the military?
17. Are you married?
18. How many children do you have?
Someone living in a wooded area with deer is at an increased risk for
Lyme disease.
Ashkenazi Jewish population has a high incidence of genetic and
hereditary health conditions.
Immigrants from Eastern Europe near Chernobyl have an increased
risk for genetic mutations and hereditary defects related to radioactive
contamination.
Length of time away from the home country may determine the degree
of assimilation and acculturation.
Generation may determine the degree of assimilation and acculturation.
Refugees may have post-traumatic stress disorders related to their
stay in refugee camps and suffered from rape, torture, and a host of
infectious and communicable diseases such as tuberculosis.
People living in swampy areas are at increased incidence for malaria.
People immigrating from or who have recently visited parts of
Central American may be at increased for and need to be assessed
for arthropod-borne diseases.
Income level has implications for affording medications, dressings, and
prescriptive devices.
Determines the ability to afford healthy diets.
Refer to social services for financial support.
The working poor cannot afford health insurance.
Educational level may determine ability to understand health
prescriptions.
A person may currently be retired or may now work as a salesperson
but previously worked as a coal miner, increasing the risk of black lung
disease.
People working in home remodeling may be at risk for asbestosis.
People who served in the military may suffer from post-traumatic stress
syndrome or diseases contracted in their military experiences.
Part of a standard assessment.
Part of a standard assessment.
2780_Ch02_015-044 16/07/12 11:37 AM Page 20

countries. Within each country, several dialects can
exist, but generally the differences do not cause a major
concern with communications. However, accents
and dialects within a country, region, or local area can
cause misunderstanding; for example, the “Elizabethan
English” that is spoken in parts of the United States
and the English spoken in Glasgow, Scotland, are both
completely different from the English spoken in Central
London. The Spanish spoken in Spain differs from the
versions spoken in Puerto Rico, Panama, or Mexico,
which has as many as 50 different dialects. In such cases,
dialects that vary widely may pose substantial problems
for health-care providers and interpreters in obtaining
accurate health data, in turn increasing the difficulty of
making accurate diagnoses.
◗ What is your dominant language? Do you have
difficulty understanding other dialects of your
dominant language? Have you traveled abroad
where you had difficulty understanding the
dialect or accent? What other languages beside
your dominant language do you speak?
When speaking in a nonnative language, health-
care providers must select words that have relatively
pure meanings, be certain of the voice intonation, and
avoid the use of regional slang and jargon to avoid
being misunderstood. Minor variations in pronuncia-
tion may change the entire meaning of a word or a
phrase and result in inappropriate interventions.
Given the difficulty of obtaining the precise mean-
ing of words in a language, it is best for health-care
providers to obtain someone who can interpret the
meaning and message, not just translate the individual
words. Remember, translation refers to the written
word, and interpretation refers to the spoken word.
Children should never be used as interpreters for their
family members. Not only does it have a negative
bearing on family dynamics, but sensitive information
may not be transmitted. (See Chapter 3 for guidelines
for using interpreters.)
Those with limited language ability may have inade-
quate vocabulary skills to communicate in situations in
which strong or abstract levels of verbal skills are re-
quired, such as in the psychiatric setting. Helpful com-
munication techniques with diverse patients include
displaying tact, consideration, and respect; gaining trust
by listening attentively; addressing the patient by pre-
ferred name; and showing genuine warmth and open-
ness to facilitate full information sharing. When giving
directions, be explicit. Give directions in sequential pro-
cedural steps (e.g., first, second, third). Do not use com-
plex sentences with conjunctions or contractions.
◗ Give some examples of problems communicating
with patients who did not speak or understand
English. What did you do to promote effective
communication ?
Before trying to engage in more sensitive areas of
the health interview, the health-care provider may
need to start with social exchanges to establish trust
if time permits, use an open-ended format rather than
yes or no closed-response questions, elicit opinions
and beliefs about health and symptom management,
and focus on facts rather than feelings. An awareness
of nonverbal behaviors is essential to establishing a
mutually satisfying relationship.
The context within which a language is spoken is
an important aspect of communication. Some lan-
guages are low in context, and most of the message is
explicit, requiring many words to express a thought.
Other languages are highly contextual, with most of
the information either in the physical context or inter-
nalized, resulting in the use of fewer words with more
emphasis on unspoken understandings.
Voice volume and tone are important paralanguage
aspects of communication. A loud voice volume may
be interpreted as reflecting anger, when in fact a loud
voice is merely being used to express their thoughts in
a dynamic manner. Thus, health-care providers must
be cautious about voice volume and tones when inter-
acting with diverse cultural groups so that their inten-
tions are not misunderstood.
◗ On a scale of 1 to 10, with 1 being low and
10 being high, where do you place yourself in the
scale of high-contextual versus low-contextual
communication? Do you tend to use a lot of
words to express a thought? Do you know family
members/friends/acquaintances who are your
opposite in terms of low-contextual versus high-
contextual communication? Does this sometimes
cause concerns in communication? Do you think
biomedical language is high or low context?
Cultural Communication Patterns
Communication includes the willingness of individ-
uals to share their thoughts and feelings. Some cul-
tures encourage people to disclose very personal
information about themselves, such as information
about sex, drugs, and family problems. In some cul-
tures, having well-developed verbal skills is seen as
important, whereas in other cultures, the person
who has very highly developed verbal skills is seen
as having suspicious intentions. Some cultures will-
ingly share their thoughts and feelings among family
members and close friends, but they may not easily
share thoughts, feelings, and health information
with “outsiders” (i.e., health-care providers) until
they get to know them. By engaging in small talk
and inquiring about family members before address-
ing the patient’s health concerns, health-care
providers can help establish trust and, in turn, en-
courage more open communication and sharing of
important health information.
The Purnell Model for Cultural Competence 21
2780_Ch02_015-044 16/07/12 11:37 AM Page 21

◗ How willing are you to share personal
information about yourself ? How does it differ
with family, friends, or strangers? Do you tend to
speak faster, slower, or about the same rate as
the people around you? What happens when you
meet someone who speaks much more rapidly or
much more slowly than you do? Do you normally
speak in a loud or low voice volume? How do you
respond when someone speaks louder or softer
than you do?
Touch, a method of nonverbal communication, has
substantial variations in meaning among cultures. For
the most part, individualistic cultures are low-touch
cultures, which have recently been reinforced by sexual
harassment guidelines and policies. For many, even ca-
sual touching may be seen as a sexual overture and
should be avoided whenever possible. People of the
same sex (especially men) or opposite sex do not gen-
erally touch each other unless they are close friends.
It is recognized that the low-touch individualistic cul-
ture has variations within the United States according
to age and location. However, among most collectivist
cultures, two people of the same gender can touch
each other without it having a sexual connotation, al-
though modesty remains important. Always explain
the necessity and ask permission before touching a
patient for a health examination. Being aware of
individual practices regarding touch is essential for
effective health assessments.
Personal space needs to be respected when working
with multicultural patients and staff. Among more in-
dividualistic cultures, conversants tend to place at least
18 inches of space between themselves and the person
with whom they are talking. Most collectivist cultures
require less personal space when talking with each
other (Hall, 1990). They are quite comfortable standing
closer to each other than are people from individualistic
cultures; in fact, they interpret physical proximity as a
valued sign of emotional closeness. Patients who stand
very close and stare during a conversation may offend
some health-care practitioners. These patients may in-
terpret health-care providers as being cold because they
stand so far away, perhaps appearing as being stand –
offish. Thus, an understanding of personal space and
distancing characteristics can enhance the quality of
communication among individuals.
◗ How comfortable are you with being touched
on the arm or shoulder by friends? By people
who know you well? Do you consider yourself to
be a “person who touches frequently” or do you
rarely touch friends? Can you think of groups in
the clinical setting for whom therapeutic touch is
not appropriate?
Regardless of the class or social standing of the
conversants, people from individualistic cultures are
expected to maintain direct eye contact without star-
ing. A person who does not maintain eye contact may
be perceived as not listening, not being trustworthy,
not caring, or being less than truthful. Among some
traditional collectivist cultures, sustained eye contact
can be seen as offensive; further, a person of lower
social class or status is expected to avoid eye contact
with superiors or those with a higher educational sta-
tus. Thus, eye contact must be interpreted within its
cultural context to optimize relationships and health
assessments.
The use of gestures and facial expressions varies
among cultures. Most Americans gesture moderately
when conversing and smile easily as a sign of pleasant-
ness or happiness, although one can smile as a sign of
sarcasm. A lack of gesturing can mean that the person
is too stiff, too formal, or too polite.
◗ What are your spatial distancing practices? How
close do you stand to family? Friends? Strangers?
Does this distancing remain the same with the
opposite gender? Do you maintain eye contact
when speaking with people? Is it intense? Does it
vary with the age or gender of the person with
whom you are conversing? What does it mean
when someone does not maintain eye contact
with you? How do you feel in this situation?
Preferred greetings and acceptable body language
also vary among cultural groups. An expected practice
for many cultures in business is to extend the right hand
when greeting someone for the first time. More
elaborate greeting rituals occur in Asian, Arab, and
Latin American countries and are covered in individual
chapters.
Although many people consider it impolite or
offensive to point with one’s finger, many do so and
do not see it as impolite. In other cultures, beckoning
is done by waving the fingers with the palm down,
whereas extending the thumb, like thumbs-up, is con-
sidered a vulgar sign. Among some cultures, signaling
for someone to come by using an upturned finger is a
provocation, usually done to a dog. Among the
Navajo, it is considered rude to point; rather, the
Navajo shift their lips toward the desired direction.
◗ Do you tend to use your hands a lot when
speaking? Can people tell your emotional state
by your facial expressions?
Temporal Relationships
Temporal relationships—people’s worldview in terms
of past, present, and future orientation—vary
among individuals and among cultural groups. Some
cultures, usually highly individualistic ones, are fu-
ture-oriented, and people are encouraged to sacrifice
for today and work to save and invest in the future.
The future is important in that people can influence
22 Foundations for Cultural Competence
2780_Ch02_015-044 16/07/12 11:37 AM Page 22

it. Fatalism, the belief that powers greater than
humans are in control, may be seen as negative; how-
ever, to many others, it is seen as a fact of life not to
be judged. Other cultures are regarded as a past-
oriented society, in which laying a proper foundation
by providing historical background information can
enhance communication. However, for people in
many societies, temporality is balanced among past,
present, and future in the sense of respecting the
past, valuing and enjoying the present, and saving for
the future.
Differences in temporal orientation can cause con-
cern or misunderstanding among health-care providers.
For example, in a future-oriented culture, a person is
expected to delay purchase of nonessential items to
afford prescription medications. However, in less future-
oriented cultures, the person buys the nonessential item
because it is readily available and defers purchasing the
prescription medication. The attitude is, why not
purchase it now; the prescription medication can be
purchased later.
Most people from individualistic cultures see time
as a highly valued resource and do not like to be de-
layed because it “wastes time.” When visiting friends
or meeting for strictly social engagements, punctuality
is less important, but one is still expected to appear
within a “reasonable” time frame. In the health-care
setting, if an appointment is made for 9 a.m., the per-
son is expected to be there at 8:45 a.m. so she or he is
ready for the appointment and does not delay the
health-care provider. For immigrants from rural set-
tings, time may be even less important. These individ-
uals may not even own a timepiece or be able to tell
time. Expectations for punctuality can cause conflicts
between health-care providers and patients, even if
one is cognizant of these differences. These details
must be carefully explained to individuals when such
situations occur. Being late for appointments should
not be misconstrued as a sign of irresponsibility or
not valuing one’s health.
◗ How timely are you with professional
appointments? With social engagements? What
does it mean to you when people are chronically
late? Can you give examples indicating that you
are past oriented? Present oriented? Future
oriented? Do you consider yourself more one
than the other?
Format for Names
Names are important to people, and name formats
differ among cultures. The most common Western sys-
tem is to have a first or given name, a middle name,
and then the family surname. The person would
usually write the name in that order. In formal situa-
tions, the person would be addressed with a title of
Mr., Mrs., Ms., or Miss and the last name. Friends
and acquaintances would call the person by the first
name or perhaps a nickname. Married women may
take their husband’s last name, keep their maiden
name, or use both their maiden and married names.
However, in some cultures, the family or surname
name comes first, followed by the given name and then
the middle name. The person would usually write and
introduce himself or herself in that order. Married
women usually keep their maiden name. Other name
formats are even more complex and may include a
given name, a middle name, the father’s family name,
and the mother’s maiden name. When a woman
marries, she may keep all these names plus add the
surname of her husband. She may choose any name
she wants for legal purposes. When in doubt, the
health-care provider needs to ask which name is
used for legal purposes. Such extensive naming for-
mats can create a challenge for health-care workers
keeping a medical record when they are unaware of
differences in ethnic recording of names. See indi-
vidual chapters for name formats. Table 2-2 identi-
fies guidelines for assessing the cultural domain
communication.
◗ How do you prefer to be addressed or greeted?
Does this change with the situation? How do you
normally address and greet people? Do your
responses change with the situation?
Family Roles and Organization
The cultural domain of family roles and organization
affects all other domains and defines relationships
among insiders and outsiders. This domain includes
concepts related to the head of the household, gender
roles, family goals and priorities, developmental tasks
of children and adolescents, roles of the aged and ex-
tended family members, individual and family social
status in the community, and acceptance of alternative
lifestyles, such as single parenting, nontraditional sex-
ual orientations, childless marriages, and divorce.
Family structure in the context of the larger society
determines acceptable roles, priorities, and the behav-
ioral norms for its members.
Head of Household and Gender Roles
An awareness of family decision-making patterns (i.e.,
patriarchal, matriarchal, or egalitarian) is important
for determining with whom to speak when health-care
decisions have to be made. Among many cultures, it
is acceptable for women to have a career and for men
to assist with child care, household domestic chores,
and cooking responsibilities. Both parents work in
many families, necessitating placing children in child-
care facilities. In some families, fathers are responsible
for deciding when to seek health care for family mem-
bers, but mothers may have significant influence on
final decisions.
The Purnell Model for Cultural Competence 23
2780_Ch02_015-044 16/07/12 11:37 AM Page 23

Among many, the decisions may be egalitarian, but
the male’s role in the family is to be the spokesperson
for the family. The health-care provider, when speak-
ing with parents, should maintain eye contact and di-
rect questions about a child’s illness to both parents.
◗ How would you classify the decision-making
process in your family—patriarchal, matriarchal,
or egalitarian? Does it vary by what decision has
to be made? Are gender roles prescribed in your
family? Who makes the decisions about health
and health care?
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Every society has prescriptive, restrictive, and taboo
practices for children and adolescents. Prescriptive be-
liefs are things that children or teenagers should do to
have harmony with the family and a good outcome in
society. Restrictive practices are things that children and
teenagers should not do to have a positive outcome.
Taboo practices are those things that, if done, are likely
to cause significant concern or negative outcomes for
the child, teenager, family, or community at large.
For some Western cultures, a child’s individual
achievement is valued over the family’s financial sta-
tus. This is different from some non-Western cultures
in which attachment to family may be more important
than the need for children to excel individually. At
younger ages, rather than having group toys, each
child has his or her own toys and is taught to share
them with others. Individualistic cultures encourage
autonomy in children, and after completing home-
work assignments (with which parents are expected to
help), children are expected to contribute to the family
by doing chores, such as taking out the garbage, wash-
ing dishes, cleaning their own room, feeding and car-
ing for pets, and helping with cooking. They are not
expected to help with heavy labor at home, except in
rural farm communities.
24 Foundations for Cultural Competence
❙❙◗ Table 2-2 Communication
Suggested Question Sample Rationale/Example
1. What is your full name?
2. What is your legal name?
3. By what name do you wish to be called?
4. What is your primary language?
5. Do you speak a specific dialect?
6. What other languages do you speak?
7. Do you find it difficult to share your thoughts,
feelings, and ideas with family? Friends?
Health-care providers?
8. Do you mind being touched by friends?
Strangers? Health-care workers?
9. How do wish to be greeted? Handshake?
Nod of the head, etc.?
10. Are you usually on time for appointments?
11. Are you usually on time for social engagements?
12. Observe the patient’s speech pattern. Is the
speech pattern high- or low-context?
13. Observe the patient when physical contact
is made. Does he/she withdraw from the touch
or become tense?
14. How close does the patient stand when talking
with family members? With health-care providers?
15. Does the patient maintain eye contact when
talking with the health-care provider?
Part of a standard assessment. Hispanics/Latinos have an extended
name format that includes a first name, middle name, father’s last name,
and mother’s last name, with an additional last name of the husband if a
woman is married.
Complex naming can make it difficult for medical record keeping.
Explain that the legal name is needed for accurate medical records.
Helps establish trust and increases comfort level of the patient.
Determining the preferred language for consent forms and discharge
instructions.
A dialect-specific interpreter is preferred.
Sometimes a second or third language may be helpful for interpretation
if the preferred language interpreter is not available.
Additional time may be needed to establish trust and get full disclosure,
especially with sensitive topics.
Asking permission and explaining the rationale before touching
reinforces the trust relationship.
Demonstrates respect and helps establish trust.
Explain rationale for the expectation of timeliness: will not be seen and
have to reschedule and may still be charged for the appointment.
Ask only if question is pertinent.
Patients from high-context cultures place greater value on silence and
implicit communication and may take more time to give a response.
Being aware of the patient’s level of comfort helps establish trust.
Reinforce the necessity and ask permission before touching.
Spatial distancing is culture bound. Do not take offense if a patient
stands closer or farther away than what you are accustomed to.
Some avoid eye contact with people in hierarchal positions as a sign of
respect. The health-care provider is in a hierarchal position.
2780_Ch02_015-044 16/07/12 11:37 AM Page 24

In Western cultures, children are allowed and en-
couraged to make their own choices, including man-
aging their own allowance money and deciding who
their friends might be—although parents may gently
suggest one friend as a better choice than another.
Children and teenagers are permitted and encouraged
to have friends of both the same and opposite genders.
They are expected to be well behaved, especially in
public. They are taught to stand in line—first come,
first served—and to wait their turn. As they reach the
teenage years, they are expected to refrain from pre-
marital sex, smoking, using recreational drugs, and
drinking alcohol until they leave the home. However,
this does not always occur, and teenage pregnancy and
the use of recreational alcohol and drugs remain high.
When children become teenagers, most are expected
to get a job, such as babysitting, delivering newspa-
pers, or doing yard work to make their own spending
money, which they manage as a way of learning inde-
pendence. The teenage years are also seen as a time of
natural rebellion
In Western cultures, when young adults become 18
or complete their education, they usually move out of
their parents’ home (unless they are in college) and live
independently or share living arrangements with non-
family members. If the young adult chooses to remain
in the parents’ home, then she or he might be expected
to pay rent. However, young adults are generally al-
lowed to return home, as needed, for financial or other
purposes. Individuals over the age of 18 are expected
to be self-reliant and independent, which are virtues
in the Western cultures.
This differs from most collectivist cultures in which
children are expected to live at home with their
parents until they marry because dependence, not
independence, is the virtue.
Adolescents have their own subculture, with its own
values, beliefs, and practices that may not be in har-
mony with those of their dominant culture. Being in
harmony with peers and conforming to the prevalent
choice of music, clothing, hairstyles, and adornment
may be especially important to adolescents. Thus, role
conflicts can become considerable sources of family
strain in many more traditional families who may not
agree with the values of individuality, independence,
self-assertion, and egalitarian relationships. Many
teens may experience a cultural dilemma with expo-
sure outside the home and family
◗ Were you taught to be independent and
autonomous or dependent in your family?
Was there more emphasis on the individual
or on the group?
Family Goals and Priorities
In most cultures, family goals and priorities are cen-
tered on raising and educating children. During this
stage, young adults make a personal commitment to
a spouse or significant other and seek satisfaction
through productivity in career, family, and civic inter-
ests. In most societies, young adulthood is the time
when individuals work on Erikson’s developmental
tasks of intimacy versus isolation and generativity
versus stagnation.
Western cultures place a high value on children,
and many laws have been enacted to protect children
who are seen as the “future of the society.” In most
collectivist cultures, children are desirable and highly
valued as a source of family strength, and family
members are expected to care for one another more
so than in Western cultures.
Collectivistic cultures have great reverence for the
wisdom of older people, and families eagerly make
space for them to live with extended families. Children
are expected to care for elders when they are unable
to care for themselves. A great embarrassment may
occur to family members when they cannot take care
of their older family members.
The concept of extended family membership varies
among societies. The extended family is extremely im-
portant, especially in collectivist cultures, and health-
care decisions are often postponed until the entire
family is consulted. The extended family may include
biological relatives and nonbiological members who
are considered brothers, sisters, aunts, or uncles. In
some cultures, the influence of grandparents in deci-
sion making is considered more important than that
of the parents.
Individualistic cultures also place a high value on
egalitarianism, nonhierarchical relationships, and
equal treatment regardless of their race, color, religion,
ethnicity, educational or economic status, sexual ori-
entation, or country of origin. However, these beliefs
are theoretical and not always seen in practice. For
example, throughout the world, women usually have
a lower status than men, especially when it comes to
prestigious positions and salaries. Most top-level
politicians and corporate executive officers are white
men. Subtle classism does exist, as evidenced by
comments referring to “working-class men and
women.” Many Western cultures are known for their
informality and for treating everyone the same. They
call people by their first names very soon after meeting
them, whether in the workplace, in social situations,
in classrooms, in restaurants, or in places of business.
Some readily talk with waitstaff and store clerks and
call them by their first names, considering this respect-
ful behavior. Formality can be communicated by using
the person’s last (family) name and title such as
Mr., Mrs., Miss, Ms., or Dr. To this end, achieved sta-
tus is more important than ascribed status. What one
has accumulated in material possessions, where one
went to school, and one’s job position and title are
more important than one’s family background and
The Purnell Model for Cultural Competence 25
2780_Ch02_015-044 16/07/12 11:37 AM Page 25

◗ How important are technical skills and verbal
skills in your work environment? Does your
organization encourage more formal or more
informal communication? Why? Do you believe
that everything needs to be proven scientifically?
Do you value a more direct or indirect style of
communication?
lineage. However, in some families ascribed status has
equal importance to achieved status. Without a caste
or class system, theoretically one can move readily
from one socioeconomic position to another. To some,
if formality is maintained, it may be seen as pompous
or arrogant, and some even deride the person who is
very formal. However, formality is a sign of respect in
many other cultures.
◗ What were prescriptive behaviors for you as a
child? As a teenager? As a young adult? What
were restrictive behaviors for you as a child? As
a teenager? As a young adult? What were taboo
behaviors for you as a child? As a teenager? As a
young adult? How are elders regarded in your
culture? In your family?
Alternative Lifestyles
The traditional family is nuclear, with a married man
and woman living together with one or more unmarried
children. This concept of family is becoming a more var-
ied community, including unmarried people, both
women and men, living alone; single people of the same
or different genders living together with or without chil-
dren; single parents with children; and blended families
consisting of two parents who have remarried, with
children from their previous marriages and additional
children from their current marriage.
However, in some cultures, the traditional family is
extended, with parents, unmarried children, married
children with their children, and grandparents all
sharing the same living space or at least living in very
close proximity.
The newest category of family, domestic partner-
ships, is sanctioned by many states in the United States
and grants some of the rights of traditional married
couples to unmarried heterosexual, homosexual, older
people, and disabled couples who share the traditional
bond of the family. Some states in the United States,
as well as some countries, allow gay and lesbian
couples to marry and adopt children.
Social attitudes toward homosexual activity vary
widely, and homosexual behavior occurs in societies
that deny its presence. Homosexual behavior carries a
severe stigma in some societies. Discovering that one’s
son or daughter is homosexual is akin to a cata-
strophic event for some, whether it is a collectivistic or
individualistic culture.
◗ Do you consider your family nuclear or
extended? How close are you to your extended
family? How is status measured in your family?
By money or by some other attribute? What are
your personal views of two people of the same
gender living together in a physical relationship?
What about heterosexual couples? Does divorce
cause a stigma in your culture? In your family?
When the health-care provider needs to provide as-
sistance and make a referral for a person who is
gay, lesbian, bisexual, or transsexual, a number of
options are available. Some referral agencies are local,
whereas others are national, with local or regional
chapters. Many are ethnically or religiously specific.
See DavisPlus for the links to the local and regional
offices of some national organizations. Table 2-3
identifies guidelines for assessing the cultural domain
family roles and organization.
Workforce Issues
Culture in the Workplace
A fourth domain of culture is workforce issues. Differ-
ences and conflicts that exist in a homogeneous culture
may be intensified in a multicultural workforce. Factors
that affect these issues include language barriers, degree
of assimilation and acculturation, and issues related to
autonomy. Moreover, such concepts as gender roles,
cultural communication styles, health-care practices of
the country of origin, and selected concepts from all
other domains affect workforce issues in a multicultural
work environment.
Timeliness and punctuality are two culturally based
attitudes that can create serious problems in the multi-
cultural workforce. In most Western cultures, people
are expected to be punctual on their job, with formal
meetings, and with appointments. With social engage-
ments, punctuality is not as important. However, in
many cultures, punctuality is not stressed unless one is
meeting with officials or it is required for transportation
schedules, such as for trains or air travel. Timeliness
for social engagements may not be taken seriously and
may simply begin when most of the people arrive. The
lack of adherence to meeting time demands in other
countries is often in direct opposition to the Western
concept and the ethic for punctuality.
◗ How timely are you in reporting to work?
Do you see people in the workforce who do not
report to work on time? What problems does it
cause if they are not on time? What would you
do as a supervisor to encourage people to report
to work on time?
Clinical professionals trained in their home coun-
tries now occupy a significant share of technical
and laboratory positions in health-care facilities
in many counties throughout the world. Service
26 Foundations for Cultural Competence
2780_Ch02_015-044 16/07/12 11:37 AM Page 26

employees, such as food preparation workers, nurse
aides, orderlies, housekeepers, and janitors, repre-
sent the most culturally diverse component of hos-
pital workforces. These unskilled and semiskilled
positions are among the most attainable for new
immigrants.
◗ Does your workforce (class) reflect the ethnic
and racial diversity of the community? Why?
Why not? What might you do to increase this
diversity?
Issues Related to Autonomy
Cultural differences related to assertiveness in –
fluence how health-care providers view one another.
In most Western individualistic cultures, profes –
sionals are expected to be assertive with other
professionals for the benefit of the patient. How-
ever, in some collectivist and patriarchal societies,
women, for example, may be unprepared for the
level of sophistication and autonomy expected in
individualistic cultures. Educational training for
The Purnell Model for Cultural Competence 27
❙❙◗ Table 2-3 Family Roles and Organization
Suggested Question Sample Rationale/Example
1. Who makes most of the decisions in your family?
2. What types of decisions do(es) the female(s) in
your family make?
3. What types of decisions do(es) the male(s)
in your family make?
4. What are the duties of the women in the family?
5. What are the duties of the men in the family?
6. What should children do to make a good
impression for themselves and for the family?
7. What should children not do to make a good
impression for themselves and for the family?
8. What are children forbidden to do?
9. What should young adults do to make a
good impression for themselves and for the family?
10. What should young adults not do to make a
good impression for themselves and for the family?
11. What are adolescents forbidden to do?
12. What are the priorities for your family?
13. What are the roles of older adults in your
family? Are they sought for their advice?
14. Are there extended family members in your
household? Who else lives in your household?
15. What are the roles of extended family
members in this household?
16. What gives you and your family status?
17. Is it acceptable to you for people to have
children out of wedlock?
18. Is it acceptable to you for people to live
together and not be married?
19. Are you accepting of gay, lesbian, or
transgendered people?
20. What is your sexual preference/orientation?
If the decision maker is not accessed, no decision will be made and time
will be wasted.
In many traditional families, the female usually makes decision about the
household and child care.
In many traditional families, the male usually makes decisions about af-
fairs outside the household, but not always.
Determining the division of labor can become important when
illness occurs.
Determining the division of labor can become important when
illness occurs.
A child’s behavior in the Appalachian and Greek cultures can bring
shame upon the family.
Among traditional Koreans, children are expected to do well in school,
or shame may come to the family.
Among traditional Germans, taboo behaviors include talking back to
elders and touching another person’s possessions.
Among Somalis, young adults are expected to marry and assist older
family members.
Among traditional Mexican families, young adults should not dress
in a provocative manner ; otherwise, shame can come to them or
their family.
A taboo behavior for young female adults in Haiti is engaging in sexual
activity before marriage.
For lower socioeconomic families, the priority may be having adequate
food and shelter, with stress on the present.
Among traditional Turks, no decision is made until after seeking the ad-
vice of older adults.
Most traditional Asian cultures live in extended family arrangements in
their home country.
Extended family members provide significant financial and social support
and are important sources for child care.
Status for some is having material necessities.
Among traditional Arab families, shame may occur if a pregnancy occurs
outside of marriage.
Among many Asian cultures, a man and woman living together without
being married may cause them to be rejected by their family.
Not all cultures and individuals are accepting of gay, lesbian, or gender
reassignment populations.
Lesbians have more risk factors for breast cancer than heterosexual
women.
2780_Ch02_015-044 16/07/12 11:37 AM Page 27

health-care providers varies significantly through-
out the world.
Language ability in a new country may not meet
the standards expected in the workforce, especially in
the health-care environment and in positions where
highly developed verbal skills are required. Thus, the
newer immigrant—for whom the language of the host
country is new—may need extra time in translating
messages and formulating replies.
When individuals speak in their native language at
work, it may become a source of contention for both
patients and health-care providers. Most employees
do not want to exclude or offend others, but it is easier
to speak in their native language to articulate ideas,
feelings, and humor among themselves. Negative in-
terpretations of behaviors can be detrimental to work-
ing relationships in the health-care environment.
Some foreign graduates, with limited aural language
abilities, may need to have care instructions written or
procedures demonstrated.
◗ Does your profession encourage autonomy in
the workforce? Does your current work (class)
encourage autonomy and independence? Do
you see any cultural or gender differences in
autonomy? Do people speak different languages
at work? What difficulty does this cause?
Generational Differences in the Workforce
Not only is the workforce becoming more multicul-
tural in most countries, but over the last decade, in-
creased interest has been found in the professional
literature regarding generational differences in the
workforce. Most of the literature on generational dif-
ferences describes the dominant culture of the United
States, with little mention as to how these differences
might coincide with the multiethnic workforce. How-
ever, these descriptions do not always “fit” the gener-
alizations as well as they do for the dominant,
nonethnic, nonimmigrant populations. Table 2-4 iden-
tifies guidelines for assessing the cultural domain
workforce issues.
◗ How many generations are in your work group
(class)? Are their beliefs and practices similar
to or different from what is reported in the
literature? Do the generational differences cause
conflict? Which generation takes the lead in
resolving conflicts when they arise?
Biocultural Ecology
The domain biocultural ecology identifies specific
physical, biological, and physiological variations in
ethnic and racial origins. These variations include skin
color and physical differences in body habitus; genetic,
hereditary, endemic, and topographic diseases; psy-
chological makeup of individuals; and differences in
the way drugs are metabolized by the body. No at-
tempt is made here to explain or justify any of the nu-
merous, conflicting, and highly controversial views
and research about racial variations in drug metabo-
lism and genetics.
Skin Color and Other Biological Variations
Skin coloration is an important consideration for
health-care providers because anemia, jaundice, and
rashes require different assessment skills in dark-
skinned people than in light-skinned people. To assess
for oxygenation and cyanosis in dark-skinned people,
the practitioner must examine the sclera, buccal mu-
cosa, tongue, lips, nail beds, palms of the hands, and
soles of the feet rather than relying on skin tone alone.
Jaundice is more easily determined in Asians by assess-
ing the sclera rather than relying on the overall change
in skin color. Health-care providers must establish a
baseline skin color (by asking a family member or
someone known to the individual), use direct sunlight
(if possible), observe areas with the least amount of
pigmentation, palpate for rashes, and compare skin in
corresponding areas. With people who are generally
fair-skinned, prolonged exposure to the sun places
them at an increased risk for skin cancer.
◗ Do you have difficulty assessing rashes,
bruises, and sunburn in people with a skin
color different from yours? Do you have
difficulty assessing jaundice and oxygenation
in people with a skin color different from yours?
How does your assessment of skin differ
between patients with light versus dark skin? Do
you take precautions and protect yourself
against the sun? Why? Why not?
Variations in body habits occur among ethnic and
racially diverse individuals in terms of bone density,
length of long bones, and shoulder and hip width, but
do not usually cause a concern for health-care providers.
However, bone density is greater in whites than in Asian
and Pacific Islanders; osteoporosis is lowest in black
males and highest in white females. Given diverse gene
pools, this type of information is often difficult to ob-
tain, and much of the research is inconclusive.
Diseases and Health Conditions
Some diseases are more prevalent and endemic in
certain racial or ethnic groups, especially with mi-
gration. Specific health problems are covered in
individual chapters in this book and in the Appendix.
In general, many adverse health conditions are a
result of genetics, lifestyle, and the environment.
Genetic conditions occur among families in all
races, but some conditions, such as Tay-Sachs dis-
ease, hemophilia, and cystic fibrosis, are more com-
mon among particular ethnic and racial groups.
28 Foundations for Cultural Competence
2780_Ch02_015-044 16/07/12 11:37 AM Page 28

◗ What are the most common illnesses and
diseases in your family? In your community?
What might you do to decrease the incidence of
illness and diseases in your family? In your
community?
Lifestyle causes include cultural practices and be-
haviors that can generally be controlled—for exam-
ple, smoking, diet, and stress. Environmental causes
refer to factors (e.g., air and water pollution) and
situations over which the individual has little or no
control (e.g., presence of malarial or dengue mos-
quitoes, exposure to chemical and pesticides, access
to care, and associated diseases).
◗ Are you aware of any outbreaks of new
illnesses or diseases in your community? In other
parts of the world? How might these outbreaks
have been prevented?
Variations in Drug Metabolism
Information regarding drug metabolism among racial
and ethnic groups has important implications for
health-care providers when prescribing medications.
Besides the effects of (1) smoking, which accelerates
drug metabolism; (2) malnutrition, which affects drug
response; (3) a high-fat diet, which increases absorp-
tion of antifungal medication, whereas a low-fat diet
renders the drug less effective; (4) cultural attitudes
and beliefs about taking medication; and (5) stress,
which affects catecholamine and cortisol levels on
drug metabolism, studies have identified some specific
alterations in drug metabolism among diverse racial
and ethnic groups. Information for specific groups is
included in each chapter. Health-care providers need
to investigate the literature for ethnic-specific studies
regarding variations in drug metabolism, communi-
cate these findings to other colleagues, and educate
their patients regarding these side effects. Medication
administration is one area in which health-care
providers see the importance of culture, ethnicity, and
race. Table 2-5 identifies guidelines for assessing the
cultural domain biocultural ecology.
◗ Why is it important for health-care providers
to be aware of variations in drug metabolism in
the body? What conditions besides genetics have
an influence on drug metabolism?
High-Risk Behaviors
High-risk behaviors include use of tobacco, alcohol,
or recreational drugs; lack of physical activity; in-
creased calorie consumption; unsafe driving practices;
failure to use seat belts and helmets; failure to take
precautions against human immunodeficiency virus
(HIV) and sexually transmitted infections (STIs); and
high-risk recreational activities. High-risk behaviors
occur in all ethnocultural groups, with the degree and
types of high-risk behaviors varying.
Alcohol consumption crosses all cultural and so-
cioeconomic groups. Enormous differences exist
among ethnic and cultural groups around the use of
and response to alcohol. Even in cultures in which
alcohol consumption is taboo, it is not ignored. How-
ever, alcohol problems are not simply a result of how
much people drink. When drinking is culturally ap-
proved, it is typically done more by men than women
and is more often a social, rather than a solitary, act.
The group in which drinking is most frequently prac-
ticed is usually composed of same-age social peers
The Purnell Model for Cultural Competence 29
❙❙◗ Table 2-4 Workforce Issues
Suggested Question Sample Rationale/Example
1. Do you usually report to work on time?
2. Do you usually report to meetings on time?
3. What concerns do you have about working
with someone of the opposite gender?
4. Do you consider yourself a “loyal” employee?
5. What do you do when you do not know how
to do something related to your job?
6. Do you consider yourself to be assertive
in your job?
7. What difficulty does English (or another
language) give you in the workforce?
Not all cultures espouse timeliness in reporting to work. If timeliness is
important, this must be explicitly explained along with consequences.
If timeliness is important for attendance at meetings, this must be
explicitly explained.
Strict orthodox separation of the sexes may cause disharmony if men
and women are expected to work in close proximity.
Among the Japanese, an employer may expect absolute loyalty, and
employees remain with the same company their entire lives.
Among many traditional Koreans, when an employee does not
know how to do something, rather than admitting it, they may go
to a co-worker of the same nationality (if available).
Traditional Asians are sometimes not seen as assertive as some
American employers would like. Most professionals are assertive, but
in a different way from assertiveness in individualistic cultures.
Low verbal and written literacy may have implications for accuracy in
fulfilling job requirements.
2780_Ch02_015-044 16/07/12 11:37 AM Page 29

(Peele & Brodsky, 2001). Studies on increasing controls
on the availability of alcohol to decrease alcohol con-
sumption, with the premise that alcohol-related prob-
lems occur in proportion to per capita consumption,
have not been supported. Furthermore, countries with
temperance movements have greater alcohol-related be-
havior problems than do countries without temperance
movements (Purnell & Foster, 2003a; 2003b).
Countries in which drinking alcoholic beverages is
integrated into rites and social customs, and in which
one is expected to have self-control and sociability,
have lower rates of alcohol-related problems than
those of countries and cultures in which ambivalent
attitudes toward drinking prevail (Purnell & Foster,
2003a; 2003b). Hilton’s (1987) study demonstrated a
clear and distinct difference in the alcohol abuse rate
by socioeconomic status. The conclusion of many
studies suggests that alcohol-related violence is a
learned behavior, not an inevitable result of alcohol
consumption (Purnell & Foster, 2003a; 2003b).
Health-Care Practices
Obesity and being overweight are a result of an imbal-
ance between food consumed and physical activity.
National data have shown an increase in the calorie
consumption of adults and no change in physical activ-
ity patterns. However, obesity is a complex issue related
to lifestyle, environment, and genes. Many underlying
factors have been linked to the increase in obesity, such
as increased portion sizes; eating out more often;
increased consumption of sugar-sweetened drinks;
increased television, computer, electronic gaming time;
changing labor markets; and fear of crime, which
prevents outdoor exercise.
The practice of self-care by using folk and magico-
religious practices before seeking professional care
may also have a negative impact on the health status
of some individuals. Overreliance on these practices
may mean that the health problem is in a more
advanced stage when a consultation is sought. Such
delays make treatment more difficult and prolonged.
Selected complementary and alternative health-care
practices are addressed in this chapter under the
domain healthcare practices and in each culture-
specific chapter.
The cultural domain of high-risk behaviors is one
area in which health-care providers can make a sig-
nificant impact on patients’ health status. High-risk
health behaviors can be controlled through ethnic-
specific interventions aimed at health promotion and
health-risk prevention. This can be accomplished
through educational programs in schools, business
organizations, churches, and recreational and com-
munity centers, as well as through one-on-one and
family counseling techniques. Taking advantage of
public communication technology can enhance par-
ticipation in these programs if they are geared to the
unique needs of the individual, family, or commu-
nity. Table 2-6 identifies guidelines for assessing the
cultural domain high-risk behaviors.
◗ In which high-risk health behaviors do you
engage? What do you do to control or reduce
your risk? Which high-risk health behaviors do
you see most frequently in your family? In your
community? What might you do to help decrease
these high-risk behaviors?
Nutrition
The cultural domain of nutrition includes much more
than merely having adequate food for satisfying
hunger. This domain also comprises the meaning of
30 Foundations for Cultural Competence
❙❙◗ Table 2-5 Biocultural Ecology
Suggested Question Sample Rationale/Example
1. Are you allergic to any medications?
2. What problems did you have when you took
over-the-counter medications?
3. What are the major illnesses and diseases in your family?
4. Are you aware of any genetic diseases in your family?
5. What are the major health problems in the country
from which you come (if appropriate)?
6. With what race do you identify?
7. Observe skin coloration and physical characteristics.
8. Observe for and ask about physical handicaps
and disabilities.
Part of a standard assessment.
Part of a standard assessment. Ask about medicines purchased in or
outside the United States because a variety that require a prescrip-
tion in the United States can be purchased over the counter in
other countries.
Part of a standard assessment.
Middle Eastern as well as other populations have many hereditary
and genetic illnesses.
Certain diseases and illnesses have a higher incidence among some
groups compared with other groups; for example, thalassemia are
more common among people with Mediterranean ancestry.
National agenda are addressing racial and ethnic disparities.
To assess for rashes on people with dark skin, the health-care
provider may need to palpate rather than rely on visual cues.
Many people do not disclose handicaps or disabilities upon initial
encounter unless specifically asked, especially learning disabilities.
2780_Ch02_015-044 16/07/12 11:37 AM Page 30

food to the culture; common foods and rituals; nutri-
tional deficiencies and food limitations; and the use of
food for health promotion and wellness, illness and
disease prevention, and health maintenance and
restoration. Understanding a patient’s food choices
and preparation practices is essential for providing
culturally competent dietary counseling. Health-care
providers may be considered professionally negligent
when prescribing, for example, an American diet to a
Hispanic or an Asian patient whose food choices
and mealtimes may be different from American food
patterns.
Meaning of Food
Food and the absence of food—hunger—have diverse
meanings among cultures and individuals. Cultural
beliefs, values, and the types of foods available influ-
ence what people eat, avoid, or alter to make food con-
gruent with cultural lifeways, and food offers cultural
security and acceptance. Food plays a significant role
in socialization and can denote caring or lack of car-
ing or closeness.
◗ What are your personal beliefs about weight
and health? Do you agree with the dominant
American belief that thinness correlates with
desirability and beauty? What does food mean
in your culture besides satisfying hunger?
Common Foods and Food Rituals
Traditional food habits are basic to satisfactory nutri-
tion to most people. Perhaps a traditional diet does
not really exist for some people; rather, they have
favorite foods and preparation practices that health-
care providers need to assess for effective dietary
recommendations for health illness and disease pre-
vention and health promotion and wellness. Most im-
migrants bring their favorite foods with them when
they relocate, including preferred mealtimes. Food
choices may vary according to the region of the coun-
try, urban versus rural residence, and weekdays versus
weekends. In addition, food choices vary by marital
status, economic status, climate changes, religion, an-
cestry, availability, and personal preferences.
Specific food pyramids have been developed by sev-
eral organizations and are available for Vietnamese,
African American, Chinese, Cuban, Puerto Rican,
Navajo, Jewish, and Asian Indians, to name a few. They
are included in culture-specific chapters and can also
be found on the Internet by going to a search engine
and typing in “multicultural food pyramid.” Several
ethnic food pyramids are also on DavisPlus.
Many older people and people living alone, regard-
less of cultural background, do not eat balanced
meals. They state that they do not take the time to pre-
pare a meal, even though most American homes have
labor-saving devices, such as stoves, microwave ovens,
refrigerators, and dishwashers. For those who are un-
able to prepare their own meals because of disability
or illness, most communities have a Meals on Wheels
program through which community and church or-
ganizations deliver, usually once a day, a hot meal
along with a cold meal for later and food for the fol-
lowing morning’s breakfast. Socioeconomic status
may dictate food selections—for example, hamburger
instead of steak, canned or frozen vegetables and fruit
rather than fresh produce, and fish instead of shrimp
or lobster. Special occasions and holidays are fre-
quently associated with ethnic-specific foods. Many
religious groups are required to fast during specific
The Purnell Model for Cultural Competence 31
❙❙◗ Table 2-6 High-Risk Health Behaviors
Suggested Question Sample Rationale/Example
1. How many cigarettes a day do you smoke?
2. Do you smoke a pipe (or cigars)?
3. Do you chew tobacco?
4. How much alcohol do you drink each day?
Ask about wine, beer, spirits, coffee, energy
drinks.
5. What recreational drugs do you use?
6. Do you exercise each day? What type?
How long?
7. Do you use seat belts/helmets?
8. What precautions do you take to prevent
getting a sexually transmitted infection/HIV?
A smoking history is standard for any assessment. Because smoking carries a
stigma among some, ask this question without a judgmental attitude.
Part of a smoking assessment.
Chewing tobacco is a common practice in rural areas and increases the risk
for oropharyngeal cancer.
Part of a standard assessment.
Recreational drug use is part of a standard assessment. In order for the patient
to disclose this sensitive information, ask in a nonjudgmental manner.
Physical activity or lack thereof is part of a standard assessment for health
promotion and wellness.
Part of a standard assessment.
Part of a standard assessment and an opportunity to evaluate high-risk
patients.
2780_Ch02_015-044 16/07/12 11:37 AM Page 31

holiday seasons. However, health-care providers may
need to remind patients that fasting is not required
during times of illness or pregnancy.
Given the intraethnic variations of diet, it is impor-
tant for health professionals to inquire about the specific
diets of their patients. Expecting the patient to eat ac-
cording to an American mealtime schedule and to select
American foods from an exchange list may be unrealistic
for patients of different cultural backgrounds. Counsel-
ing about food-group requirements, intake restrictions,
and exercise must respect cultural behaviors and indi-
vidual lifeways. Culturally congruent dietary counseling,
such as changing amounts and preparation practices
while including preferred ethnic food choices, can reduce
the risk for obesity, cardiovascular disease, and cancer.
Whenever possible, determining a patient’s dietary prac-
tices should be started during the intake interview.
◗ In what food rituals does your family engage?
Do you have specific foods and rituals for
holidays? What would happen if you changed
these rituals? Do food patterns change for you
by the season? During the week versus the
weekend?
Dietary Practices for Health Promotion
The nutritional balance of a diet is recognized by most
cultures throughout the world. Most cultures have their
own distinct theories of nutritional practices for health
promotion and wellness, illness and disease prevention,
and health maintenance and restoration. Common folk
practices and selected diets are recommended during pe-
riods of illness and for prevention of illness or disease.
For example, cultures subscribe to the hot-and-cold (op-
posites) theory of food selection to prevent illness and
maintain health. Although each of these cultural groups
has its own specific name for the hot-and-cold theory of
foods, the overall belief is that the body needs a balance
of opposing foods. These practices are covered in cul-
ture-specific chapters.
◗ What do you eat to maintain your health?
What does a healthy diet mean to you? Do you
agree with the U.S. Department of Agriculture
Food Pyramid? Why? Why not? What do you
eat when you are ill?
Nutritional Deficiencies and Food Limitations
Because of limited socioeconomic resources or limited
availability of their native foods, immigrants may eat
foods that were not available in their home country.
These dietary changes may result in health problems
when they arrive in a new environment. This is more
likely to occur when individuals immigrate to a coun-
try where they do not have native foods readily avail-
able and do not know which new foods contain the
necessary and comparable nutritional ingredients.
Consequently, they do not know which foods to select
for balancing their diet.
Enzyme deficiencies exist among some ethnic and
racial groups. For example, many people are lactose-
intolerant and are unable to drink milk or eat dairy
products to maintain their calcium needs. Thus, the
health-care provider may need to assist patients and
their families in identifying foods high in calcium
when they are unable to purchase their native foods.
In general, the wide availability of foods in the United
States reduces the risks of these disorders as long as
people have the means to obtain culturally nutritious
foods. Recent emphasis on cultural foods has resulted
in larger grocery stores having sections designated for
ethnic goods and in small businesses selling ethnic
foods and spices to the general public. The health-care
provider’s task is to determine how to assist the patient
and identify alternative foods to supplement the diet
when these stores are not financially or geographically
accessible. Table 2-7 identifies guidelines for assessing
the cultural domain nutrition.
◗ What enzyme deficiencies run in your family?
Do you have any difficulty getting your preferred
foods? What other food limitations do you have?
Pregnancy and Childbearing
Practices
The cultural domain pregnancy and childbearing prac-
tices includes culturally sanctioned and unsanctioned
fertility practices; views toward pregnancy; and pre-
scriptive, restrictive, and taboo practices related to
pregnancy, birthing, and the postpartum period.
Many traditional, folk, and magico-religious beliefs
surround fertility control, pregnancy, childbearing,
and postpartum practices. The reason may be the mys-
tique that surrounds the processes of conception,
pregnancy, and birthing. Ideas about conception,
pregnancy, and childbearing practices are handed
down from generation to generation and are accepted
without validation or being completely understood.
For some, the success of modern technology in induc-
ing pregnancy in postmenopausal women and others
who desire children through in vitro fertilization and
the ability to select a child’s gender raises serious
ethical questions about parenting.
Fertility Practices and Views Toward Pregnancy
Commonly used methods of fertility control include
natural ovulation methods, birth control pills, foams,
Norplant, the morning-after pill, intrauterine devices,
tubal ligation or sterilization, vasectomy, prophylac-
tics, and abortion. Although not all of these methods
are acceptable to all people, many women use a com-
bination of fertility control methods. The most ex-
treme examples of fertility control are sterilization and
32 Foundations for Cultural Competence
2780_Ch02_015-044 16/07/12 11:37 AM Page 32

❙❙◗ Table 2-7 Nutrition
Suggested Question Sample Rationale/Example
1. Are you satisfied with your weight?
2. Which foods do you eat to
maintain your health?
3. Which foods do you avoid to
maintain your health?
4. Do you avoid specific foods?
Why do you avoid these foods?
5. Which foods do you eat when
you are ill?
6. Which foods do you avoid when
you are ill?
7. Why do you avoid these foods
(if appropriate)?
8. For what illnesses do you eat
certain foods?
9. Which foods do you eat to balance
your diet?
10. Which foods do you eat
every day?
11. Which foods do you eat
every week?
12. Which foods do you eat that
are part of your cultural heritage?
13. Which foods are high-status foods
in your family/culture?
14. Which foods are eaten only
by men? Women? Children?
Teenagers? Older people?
15. How many meals do you eat
each day?
16. What time do you eat each meal?
17. Do you snack between meals?
18. What foods do you eat when
you snack?
19. What holidays do you celebrate?
20. Who usually buys the food in your
household?
21. Who does the cooking in your
household?
22. Do you have a refrigerator?
23. How do you cook your food?
24. How do you prepare meat?
25. How do you prepare vegetables?
26. What do you drink with your
meals?
27. Do you drink special teas?
28. Do you have any food allergies/
intolerances?
29. Are there certain foods that cause
you problems when you eat them?
30. How does your diet change with
each season?
Not all cultures adhere to or believe in the U.S. weight recommendations.
Food choices are seen as a means for promoting health.
Each culture has certain foods people avoid for maintaining their health.
Kosher Jews do not eat pork.
Common foods eaten when ill among many cultures include toast and tea or ginger ale
when ill.
If the health-care provider recommends a food that the person culturally or personally
avoids, it may not be followed.
This is usually a culturally learned practice.
People drink a “hot toddy” for a cold or minor illness. The ingredients vary, but generally in-
clude tea, lemon or lime, sugar or honey, and some type of alcohol, such as whiskey or rum.
Many cultures adhere to specific foods for balancing a diet; frequently related to
opposite qualities of food such as the hot-and-cold theories.
Incorporating these foods into dietary prescriptions will increase compliance with
dietary instructions.
Incorporating these foods into dietary prescriptions will increase compliance with
dietary instructions.
Including culturally preferred foods into nutritional recommendations increases
compliance.
High-status foods vary according to cost and availability.
Among some Guatemalan highland indigenous populations, men primarily eat eggs for the
added protein value. The belief is that because men do heavy labor, they need more protein.
However, they are supposed to share the protein foods on their plates with children.
Many Turks eat 4 to 6 times a day, but in smaller amounts than most
European Americans do.
May have implications for medication administration.
Snacks can be a significant source of added calories.
Many snacks are not considered healthy food choices.
Holidays are a time for special meals and a time when many people overconsume calories.
Many times it is just as important to talk with the person who purchases the food as it
is with the person who prepares the meals. In migrant worker camps, the person who
prepares the meals is not the person who purchases food for the group. If one member
of the group needs a special diet, such as with a diabetic, the purchaser of the food
needs to be included in nutritional education.
The person who does the cooking should be included in dietary counseling and
education for special diets.
For the homeless and those in severe poverty, proper food storage must be taken into
consideration.
Preparation practices with butter, lard, etc., can add significant calories to meals.
Preparation practices can add significant calories.
Preparation practices add significant calories to meals, such as adding
butter or bacon fat to vegetables.
Beverages can add significant calories to meals. Be sure to ask if sugar is added to bever-
ages, including natural juices.
Teas are used by many people for health promotion and wellness and in times of illness.
Many American Indians and Asians have lactose intolerance.
Looking for allergies or side effects of specific foods to avoid in dietary counseling.
For those who live in colder climates, fresh fruits and vegetables may be too expensive
in the colder months.
2780_Ch02_015-044 16/07/12 11:37 AM Page 33

abortion. Sterilization in the United States is now
strictly voluntary; however, some countries still per-
form involuntary sterilization to control birth rates
and to control conception in people with mental re-
tardation or deformities. Abortion remains a contro-
versial issue in many countries and religions. For
example, in some countries, women are encouraged to
have as many children as possible, and abortion is
illegal. However, in other countries, abortion is com-
monly used as a means of limiting family size for a
variety of reasons. The “morning-after pill” also
continues to be controversial to some.
Fertility practices and sexual activity, sensitive topics
for many, is one area in which “outside” health-care
providers may be more effective than health-care
providers known to the patient because of the concern
about providing intimate information to someone they
know. Some of the ways health-care providers can pro-
mote a better understanding of practices related to fam-
ily planning include using videos in the native language
and videos and pictures of native ethnic people, using
material written at the individual’s level of education,
and providing written instructions in both English and
the native language. Health-care providers should avoid
family planning discussions on the first encounter; such
information may be better received on subsequent visits
when some trust has developed. Approaching the sub-
ject of family planning obliquely may make it possible
to discuss these topics more successfully.
◗ Does pregnancy have a special meaning in
your culture? Is fertility control acceptable in
your culture? Do most people adhere to fertility
control practices in your culture? What types of
fertility control are acceptable? Unacceptable?
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Most societies have prescriptive, restrictive, and taboo
beliefs for maternal behaviors and the delivery of a
healthy baby. Such beliefs affect sexual and lifestyle
behaviors during pregnancy, birthing, and the imme-
diate postpartum period. Prescriptive practices are
things that the mother should do to have a good out-
come (healthy baby and pregnancy). Restrictive prac-
tices are those things that the mother should not do
to have a positive outcome (healthy baby and deliv-
ery). Taboo practices are those things that, if done, are
likely to harm the baby or mother.
One prescriptive belief is that women are expected
to seek preventive care, eat a well-balanced diet, and get
adequate rest to have a healthy pregnancy and baby. A
restrictive belief is that pregnant women should refrain
from being around loud noises for prolonged periods
of time. Taboo behaviors during pregnancy include
smoking, drinking alcohol, drinking large amounts of
caffeine, and taking recreational drugs—practices that
are sure to cause harm to the mother or baby.
A taboo belief common among many cultures is
that a pregnant woman should not reach over her
head because the baby may be born with the umbil-
ical cord around its neck. A restrictive belief among
others is that permitting the father to be present in
the delivery room and seeing the mother or baby be-
fore they have been cleaned can cause harm to the
baby or mother. If the father is absent from the de-
livery room or does not want to see the mother or
baby immediately after birth, it does not mean that
he does not care about them. However, in many cul-
tures, the father is often encouraged to take prenatal
classes with the expectant mother and provide a sup-
portive role in the delivery process; fathers with
opposing beliefs may feel guilty if they do not com-
ply. The woman’s female relatives provide assistance
to the new mother until she is able to care for herself
and the baby. Additional cultural beliefs carried over
from cultural migration and American diversity
include the following:
• If you wear an opal ring during pregnancy, it will
harm the baby.
• Birthmarks are caused by eating strawberries or
seeing a snake and being frightened.
• Congenital anomalies can occur if the mother sees
or experiences a tragedy during her pregnancy.
• Nursing mothers should eat a bland diet to avoid
upsetting the baby.
• The infant should wear a band around the
abdomen to prevent the umbilicus from
protruding and becoming herniated.
• A coin, key, or other metal object should be put on
the umbilicus to flatten it.
• Cutting a baby’s hair before baptism can cause
blindness.
• Raising your hands over your head while pregnant
may cause the cord to wrap around the baby’s neck.
• Moving heavy items can cause your “insides” to
fall out.
• If the baby is physically or mentally abnormal,
God is punishing the parents.
In some other cultures, the postpartum woman is
prescribed a prolonged period of recuperation in the
hospital or at home, something that may not be feasi-
ble in the United States because of the shortened
length of confinement in the hospital after delivery.
The health-care provider must respect cultural be-
liefs associated with pregnancy and the birthing
process when making decisions related to the health
care of pregnant women, especially those practices
that do not cause harm to the mother or baby.
Most cultural practices can be integrated into preven-
tive teaching in a manner that promotes compliance.
34 Foundations for Cultural Competence
2780_Ch02_015-044 16/07/12 11:37 AM Page 34

Table 2-8 identifies guidelines for assessing the cultural
domain pregnancy and childbearing practices.
◗ What are some prescriptive practices for
pregnant women in your culture? What are some
restrictive practices for pregnant women in your
culture? What are some taboo practices for
pregnant women in your culture? What special
foods should a woman eat to have a healthy baby
in your culture? What foods should be avoided?
What foods should a nursing mother eat
postpartum? What foods should she avoid?
Death Rituals
The cultural domain death rituals includes how the in-
dividual and the society view death and euthanasia,
rituals to prepare for death, burial practices, and be-
reavement. Death rituals of ethnic and cultural groups
are the least likely to change over time and may cause
concerns among health-care personnel. Some staff
may not understand the value of customs with which
they are not familiar, such as the ritual washing of the
body. Death practices, beliefs, and rituals vary signifi-
cantly among cultural and religious groups. To avoid
The Purnell Model for Cultural Competence 35
❙❙◗ Table 2-8 Pregnancy and Childbearing Practices
Suggested Question Sample Rationale/Example
1. How many children do you have?
2. Have you ever had an abortion? Stillbirth?
Miscarriage?
3. What do you use for birth control?
4. What does it mean to you and your family
when you are pregnant?
5. What special foods do you eat when you are
pregnant?
6. What foods do you avoid when you are
pregnant?
7. What activities do you avoid when you
are pregnant?
8. Do you do anything special when you
are pregnant?
9. Do you eat nonfood substances when
you are pregnant?
10. Who do you want with you when you
deliver your baby?
11. In what position do you want to be when
you deliver your baby?
12. What special foods do you eat after delivery?
13. What foods do you avoid after delivery?
14. What activities do you avoid after you deliver?
15. Do you do anything special after delivery?
16. Who will help you with the baby after delivery?
17. What bathing restrictions do you have
after you deliver?
18. Do you want to keep the placenta?
19. What do you do to care for the baby’s
umbilical cord?
Part of a standard assessment.
Part of a standard OB/GYN assessment.
Each cultural and religious group has acceptable and unacceptable
methods of birth control.
In some cultures, a woman is not a true woman and has not reached her
potential until she becomes pregnant.
Although there are no specifically prescribed foods for a pregnant Polish
woman, she is expected to eat for two.
Chinese women are reluctant to take iron because they believe it will
make delivery more difficult.
A belief among many traditional Panamanians is that a pregnant woman
should not walk in the moonlight for fear the baby will be born with a
cleft lip or palate.
Korean women are expected to work hard during pregnancy to help
ensure having a smaller baby.
Eating nonfood substances, pica, is common among many cultural groups.
One example is clay, which can interfere with iron absorption.
Some women prefer their mothers or another female family member
rather than their husbands.
Traditional Indian women in Guatemala prefer to deliver in a squatting
position rather than in the supine position. Negotiating for the position
during delivery may be necessary in some organizations.
Hindu women are restricted to liquids, rice, gruel, and bread.
Guatemalan women avoid eating spicy foods because the milk will cause
irritability in the baby.
Russian women should do no strenuous activity after delivery to prevent
any complications.
Traditional Japanese women should not wash their hair for several days
postpartum
Looking for home support for the mother.
Many Egyptian women may be reluctant to bathe postpartum because
air may get into the mother and cause illness. However, a sponge bath is
acceptable.
Some American Indians bury the placenta outside their home to keep
away evil spirits.
A common practice among Mayans is to place a coin or metal object,
held on with an abdominal binder, to prevent the umbilicus from
protruding when the baby cries.
2780_Ch02_015-044 16/07/12 11:37 AM Page 35

cultural taboos, health-care providers must become
knowledgeable about unique practices related to
death, dying, and bereavement.
Death Rituals and Expectations
For many health-care providers educated in a culture
of mastery over the environment, death is seen as one
more disease to conquer, and when this does not hap-
pen, death becomes a personal failure. Thus, for many,
death does not take a natural course because it is
“managed” or “prolonged,” making it difficult for
some to die with dignity. Moreover, death and re-
sponses to death are not easy topics for many to ver-
balize. Instead, many euphemisms are used rather
than verbalizing that the person died—for example,
“passed away,” “no longer with us,” and “was visited
by the Grim Reaper.” The individualistic cultural be-
lief in self-determination and autonomy extends to
people making their own decisions about end-of-life
care. Mentally competent adults have the right to re-
fuse or decide what medical treatment and interven-
tions they wish to extend life, such as artificial life
support and artificial feeding and hydration.
◗ What terms do you use when referring to
death? Why do you use these terms? What
specific burial practices do you have in your
family/culture?
Among most Westerners, the belief is that a dying
person should not be left alone, and accommodations
are usually made for a family member to be with the
dying person at all times. Health-care personnel are ex-
pected to care for the family as much as for the patient
during this time. Most people are buried or cremated
within 3 days of the death, but extenuating circum-
stances may lengthen this period to accommodate fam-
ily and friends who must travel a long distance to
attend a funeral or memorial service. The family can
decide whether to have an open casket—so family and
friends can view the deceased—or a closed casket. Sig-
nificant variations in burial practices occur with other
ethnocultural groups throughout the world.
Responses to Death and Grief
Numerous countries have been launching major ini-
tiatives to help patients die as comfortably as possible
without pain. As a result, more people are choosing
to remain at home or to enter a hospice for end-of-life
care where their comfort needs are better met. When
death does occur, some people conservatively control
their grief, although women are usually more expres-
sive than men. For many, especially men, they are ex-
pected to be stoic in their reactions to death, at least
in public. Generally, tears are shed, but loud wailing
and uncontrollable sobbing rarely occur. The belief is
that the person has moved on to a better existence and
does not have to undergo the pressures of life on
earth. Regardless of the gender or culture, bereave-
ment is a very private issue, and there are no norms;
people grieve in their own way.
Variations in the grieving process may cause confu-
sion for health-care providers, who may perceive some
patients as overreacting and others as not caring. The
behaviors associated with the grieving process must be
placed in the context of the specific ethnocultural be-
lief system in order to provide culturally competent
care. Caregivers should accept and encourage ethni-
cally specific bereavement practices when providing
support to family and friends. Bereavement support
strategies include being physically present, encourag-
ing a reality orientation, openly acknowledging the
family’s right to grieve, accepting varied behavioral re-
sponses to grief, acknowledging the patient’s pain, as-
sisting them to express their feelings, encouraging
interpersonal relationships, promoting interest in a
new life, and making referrals to other resources, such
as a priest, minister, rabbi, or pastoral care. Table 2-9
identifies guidelines for assessing the cultural domain
death rituals.
◗ How do men grieve in your culture? How do
women grieve in your culture? Do you have a
living will or advance directive? Why? Why not?
Are you an organ donor? Why? Why not? Is
there a specific time frame for bereavement?
Spirituality
The domain spirituality involves more than formal re-
ligious beliefs related to faith and affiliation and the
use of prayer. For some people, religion has a strong
influence over and shapes nutrition practices, health-
care practices, and other cultural domains. Spirituality
includes all behaviors that give meaning to life and
provide strength to the individual. Furthermore, it is
difficult to distinguish religious beliefs from cultural
beliefs because for some, especially the very devout,
religion guides the dominant beliefs, values, and prac-
tices even more than their culture does.
Spirituality, a component of health related to the
essence of life, is a vital human experience that is
shared by all humans. Spirituality helps provide bal-
ance among the mind, body, and spirit. Trained and
traditional religious leaders provide comfort to both
the patient and the family. Spirituality does not have
to be scientifically proven and is patterned uncon-
sciously from a person’s worldview. Accordingly, peo-
ple may deviate somewhat from the majority view or
position of their formally recognized religion.
Dominant Religion and Use of Prayer
Of the major religions in the world, 33 percent of
people are Christians (17 percent are Roman
36 Foundations for Cultural Competence
2780_Ch02_015-044 16/07/12 11:37 AM Page 36

Catholic); 16 percent are Muslim; 13 percent are
Hindu; 6 percent are Buddhists; 12 percent are non-
religious; and over 2 percent are atheist (CIA World
Factbook, 2011).
Many people migrate for religious freedom. Further-
more, specific religious groups are concentrated region-
ally within a country. Unlike in many countries that
support a specific church or religion and in which peo-
ple discuss their religion frequently and openly, religion
is not an everyday topic of conversation for most
Americans. The health-care provider who is aware of
the patient’s religious practices and spiritual needs is in
a better position to promote culturally competent
health care. The health-care provider must demonstrate
an appreciation of and respect for the dignity and spir-
itual beliefs of patients by avoiding negative comments
about religious beliefs and practices. Patients may find
considerable comfort in speaking with religious leaders
in times of crisis and serious illness.
Prayer takes different forms and different mean-
ings. Some people pray daily and may have altars in
their homes. Others may consider themselves
devoutly religious and say prayers only on special
occasions or in times of crisis or illness. Health-care
providers may need to make special arrangements for
individuals to say prayers in accordance with their
belief systems.
◗ With what religion do you identify? Do you
consider yourself devout? Do you need anything
special to pray? When do you pray? Do you pray
for good health? How do religiosity and
spirituality differ for you? What gives meaning
to your life? How are spirituality, religiosity, and
health connected for you?
Meaning of Life and Individual Sources
of Strength
What gives meaning to life varies among and within
cultural groups and among individuals. To some
people, their formal religion may be the most impor-
tant facet of fulfilling their spirituality needs, whereas
for others, religion may be replaced as a driving force
by other life forces and worldviews. Among other peo-
ple, family is the most important social entity and is
extremely important in helping meet their spiritual
needs. For others, what gives meaning to life is good
health and well-being. For a few, spirituality may in-
clude work or money.
A person’s inner strength comes from different
sources. For some, inner self is dependent on being in
harmony with one’s surroundings, whereas for others,
a belief in a supreme being may give personal strength.
For most people, spirituality includes a combination
of these factors. Knowing these beliefs allows health-
care providers to assist individuals and families in their
quest for strength and self-fulfillment.
Spiritual Beliefs and Health-Care Practices
Spiritual wellness brings fulfillment from a lifestyle of
purposeful and pleasurable living that embraces free
choices, meaning in life, satisfaction in life, and self-
esteem. For some, ritual dancing and herbal treat-
ments (combined with prayers and songs) are
performed for total body healing and the return of
spirits to the body. Practices that interfere with a per-
son’s spiritual life can hinder physical recovery and
promote physical illness.
Health-care providers should inquire whether the
person wants to see a member of the clergy even if
The Purnell Model for Cultural Competence 37
❙❙◗ Table 2-9 Death Rituals
Suggested Question Sample Rationale/Example
1. What special activities need to be performed to
prepare for death?
2. Would you want to know about your impending
death?
3. What is your preferred burial practice? Interment,
cremation?
4. How soon after death does burial occur?
5. How do men grieve in your culture?
6. How do women grieve in your culture?
7. What does death mean to you?
8. Do you believe in an afterlife?
9. Are children included in death rituals?
When death is impending, Muslims want the bed to face toward Mecca.
A belief among traditional Somalis is that a person might give up hope if
impending death is made known.
Patient’s wishes should be granted.
For traditional Jews, burial is before sundown the next day.
In some cultures, men are expected to be stoical and maintain control of
their emotions. Expressions of grief have a wide variation.
In some cultures, women are expected to be histrionic with their grief to
demonstrate their care for the deceased loved one. Expressions of grief
have a wide variation.
Among Hindus, death means rebirth.
Many Christians believe that there is a better life after death.
The Amish include children in all aspects of dying and burial.
2780_Ch02_015-044 16/07/12 11:37 AM Page 37

she or he has not been active in church. Religious
emblems should not be removed because they pro-
vide solace to the person, and removing them may
increase or cause anxiety. A thorough assessment of
spiritual life is essential for the identification of
solutions and resources that can support other treat-
ments. Table 2-10 identifies guidelines for assessing
the cultural domain spirituality.
Health-Care Practices
Another domain of culture is health-care practices.
The focus of health care includes traditional, magico-
religious, and biomedical beliefs; individual responsi-
bility for health; self-medicating practices; and views
toward mental illness, chronicity, rehabilitation, and
organ donation and transplantation. In addition, re-
sponses to pain and the sick role are shaped by specific
ethnocultural beliefs. Significant barriers to health
care may be shared among cultural and ethnic groups.
Health-Seeking Beliefs and Behaviors
For centuries, people’s health has been maintained by
a wide variety of healing and medical practices. Cur-
rently, most of the world is undergoing a paradigm
shift from one that places high value on curative and
restorative medical practices with sophisticated tech-
nological care to one of health promotion and well-
ness; illness, disease, and injury prevention; health
maintenance and restoration; and increased personal
responsibility. Most believe that the individual, the
family, and the community have the ability to influ-
ence their health. However, among other populations,
good health may be seen as a divine gift from a
superior being, with individuals having little control
over health and illness.
The primacy of patient autonomy is generally ac-
cepted as an enlightened perspective in individualistic
cultures. To this end, advance directives, such as
“durable power of attorney” or a “living will” are an
important part of medical care. Accordingly, patients
can specify their wishes concerning life and death de-
cisions before entering an inpatient facility. The
durable power of attorney for health care allows the
patient to name a family member or significant other
to speak for the patient and make decisions when or
if the patient is unable to do so. The patient can also
have a living will that outlines the person’s wishes in
terms of life-sustaining procedures in the event of a
terminal illness. Most inpatient facilities have forms
that patients may sign, or they can elect to bring their
own forms, many of which are available on the Inter-
net. Most countries and cultural groups engage in pre-
ventive immunization for children. Guidelines for
immunizations were developed largely as a result of
the influence of the World Health Organization
(WHO). Specific immunization schedules and the ages
at which they are prescribed vary widely among coun-
tries and can be obtained from the WHO website
(see DavisPlus). However, some religious groups, such
as Christian Scientists, do not believe in immunizations.
Beliefs like this, which restrict optimal child health, have
resulted in court battles with various outcomes.
Responsibility for Health Care
The world is moving to a paradigm in which people
take increased responsibility for their health. In a
society in which individualism is valued, people are
expected to be self-reliant. In fact, people are expected
to exercise some control over disease, including con-
trolling the amount of stress in their lives. If someone
does not maintain a healthy lifestyle and then gets
sick, some believe it is the person’s own fault. Unless
someone is very ill, she or he should not neglect social
and work obligations.
The health-care delivery system of the country of ori-
gin and degree of individualism and collectivism may
shape patients’ beliefs regarding personal responsibility
for health care. Most countries in the world have some
kind of basic universal coverage for their citizens, al-
though access and quality may vary significantly from
rural and urban settings and for vulnerable populations.
◗ What do you do to take responsibility for your
health? Do you take vaccines yearly to prevent
the flu or other illnesses? Do you have adequate
health insurance? Do you have regular checkups
with your health-care provider?
A potential high-risk behavior in the self-care context
includes self-medicating practices. Self-medicating be-
havior in itself may not be harmful, but when combined
with or used to the exclusion of prescription medica-
tions, it may be detrimental to the person’s health. A
38 Foundations for Cultural Competence
❙❙◗ Table 2-10 Spirituality
Suggested Question Sample Rationale/Example
1. What is your religion? Part of a standard
assessment.
2. Do you consider yourself Religion may have more
deeply religious? influence than the culture.
3. How many times a day do Islam requires prayer five
you pray? times a day.
4. What do you need to say If possible, Muslims need a
your prayers? prayer rug.
5. Do you meditate? Meditation can be used for
relaxation and for pain
control.
6. What gives strength and For some, the most
meaning to your life? important thing in their
life is family.
7. In what spiritual practices Prayer, meditation, yoga, and
do you engage for your quiet time are some
physical and emotional examples.
health?
2780_Ch02_015-044 16/07/12 11:37 AM Page 38

common practice with prescription medications is for
people to take medicine until the symptoms disappear
and then discontinue the medicine prematurely. This
practice commonly occurs with antihypertensive med-
ications and antibiotics. No culture is immune to self-
medicating practices; almost everyone engages in it to
some extent.
Each country has some type of control over the pur-
chase and use of medications. The United States is
more restrictive than many countries and provides
warning labels and directions for the use of over-the-
counter medications. In many countries, pharmacists
may be consulted before physicians for fever-reducing
and pain-reducing medicines. In parts of Central
America, a person can purchase antibiotics, intra-
venous fluids, and a variety of medications over the
counter; most stores sell medications, and vendors sell
drugs in street-corner shops and on public transporta-
tion systems. People who are accustomed to purchas-
ing medications over the counter in their native
country frequently see no problem in sharing their
medications with family and friends. To help prevent
contradictory or exacerbated effects of prescription
medications and treatment regimens, health-care
providers should ask about patients’ self-medicating
practices. One cannot ignore the ample supply of over-
the-counter medications in pharmacies worldwide, the
numerous television advertisements for self-medication,
and media campaigns for new medications, encourag-
ing viewers to ask their doctor or health-care provider
about a particular medication.
◗ In what self-medicating practices do you
engage? What makes you decide when to see
your health-care provider when you have an
illness?
Folk and Traditional Practices
Some societies and individuals favor traditional, folk,
or magico-religious health-care practices over biomed-
ical practices and use some or all of them simultane-
ously. For many, what are considered alternative or
complementary health-care practices in one country
may be mainstream medicine in another society or
culture. In the United States, interest has increased in
alternative and complementary health practices. The
U.S. government has a National Center for Comple-
mentary and Alternative Medicine at the National In-
stitutes of Health that has awarded millions of dollars
in grants to bridge the gap between traditional and
nontraditional therapies.
◗ In the context of Western medicine, in what
complementary and alternative practices have
you practiced? For what conditions have you
used them? Were they helpful? How willingly
do you accept other people’s traditional
practices?
As an adjunct to biomedical treatments, many
people use acupuncture, acupressure, acumassage,
herbal therapies, and other traditional treatments.
Some cultural groups and individuals commonly
visit traditional healers because modern medicine is
viewed as inadequate. Examples of folk medicines in-
clude covering a boil with axle grease, wearing cop-
per bracelets for arthritis pain, swallowing wild
turnip root and honey for a sore throat, and drinking
herbal teas. The Chinese subscribe to the yin-and-
yang theory of treating illnesses, and Hispanic
groups believe in the hot-and-cold theory of foods
for treating illnesses and disease. Traditional schools
of pharmacy in many countries sell folk remedies.
Most people practice folk medicine in some form;
they may use family remedies passed down from pre-
vious generations.
An awareness of combined practices when treating
or providing health education to individuals and fam-
ilies helps ensure that therapies do not contradict one
another, intensify the treatment regimen, or cause an
overdose. At other times, they may be harmful, con-
flict with, or potentiate the effects of prescription
medications. Many times, these traditional, folk, and
magico-religious practices are and should be incorpo-
rated into the plans of care for patients. Inquiring
about the full range of therapies being used, such as
food items, teas, herbal remedies, nonfood substances,
over-the-counter medications, and medications pre-
scribed or loaned by others, is essential so that con-
flicting treatment modalities are not used. If patients
perceive that the health-care provider does not accept
their beliefs, they may be less compliant with prescrip-
tive treatment and less likely to reveal their use of
these practices.
Barriers to Health Care
For people to receive adequate health care, a number
of considerations must be addressed. Several studies
in the United States have identified that a lack of flu-
ency in language is the primary barrier to receiving
adequate health care in the United States (Institute of
Medicine, 2001; Joint Commission, 2010a; 2010b; The
Disparities Solutions Center, 2010). One can only de-
duce that this is true for other countries as well. Other
barriers include the following:
• Availability: Is the service available and at a time
when needed? For example, no services exist after
6 p.m. for someone who needs suturing of a minor
laceration. Clinic hours coincide with patients’
work hours, making it difficult to schedule
appointments for fear of work reprisals.
• Accessibility: Transportation services may not be
available, or rivers and mountains may make it dif-
ficult for people to obtain needed health-care serv-
ices when no health-care provider is available in
The Purnell Model for Cultural Competence 39
2780_Ch02_015-044 16/07/12 11:37 AM Page 39

their immediate region. It can be difficult for a sin-
gle parent with four children to make three bus
transfers to get one child immunized.
• Affordability: The service is available, but the
patient 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 account-
able for their own education and do they learn
about the cultures of the people they serve? Are
they culturally aware, sensitive, and competent?
• Adaptability: A mother brings her child to the
clinic for an immunization. Can she get a mammo-
gram at the same time or must she make another
appointment?
• Acceptability: Are services and patient education
offered in a language preferred by the patient?
• Awareness: Is the patient aware that needed serv-
ices exist in the community? The service may be
available, but if patients are not aware of it, the
service will not be used.
• Attitudes: Adverse subjective beliefs and attitudes
from caregivers mean that the patient 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 patients feel welcomed?
Do health-care providers and receptionists greet
patients in the manner in which they prefer? This in-
cludes greeting patients with their preferred names.
• Alternative practices and practitioners: Do biomed-
ical providers incorporate patients’ alternative or
complementary practices into treatment plans?
• Additional services: Are child- and adult-care serv-
ices available if a parent must bring children or an
aging parent to the appointment with them?
• Literacy: Language has been identified as the biggest
barrier to health care, and not just for those for
whom English is a second language. See Chapter 3 to
identify patients with health literacy needs.
Health-care providers can help reduce some of
these barriers by calling an area ethnic agency or
church for assistance, establishing an advocacy
role, involving professionals and laypeople from the
same ethnic group as the patient, using cultural
brokers, and organizationally providing culturally
congruent and linguistically appropriate services. If
all of these elements are in place and used appropri-
ately, they have the potential of generating culturally
responsive care.
◗ Looking at the list of barriers to health care,
which apply to you? How can you decrease these
barriers? What are the barriers to health care in
your community?
Cultural Responses to Health and Illness
Significant research has been conducted on patients’
responses to pain, which has been called the “fifth
vital sign.” Most health-care professionals believe that
patients should be made comfortable and not have to
tolerate high levels of pain. Accrediting bodies, such
as the Joint Commission, survey organizations to
ensure that patients’ pain levels are assessed and that
appropriate interventions are instituted.
A number of studies related to pain and the ethnicity/
culture of the patient have been completed. Most of
the studies have come from end-of-life care. Some of
the salient research findings follow:
• Sixty-five percent of “minority” patients have inad-
equate pain control versus 30 percent of “nonmi-
nority” patients (Anderson et al., 2002; Cleeland
et al., 1994; 1997; Foley, 2000).
• A patient’s ethnicity has a greater influence on the
amount of opioid prescribed by the clinician than
on the amount of opioid self-administered by the
patient (Ng, Dimsdale, Rollnik, & Shapiro, 1996).
• Communication between patient and health-care
provider influences pain diagnosis and treatment
(American Academy of Pain Medicine, 2004;
Purnell & Paulanka, 2005).
• The brain’s pain-processing and pain-killing
systems vary by race and ethnicity (American
Academy of Pain Medicine, 2004).
• Few minority patients are told in advance about
possible side effects of pain medicine and how to
manage them (Anderson et al., 2002).
• African American and Hispanic patients with
severe pain are less likely than white patients to
be able to obtain needed pain medicine because
pharmacies do not carry the medicines (Morrison,
Wallenstein, Natale, Senzel, & Huang, 2001).
• African Americans are less likely to have their pain
recorded (Bernabei et al., 1998).
• Inadequate education of pain and analgesia expec-
tations may contribute to poor pain relief in the
Asian populations (Kuhn et al., 1990).
• Disparities in pain management and quality care at
end of life exist among African American women
in general and, specifically, those with breast can-
cer (Payne, Medina, & Hampton, 2003).
• Hispanic patients are more likely to describe pain
as “suffering,” the emotional component. African
Americans are more likely to describe pain as
“hurts,” the sensory component (Anderson et al.,
2002).
• Socioeconomic factors negatively influence
prescribing pain medicine.
• Pain does not have the same debilitating effect
for patients from Eastern cultures as it does for
patients from Western cultures (Kodiath &
Kodiath, 1992).
40 Foundations for Cultural Competence
2780_Ch02_015-044 16/07/12 11:37 AM Page 40

• Stoicism, fatalism, family, and spirituality have a
positive impact on Hispanics and pain control
(Purnell & Paulanka, 2005).
• Chinese, Korean, and Vietnamese patients do not
favor taking pain medicine over a long period of time.
• Vietnamese Canadians prefer herbal therapies over
prescription pain medicine (Voyer, Rail, Laberge,
& Purnell, 2005).
• Haitians, Haitian Americans, and Haitian Canadians
combine herbal therapies with prescription medi-
cine without telling the health-care provider
(Voyer et al., 2005).
• Black, Hispanic, and Asian women receive less
epidural analgesia than do white women (Rust
et al., 2004).
• Cultural background, worldview, and variant char-
acteristics of culture influence the pain experience.
• The greater the language differences, the poorer the
pain control.
• For Asians, tolerating pain may be a way of
atoning for past sins.
Pain scales are in different languages and with faces
appropriate to the language and ethnicity of the patient
(Pain Source Book, 2005). Additional resources
for pain are the American Pain Foundation, The
American Pain Society, the Boston Cancer Pain Edu-
cation Center (in 11 languages), and the OUCHER
Pain scale for children (OUCHER!, n.d.), all of which
are available on the Internet. Health-care practitioners
must investigate the meaning of pain to each person
within a cultural explanatory framework to interpret
diverse behavioral responses and provide culturally
competent care. The health-care provider may need to
offer and encourage pain medication and explain that
it will help the healing progress.
◗ What is your first line of intervention when you
are having pain? When do you decide to see a
health-care practitioner when you are in pain?
What differences do you see between yourself and
others when they are in pain? Where did you learn
your response to pain? Do you see any difference
in the clinical setting in response to pain among
ethnic and cultural groups? Between men and
women?
The manner in which mental illness is perceived and
expressed by a cultural group has a direct effect on
how individuals present themselves and, consequently,
on how health-care providers interact with them. In
some societies, mental illness may be seen by many as
not being as important as physical illness. Mental ill-
ness is culture-bound; what may be perceived as a
mental illness in one society may not be considered a
mental illness in another. For some, mental illness and
severe physical handicaps are considered a disgrace
and taboo. As a result, the family is likely to keep the
mentally ill or handicapped person at home as long as
they can. This practice may be reinforced by the belief
that all individuals are expected to contribute to the
household for the common good of the family, and
when a person is unable to contribute, further disgrace
occurs. In some cultures, children with a mental dis-
ability are stigmatized, and the lack of supportive
services may cause families to abandon their loved
ones because of the cost of long-term care and the
family’s desire and desperate need for support. Such
children may be kept from the public eye in hope of
saving the family from stigmatization.
◗ What are your perceptions about mental ill-
ness? Does mental illness have the same value as
physical illness and disease? When you are
having emotional difficulties, what is your first
line of defense? Have you observed different
attitudes/responses from providers regarding
physical and mental illnesses?
Rehabilitation and occupational health services
focus on returning individuals with handicaps to
productive lifestyles in society as soon as possible. The
goal of the health-care system is to rehabilitate every-
one: convicted criminals, people with alcohol and
drug problems, as well as those with physical condi-
tions. To establish rapport, health-care practitioners
working with patients suffering from chronic disease
must avoid assumptions regarding health beliefs and
provide rehabilitative health interventions within the
scope of cultural customs and beliefs. Failure to re-
spect and accept patients’ values and beliefs can lead
to misdiagnosis, lack of cooperation, and alienation
of patients from the health-care system.
◗ Do you see physically challenged individuals as
important as nonphysically challenged individu-
als in terms of their worth to society? What are
your beliefs about rehabilitation? Should every-
one have the opportunity for rehabilitation?
Sick role behaviors are culturally prescribed and
vary among ethnic societies. Traditional individualis-
tic cultural practice calls for fully disclosing the health
condition to the patient. However, traditional collec-
tivistic families may prefer to be informed of the bad
news first, and then slowly break the news to the sick
family member. Given the ethnocultural acceptance
of the sick role, health-care providers must assess each
patient and family individually and incorporate cul-
turally congruent therapeutic interventions to return
the patient to an optimal level of functioning.
◗ What do you normally do when you have a
minor illness? Do you go to work (class)
anyway? What would make you decide not to go
to work or class? Does the sick role have a
specific meaning in your culture?
The Purnell Model for Cultural Competence 41
2780_Ch02_015-044 16/07/12 11:37 AM Page 41

Blood Transfusions and Organ Donation
Most religions favor organ donation and transplanta-
tion and transfusion of blood or blood products.
Jehovah’s Witnesses do not believe in blood transfu-
sions. Some individuals and cultures choose not to
participate in organ donation or autopsy because of
their belief that they will suffer in the afterlife or that
the body will not be whole on resurrection. Informa-
tion about kidney transplants and ethnicity can be
found at the National Kidney Foundation’s website
and in individual chapters in this book. Health-care
providers may need to assist patients in obtaining a
religious leader to support them in making decisions
regarding organ donation or transplantation.
Some people do not sign donor cards because the
concept of organ donation and transplantation is not
customary in their homelands. Health-care providers
should supply information regarding organ donation
on an individual basis, be sensitive to individual and
family concerns, explain procedures involved with
organ donation and procurement, answer questions
factually, and explain involved risks. A key to success-
ful marketing approaches for organ donation is cul-
tural awareness. Table 2-11 identifies guidelines for
assessing the cultural domain health-care practices.
◗ Are you averse to receiving blood or blood
products? Why? Why not? Are you an organ
donor? Why? Why not?
Health-Care Providers
The domain health-care providers includes the status,
use, and perceptions of traditional, magico-religious,
42 Foundations for Cultural Competence
❙❙◗ Table 2-11 Health-Care Practices
Suggested Question Sample Rationale/Example
1. In what prevention activities do you engage to
maintain your health?
1. Who in your family takes responsibility for the
family’s health?
2. What over-the-counter medicines do you use?
3. What herbal teas and folk medicines do you use?
4. For what conditions do you use herbal medicines?
5. What do you usually do when you are in pain?
6. How do you express your pain?
7. How are people in your culture viewed or
treated when they have a mental illness?
8. How are people with physical disabilities treated
in your culture?
9. What do you do when you are sick? Stay in
bed; continue your normal activities, etc.?
10. What are your beliefs about rehabilitation?
11. How are people with chronic illnesses viewed
or treated in your culture?
12. Are you averse to blood transfusions?
13. Is organ donation acceptable to you?
14. Are you an organ donor?
15. Would you consider having an organ transplant
if needed?
A strong value in the dominant European American culture is to have reg-
ularly scheduled health checkups, including self breast examinations, mam-
mograms, and colonoscopies.
Among Arabs, family, not the individual, has the primary responsibility for a
person’s health-seeking care.
All cultural groups and individuals use over-the-counter medication; some
use them to the exclusion of prescription medicines.
Panamanians, like many Hispanic/Latino populations, use a wide variety of
herbal teas for many health conditions.
Iranians use a variety of berries, leaves, seeds, and dried flowers steeped in
hot or cold water and drunk for digestive problems.
African Americans may see pain and suffering as inevitable and something
that is to be endured.
Among Mexicans, being able to endure pain is seen as a sign of strength.
Having a mental illness in many Arab cultures is seen as a stigma; there-
fore, the person with a mental illness may be well cared for but kept hid-
den from society.
The Amish approach disability as a community responsibility, and those
with a disability are incorporated into all family and social activities.
For many from the European American culture, a belief is “if you are not
dead,” take something for relief and continue with your daily routines.
Studies demonstrate that for Germans, if rehabilitation is needed to func-
tion at maximum capacity, then all rehab exercises are done.
For most Arabs, if a chronic illness is debilitating, family members readily
assume that person’s responsibilities.
Besides a religious prohibition for a Jehovah’s Witness to receive blood,
many people do not want a blood transfusion for fear of contracting
HIV/AIDS.
Jewish law views organ transplants for four perspectives: the recipient, the
living donor, the cadaver donor, and the dying donor. Because life is sacred,
if the recipient’s life can be prolonged without considerable risk, then the
transplant is favorably viewed.
Part of a standard assessment.
Organ donation and transplantation among Muslims are individual
decisions.
2780_Ch02_015-044 16/07/12 11:37 AM Page 42

The Purnell Model for Cultural Competence 43
❙❙◗ Table 2-11 Health-Care Practices Continued from page 42
Suggested Question Sample Rationale/Example
16. Are health-care services readily available to you?
17. Do you have transportation problems accessing
needed health-care services?
18. What traditional health-care practices
do you use? Acupuncture, acupressure, cai gao,
moxibustion, aromatherapy, coining, etc.?
The health-care provider needs to be aware of access problems for
health care and make attempts to improve access.
Many organizations have vouchers for public transportation.
If the health-care provider is familiar with traditional practices within the
culture, more specific information can be obtained.
and biomedical health-care providers. This domain is
interconnected with communications, family roles and
organization, and spirituality. In addition, the gender
of the health-care provider may be significant for
some people.
Traditional Versus Biomedical Providers
Most people combine the use of biomedical health-
care providers with traditional practices, folk healers,
and/or magico-religious healers. The health-care sys-
tem abounds with individual and family folk practices
for curing or treating specific illnesses. A significant
percentage of all care is delivered outside the perime-
ter of the formal health-care arena. Many times
herbalist-prescribed therapies are handed down from
family members and may have their roots in religious
beliefs. Traditional and folk practices often contain el-
ements of historically rooted beliefs.
◗ What alternative health-care providers do you
see for your health-care needs besides traditional
allopathic-care providers? For what conditions
do you use nonallopathic providers? Do you
think traditional health-care providers are as
valuable as allopathic health-care providers?
The traditional practice in the United States is to as-
sign staff to patients regardless of gender differences,
although often an attempt is made to provide a same-
gender health-care provider when intimate care is in-
volved, especially when the patient and caregiver are
of the same age. However, health-care providers should
recognize and respect differences in gender relation-
ships when providing culturally competent care be-
cause not all ethnocultural groups accept care from
someone of the opposite gender. Health-care providers
need to respect patients’ modesty by providing ade-
quate privacy and assigning a same-gender caregiver
whenever possible.
◗ Do you prefer a same-gender health-care
provider for your general health care? Do you
mind having an opposite-gender provider for
intimate care? Why? Why not? Do you prefer
Western-trained health-care providers or does it
not make any difference?
Status of Health-Care Providers
Health-care providers are perceived differently among
ethnic and cultural groups. Individual perceptions of
selected health-care providers may be closely associ-
ated with previous contact and experiences with
health-care providers. In many Western societies,
health-care providers, especially physicians, are viewed
with great respect, although recent studies show that
this is declining among some groups. Although many
nurses in the United States do not believe they are re-
spected, public opinion polls usually place patients’
respect of nurses higher than that of physicians. The
advanced practice role of registered nurses is gaining
respect as more of them have successful careers and
the public sees them as equal or preferable to physi-
cians and physician assistants in many cases.
◗ Does one type of health-care provider have
increased status over another type? Should all
health-care providers receive equal respect,
regardless of educational requirements? Does
the ethnicity or race of a provider make any
difference to you? Why? Why not?
Depending on the country of origin and experience
of working with professional nurses, some physicians
may misunderstand the assertive behavior of Western-
educated nurses because in their home country, nurses
were not expected to be assertive. Some patients per-
ceive older male physicians as being of higher rank
and more trustworthy than younger health profession-
als, especially for patients who come from a collectivist
culture where they are taught from a very early age to
respect elders and to show deference to nurses and
physicians, regardless of gender or age.
Evidence suggests that respect for professionals is
correlated with their educational level. In some cul-
tures, the nurse is expected to defer to physicians. In
many countries, the nurse is viewed more as a domes-
tic than as a professional person, and only the physi-
cian commands respect. Health beliefs are not border
bound. People bring their beliefs with them upon mi-
gration.
In some cultures, folk and magico-religious health-
care providers may be deemed superior to biomedically
2780_Ch02_015-044 16/07/12 11:37 AM Page 43

educated physicians and nurses. It may be that folk,
traditional, and magico-religious health-care providers
are well known to the family and provide more indi-
vidualized care. In such cultures, health-care providers
take time to get to know patients as individuals and
engage in small talk totally unrelated to the health-care
problem to accomplish their objectives. Establishing
satisfactory interpersonal relationships is essential for
improving health care and education in these ethnic
groups. Table 2-12 identifies the guidelines for assessing
the cultural domain health-care practitioners.
R E F E R E N C E S
American Academy of Pain Medicine. (2004). Retrieved from
www.painmed.org
Anderson, K., Richman, S., Hurley, J., Palos, G., Valero, V.,
Mendoza, T., et al. (2002). Cancer pain management among
underserved minority outpatients: Perceived needs and barriers
to optimal control. Cancer, 94(8), 2295–2304.
Bernabei, R., Gambassi, G., Lapane, K., Landi, F., Gasonis, C.,
Dunlop, R., et al. (1998). Management of pain in elderly
patients with cancer. Journal of the American Medical Associ-
ation, 279(23), 1877–1882.
CIA World Factbook. (2011). The World. Retrieved from
https://www.cia.gov/library/publications/the-worldfactbook/
geos/xx.html
Cleeland, C., Gonin, R., Baez, L., Loehrer, P., & Pandya, K. (1997).
Pain and treatment of pain in minority patients with cancer: The
Eastern Cooperative Oncology Group Minority Outpatient Pain
Study. Annals of Internal Medicine, 127(9), 813–816.
Cleeland, C., Gonin, R., Hatfield, A., Edmonson, J., Blum, R.,
Steward, J., et al. (1994). Pain and its treatment in outpatients with
metastatic cancer. New England Journal of Medicine, 330, 592–596.
Foley, K. (2000). Controlling cancer pain. Hospital Practice, 35(4),
111–112.
Hall, E. (1990). The silent language. New York: Anchor Books.
Hilton, M. (1987). Demographic characteristics and the frequency
of heavy drinking as predictors of drinking problems. British
Journal of Addiction, 82, 913–925.
Institute of Medicine. (2001). Crossing the quality chasm. Retrieved
from http://www.iom.edu/Reports/2001/Crossing-the-Quality-
Chasm-A-New-Health-System-for-the-21st-Century.aspx
Joint Commission. (2005). Pain source book. Retrieved from
www.painsourcebook.ca
Joint Commission. (2010a). Advancing effective communication,
cultural competence, and family centered care: A roadmap for
hospitals. Joint Commission.
Joint Commission. (2010b). Patient-centered communication stan-
dards and EPs. Joint Commission.
Kodiath, M., & Kodiath, A. (1992). A comparative study of
patients with chronic pain in India and the United States. Clin-
ical Nursing Research, 3, 278–291.
Kuhn, S., Cooke, K., Collins, M., Jones, J., & Mucklow, J. (1990).
Perceptions of pain relief after surgery. British Medical Journal,
300, 1687–1690.
Morrison, R.S., Wallenstein, S., Natale, D.K., Senzel, R.S., & Huang,
L.L. (2001). “We don’t carry that”—Failure of pharmacies in pre-
dominantly nonwhite neighborhoods to stock opioid analgesics.
New England Journal of Medicine, 342(14), 1023–1026.
Ng, B., Dimsdale, J., Rollnik, J., & Shapiro, H. (1996). The effect
of ethnicity on prescriptions for patient-controlled analgesia
for post-operative pain. Pain, 66(1), 9–12.
Payne, R., Medina, E., & Hampton, J. (2003). Quality of life concerns
in patients with breast cancer: Evidence for disparity of outcomes
and experiences in pain management and palliative care among
African-American Women. Cancer, 97(1 Suppl), 311–317.
Peele, S., & Brodsky, A. (2001). Alcohol and society. Retrieved
from http://www.peele.net OUCHER! (N.D.). Retrieved from

Oucher!

Purnell, L., & Foster, J. (2003a). Cultural aspects of alcohol use:
Part I. The Drug and Alcohol Professional, 3(3), 17–23.
Purnell, L., & Foster, J. (2003b). Cultural aspects of alcohol use:
Part II. The Drug and Alcohol Professional, 2(3), 3–8.
Purnell, L. & Paulanka, B. (2005). Guide to culturally competent
health care. Philadelphia: F. A. Davis Company.
Rust, G., Nembhard, W., Nichols, M., Omole, R., Minor, P., et al.
(2004). Racial and ethnic disparities in the provision of epidural
analgesia to Georgia Medicaid beneficiaries during labor and de-
livery. American Journal of Obstetrics and Gynecology, 191, 456–462.
The Disparities Solutions Center at Massachusetts General Hos-
pital. (2010). Improving quality and achieving equity: A guide
for hospital leaders. Boston, MA: The Disparities Solutions
Center at Massachusetts General Hospital.
Voyer, P., Rail, G., Laberge, S., & Purnell, L. (2005). Cultural mi-
nority older women’s attitudes toward medication and impli-
cations for adherence to a drug regimen. Journal of Diversity
in Health and Social Care, 2(1), 47–61.
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
44 Foundations for Cultural Competence
❙❙◗ Table 2-12 Health-Care Providers
Suggested Question Sample Rationale/Example
1. What health-care
providers do you see
when you are ill?
Physicians, nurses?
2. Do you prefer a same-sex
health-care provider for
routine health problems?
For intimate care?
3. What healers do you use
besides physicians and
nurses?
4. For what conditions do
you use healers?
Adapted from Purnell, L. (2009). Guide to culturally competent health care.
Philadelphia: F.A. Davis Co.; and Purnell, L. (2011). Models and theories
focused on culture. In J.B. Butts and K.L. Rich (Eds.), Philosophies and theo-
ries for advanced practice nursing. Sudbury, MA: Jones & Bartlett Learning.
Not all patients see West-
ern allopathic practitioners
for illnesses, at least not as
first access. Some use
Western providers and
traditional providers
simultaneously.
Among Orthodox Jewish
Islamic patients, a same-
sex provider should be
assigned unless it is an
emergency.
If the health-care provider is
familiar with the specific cul-
ture, better/more pointed
questions can be asked.
Among many
Hispanics/Latinos, folk prac-
titioners are consulted for
the evil eye and other
conditions.
Many American Indians use
a variety of traditional heal-
ers. Being able to integrate
traditional healers with allo-
pathic professionals will
increase compliance with
recommendations.
2780_Ch02_015-044 16/07/12 11:37 AM Page 44

45
Chapter 3
Individual Cultural Competence
and Evidence-Based Practice
Larry D. Purnell and Susan Salmond
Individual Cultural Competence
Self-Awareness and Health Professions
Culture has a powerful unconscious impact on patients
and health professionals. Culture in health-care settings
is extremely complex for the following reasons:
• Each patient has a culture.
• Each health-care provider has a culture that may
be different from that of the patient.
• Each profession, nursing, medicine, physical ther-
apy, occupational therapy, and social work, to
name a few, has a culture.
• Each specialty such as medicine, surgery, gerontol-
ogy, psychiatry, hospice/palliative care, pediatrics,
rehabilitation, to name a few, has a subculture of
the dominant professional culture.
• Each organization has a culture with subcultures
within each organization.
When all these competing cultures and subcultures
are combined, a significant mismatch may occur, cre-
ating an increased complexity of providing culturally
competent care.
The way health-care providers perceive themselves
as competent providers is often reflected in the way
they communicate with patients. Thus, it is essential
for health-care providers to think about their cultures,
their behaviors, and their communication styles in re-
lation to their perceptions of cultural differences. They
should also examine the impact their beliefs have on
others, including patients and coworkers, who are cul-
turally diverse. Before addressing the multicultural
backgrounds and unique individual perspectives of
each patient, health-care providers must first address
their own personal and professional knowledge, val-
ues, beliefs, ethics, and life experiences in a manner
that optimizes interactions and assessment of cultur-
ally diverse individuals.
Self-knowledge and understanding promote strong
professional perceptions that free health-care profes-
sionals from prejudice and allow them to interact
with others in a manner that preserves personal in-
tegrity and respects uniqueness and differences
among individual patients. The process of profes-
sional development and diversity competence begins
with self-exploration or critical reflection. Although
the literature provides numerous definitions of self-
awareness, discussion of research integrating the con-
cept of self-awareness with multicultural competence
is minimal. Many theorists and diversity trainers
imply that self-examination or awareness of personal
prejudices and biases is an important step in the cog-
nitive process of developing cultural competence
(Boyle & Andrews, 2011; Calvillo et al., 2009; Giger
et al., 2007). However, discussions of emotional feel-
ings elicited by this cognitive awareness are somewhat
limited, given the potential impact of emotions and
conscious feelings on behavioral outcomes.
◗ In your opinion, why is there conflict about
working with culturally diverse patients? What
attitudes are necessary to deliver quality care to
patients whose culture is different from yours?
Self-awareness in cultural competence is a deliber-
ate and conscious cognitive and emotional process of
getting to know yourself: your personality, your val-
ues, your beliefs, your professional knowledge stan-
dards, your ethics, and the impact of these factors on
the various roles you play when interacting with indi-
viduals different from yourself. Critically analyzing
our own values and beliefs in terms of how we see dif-
ferences enables us to be less fearful of others whose
values and beliefs are different from our own (Calvillo
et al., 2009). The ability to understand oneself sets the
stage for integrating new knowledge related to cultural
2780_Ch03_045-059 16/07/12 11:38 AM Page 45

differences into the health-care provider’s knowledge
base, perceptions of health, interventions, and the im-
pact these factors have on the various roles of profes-
sionals when interacting with multicultural patients.
◗ What have you done in the last 5 to 10 years to
increase your self-awareness? Has increasing
your self-awareness resulted in an increased
appreciation for cultural diversity? How might
you increase your knowledge about the diversity
in your community? In your school?
Measuring Individual Cultural Competence
Much has been debated, especially since the early 1990s,
about objectively measuring individual competence.
Most tools for measuring cultural competence are self-
reported and subjective in nature. A number of tools
have been developed to assess individual and organiza-
tional cultural competence. Some have been validated
and are specific to a discipline or area of practice,
whereas others are more general in nature. To select one
that more specifically meets your needs, go to an Inter-
net search engine such as www.scholar.google.com and
enter “cultural competence measurement” or “cultural
competence assessment tools” in the search field. The
Office of Minority Health also has a document on
Cultural Competence Standards (www.omhrc.gov). In
general, cultural competence is a journey involving the
willingness and ability of an individual to deliver cul-
turally congruent and acceptable health and nursing
care to the patients to whom one provides care. To this
author, individual cultural competence can be arbitrar-
ily divided among cultural general approaches, the
clinical encounter, and language.
The American Academy of Nursing with represen-
tatives from the Transcultural Nursing Society has de-
veloped Standards of Practice for Culturally Competent
Nursing Care based on social justice (Douglas et al.,
2011). Box 3-1 lists the 12 standards,.
Cultural General Approaches
A number of general approaches exist to help health-
care providers achieve cultural competence, including
the following:
1. Developing an awareness of one’s own existence,
sensations, thoughts, and environment without
letting it have an undue influence on those from
other backgrounds.
2. Continuing to learn cultures of patients to
whom one provides care.
3. Demonstrating knowledge and understanding of
the patient’s culture, health-related needs, and
meanings of health and illness.
4. Accepting and respecting cultural differences in
a manner that facilitates the patient’s and the
family’s ability to make decisions to meet their
needs and beliefs.
5. Recognizing that the health-care provider’s
beliefs and values may not be the same as the
patient’s.
6. Resisting judgmental attitudes such as “different
is not as good.”
7. Being open to new cultural encounters.
8. Recognizing that variant cultural characteristics
determine the degree to which patients adhere
to the beliefs, values, and practices of their
dominant culture.
9. Having contact and experience with the commu-
nities from which patients come.
10. Being willing to work with patients of diverse
cultures and subcultures.
11. Accepting responsibility for one’s own education
in cultural competence by attending conferences,
reading literature, and observing cultural practices.
12. Promoting respect for individuals by discourag-
ing racial and ethnic slurs among coworkers.
13. Intervening with staff behavior that is insensi-
tive, lacks cultural understanding, or reflects
prejudice.
14. Having a cultural general framework for assess-
ment as well as having cultural-specific knowledge
about the patients to whom care is provided.
The Clinical Encounter
The clinical encounter is a rich area for learning about
and becoming more culturally competent. As clinical
practice begins seeing increasing numbers of diverse
patients and families, health-care providers increase
their knowledge base and skills. Some specific ap-
proaches that are helpful in becoming more culturally
competent are:
• Adapting care to be congruent with the patient’s
culture.
• Responding respectively to all patients and their
families (includes addressing patients and family
members as they prefer, formally or informally).
• Collecting cultural data on assessments.
• Forming generalizations as a method for formulat-
ing questions rather than stereotyping.
• Recognizing culturally based health-care beliefs
and practices.
• Knowing the most common diseases and illnesses
affecting the unique population to whom care is
provided.
• Individualizing care plans to be consistent with the
patient’s cultural beliefs.
• Having knowledge of the communication styles of
patients to whom you provide care.
• Accepting varied gender roles and childrearing
practices from patients to whom you provide care.
• Having a working knowledge of the religious and
spirituality practices of patients to whom you pro-
vide care.
46 Foundations for Cultural Competence
2780_Ch03_045-059 16/07/12 11:38 AM Page 46

• Having an understanding of the family dynamics
of patients to whom you provide care.
• Using faces and language pain scales in the ethnic-
ity and preferred languages of the patients.
• Recognizing and accepting traditional, comple-
mentary, and alternative practices of patients to
whom you provide care.
• Incorporating patient’s cultural food choices and
dietary practices into care plans and
• Incorporating patient’s health literacy into care
plans and health education initiatives.
Language Interpretation, Health Literacy,
and Translation
Language
Language ability, as mentioned previously, is the biggest
barrier to effective health-care access, diagnosis,
assessment, and comprehension of medication and
health prescription instructions. Strategies for improv-
ing language ability for effective communication with
patients and family follow:
• Developing skills and using interpreters (includes
sign language) with patients and families who have
limited English proficiency.
• Providing patients with educational documents
that are translated into their preferred language.
• Providing discharge instructions at a level
the patient and the family understand and
in the language the patient and the family
prefer.
• Providing medication and treatment instructions in
the language the patient prefers.
• Using pain scales in the preferred language of the
patient.
Individual Cultural Competence and Evidence-Based Practice 47
❙❙◗ Box 3-1 Standards of Practice for Culturally Competent Nursing Care
• Standard 1: Social Justice
Professional nurses shall promote social justice for all. The applied principles of social justice guide decisions of nurses related to
the patient, family, community, and other health-care professionals. Nurses will develop leadership skills to advocate for socially
just policies.
• Standard 2: Critical Reflection
Nurses shall engage in critical reflection of their own values, beliefs, and cultural heritage in order to have an awareness of how
these qualities and issues can impact culturally congruent nursing care.
• Standard 3: Knowledge of Cultures
Nurses shall gain an understanding of the perspectives, traditions, values, practices, and family systems of culturally diverse
individuals, families, communities, and populations for whom they care, as well as knowledge of the complex variables that
affect the achievement of health and well-being.
• Standard 4: Culturally Competent Practice
Nurses shall use cross-cultural knowledge and culturally sensitive skills in implementing culturally congruent nursing care.
• Standard 5: Cultural Competence in Healthcare Systems and Organizations
Healthcare organizations should provide the structure and resources necessary to evaluate and meet the cultural and language
needs of their diverse patients.
• Standard 6: Patient Advocacy and Empowerment
Nurses shall recognize the effect of healthcare policies, delivery systems, and resources on their patient populations, and shall
empower and advocate for their patients as indicated. Nurses shall advocate for the inclusion of their patients’ cultural beliefs
and practices in all dimensions of their health care when possible.
• Standard 7: Multicultural Workforce
Nurses shall actively engage in the effort to ensure a multicultural workforce in health-care settings. One measure to achieve a
multicultural workforce is through strengthening of recruitment and retention effort in the hospital and academic setting.
• Standard 8: Education and Training in Culturally Competent Care
Nurses shall be educationally prepared to promote and provide culturally congruent health care. Knowledge and skills necessary
for ensuring that nursing care is culturally congruent shall be included in global health-care agendas that mandate formal
education and clinical training, as well as required ongoing, continuing education for all practicing nurses.
• Standard 9: Cross-Cultural Communication
Nurses shall use culturally competent verbal and nonverbal communication skills to identify patient’s values, beliefs, practices,
perceptions, and unique health-care needs.
• Standard 10: Cross-Cultural Leadership
Nurses shall have the ability to influence individuals, groups, and systems to achieve positive outcomes of culturally competent
care for diverse populations.
• Standard 11: Policy Development
Nurses shall have the knowledge and skills to work with public and private organizations, professional associations, and
communities to establish policies and standards for comprehensive implementation and evaluation of culturally competent care.
• Standard 12: Evidence-Based Practice and Research
Nurses shall base their practice on interventions that have been systematically tested and shown to be the most effective for the
culturally diverse populations that they serve. In areas where there is a lack of evidence of efficacy, nurse researchers shall
investigate and test interventions that may be the most effective in reducing the disparities in health outcomes.
2780_Ch03_045-059 16/07/12 11:38 AM Page 47

◗ Look at the list of activities that promote
individual cultural competence. Which of these
activities have you used to increase your cultural
competence? Which ones can you easily add to
increase your cultural competence? Which ones
are the most difficult for you to incorporate?
Provider cross-cultural skills and interpreter serv-
ices, and written patient materials in different lan-
guages and at a low level of health literacy, ensure that
patients understand their options, choices, costs, and
benefits. The health-care provider and the organiza-
tion should become familiar with the Code of Ethics
for Medical Interpreters (1987) and make this
National Standards on Interpreting in Health Care
(2007).
One of the biggest barriers to effective health care,
in addition to access, is health literacy, and this is not
just for people for whom English is a second language.
Over 40 percent of adults have significant literacy
challenges, and 88 percent of adults have less than
“proficient” health literacy skills. Communication dif-
ficulties may lead to misdiagnosis and inappropriate
treatment, and may limit the process of truly informed
consent. Communication problems are the most fre-
quent cause of serious adverse events, as recorded by
the Joint Commission. Furthermore, patients with
limited English proficiency have longer hospital stays
than English speakers for some common medical and
surgical conditions (Joint Commission, 2010). In ad-
dition, patients may not understand discharge instruc-
tions, and some may be afraid to seek care due to
language barriers and embarrassment or cultural dif-
ferences. Recognizing that a patient needs help reading
or completing admission forms can be a sensitive
issue, and staff should obtain the necessary informa-
tion without embarrassing the patient. Some recom-
mendations for interpretation are shown in Box 3-2.
Health Literacy
The health-care provider has a responsibility to deter-
mine if a patient has low health literacy. Patients with
low health literacy may have great difficulty under-
standing their health information, participating in
treatment decisions, and following through with treat-
ment plans. Some comments by patients that might
indicate low literacy include forgetting their glasses,
wanting another family member to complete forms,
and wanting to take forms home to complete them.
Health-care providers should ask the patient if he or
she needs assistance in completing forms and offer to
assist the patient. Alternative media, such as a video
with pictures and diagrams can help to reinforce key
points. It is a good idea to have the patient or the re-
sponsible family member demonstrate the procedure
to show that the patient understands (Joint Commis-
sion, 2010).
Translation
Whereas interpretation is verbal, translation is writ-
ten. Sometimes a patient may have adequate verbal
skills for understanding health-related information
but not have adequate reading skills. To help ensure
health literacy of written materials, present materials
at a fifth-grade or lower reading level, use bulleted
points for crucial information, and translate materials
into the patient’s referred language (Office of Disease
Prevention and Health Promotion, 2011). In addition,
use information from the National Network of
Libraries of Medicine (2011) that includes health
information for professionals and the public.
48 Foundations for Cultural Competence
❙❙◗ Box 3-2 Recommendations for Working with
an Interpreter
• Use interpreters who can decode the words and provide
the meaning behind the message.
• Use dialect-specific interpreters whenever possible.
• Use interpreters trained in the health-care field.
• Give the interpreter time alone with the patient.
• Provide time for translation and interpretation.
• Use same-gender interpreters whenever possible.
• Maintain eye contact with both the patient and the inter-
preter 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 as many words as possible in the patient’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 patients 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 times 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 a certified interpreter is unavailable, the use of an uncerti-
fied interpreter may be acceptable; however, the difficulty
might be omission of parts of the message or distortion of
the message, including transmission of information not
given by 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 patient may result in the interpreter’s
not reporting information that he or she perceives as
superstitious or unimportant.
2780_Ch03_045-059 16/07/12 11:38 AM Page 48

Use national- and state-level data on sexual orien-
tation from Web sites such as http://www.census.org
and http://www.gaydata.org to develop initiatives that
address the health concerns of gay and lesbian patients
(Joint Commission, 2010).
Evidence-Based Practice
and Culturally Congruent
Best Practices
The mandate for evidence-based practice (EBP) to re-
duce the “know-do” gap (Antes, Sauerland, & Seiter,
2006) between known science and implementation in
practice has been driven by the demand for improved
safety and quality outcomes for clients (Box 3-3). This
has necessitated a culture shift from an opinion-based
culture grounded in intuition, clinical experience/
expertise, and pathophysiological rationale (Swanson,
Schmitz, & Chung, 2010) to a culture of EBP in which
there is conscientious, explicit, and judicious use
of current best evidence in making decisions about
the care of individuals or groups of patients. Evi-
dence alone does not constitute EBP, but rather evi-
dence is one component needed to inform decision
making. Evidence-based practice is put in action
when evidence, clinical expertise, clinical context,
and patient preferences and values inform one an-
other in a positive way (Kitson, 2002). No one com-
ponent is the most important; rather, the weight
given to each component varies according to the clin-
ical situation (Melnyk, Fineout-Overholt, Stilwell, &
Williamson, 2009). Figure 3-1 portrays the dynamic
nature of the process as it combines the four core
components contributing to clinical decision mak-
ing. Table 3-1 summarizes the components of EBP
and the actions and resources needed to facilitate its
implementation.
Understanding the Four Components
of Evidence-Based Practice
The four components of EBP, all of which contribute
to the best patient outcomes, are best research
Individual Cultural Competence and Evidence-Based Practice 49
❙❙◗ Box 3-3 Quality and Safety Education for Nurses
The Institute of Medicine (IOM) Health Profession Education Report on safety and quality in the United States’ health-care system has
fueled a number of organizations and commissions to address quality and safety in education for health professionals. A few of these
are listed as follows and further described on DavisPlus Web Resources:
• Quality and Safety Education for Nurses (QSEN)
• National Quality Forum (NQF)
• Agency for Health Research and Quality (AHRQ)
• Institute for Healthcare Improvement (IHI)
• National Association of Healthcare Quality (NAHQ)
Although some of the initiatives are discipline-specific with well-developed documents for including content and teaching strategies
for quality and safety, the overarching principles are the same for all professions. The IOM’s initial five core areas are as follows:
• Delivering patient-centered care
• Working as part of interdisciplinary teams
• Practicing evidence-based medicine
• Focusing on quality improvement
• Using information technology
The Robert Wood Johnson Foundation funded the American Association of Colleges of Nursing (AACN) to develop teaching
strategies that address the IOM’s competencies, which included safety as a separate core area. The task force convened by the AACN
enhanced the essentials of baccalaureate education that included the knowledge, skills, and attitudes required to meet the education
needs of QSEN (www.aacn.nche.edu).
Patient-Centered Care
Patient-centered care accounts for and recognizes that the patient and family are co-participants to ensure culturally competent
care and that their cultural preferences, values, and needs are addressed (see cultural general approaches and the clinical encounter
in this chapter). In order for preferences to be adequately addressed, culturally acceptable communication is a core requirement for
developing trust with full disclosure (Institute for Patient and Family Centered Care: www.ipfcc.org) (see the section on communication
in Chapter 2). Health-care providers must respect patients’ expertise and recognize that beliefs and values of the health-care providers
may not be the same as those of the patients.
Teamwork and Cultural Care
Teamwork and collaboration are extremely important processes in culture. Given the complexity of the culture of the patient, the
cultures of individual team members, the cultures of the professions and specialties, and the culture of the organization (see Chapter 4),
to function effectively, mutual respect and shared decision making are essential (Cronenwett et al., 2007).
Evidence-Based Practice
Evidence-based practice (EBP) has proven to be difficult to integrate into cultural care because the available literature on EBP is still
in its infancy with few large studies. Best practices in clinical care integrate clinical expertise and patient/family preferences for optimal
delivery (see the section on EBP in this chapter).
Continues on page 50
2780_Ch03_045-059 16/07/12 11:38 AM Page 49

evidence, clinical expertise, patient preferences and
values, and clinical context (see Figure 3-1).
Best Evidence
Locating Best Evidence from the Literature When one
considers that there are more than 1500 new articles
and 55 new clinical trials per day, the impossibility of
staying current in all of the conditions and situations
that patients present with becomes apparent. Practic-
ing from an evidence-based (EB) perspective requires
the clinician to recognize these knowledge limitations
and to reflect on their ongoing practice to determine
what evidence they are relying on and when they need
evidence. Ask “why” things are being done as they are,
“whether” there is evidence supporting the approach,
or “what” the evidence suggests may be best in this
clinical situation and “whether” there are likely to be
cultural considerations that necessitate examining ev-
idence specific to your cultural group (Salmond, 2007).
Asking Clinical Questions to Retrieve Evidence Prac-
ticing from an EB perspective requires asking clinical
questions and searching for the evidence to guide
practice. There is a technique to asking clinical ques-
tions so that the evidence can be retrieved quickly and
50 Foundations for Cultural Competence
❙❙◗ Box 3-3 Quality and Safety Education for Nurses Continued from page 49
Quality Improvement
Quality improvement in cultural care is a combination of individual and organizational cultural competence (see Chapter 4). Quality
cultural care cannot occur without the support of the organization in which care is delivered and should include expertise from the
community it serves.
Health Literacy and Safety
Safety and minimizing risk are concerns on multiple levels, but specific to cultural aspects are health literacy and interpretation and
translation services (see language interpretation, translation, and health literacy in this chapter). Health-care providers in all professions
must discuss safety issues with their patients in both home and environmental contexts with patients’ occupations—for example,
the use of pesticides with people who work in agricultural environments.
Informatics
Informatics and information technology include the ability of health-care providers to access cultural information, specifically knowing
where to obtain cultural general and specific information. Information must be obtained from recognized peer-reviewed literature,
professional organizations and associations, and other credible sources whose content has been validated.
Outcomes
Measurement
Outcomes
Measurement
Best Patient
Outcomes
“Best”
Research
Evidence
Clinical
Expertise
Patient
Values
Clinical
Context
O
u
tco
m
e
s
M
e
a
su
re
m
e
n
t
O
u
tco
m
e
s
M
e
a
su
re
m
e
n
t
Figure 3-1 Components of Evidence-Based Practice
❙❙◗ Table 3-1 The Evidence-Based Practice Process
Components Resources/Change Needed
Identify best
evidence
Clinical inquiry: What knowledge is needed?
Informed skepticism: Why are we doing it this way?
Is there a better way to do it? What is the evi-
dence for what we do? Would doing this be as
effective as doing that? (Salmond, 2007)
• Shift from “know how” and doing to “know why”
• Reflect on what information is needed to provide
“best” care
• Generate questions about practice and care
• Role model clinical inquiry at report, rounds,
conferences
• Use interdisciplinary case reviews to evaluate
actual care
• Include clinical librarians as members of teams
participating in clinical rounds and conferences
2780_Ch03_045-059 16/07/12 11:38 AM Page 50

Individual Cultural Competence and Evidence-Based Practice 51
❙❙◗ Table 3-1 The Evidence-Based Practice Process Continued from page 50
Components Resources/Change Needed
Clinical
experience and
expertise
Patient values
and preferences
Translation
evidence from
total process
into clinical
decisions and
strategies for
best patient
outcomes
Monitor patient
outcomes
Convert information needs from practice into
focused, searchable questions (patient
intervention-comparison-outcome [PICO]
framework).
Search databases for highest level of evidence in a
timely manner
Use critical appraisal process to determine
strength and validity of evidence and relevance
to one’s practice
Use clinical expertise to determine how to use
evidence in care of patient and how to manage
patient in absence of evidence or presence of
conflicting evidence
Demonstrate ability to perform a culture assess-
ment and identify patient preferences and values
that inform the clinical decision.
Use all four components in clinical decision-
making process and implementation of clinical
decision
Use outcome tools to track patient outcomes
• Consider recurring clinical issues, need for informa-
tion, negative incidents/events as sources for
questions or information needs
• Identify clinical issues sensitive to nursing
interventions
• Narrow broad clinical issues/questions into
searchable, focused questions
• Use the mnemonic PICO to frame questions
• Specify population of interest by using the specific
cultural group identifier or broader terms such as
multiethnic, multicultural
• Use evidence-searching skills to target relevant
focused evidence
• Begin search with filtered resources
• Understand the match between question and
design
• Search strategies: key terms, multiple databases,
point-of-care data
• Use assistance of clinical librarian
• Clinical Practice Guidelines available at www.
clearinghouse.gov
• Demonstrate knowledge of research design
• Demonstrate knowledge of statistics
• Use critical appraisal tools to guide process of
research critique
• Utilize journal clubs
• Summarize findings from evaluation, resolving
conflicting evidence
• Consider evidence in relation to own patient
population
• Consider cost-benefit ratio
• Consider multidimensionality of patient and clinical
situation in relation to evidence that is often
reductionistic
• Ensure holistic assessment and planning inclusive of
the social and cultural context
• Understand culture-general and culture-specific
knowledge to guide interactions with patient
• Use interview skills to avoid culture imposition and
seek client’s true preferences
• Communicate evidence and treatment options
considering patient values and preferences using
decision aids when available
• Involve patient and family in both information giving
and decision making
• Provide plan of care based on evidence, clinical
judgment, patient preferences, and organizational
context
• Use implementation frameworks for translating evi-
dence into practice throughout an organization or
care site including the community
• Develop audit systems to track patient outcomes
• Make clinical outcomes accessible electronically for
analysis
• Analyze outcomes and effectiveness of “evidence-
based” clinical intervention
2780_Ch03_045-059 16/07/12 11:38 AM Page 51

efficiently. The key is to ask focused questions. Who is
the population of interest? What is the intervention or
phenomenon of interest? What is the outcome of inter-
est? If the broad interest is duration of breastfeeding,
it should be narrowed further. Determine if evidence
for a particular cultural or social group is needed, and
specify this population by using key words as outlined
in Table 3-2. Narrow down what the intervention of
interest is—for example, barriers to breastfeeding, in-
terventions to support breastfeeding, or educational
and support programs to encourage breastfeeding.
Finally, for quantitative studies, select an outcome
that defines how success of the program will be meas-
ured—for example, initiation of breastfeeding, exclu-
sive breastfeeding, or duration of breastfeeding. Put-
ting it all together, the question might be “Does a
structured doula program (support program) affect the
initiation of breastfeeding among urban minority
women?” or “What is the experience of breastfeeding
for teenage mothers?” Table 3-2 provides a quick ref-
erence to asking clinical questions.
The question has been asked, and the goal is to
search for the “best” evidence. Best evidence is usually
found in clinically relevant research that has been
conducted using sound methodology (Sackett, 2000).
For the busy clinician, the key is to know how to find
52 Foundations for Cultural Competence
❙❙◗ Table 3-2 Locating Evidence Sources
Asking Clinical Questions
and Search Terms to Locate
Practices with Cultural
Variation
Systematic Reviews
Evidence-Based Guidelines
Bibliographic Databases
Grey Literature
1. Include your specific phenomena of interest or intervention of interest: (breastfeeding, liter-
acy, patient education, type of drug, exercise regimen)
2. Include your population and/or group interest: Consider who you are interested in, age, gen-
der, diagnosis (middle-aged obese women, adolescents, elders residing in the community), cul-
tural group that could include:
• culture (or specific culture group, i.e., Hispanic, Muslim), cross-cultural, transcultural
• ethnocultural, multicultural, multiethnic groups
• minority, ethnic minority groups
• immigrants, newcomers
• country of interest (i.e., Canada, Vietnam, Tanzania)
3. Include outcome of interest (breastfeeding duration, breastfeeding satisfaction, weight loss,
quality of life, HbA1c levels, adherence to low-sodium diet)
4. Include type of information desired
• Systematic review
• Clinical practice guidelines
• Research Method (i.e., randomized controlled trial, qualitative)
Cochrane Collaboration Library: http://www2.cochrane.org/reviews/
Campbell Collaboration Library: http://www.campbellcollaboration.org/library.php
Joanna Briggs Institute Library: http://www.joannabriggs.edu.au
Agency for Healthcare Research & Quality: http://www.ahrq.gov/clinic/epcindex.htm
International Journal of Evidence Based Healthcare
Bibliographic Databases (select systematic reviews, meta-analysis, or add as search terms)
National Guideline Clearinghouse: http://www.guideline.gov/
Guidelines International Network (G-I-N): http://www.openclinical.org/prj_gin.html
Academic Search Premiere PsychARTICLES
CINAHL PsychINFO
Embase PubMed
Medline REHABDATA
Proquest Social Science Journals
New York Academy of Medicine Grey Literature: http://www.nyam.org/library/online-
resources/grey-literature-report/current-grey-literature.html
WorldWideScience.org: http://worldwidescience.org/
World Health Organization: http://www.who.int/topics/
Pan American Health Organization: http://new.paho.org/
Family Health International: http://www.fhi.org/en/AboutFHI/index.htm
United Nations Educational, Scientific and Cultural Organization: http://portal.unesco.org/
culture
Kaiser Permanente Institute for Health Research: http://www.kpco-ihr.org/index.htm
Kaiser Family Foundation: http://www.kff.org/
Scirus for Scientific Information: http://www.scirus.com/
2780_Ch03_045-059 16/07/12 11:38 AM Page 52

this evidence. Haynes (2006) suggests beginning with
sources where the clinician can access filtered evidence
that has already been critically appraised and deter-
mined to be of sufficient rigor to be considered for ap-
plication into practice. These include systematic
reviews, critically appraised topics (guidelines), and
critically appraised individual articles.
Because one study is generally not enough to change
practice, the best evidence often comes from systematic
reviews that have pooled the primary research data for
assessment and summarization. By using a systematic
review, the clinician can generally rely on the fact that
a comprehensive search for all available information
has taken place, that the information has been screened
for relevance to the clinical question, and that the
information has been appraised for the rigor of the
research. The studies actually included in the final
summarization or synthesis are appraised to be of high
quality and pooled together, providing more precise,
powerful, and convincing conclusions. Sources for sys-
tematic reviews (see Table 3-2) include the AHRQ,
Cochrane Collaboration, Campbell Collaboration,
and Joanna Briggs libraries. Bibliographic databases
should also be searched. The International Journal of
Evidence Based Healthcare is a publication dedicated
to systematic reviews.
Practice Guidelines Practice guidelines (preferably
based on systematic reviews) translate research find-
ings into systematically developed statements to assist
health-care providers and patients in making decisions
about appropriate health care for specific clinical cir-
cumstances. Guidelines are just what the name im-
plies: a guide to inform health-care providers in
applying best practice, not a cookbook where a recipe
must be followed. Sources for guidelines include
AHRQ and the guideline.gov Web site and the Guide-
lines International Network (see Table 3-2). Guidelines
can be specific to a disease condition such as asthma
management (Management of Asthma Working
Group, 2009) or HIV prevention (Kaplan, Benson,
Holmes, Brooks, Pau, & Masur, 2009), or they can
address broader program and intervention issues such
as programming for HIV prevention for adolescents
(Family Health International, 2010) or population-
specific recommendations (Foggs, 2008).
In the absence of systematic reviews or practice
guidelines, search for single studies using bibliographic
databases (see Table 3-2). Many EB journals, such as
Evidence-Based Nursing, Evidence-Based Medicine, and
Evidence-Based Mental Health, provide filtered litera-
ture synopses of primary research providing the reader
with a summary, an appraisal, and recommendations
for translation into practice. To review filtered literature,
a single-paper search should be done in these journals
by adding the journal in the key word search.
If the question is still unanswered after searching
the filtered literature, search for primary studies (non-
filtered) by searching the bibliographic databases. If
there are journals that commonly carry articles related
to the topic, include the journal title in the electronic
search or hand-search the journal. The Journal of
Transcultural Nursing may be a helpful source for
information on culture.
Articles retrieved from nonfiltered sources need to
be critically appraised to determine scientific rigor
prior to use in practice. This requires determining
whether the best or strongest design was used for the
particular questions and whether the study design was
rigorous. For questions of intervention (e.g., “In
African Americans with newly diagnosed hyperten-
sion, what is the best diuretic treatment in lowering
blood pressure?”), randomized controlled trials are
the best type of design, followed by cohort studies,
case-controlled studies, case series, and descriptive
Individual Cultural Competence and Evidence-Based Practice 53
❙❙◗ Table 3-2 Locating Evidence Sources Continued from page 52
Internet Searching
Journals Specific to Evidence-
Based Care
Patient Decision Aids
Health Sciences Online: http://hso.info/hso/cgi-bin/query-meta?v%3aframe=form&frontpage=
1&v%3aproject=HSO&
Culture Link Network: http://www.culturelink.org/dbase/index.html
www.google.com
www.altheweb.com
Clinical Evidence
Evidence-Based Nursing, Evidence-Based Mental Health, Evidence-Based Healthcare
Electronic Journals on Evidence-Based Practice: http://www.wcpt.org/node/29660
Ottowa Hospital Research Institute: http://decisionaid.ohri.ca/index.html
Dartmouth Hitchcock Center for Shared Decision Making: http://patients.dartmouth-
hitchcock.org/shared_decision_making/decision_aid_library.html
Foundation for Informed Medical Decision Making: http://www.fimdm.org/about.php
Mayo Clinic Shared Decision Making National Resource Center: http://shareddecisions.
mayoclinic.org/
2780_Ch03_045-059 16/07/12 11:38 AM Page 53

studies. For questions about meaning or understand-
ing an experience (e.g., “What is the experience of
marginalization in new African immigrants?”), quali-
tative studies are the best design. Rigor is assessed by
reviewing the article for its adherence to design prin-
ciples. There are many tools to assist in this process.
One good source is the CASP International (www.
caspinternational.org), which has a tool for the different
study design types.
Grey Literature. Another source of evidence that
can provide valuable information, especially in the area
of culture, is grey literature, which consists of material
that is not formally published by commercial publish-
ers or peer-reviewed journals. It includes technical re-
ports, fact sheets, state-of-the-art reports, conference
proceedings, and other documents from institutions,
organizations, government agencies, Internet-based
materials and sites, and other forms of media (news-
papers, films, published photographs) and the like. The
“grey” non-peer-reviewed literature is an important
source of information on culture because there are few
peer-reviewed publications on specific diseases and cul-
tural implications or diseases and management among
the culturally and linguistically diverse. It is important
that grey literature be authenticated as reliable and
accurate as far as this can be assessed.
At the New York Academy of Medicine there has
been a push by public health and health policy re-
searchers for the Academy Library to obtain grey liter-
ature and to add it to the catalog (Gray, 1998). This has
developed into the New York Academy of Medicine’s
Grey Literature Report, a bimonthly online report tar-
geting researchers, health-care providers, practitioners,
students, and the lay public who are interested in public
health, health and science policy, health of minorities,
vulnerable and special populations (children, women,
uninsured, elderly), and those areas of general medicine
and disease in which the Academy has research interests.
Other key grey literature sites are listed in Table 3-2.
Examples of valuable grey literature reports relevant to
understanding the impact of culture on health decision
making or reporting on cultural health issues include
Cross-Cultural Considerations in Promoting Advance
Care Planning in Canada (Con, 2008); Culture and Men-
tal Health in Haiti: A Literature Review (WHO/PAHO,
2010); and 2010 National Healthcare Disparities Report
(Agency for Healthcare Research and Quality, 2010).
Best Clinical Expertise
Although locating and drawing from best evidence is
important, by itself it cannot direct practice. One rea-
son for this is the lack of quality evidence on topics
of interest. This is especially true for evidence on
social and cultural influences on health and health
outcomes. Very few studies have been devoted to eth-
nic minority groups. Although legislation was passed
in the early 1990s requiring NIH-funded researchers
to include ethnic minorities as subjects in numbers ad-
equate to allow for valid subgroup analyses of differ-
ences in effect by ethnic group, it is still difficult to get
ethnic minority groups to participate in research
(Hulme, 2010). A second reason is that there is poor
fit between our patients in actual practice and those
studied in research studies. Most studies control for
one or two variables, whereas in practice our patients’
problems can be very complex and their value systems
very different. Mosley (2009) articulates that “we are
living in a spectrum from good evidence at one end to
no evidence at the other. We spend most of our lives
in the gray area in the middle with somewhat adequate
evidence, and we are often not really sure what is good
evidence and what is not for the findings to be put into
practice.” Navigating this gray area requires clinicians
to use their practical knowledge, professional-craft
knowledge, or practical know-how (Rycroft-Malone,
Seers, Titchen, Harvey, Kitson, & McCormack, 2004).
Evidence informs clinicians. Clinicians rely on their
clinical judgment and expertise to thoroughly assess
the patient and differentiate nuances that influence
treatment perspectives. Unfortunately, in health care
significant emphasis is placed on assessment of the
biophysical domain, with much less attention paid to
psychological, cultural, and social factors that clearly
affect health behaviors and outcomes. Clinical expert-
ise must be holistic and recognize the social and cul-
tural determinants of health (McMurray, 2004) and
evidence this in an inclusive skill set for cultural as-
sessment and culturally competent interaction. The
clinician must be able to evaluate and adapt research
evidence and clinical guidelines in light of not only the
clinical presentation but in response to social and cul-
tural values of the client. They must use their clinical
acumen to question why the client is or is not respond-
ing to treatment and use a holistic framework to de-
termine whether there are intervening biophysical,
psychological, social, or cultural considerations that
have not been accounted for that could be influencing
outcomes and then make necessary adjustments (Shah
& Chung, 2009).
Patient Values and Preferences
It is insufficient to simply blend expertise and evidence
because at the heart of the issue is the patient. Al-
though critics of EBP have indicated that there is too
great an emphasis on empirical evidence and clinical
expertise, the reality is that EBP that integrates all four
components is complementary with patient-centered
care. Practicing from an EB perspective requires the
clinician to recognize the uniqueness of the patient
and family and to value the patient as a co–decision
maker in selection of interventions or approaches
toward his or her improved health.
The individual’s or group’s beliefs about health
and illness must be understood if one is to design
54 Foundations for Cultural Competence
2780_Ch03_045-059 16/07/12 11:38 AM Page 54

interventions that are likely to have an impact on
health behavior. Their definitions of health and their
perceptions of the importance of health states such
as mobility, freedom from pain, prolonged life ex-
pectancy, and preservation of faculties are important
to define because they are valued differently, and
these values influence both clinician recommenda-
tions and patient decisions. Failure to consider these
patient preferences and practicing from a medical
model value system leads to unintentional bias to-
ward a professional’s view of the world (Kitson,
2002). If EBP is to be value-added, it is critical to en-
sure that the users of the knowledge—the health-care
providers—become active shapers of knowledge and
action (Clough, 2005). Health-care providers must
be prepared to make “real-time” adjustments to their
approach to care based on patient feedback.
Culture embodies a way of living, a worldview tar-
geting our beliefs about human nature, interpersonal
relationships, relationships of people to nature, time
or the temporal focus of life, and ways of living one’s
life (activity). Health-care providers armed with this
culture-general knowledge are more open to multiple
ways of being, and it serves as a framework for build-
ing culture-specific knowledge. It is important to un-
derstand the factors that an individual from one
cultural group believes cause different types of ill-
nesses and the culture-specific remedies to treat those
illnesses. Although not easy to assess, Hulme (2010)
provides questions to determine an individual’s ex-
planatory model for health conditions. Questions ad-
dress the patients’ perception of what they think
caused the problem, why they think it started, and
when it started; what they think their sickness does to
them; how they perceive the severity and duration of
the illness; what they expect from the treatment; the
main problems the illness has caused them; and their
fears about the illness.
When designing counseling and prevention pro-
grams for communities and populations, it is impor-
tant to be guided by the notion that best practices in
counseling and prevention programs do not automat-
ically translate intact across cultural lines (Giihert,
Harvey, & Belgrave, 2009). Adaptations of best prac-
tices to integrate culture-specific approaches can
become an active ingredient in enhancing outcomes.
Giihert and colleagues (2009) identified that Africen-
tric interventions and culturally congruent practices
targeting African American populations have demon-
strated significantly greater positive outcomes across
several important behavioral health areas, including
increases in positive child, adolescent, and family de-
velopment; improved outcomes for incarcerated indi-
viduals; and decreases in substance abuse and HIV
risk behavior. Cultural translation is the process of
adapting EB guidelines or best practice to be congru-
ent with select populations of interest and should be
undertaken when there is “variability across groups,
when cultural or contextual processes influence risk or
protection from target problems, or when the external
validity of evidence-based interventions is jeopardized
by differences in engagement (e.g., participation rates,
attrition, and compliance)” (DePue et al., 2010).
Understanding and integrating patient values require
attention to salient ethnocultural factors, such as beliefs,
language, and traditions. Developing a relationship with
the patient; listening to the patient’s expectations, con-
cerns, and beliefs; and informing the patient of the evi-
dence is the beginning to making the patient central to
the decision-making process. With this base it is possible
for a professional’s perspective as health-care provider
and the patient’s preferences and characteristics to
be weighed equally in the decision-making process, a
process known as shared decision making. In shared de-
cision making, the clinician contributes technical expert-
ise, while the patient is the expert on his or her own
needs, situations, and preferences. Bringing the two to-
gether advances the goal of the decision-making process
to match care with patient preferences and to shift the
locus of decision making from solely the clinician to the
patient (Johnson, Kim, & Church, 2010).
Shared decision making is called for when there is
no clearly indicated “best” therapeutic option or in
preference-sensitive situations or situations where the
best choice depends on the patients’ values or their pref-
erences for the benefits, harms, and scientific uncertain-
ties of each option (Godolphin, 2009). It is the process
of interacting with patients who wish to be involved in
arriving at an informed, values-based choice among two
or more medically reasonable alternatives. Examples of
preference-sensitive situations include the following:
1. Should I have knee replacement surgery for my
arthritis?
2. Should I take warfarin to prevent a stroke?
3. Should I take allergy shots?
4. Should I have an MRI for low back pain?
5. Should I stop taking my antidepressants and take
herbal treatments?
6. Facilitating shared decision making involves com-
municating individualized information on treatment
options, treatment outcomes, and probabilities of
the benefits and risks and having patients reflect
and discuss their personal values or the importance
they place on benefits versus harms so that a deci-
sion on the best strategy can be reached.
7. Hulme (2010) emphasizes that not involving pa-
tients in shared decision making because of per-
ceptions of inability to pay or different cultural
models is paternalistic at best and an example of
institutional racism at worst.
8. Clinicians need to partake in shared decision
making with all patients and be willing to discuss
options congruent with culture.
Individual Cultural Competence and Evidence-Based Practice 55
2780_Ch03_045-059 16/07/12 11:38 AM Page 55

To assist clinicians with shared decision making,
EB patient decision aids (PtDAs) have been devel-
oped. PtDAs are tools that help people become in-
volved in decision making by providing information
about the options and outcomes and by clarifying
personal values (Godolphin, 2009). They aid people
in making specific and deliberative choices among
options by providing information about the options
and outcomes that are relevant to a person’s health
status. In randomized trials, PtDAs have improved pa-
tient knowledge, improved the proportion of patients
with realistic perceptions of the chances of benefits
and risks, reduced decisional conflict/uncertainty, and
prevented overuse of options that informed patients
do not value (O’Connor, Llewellyn-Thomas, & Flood,
2004). They are different from traditional patient
education material because they present balanced,
personalized information about options in enough de-
tail for patients to make informed judgments about
the personal value of the options (O’Connor et al.,
2007). They are designed to complement, rather than
replace, counseling from a health-care provider.
O’Connor and colleagues (2004) found that deci-
sion aids had the following core elements: tailored in-
formation provision, exercises that support values
clarification, and guidance in how to arrive at deci-
sions. For a patient, a decision-making aid can help to
clarify what he or she wants in a treatment, to weigh
the pros and cons of different options, and to under-
stand how the options would affect her or him person-
ally (Edwards & Elwyn, 2009). With the use of a
decision-making aid, patients can feel confident that
they have the information necessary to make a deci-
sion. For clinicians, decision aids can promote more
effective counseling by providing the clinician with
more accurate, structured, and complete information;
reducing the need to memorize information; and help-
ing ensure compliance with standards (Elwyn, Frosch,
Volandes, Edwards, & Montori, 2010).
The Ottowa Hospital Research Institute has as one
of its primary missions practice-changing research with
an emphasis on knowledge translation, clinical decision
rules, and patient decision aids. It is a leader in shared
decision-making research and has a tool for a general
decision guide that can be used for any health or social
decision, as well as nearly 300 decision aids on specific
treatment topics. Other developers of PtDAs include the
Foundation for Informed Medical Decision Making
and its commercial partner Health Dialog, Healthwise,
the Mayo Clinic, and the Dartmouth Hitchcock Center
for Shared Decision Making. The National Cancer
Institute and the Centers for Disease Control and
Prevention are compiling and managing clearinghouses
of decision aids. Searches for decision aids can be done
by keying in the terms decision aid, patient decision aid,
decision guide, or patient decision guide and the condi-
tion of interest.
To ensure quality in PtDA development, the
CREDIBLE quality standards acronym can be used
to evaluate the tool as shown in Table 3-3. The criteria
were developed as part of the Cochrane Systematic
Review of Patient Decision Aids.
Clinical Context
The clinical context encompasses the setting in which
okay health care is provided or the environment in
which the proposed change is to be implemented
(McCormack, Kitson, Harvey, Rycroft-Malone,
Titchen, & Seers, 2002). Drennan (1992) argues that
culture, or “the way things are done around here,” at
56 Foundations for Cultural Competence
❙❙◗ Table 3-3 CREDIBLE Criteria for Evaluating
Patient Aids
C Competently Developed
R Recently Updated
E Evidence-Based
DI Disclosures of Conflicts of Interest
BLBalanced Presentation of Options, Benefits,
and Harms
E Decision Aid Is Efficacious at Improving
Decision Making
• Are the essential components
that promote quality decision
making included?
• Are the credentials of developers
included in the decision aid or
supporting materials?
• Is the development process ade-
quate? A complete development
process includes a needs assess-
ment and review by a panel of
experts and a panel of potential
users.
• Does the developer have an up-
date policy or evidence review
process that is continuous or at
least every two years?
• Is there a link to an evidence re-
view group, or is the process that
was used to identify and appraise
evidence described?
• Are references to scientific stud-
ies or systematic overviews used
to support statements describing
benefits/harms?
• Is there disclosure of sponsorship
and conflict of interest?
• Is there a balanced presentation
of potential harms and benefits?
• Do the majority of users find it
balanced?
• Do evaluations show that the
decision aid improves knowledge?
• Do evaluations show that the
decision aid is acceptable to
users?
• Do evaluations show other
benefits?
• Do evaluations show that it was
free from adverse effects?
• Do evaluations include a
randomized controlled trial?
2780_Ch03_045-059 16/07/12 11:38 AM Page 56

the individual, team, and organizational levels creates
the context for practice and change. Organizational
culture is a paradigm—a way of thinking about the
organization, comprising a linkage of basic assump-
tions, values, and artifacts (Schein, 1992) and having
its own belief system, paradigms, customs, and lan-
guage. In addition to organizational culture, the med-
ical culture also has a powerful influence on treatment
approaches and modalities. The medical culture val-
ues objectivity, cause and effect, biophysical care,
and, in many cases, the power of their own expertise
and status. These cultures may be resistant to new
paradigms calling for EBP. Additionally, these values
may be in opposition to patient values, creating
clashes between providers and patients.
A largely unexplored disparity currently exists be-
tween the beliefs and expectations of health-care
providers and patients, particularly when there is also
a disparity between the cultures/ethnicity of the two
(Asthma and Allergy Foundation of America, 2005;
Enarson & Ait-Khaled, 1999; Walker, Weeks, McAvoy,
& Demetriou, 2005). Viewing biomedicine as a culture
in itself, such that interactions between patients and
health-care providers become a communication
between cultures or transactions between worldviews,
appears to be a necessary process in establishing a
trusting and effective partnership and thus improving
the health outcomes of patients.
The clinical context also includes the environment
in which health behaviors are enacted. As such it goes
beyond the traditional health-care organizational set-
ting and includes the home, residential care, the neigh-
borhood, and the broader community. The importance
of context is becoming more apparent, with a greater
emphasis on implementation science or the study of
methods to promote the transfer of research findings
into routine health-care policy and practice. However,
evidence on which interventions work in specific
contexts is not readily available.
Clearly, more research is needed that focuses on the
contextual realities of implementation. It is believed
that better attention to context will result in testable
approaches to facilitate knowledge into action in real-
world settings. Innovative approaches have been de-
veloped and can serve as models for clinicians. Three
examples include the Centers for Disease Control
and Prevention’s (CDC) ‘s DEBI (Diffusion of Effec-
tive Behavioral Interventions , 2001) project (www.
effectiveinterventions.org), the RE-AIM framework,
and the Health Care Innovations Exchange.
The DEBI project was designed to bring science-
based, community, group, and individual-level HIV
prevention interventions to community-based service
providers and state and local health departments and
has documented many innovations for implementa-
tion science approaches. It provides strategies for com-
munity, group, and structural interventions to facilitate
adoption of health behaviors that will reduce the
spread of HIV.
The RE-AIM (2011) framework (www.re-aim.org)
was first used as a model to encourage consistent re-
porting of research results, then as a way to organize
reviews of the existing literature on health promotion
and disease management in different settings, and,
subsequently, as a model to translate research into
practice and to help plan programs and improve their
chances of working in real-world settings. It is a valu-
able framework for understanding the relative strengths
and weaknesses of different approaches to health pro-
motion and chronic disease self-management, such as
in-person counseling, group education classes, tele-
phone counseling, and Internet resources in a variety
of contexts. These are the five steps to translate
research into action:
1. Identify strategies to effectively Reach your target
population.
2. Test the Effectiveness or efficacy in the target
population.
3. Develop strategies to facilitate Adoption of
strategies by target settings or institutions.
4. Ensuring that the intervention is Implemented
consistently.
5. Maintenance of intervention effects in individuals
and settings over time.
Reach and efficacy are individual levels of impact.
In order to reach beyond the individual level to gain
wider translation, it is necessary to consider organiza-
tional strategies: adoption and implementation. Main-
tenance can be at both individual and organizational
levels of impact.
Finally, AHRQ, Health Care Innovations Ex-
change is a web-based repository of evidence aimed
at increasing the rate of implementation of new and
better ways of delivering health care toward its mis-
sion to improve the quality of health care and reduce
disparities. It offers busy health professionals and re-
searchers a variety of opportunities to share, learn
about, and ultimately adopt EB innovations and tools
suitable for a range of health-care settings and popu-
lations (http://www.innovations.ahrq.gov/about.aspx).
The abundance of new evidence that has not been
successfully translated into practice is a critical re-
minder of the importance of context and the strength
of the existing culture. Difficult questions remain to
be addressed. What should be done with health-care
providers who cannot or will not adapt to EBP? How
will lack of interdisciplinary collaboration be ap-
proached? How will it be handled if long-standing
treatment approaches show no evidence of fostering
improvement? What is the individual’s responsibility
compared with the organization’s and community’s
responsibilities in ensuring readiness for EBP? What
are the best approaches for facilitating knowledge
Individual Cultural Competence and Evidence-Based Practice 57
2780_Ch03_045-059 16/07/12 11:38 AM Page 57

translation in different contexts? Knowing the answer
to some of these questions will influence outcomes of
getting knowledge into practice.
Evidence-based practice is not research-directing
practice but evidence-informing practice. The clinician
evaluates best evidence in light of his or her clinical
expertise, patient preferences, and clinical context to
make decisions about patient or program manage-
ment. Health-care providers practicing from an EB
perspective need the skills to acquire and evaluate ev-
idence, make decisions about adaptation of evidence,
or plan to be congruent with the patient values and
clinical context.
R E F E R E N C E S
Agency for Healthcare Research and Quality. (2010). 2010 Na-
tional healthcare disparities report. U.S. Department of Health
and Human Services. Rockville, MD. Retrieved from
http://www.ahrq.gov/qual/nhdr10/nhdr10
Antes, G., Sauerland, S., & Seiler, C. M. (2006). Evidence-based
medicine—From best research evidence to a better surgical
practice and health care. Archives of Surgery, 391, 61–67.
Asthma and Allergy Foundation and the National Pharmaceuti-
cal Council. (2005). Asthma and Allergy Foundation of Amer-
ica. Ethnic disparities in the burden and treatment of asthma.
National Pharmaceutical Council.
Boyle, J., & Andrews, M. (2011). Transcultural concepts in nursing
(5th ed.). Philadelphia: Lippincott.
Calvillo, E., Clark, L. Ballantyne, J., Pacquiao, D., Purnell, L., &
Villarruel, A. (2009). Cultural competency in baccalaureate ed-
ucation. Journal of Transcultural Nursing, 20(2), 137–145.
CASP International. (2011). Retrieved April 8, 2011 from http://
www.caspinternational.org/?o=1012
Clough, E. (2005). Foreword. In J. Burr and P. Nicholson (Eds.), Re-
searching health care consumers, critical approaches (pp. ix–xi).
Basingstoke, UK: Palgrave (MacMillan).
International Medical Interpreters Association. (1987). Code of
ethics for medical interpreters. Retrieved from http://www.
imiaweb.org/uploads/pages/376
Con, A. (2008). Cross-cultural considerations in promoting advance
care planning in Canada. Retrieved from http://www.bccancer.
b c . c a / N R / r d o n l y r e s / E 1 7 D 4 0 8 A – C 0 D B – 4 0 FA – 9 6 8 2 –
9DD914BB771F/28582/COLOUR030408_Con
Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner, J., Moore, S.,
Sullivan, D.T., Ward, D., & Warren, J. (2009). Quality and
safety education for advanced nursing practice. Nursing Out-
look, 57(6), 338–348.
DePue, J.D., Rosen, R.K., Batts-Turner, M., Bereolos, N., House,
M. Held, R.F., Nu’usolia, O., Tuitele, J., Goldstein, M.G., &
McGarvey, S.T. (2010). Cultural translation of interventions:
Diabetes care in American Samoa. American Journal of Public
Health, 100(11), 2085–2093.
Douglas, M., Pierce, J., Rosenkoetter, M., Clark Callister, L., Hattar-
Pollara, M., Lauderdale, J., Milstead, J., Nardi, D., Pacquiao, D.,
& Purnell, L. (2011). Standards of practice for culturally compe-
tent nursing care. Journal of Transcultural Nursing, 22(4),
317–334.
Drennan, D. (1992). Transforming company culture. London:
McGraw-Hill.
Edwards, A., & Elwyn, G., eds. (2009). Shared decision-making. Achiev-
ing evidence-based patient choice. Oxford: Oxford University Press.
Elwyn, G., Frosch, D., Volandes, A.E., Edwards, A., & Montori,
V.M. (2010). Investing in deliberation: A definition and classi-
fication of decision support interventions for people facing dif-
ficult health decisions. Medical Decision Making, 30, 701–711.
Enarson, D.A., & Ait-Khaled, N. (1999) Cultural barriers to
asthma management [commentary] Pediatric Pulmonology, 28,
297–300.
Family Health International. (2010). Evidence-based guidelines for
youth peer education. Retrieved from http://www.fhi.org/NR/
rdonlyres/einc2hb5no52blspygp6gksckcgdvpa6b76gfevo7k537
fzyc53zrangjrhxisliwsagwqjeju7kfn/peeredguidelines
Foggs, M.B. (2008). Guidelines management of asthma in a busy
urban practice. Current Opinions in Pulmonary Medicine, 14(1),
46–56.
Giger, J., Davidhizar, R., Purnell, L., Taylor Harden, J., Phillips,
J., & Strickland, O. (2007). American Academy of Nursing Ex-
pert Panel Report: Developing cultural competence to elimi-
nate health disparities in ethnic minorities and other vulnerable
populations. Journal of Transcultural Nursing, 18(2), 95–102.
Giihert, D.J., Harvey, Á.R., & Belgrave, F.Z. (2009). Advancing
the Africentric paradigm shift discourse: Building toward
evidence-based Africentric interventions in social work practice
with African Americans. Social Work, 54(1), 243–252.
Godolphin, W. (2009). Shared decision making. Healthcare Quality,
12, 186–190.
Gray, B. (1998). Sources used in health policy research and impli-
cations for information retrieval systems. Journal of Urban
Health, 75(4), 842–852.
Haynes, R.B. (2006). Of studies, syntheses, synopses, summaries
and systems: The “5S” evolution of information services for
evidence-based health care decisions. American Collge of Physi-
cians (ACP) Journal Club, 145(3), A8–A9.
Hulme, P.A. (2010). Cultural considerations in evidence-based
practice. Journal of Transcultural Nursing, 21(3), 271–280.
Johnson, S.L., Kim, Y.W., Church, K. (2010). Towards client-
centered counseling: Development and testing of the WHO
Decision-Making Tool, Patient Education and Counseling, 81,
355–361.
Joint Commission. Advancing effective communication, cultural
competence and family centered care: A roadmap for hospitals.
(2010). Joint Commission.
Kaplan, J.E., Benson, C., Holmes, K.H., Brooks, J.T., Pau, A., &
Masur, H. (2009). Centers for Disease Control and Prevention
(CDC), National Institutes of Health, HIV Medicine Associ-
ation of the Infectious Diseases Society of America. Guide-
lines for prevention and treatment of opportunistic infections
in HIV-infected adults and adolescents: Recommendations
from CDC, the National Institutes of Health, and the HIV
Medicine Association of the Infectious Diseases Society
of America. MMWR Recommendation Report, 10, 58(RR-4),
1–207.
Kitson, A. (2002). Recognizing relationships: Reflections on
evidence-based practice. Nursing Inquiry, 9(3), 179–186.
Management of Asthma Working Group. (2009). VA/DoD clinical
practice guideline for management of asthma in children and
adults. Washington, DC: Department of Veteran Affairs,
Department of Defense.
McMurray, A. (2004). Culturally sensitive evidence-based prac-
tice. Collegian, 11, 14–18.
McCormack, B., Kitson, A., Harvey, G., Rycroft-Malone, J.,
Titchen, A., & Seers, K. (2002). Getting evidence into practice:
The meaning of “context.” Journal of Advanced Nursing, 38(1),
94–104.
Melnyk, B.M., Fineout-Overholt, E., Stillwell, S.B., & Williamson,
K.M. (2009). Igniting a spirit of inquiry: An essential foundation
58 Foundations for Cultural Competence
2780_Ch03_045-059 16/07/12 11:38 AM Page 58

for evidence-based practice. American Journal of Nursing,
109(11), 49–52.
Mosley, C. (2009). Evidence-based medicine: The dark side. Jour-
nal of Pediatric Orthopedics, 29(8), 839–843.
National Assessment of Adult Literacy. (2003). Retrieved from
http://nces.ed.gov/naal/
National Council on Interpreting in Health Care. (2007). Retrieved
from www.ncihc.org/
National Network of Libraries of Medicine. (2011). Retrieved
from http://nnlm.gov/
New York Academy of Medicine. (2011). Grey literature report.
Retrieved from http://www.nyam.org/library/online-resources/
grey-literature-report/
O’Connor, A.M., Stacey, D., Entwistle, V., Llewellyn-Thomas, H.,
Rovner, D., Holmes-Rovner, M., Tait, V., Tetroe, J., Fiset, V.,
Barry, M., & Jones J. (2004). Decision aids for people facing
health treatment or screening decisions. Cochrane Review, Issue
1. Chichester, UK: John Wiley & Sons, Ltd.
O’Connor, A.M., Llewellyn-Thomas, H.A., & Flood, A.B. (2004).
Modifying unwarranted variations in health care: Shared de-
cision making using patient decision aids. Health Affairs, no.
(2004). Retrieved from http://content.healthaffairs.org/con-
tent/early/2004/10/07/hlthaff.var.63.citation
O’Connor, A.M., Wennberg, J.E., Legare, F., Llewellyn-Thomas,
H.A., Mouton, B.W., Sepucha, K.R., Sodano, A.G., & King,
J.S. (2007). Toward the “Tipping Point”: Decision aids and in-
formed patient choice. Health Affairs, 26(3), 716–725.
Ottowa Hospital Research Institute. (2011). Retrieved from
http://decisionaid.ohri.ca/AZinvent.php
RE-AIM: Reach, Effectiveness, Adaptation, Implementation, and
Effectiveness. (2011). Retrieved April 8, 2011 from http://www.
re-aim.org/about-re-aim.aspx
Rycroft-Malone, J., Seers K., Titchen, A., Harvey, G., Kitson, A.,
& McCormack, B. (2004). Journal of Advanced Nursing, 47(1),
81–90.
Sackett, D. (2000). Evidence-based medicine: How to practice and
teach EB (2nd ed.). Amsterdam, The Netherlands: Churchill
Livingtone.
Salmond, S. (2007). Advancing evidence-based practice: A primer.
Orthopaedic Nursing, 26(2), 114–123.
Schein, E. H. (1992). Organizational culture and leadership (2nd
ed). San Francisco, CA: Jossey-Bass.
Shah, H.M., & Chung, K.C. (2009). Archie Cochrane and his vi-
sion for evidence-based medicine. Plastic and Reconstructive
Surgery, 124(3), 982–988.
Swanson, J.A., Schmitz, D., & Chung, K.C. (2010). How to prac-
tice evidence-based medicine. Plastic & Reconstructive Surgery,
126(1), 286–294.
Walker, C., Weeks, A., McAvoy, B., & Demetriou, E. (2005). Ex-
ploring the role of self-management programs in caring for
people from culturally and linguistically diverse backgrounds
in Melbourne, Australia. Health Expect, 8, 315–323.
World Health Organization/Pan American Health Organization
(HO/PAHO). (2010). Culture and mental health in Haiti: A lit-
erature review. Geneva: WHO. Retrieved from http://www.
who.int/mental_health/emergencies/culture_mental_health_
haiti_eng
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
Individual Cultural Competence and Evidence-Based Practice 59
2780_Ch03_045-059 16/07/12 11:38 AM Page 59

Chapter 4
Organizational Cultural
Competence
Stephen R. Marrone
Throughout the world, an emerging consensus is that
cultural competence is an essential component of ac-
cessible, socially responsive, and fiscally efficient qual-
ity health care. According to the Institute of Medicine
(2002), the key component that affects health dispar-
ities is the cultural competency of the health-care
provider. However, providing culturally competent
care has been hindered to some extent by a dearth of
systematic approaches and organizational support.
Cultural competence does not relate solely to the
care of patients, families, and the community; it is also
applicable to educational, health-care, and professional
organizations. As described in the Purnell Model (see
Chapter 2), the workforce issues domain can be used
to assess organizational culture and cultural issues
among staff.
The purpose of this chapter, therefore, is to provide
an overview of the requisite organizational infrastruc-
ture designed to create and sustain cultural compe-
tency. The National Standards for the Delivery of
Culturally and Linguistically Appropriate Health
Care Services (Office of Minority Health, 2001), the
Cultural Competence Assessment Profile (HRSA,
2002), and the Purnell Model for Cultural Compe-
tence, provide the organizing framework for this
chapter.
Health Disparities
Racial and ethnic diversity among health-care
providers correlates with the delivery of quality care
to diverse patient populations (Betancourt, Green,
Carrillo, & Ila, 2003). Evidence demonstrates that
racial concordance between minority patients and
minority physicians is associated with greater pa-
tient satisfaction and higher self-rated quality of
care (Saha, Komaromy, Koepsell, & Bindman,
1999). Evidence also supports that minority patients
prefer minority physicians regardless of practice
location or other geographic issues (Saha, Taggart,
Kamaromy, & Bindman, 2000). Spanish-speaking
patients, for example, report greater satisfaction
when care is provided by Spanish-speaking providers
than by non–Spanish-speaking providers (Morales,
Cunningham, Brown, Liu, & Hays, 1999). Likewise,
African-American patients report more satisfaction
with care when their physician utilizes an inclusive,
participatory decision-making approach to health
care (Cooper-Patrick et al., 1999). However, other
surveys report that not all patients prefer a health-care
provider of the same background (Robert Wood Johnson
Foundation, 2011).
Health disparities data suggest that members of mi-
nority groups experience a disproportionately higher
rate of illness, more severe complications, and in-
creased mortality and morbidity related to cardiovas-
cular disease, diabetes, asthma, and cancer (OMH,
2002). Multiple factors external to the health-care
system influence health disparities—namely, lower
socioeconomic status of minorities, hazardous jobs
with increased incidence of injury, lower educational
and literacy levels, lack of or inadequate health insur-
ance, fear of the health-care system, overuse of over-
the-counter medications and home remedies, and the
use of the emergency department for care. A systemic
review of the literature entitled Unequal Treatment:
Confronting Racial/Ethnic Disparities in Health Care,
conducted by the Institute of Medicine, reported the
findings of more than 175 studies that illustrated racial
and ethnic disparities in the diagnosis and treatment
of multiple medical conditions, even when analyses
were controlled for socioeconomic status, insurance
status, site of care, stage of disease, comorbidities, and
age (IOM, 2003).
The root causes of health disparities relate to a dis-
connect between patients’ health beliefs, values, pref-
erences, and behaviors and those of the dominant
60
2780_Ch04_060-073 16/07/12 11:38 AM Page 60

health-care system (Coleman-Miller, 2000). This lack
of fit includes variations in patient recognition of
symptoms; thresholds for seeking care; the ability to
communicate symptoms to a provider who under-
stands their meaning; the ability to understand the
prescribed treatment plan, including use of medica-
tions; expectations of care; access to and utilization
of diagnostic and therapeutic procedures; and adher-
ence to preventive measures (Einbinder & Schulman,
2000). These core factors are considered to be the
primary influencers for decision making among pa-
tients and health-care providers, physicians in par-
ticular, and the degree to which patients access and
interact with the health-care delivery system (Public
Health Reports, 2003). Emphasis on cultural com-
petency in health care and culturally competent
health-care organizations has emerged as a result of
these findings.
Culturally Competent Health-Care
Organizations
Cultural competence in health care has been defined
as “a set of congruent behaviors, attitudes, and poli-
cies that come together in a system, agency, or
among professionals and enable that system, agency,
or those professionals to work effectively in cross-
cultural situations” (HRSA, 2002, p. 3). The tenets
of cultural competency are not specific to one
health-care discipline and must be inclusive of all
professional disciplines, as well as clerical, technical,
and unlicensed assistive personnel. Hence, the pro-
vision of culturally safe care relies on all members
of the health-care team receiving consistent and
comparable information about the needs of the di-
verse patients, families, and communities they serve
(Public Health Reports, 2003). It is important to un-
derstand that cultural competency is a process and
not a result (Purnell, Davidhizar, Giger, Fishman,
Strickland, & Allison, 2011). To be effective, health
care must reflect the unique understanding of the
values, beliefs, attitudes, lifeways, and worldviews of
diverse populations and individual acculturation
patterns (Purnell, 2008).
A culturally competent health-care organization in-
corporates culture at all levels to meet culturally unique
needs (Purnell et al., 2011). Culturally competent
health-care organizations outperform their competitors
by achieving and sustaining greater performance and
outcomes measures and increased market share as evi-
denced by improved consumer access to care. Enhanced
quality of care reduces health disparities and improves
health outcomes for vulnerable and underserved pop-
ulations. Thus, greater patient and staff satisfaction
leads to an increased consumer market share to and
secures financial sustainability of the organization
(Marrone, 2010).
◗ Examining where you work/go to school, what
evidence can you find that the mission and
philosophy of the organization include statements
on diversity and inclusion? Is the board of trustees
reflective of the diversity of the community and
patient population?
Culturally competent health-care delivery organiza-
tions provide consumers with effective, understandable,
and respectful care provided in ways that fit with their
cultural values and beliefs and in the consumer’s pre-
ferred language. To achieve this goal, organizations de-
velop, implement, and promote a written strategic plan
that outlines clear goals, policies, operational plans, and
management accountability/oversight mechanisms to
provide culturally and linguistically appropriate serv-
ices. Consequently, to ensure the design of an evidence-
based strategic plan, the organization conducts initial
and ongoing organizational self-assessments of diver-
sity-related activities. It integrates cultural and linguistic
competence-related measures into internal audits, per-
formance improvement programs, patient satisfaction
assessments, and outcomes-based evaluations. Finally,
it collects and updates information related to con-
sumers’ race, ethnicity, and spoken and written lan-
guage(s) and integrates this information into the
organization’s data management system. These data
help maintain a current demographic, cultural, and epi-
demiological profile of the community to plan for and
implement services that respond to its cultural and
linguistic characteristics (OMH, 2001).
◗ Does the organization where you work/go to
school have a strategic plan that reflects the needs
of the community? What would you recommend
to improve organizational competence?
To determine the need for diversity-related serv-
ices, it is essential that organizations create a com-
munity demographic needs assessment tool to assess
the cultural beliefs and language needs of the people
who live there. To provide effective patient educa-
tion, it is necessary to review the language literacy
level and the use of culturally respectful images in
written and visual (i.e., television or video) patient
education materials. Organizations should develop
systems that indicate whether language assistance is
needed prior to or at the point of entry into the
organization (Purnell et al., 2011)
A key ingredient to creating and sustaining organi-
zational cultural competency is to designate diversity
champions who have acquired the requisite knowledge
and skills to provide culturally congruent care at all
levels within the organization. Champions can mentor
other health-care providers within their discipline
and/or department to expand their influence on
consumer care and services. Furthermore, culturally
competent human resources departments promote
Organizational Cultural Competence 61
2780_Ch04_060-073 16/07/12 11:38 AM Page 61

patient-centered care by including patient satisfaction
measures in employee performance appraisals (Purnell
et al., 2011), by establishing diversity-related sentinel
events, and by completing a root cause analysis. Cul-
turally competent organizations create their own or
revise standardized consumer satisfaction tools to in-
clude items related to the provision of culturally and
linguistically appropriate care and monitor data at all
levels of committee and council meetings throughout
the organization. Developing a data bank with best
practices and lessons learned need not be complex.
The following items have been used successfully:
1. “Did you receive care that was respectful to your
cultural and religious beliefs?”
2. “Did you receive care in your preferred language?”
3. “Did you receive care in a language that helped
you to make informed decisions?”
To be effective, written satisfaction surveys should
be translated into the languages that represent the
catchment area for the organization (Purnell et al.,
2011).
Andrews (1998) provided the following six-step
framework for ensuring organizational cultural
competency:
1. Collect demographic and descriptive data of the
prevalent cultural, ethnic, linguistic, and spiritual
groups represented among patients, families, visitors,
the community, and the staff in the service area.
2. Describe the effectiveness of current systems and
processes in meeting diverse needs.
3. Assess the organization’s strengths and limitations
by examining the institution’s ethos toward cul-
tural diversity and the presence or absence of a
corporate culture that promotes accord among its
constituents.
4. Determine organizational need and readiness for
change through dialogue with key stakeholders
aimed at discovering foci of anticipated support
and recognizing areas of potential resistance.
5. Implement strategic plans, policies, and proce-
dures that include measurable benchmarks of suc-
cess and an ongoing process to ensure that change
is maintained.
6. Evaluate actual outcomes against established
benchmarks utilizing performance improvement,
quality, and customer satisfaction data.
Culturally competent health-care organizations im-
plement strategies to recruit, retain, and promote at
all levels of the organization a diverse staff and lead-
ership team that are representative of the demograph-
ics of the service area. The goal of recruiting and
retaining a diverse workforce that matches the demo-
graphics of the service area is to reduce health dispar-
ities among vulnerable and underserved populations
that often results from discordant consumer–provider
relationships. Culture and language discordance can
lead to decreased access to care, decreased quality of
care, increased cost of care, decreased patient satisfac-
tion, recidivism, discrimination, and poor health out-
comes (American Association of Critical Care Nurses,
2008; Europa, 2010).
◗ In the organization where you work/go to
school, are pictures, posters, and calendars repre-
senting the diversity of the patient and staff
posted throughout the organization? What addi-
tional pictures or posters would you include?
To reduce discordance between consumers and
providers, an organization needs to integrate diversity
into the organization’s mission statement, strategic
plans, and goals (Purnell et al., 2011). A diverse work-
force program should include mentoring programs,
community-based internships, and collaborations with
academic partners such as universities, local schools,
training programs, and faith-based organizations. To
expand the recruitment base, organizations should re-
cruit at minority health and recruitment fairs, advertise
in multiple languages, and list job opportunities in mi-
nority publications such as local newspapers and com-
munity newsletters (Purnell et al., 2011).
CLAS Standards
The National Standards on Culturally and Linguisti-
cally Appropriate Services in Health Care (CLAS
Standards) were developed via national consensus by
the U.S. Department of Health and Human Services—
Office of Minority Health (OMH). The CLAS Stan-
dards were intended to guide health-care organizations
in the provision of safe care and services that were cul-
turally, ethnically, linguistically, and spiritually appro-
priate and effective. The guiding principles and
associated actions and interventions of culturally and
linguistically appropriate health-care services are in-
tended to be integrated throughout the organization
and designed, implemented, and evaluated in partner-
ship with the communities being served (OMH, 2001).
The 14 CLAS Standards are organized according
to the following themes (OMH, 2001):
1. Standards 1–3 reflect culturally competent care.
2. Standards 4–7 refer to language access services,
such as interpreter and translation services.
3. Standards 8–14 outline organizational support for
cultural competence in health care. These stan-
dards are currently under revision and therefore
will not be repeated here in their entirety.
Cultural Competence Assessment
Profile
The Cultural Competence Assessment Profile, funded by
the U.S. Department of Health and Human Services—
Health Resources and Services Administration (HRSA),
62 Foundations for Cultural Competence
2780_Ch04_060-073 16/07/12 11:38 AM Page 62

was developed to answer the question “How do we
know cultural competence when we see it?” (HRSA,
2002). The Profile is based on evidence from founda-
tional work in organizational cultural competency
such as the CLAS Standards and provides the infra-
structure to conceptualize how to assess cultural com-
petence at the organizational level. Essentially, the
profile is intended to gather information based on the
specific performance and outcomes characteristics
that should be evident across the health-care contin-
uum in a culturally competent organization. The Pro-
file can assist organizations by providing a framework
to organize activities related to the cultural compe-
tence and quality monitoring for compliance with
cultural competence standards (HRSA, 2002).
The Assessment Profile was built on the following
assumptions:
• Organizational cultural competence is an integral
component of patient-centered care and can con-
tribute to improving access to care, quality of care,
and health outcomes.
• Health-care organizations drive the development
and maintenance of individual provider cultural
competence and the environment of care.
• Cultural competence is a business imperative that
supports organizational branding and increases the
organization’s market share among diverse cultural
groups, thereby leading to continuous service and
process improvements (HRSA, 2002).
The performance areas of the Cultural Competence
Assessment Profile include organizational values,
governance, planning and monitoring/evaluation,
communication, staff development, organizational
infrastructure, and services/interventions (HRSA,
2002). Organizational values refer to the organiza-
tion’s viewpoint regarding cultural competence and its
commitment to provide culturally congruent care.
Governance relates to goal-setting, policy-making,
and oversight methods used to help ensure the deliv-
ery of culturally congruent care. Planning, monitoring,
and evaluation include the use of internal and external
stakeholders in short- and long-term planning for the
delivery of culturally congruent health-care services.
Communication focuses on the schema through
which information is exchanged, vertically and hori-
zontally, with internal and external consumers, exec-
utives, and members of the health-care team in order
to promote cultural competence. Staff development
underscores the need for organizations to ensure that
staff at all levels of the organization acquire the atti-
tudes, knowledge, and skills for delivering culturally
congruent care. Organizational infrastructure refers to
organizational resources required to hardwire the de-
livery of culturally congruent care and services
throughout the continuum of care. Services and inter-
ventions relate to an organization’s delivery of clinical
and community health services that reflect the needs
of the diverse consumer groups within the organiza-
tion’s service area (HRSA, 2002).
The Purnell Model
Theories and conceptual models are essential in sci-
entific disciplines because they enable health-care
providers to describe, explain, and predict concepts
and phenomena. Nursing and health-care theories
guide practice, influence decisions and interventions,
and provide a framework for evaluating outcomes.
Theory serves as the foundation for the provision of
culturally congruent care by culturally competent
health-care providers.
The Purnell Model is based on theories and evi-
dence derived from organizational, administrative,
communication, and family development theories, in
addition to anthropology, sociology, psychology,
anatomy and physiology, biology, ecology, nutrition,
pharmacology, religion, history, economics, political
science, and linguistics. Hence, the major assumptions
of the Purnell Model that affect organizational cul-
tural competency were developed from a broad per-
spective, allowing their use across practice disciplines
and organizational/environmental contexts. See Chap-
ter 2 for a complete description of the Purnell Model.
The Purnell Model is germane to all health-care
disciplines in a variety of environmental contexts.
The 12 domains of the Purnell Model can provide an
organizing framework for organizational cultural
competency as it highlights the importance of inter-
professional collaboration with emphasis on patient-
centered care, managed care, and case management
across the health-care continuum. The model can
guide the development of assessment instruments,
planning strategies, and individualized patient, fam-
ily, or community interventions
As outlined in Table 4-1, triangulation among the
Purnell Model, current CLAS Standards (OMH,
2002), and the Cultural Assessment Profile (HRSA,
2002) can be used to frame the design of an organiza-
tional cultural competency program. The Purnell do-
main overview and heritage supports that culturally
competent organizations articulate mission and vision
statements, values, a strategic plan, and standard
operating procedures (policies and procedures) that
reflect the value of diversity. The mission, vision, and
values drive the shared governance model that pro-
vides for a dedicated chief diversity officer to oversee
the activities of a transdisciplinary diversity council.
A cultural health assessment should be included in
patient history and assessment data at all points of
entry into the system. Traditional or folk healing prac-
tices that are integrated into the plan of care should
be identified.
The Purnell domain communication supports orga-
nizational efforts to ensure that signage is placed in all
Organizational Cultural Competence 63
(continued on page 68)
2780_Ch04_060-073 16/07/12 11:38 AM Page 63

64 Foundations for Cultural Competence
❙❙◗ Table 4-1 Crosswalk: Purnell Model, CLAS Standards, and Cultural Assessment
Purnell Model Domains1 CLAS Standards2 Cultural Assessment Profile3 Indicators
Overview/Heritage
Advocates for the formation of
a transdisciplinary diversity
council, ethics committee, and
patient education committee
that include community mem-
bers and give attention to the
health literacy of the service
area. A strong community part-
nerships with key individuals
and agencies reflective of the
demographics in the service
area, and the health-care team
should include community
members of governing board
(Purnell, 2011).
Communication supports organi-
zational efforts to ensure that
signage is placed in all areas in
multiple languages related to di-
rections within the organization.
Requires that the availability of
language assistance services and
includes sign language, the
translation of critical documents
such as consents and patient
education materials, pain scales,
and communication boards/aids
for patients who are not able to
speak or understand the domi-
nant language.
Standard 1:
Effective, respectful care
in preferred language.
Standard 2:
Cultural, demographic,
and epidemiological
community profile.
Language assistance
services
Standard 5:
Notice of language
assistance services
Standard 6:
Competence of lan-
guage assistance
services provided by
interpreters
Standard 7:
Translated signage and
patient materials
Domains:
Organizational values
Governance
Staff development
Organizational infrastructure
Domain:
Governance
• Mission, vision, values, strate-
gic plan, and standard operat-
ing procedures (policies and
procedures) that reflect value
of diversity
• Shared governance model
• Dedicated chief diversity
officer
• Diversity competence pro-
gram for all levels of staff
• History and assessment data-
bases that include traditional
and folk healing practices
• Cultural health assessment
performed by clinical staff
• Code of professionalism that
outlines diverse behavioral
expectations
• Breaches trigger a “culture
code” for immediate inter-
vention
• Transdisciplinary diversity
council, ethics committee,
and patient education com-
mittee that include commu-
nity members
• Community partnerships
with key individuals and agen-
cies reflective of the demo-
graphics in the service area
and the health-care team
• Community members of the
governing board and deci-
sion-making groups
• Dynamic demographic data
collection and management
systems
• Signage in multiple languages
• Translation of critical docu-
ments such as consent forms,
patient education materials,
pain scales, communication
boards
• Patient education programs
that address diversity of the
service area, such as meal
planning for diabetes man-
agement of Caribbean
Americans
• Customer service initiatives
that address diversity
• Maintain an organizational
language
2780_Ch04_060-073 16/07/12 11:38 AM Page 64

Organizational Cultural Competence 65
❙❙◗ Table 4-1 Crosswalk: Purnell Model, CLAS Standards, and Cultural Assessment Continued from page 64
Purnell Model Domains1 CLAS Standards2 Cultural Assessment Profile3 Indicators
Family roles and organization
Can guide the development of
organizational visitation poli-
cies, including open visiting
hours that address cultural
norms and visitor role respon-
sibilities; policies related to
diverse decision-making prac-
tices, such as informed consent;
and the purchase and utiliza-
tion of racially, ethnically, and
age-appropriate toys for infants
and children and high-fidelity
manikins used in simulation
education.
Workforce issues
Supports the development of
diversity-related education
content and competencies
integrated into orientation,
in-service education, staff
development, and continuing
education programs for all lev-
els of staff and the integration
and utilization of a standard-
ized communication method
such as SBAR (Situation,
Background, Assessment, and
Recommendation) among
the interprofessional health-
care team
Biocultural ecology
Gives direction to the develop-
ment of educational programs
and clinical practices that rec-
ognize physical and genetic
variations that have an impact
on assessment and treatment
plans including preventive serv-
ices and early screening, and to
the design of patient educa-
tion, counseling, and screening
related to known genetic pre-
dispositions to diseases and
biological variations regarding
the pharamcokinetics of med-
ications and other substances.
Standard 1:
Effective, respectful care
in preferred language
Standard 2:
Recruit, retain, and
promote diversity
Standard 3:
Ongoing staff education
Standard 8:
Written strategic plan
Standard 9:
Conduct organizational
self-assessment
Standard 10:
Collect demographics
and integrate into
data management
system
Standard 11:
Implement services
based on demo-
graphic profile
Standard 12:
Collaborative commu-
nity partnerships
Standard 13:
Culturally relevant con-
flict management
processes
Standard 14:
Inform public of diversity-
related initiatives
Standard 1:
Effective, respectful care
in preferred language
Domains:
Organizational values
Planning Monitoring, and
evaluation
Staff development
Organizational infrastructure
Services and interventions
Domains:
Organizational values
Governance
Communication
Staff development
Organizational infrastructure
Domains:
Organizational values
Planning
Monitoring and evaluation
Staff development
Organizational infrastructure
Services and interventions
• Visitation policies, including
open visiting hours that ad-
dress cultural norms and visi-
tor role responsibilities
• Protocols for diverse deci-
sion-making practices, such as
informed consent
• Racially, ethnically, and age-ap-
propriate toys and manikins
used in simulation education
• Diversity content and com-
petencies integrated into ori-
entation, in-service education,
staff development, and con-
tinuing education programs
for all levels of staff
• Standardized communication
methods among caregivers,
such as using SBAR or other
shared mental and communi-
cation models
• Educational programs and
clinical practices that recog-
nize physical and genetic vari-
ations that affect assessment
and treatment plans including
preventive services and early
screening.
• Patient education, counseling,
and screening related to
known genetic predisposi-
tions to diseases and biologi-
cal variations regarding drug
metabolism.
Continues on page 66
2780_Ch04_060-073 16/07/12 11:38 AM Page 65

66 Foundations for Cultural Competence
❙❙◗ Table 4-1 Crosswalk: Purnell Model, CLAS Standards, and Cultural Assessment Continued from page 65
Purnell Model Domains1 CLAS Standards2 Cultural Assessment Profile3 Indicators
High-risk behavior
Identifies the need for assessing
known high-risk behaviors in
the service area and including
these behaviors on the risk as-
sessment portions of patient
admission histories and health
screenings for inclusion in pa-
tients’ plans of care.
Nutrition
Lends importance to creating
menu plans that reflect the de-
mographics of the services
area, such as offering kosher or
halal meals or other ethnic
meal choices; formulating poli-
cies and procedures that ad-
dress bringing ethnic foods
from home; using hot versus
cold foods and drinks during
illness and recovery; and estab-
lishing flexible meal times to
accommodate culturally driven
meal time preferences, for ex-
ample, offering dinner at sun-
down for fasting during
Ramadan for Muslim patients.
Pregnancy and childbearing
practices
Supports the development of
perinatal practices, policies, and
procedures that address diverse
birthing practices, including gen-
der roles and responsibilities be-
fore, during, and after birth; hot
versus cold; and views of birth
as a sickness/illness or natural
experience.
Death rituals
Requires that organizations de-
velop plans for the provision of
culturally relevant palliative
care services, policies, proce-
dures, and staff competencies
that address diverse dying and
bereavement practices across
the lifespan, and culturally rele-
vant counseling services re-
lated to death and dying, organ
donation, and care of the body
at the time of death.
Standard 1:
Effective, respectful care
in preferred language
Standard 1:
Effective, respectful care
in preferred language.
Standard 1:
Effective, respectful care
in preferred language.
Standard 1:
Effective, respectful care
in preferred language.
Domains:
Organizational values
Planning Monitoring and
evaluation
Staff development
Organizational infrastructure
Services and interventions
Domains:
Organizational values
Planning Monitoring ,and
evaluation
Staff development
Organizational infrastructure
Services and interventions
Domains:
Organizational values
Planning Monitoring and
evaluation
Staff development
Organizational infrastructure
Services and interventions
Domains:
Organizational values
Planning Monitoring and
evaluation
Staff development
Organizational infrastructure
Services and interventions
• Assessment for known high
risk behaviors in the service
area included on admission
histories and health screen-
ings to be included in the pa-
tients plan of care.
• Patient and community edu-
cation programs that address
high-risk behaviors in the
catchment area, i.e., smoking
cessation, alcohol and drug
abuse, teen pregnancy.
• Community outreach pro-
grams and community part-
nerships that address high
risk behaviors related to
morbid and mortality in the
service area.
• Menu plans that reflect the
demographics of the services
area, i.e., Kosher, Halal, or
other ethnic meal choices.
• Policies and procedures that
address bring food from
home.
• Use of hot versus cold foods
during illness and recovery.
• Flexible meal times to ac-
commodate culturally driven
meal time preferences i.e.,
day time fasting for Muslim
patients during Ramadan.
Labor and delivery and post-
partum policies and proce-
dures that address diverse
birthing practices, including
gender roles and responsibili-
ties, hot versus cold, and
views of birth as a sickness/
illness or natural experience
• Culturally relevant palliative
care services.
• Policies, procedures, and
competencies that address
diverse dying and bereave-
ment practices across the
lifespan.
• Culturally relevant counseling
services related to death and
dying, organ donation, and
care of the body.
2780_Ch04_060-073 16/07/12 11:38 AM Page 66

Organizational Cultural Competence 67
❙❙◗ Table 4-1 Crosswalk: Purnell Model, CLAS Standards, and Cultural Assessment Continued from page 66
Purnell Model Domains1 CLAS Standards2 Cultural Assessment Profile3 Indicators
Spirituality
Requires organizations to
make certain that chaplain
services are available for
each religion that is repre-
sented within the service
area. Partnerships with key
community religious leaders,
including traditional and folk
healers should be estab-
lished in response to the
cultural and spiritual needs
of consumers and staff.
Health-care practice
Underscores the need for
cultural competent educa-
tion for all levels of clinical
and administrative staff that
addresses cultural perspec-
tives of the sick role; med-
ical management, including
folk and traditional healing
practices. Cultural emphasis
on preventive versus acute
care can guide the provision
of community health and
wellness programs to in-
crease access to care, en-
hance quality of care,
improve health outcomes at
the individual and commu-
nity levels, and reduce
health disparities.
Health-care provider
Highlights the need for a
dedicated chief diversity of-
ficer to oversee diversity-
related initiatives such as
the diversity council, affirma-
tive action program, dis-
crimination events, culture
codes, and culturally related
conflict management and
grievance procedures. Addi-
tionally, this domain sup-
ports the creation of job
descriptions that outline
role-related cultural compe-
tencies, job requirements
that specify role specific lan-
guage proficiency and cul-
tural competencies, and
initial and ongoing perform-
ance appraisals that include
cultural competency re-
quirements.
Sources: 1Purnell et al., 2011.
2OMH, 2001.
3HRSA, 2002.
Standard 1:
Effective, respectful care
in preferred language.
Standard 1:
Effective, respectful care
in preferred language
Standard 1:
Effective, respectful care
in preferred language
Domains:
Organizational values
Planning
Monitoring and evaluation
Staff development
Organizational infrastructure
Services and interventions
Domains:
Organizational values
Staff development
Domains:
Organizational values,
Communication,
Organizational infrastructure
• Chaplain services for all
dominant religions.
• Partnerships with community
leaders.
• Policies and procedures that
address work schedule, meal
and medication times, and
hours of operation (i.e., clinic
visits) in response to cultural
and spiritual needs of con-
sumers and staff.
Cultural competency education
that addresses cultural per-
spectives of the sick role,
medical management includ-
ing folk and traditional healing
practices, genetic implications
for care across the contin-
uum, and cultural emphasis
on preventive versus acute.
• Chief Diversity Officer posi-
tion to oversee diversity-
related initiatives. affirmative
action, discrimination, culture
codes, conflict management,
and grievance procedures.
• Job descriptions that outline
cultural competency.
• Job requirements that specify
language proficiency and
cultural competency.
• Initial and ongoing perform-
ance appraisals that include
cultural competency
requirements.
2780_Ch04_060-073 16/07/12 11:38 AM Page 67

areas in multiple languages related to directions within
the organization. It also requires that the availability
of language assistance services include sign language,
the translation of critical documents such as consents
and patient education materials, pain scales, and com-
munication boards/aids for patients who are not able
to speak or understand the dominant language.
Knowledge and Skill Acquisition
Health-care organizations should ensure that staff at
all levels and across all disciplines receive ongoing ed-
ucation related to culturally and linguistically appro-
priate service delivery (OMH, 2001). To ensure the
successful acquisition and maintenance of culturally
and linguistically appropriate knowledge and skills,
organizations must plan to allocate fiscal resources to
educate staff at all levels in order to develop the req-
uisite role-specific competencies for the provision of
culturally congruent care. In addition, if bilingual
staff express an interest in, and are able to provide, the
service, internal and/or external funding sources
should be made available to support the training of
staff as medical interpreters.
Educational programming and learning outcomes
related to cultural competence need to include, prin-
cipally, the cognitive and affective domains of learn-
ing, with, to a lesser degree, the psychomotor domain.
The curriculum should follow the educational design
principle of simple-to-complex and general-to-specific.
The learning objectives and educational content
should be evidence-based and address definitions of
cultural competence; discrimination, prejudice, and
stereotyping; role-specific performance criteria for the
provision of culturally congruent care; and the com-
pletion of a cultural health assessment, in general, and
specific culture care needs of the most commonly en-
countered demographics of the service area in partic-
ular. Moreover, the education should also include
self-reflection, critical thinking, and cross-cultural
communication, including the appropriate use of
medical interpreters. Generational diversity and the
diversity that exists among the health-care team
should also be addressed.
Diversity-related education must start in orienta-
tion and continue through unit/department-based,
population-specific orientation programs. Addition-
ally, diversity education should be woven into annual
educational initiatives and performance appraisals
using evidence-based assessment instruments to en-
sure the initial and ongoing maintenance of compe-
tency, including the proficiency of trained medical
interpreters. To accommodate the variety of learning
styles that exist within the health-care team, a variety
of educational venues, such as face-to-face classroom
interaction, online, Web-based programs, and online
and/or hard-copy resources at the point of care should
be available. Informal venues such as lunch-and-learn,
and including diversity-related topics on staff meeting
agenda has been helpful to keep cultural competency
visible in daily operations.
◗ In the organization where you work/go to
school, are culturally diversity classes required
as part of orientation and on a yearly basis for
administrators, professionals, and other health-
care providers?
Transdisciplinary, interprofessional team learning
approaches have demonstrated improved communica-
tion within the health-care team. Onsite consultation
and conferences and workshops conducted by experts
in the fields of transcultural nursing, cultural compe-
tency, and organizational culture have been reported
to help sustain diversity initiatives in fast-paced
health-care delivery systems (IOM, 2002; Marrone,
2008). Other successful strategic initiatives within cul-
turally competent organizations that support staff
knowledge and skill acquisition include providing
staff with incentives such as reward and recognition
ceremonies, pins, acknowledgment in organizational
newsletters or Web sites, preference to attend external
conferences and workshops for staff that have com-
pleted initial and ongoing cultural competency edu-
cation and competency requirements, and incentives
for staff to volunteer in the community to learn about
community members and the cultures represented
within the service area.
Language Assistance Services
Culturally competent health-care organizations must
provide language assistance services, including inter-
preter services, at no cost to the customer with limited
English (or dominant language) proficiency at all
points of contact and in a timely manner during all
hours of operation. In addition, organizations must
provide consumers in their preferred language both
verbal and written notices informing them of their
rights to receive language assistance services. Likewise,
organizations must ensure the competence of lan-
guage assistance provided to limited English proficient
(or dominant language) consumers by interpreters
and must make available easily understood patient-
related materials and post signage in the languages of
the commonly encountered groups and/or groups rep-
resented in the service area.
◗ In your work setting, are major patient
documents translated into the languages of the
clients served? Which languages are included?
What other languages would you recommend?
According to multiple sources, language discor-
dance can lead to decreased access to care, decreased
quality of care, increased cost of care, decreased pa-
tient satisfaction, recidivism, discrimination, and poor
health outcomes (AACN, 2003; 2008; Europa, 2010).
68 Foundations for Cultural Competence
2780_Ch04_060-073 16/07/12 11:38 AM Page 68

Patients who speak little or no English (or nondomi-
nant language) are at greater risk of medical errors or
misdiagnosis if they are not provided with an inter-
preter, are less likely to use preventive care services, and
are more likely to use emergency rooms than English
(or dominant language) speakers (Cornelio, 2004).
Culturally competent health-care organizations must
provide language assistance at all points of entry and
care and during all hours of operation. Incorrect inter-
pretation and/or translation can result in patient confu-
sion, threaten patient safety, and cause emotional
distress, resulting in increased costs to the organization.
Resources for interpretation and translation services
include interpretation agencies, community language
banks, telephonic services at the point of care, and in-
teractive video- or computer-based services for the deaf
or hearing impaired (Tang, 2010). Frequently used
techniques to identify the languages spoken within the
community and service area—as well as the need for
sign language—include information from the local
community; community organizations; directly from
consumers; national, regional, and community census
data; and community needs assessment (Tang, 2010).
Critical documents such as informed consent forms,
patient education materials, and pain assessment
tools, as well as signage and directions within the or-
ganization, should be translated into the major lan-
guages spoken by the consumers in the service area
(Purnell et al., 2011).
◗ What does your organization do to provide in-
terpreters to patients who do not have a good
command of English? What in-house resources
are available to staff ? Are language interpreta-
tion lines used? In what languages is interpreta-
tion readily available? What languages are
needed but not available?
There is an emerging body of knowledge related to
health literacy and its relationship to patient health,
compliance with medical treatment plans, and access
to care. Health literacy is the degree to which an indi-
vidual is able to read, understand, and use informa-
tion to make health-care decisions (see Chapter 3).
Low health literacy can have a negative impact on
health outcomes and potentially increase the risk of
medical errors. Negative sequelae can be minimized
by the use of correctly interpreted and simple printed
information with pictures and diagrams (see Chapter
3). Written policies and procedures for the develop-
ment and purchase of written and/or video/audio pa-
tient education materials in the dominant and
nondominant languages should be evaluated by a
transdisciplinary patient education team, the members
of which should include community partners and or-
ganizational constituents who are knowledgeable in
health literacy and cultural competency (Marrone,
2010; Tang, 2010).
Community Resources
and Partnerships
Socially responsible educational, health-care, and pro-
fessional organizations, must be forged that use a va-
riety of formal and informal mechanisms to facilitate
community and consumer involvement in designing,
implementing, and evaluating diversity-related initia-
tives (OMH, 2001). Active, bidirectional, and mutu-
ally beneficial partnerships with formal and informal
community leaders and key informant interviews and
focus group meetings with cultural and spiritual lead-
ers, political and regulatory leaders and accrediting
agencies, natural and lay healers, and community eld-
ers are all mechanisms to ensure that organizations
provide culturally relevant services. Health-care or-
ganizations, in particular, need to negotiate with man-
aged care organizations for culturally relevant health
services across the continuum of care and advocate on
behalf of the vulnerable and underserved populations
within the organization’s service sector.
Advocacy
Advocacy on behalf of consumer and health-care
team diversity is a critical element within the schema
of organizational cultural competency. Culturally
competent health-care organizations ensure that con-
flict and grievance resolution processes are culturally
and linguistically sensitive and capable of identifying,
preventing, and resolving cross-cultural conflicts or
complaints by patients/consumers (OMH, 2002). Fur-
thermore, culturally competent health-care organiza-
tions establish an environment committed to diversity
nondiscrimination through clearly articulated behav-
ioral and performance expectations that are commu-
nicated to all levels of staff both verbally and in
writing. In essence, culturally competent organizations
create and sustain a culture of zero tolerance for dis-
crimination in all sectors of the work environment.
◗ Does the organization where you work/go to
school have cultural brokering/mentoring
programs for new employees? What strategies
would you use to initiate such a program?
Best practice supports the development of the chief
diversity officer role to lead all diversity-related orga-
nizational initiatives, such as the diversity council. The
chief diversity office and diversity council would have
the following roles:
• Advise the chief executive team in the development
of strategies that support diversifying the organiza-
tion’s workforce.
• Review organizational policies, recruitment practices,
patient education materials, and care practices that
may have an adverse impact on one or more con-
sumer groups within the service area (Thornicroft,
Brohan, Kassam, & Lewis-Holmes, 2008).
Organizational Cultural Competence 69
2780_Ch04_060-073 16/07/12 11:38 AM Page 69

• Establish written, evidence-based criteria for hiring
external and promoting internal candidates and
apply policies consistently to all candidates.
• Revise job standards for job performance to rea-
sonably accommodate individuals with disabilities
(Tartaglia, McMahon, West, Belongia, & Shier
Beach, 2007).
• Develop policies that address discrimination,
conflict management, and grievance resolution
processes and incorporate them into the patient bill
of rights.
• Educate staff as mediators in cross-cultural
conflicts.
• Train or hire patient advocates.
• Post signage that notifies patients and families that
a grievance process exists.
◗ Does the organization where you work/go
to school have culturally appropriate toys
available on pediatric units, in the Emergency
Department, and in reception areas where
children are likely to be? Where might you go to
obtain such toys?
Transparency
Health-care organizations are encouraged to regularly
make available to the public information about their
progress and successful innovations in implementing
diversity initiatives and to provide public notice in
their communities about the availability of this infor-
mation (OMH, 2001). Strategies that have proven ben-
eficial include the following (Marrone, 2010; Purnell
et al., 2011):
• Create and distribute brochures to patients/families
and include in admissions packets that highlight
the attention to and respect for diversity within the
organization.
• Include diversity services on patient/family educa-
tion television channels and in the organization’s
Web site and brochures.
• Publish articles in professional health-care
journals and local/neighborhood periodicals
to market diversity services and to share success
stories.
• Inform community agencies and local advocacy
groups regarding the diversity services that are of-
fered by the organization and the benefits thereof.
• Reach out to professional associations to present
and publish diversity-related initiatives and out-
comes in the association’s publications, on their
Web sites, and at local, regional, national, and in-
ternational conferences.
• Partner with case managers and discharge planners
regarding patients with needs related to culture,
health literacy, and the ability of ambulatory/
community services to provide culturally relevant
care following hospitalization.
• Use legislative representative as a vehicle for con-
stituents who need health-care providers who are
sensitive to cultural issues.
Outcomes Metrics to Assess
Cultural Competence
Several methods have been developed to assess orga-
nizational cultural competence. However, to date, con-
sensus has not been achieved regarding which data
elements to be measured. Few reliable data collection
instruments are available to assess organizational
cultural competence (HRSA, 2002). In spite of this
limitation, a review of the literature reveals that indi-
cators of cultural competence in health-care delivery
organizations typically include organizational values
and governance structures, quality monitoring and
evaluation, communication, education, services, com-
munity involvement, access, health outcomes, financial
stability/viability, and data management/data-driven de-
cisions (Joint Commission, 2011; Marrone, 2008).
Outcomes metrics for organizational cultural com-
petency include the following:
1. Organizational Values and Governance
Structures
a. Philosophy, mission, vision, values, and strate-
gic plan that reflect responsiveness to internal
and external diversity.
b. Annual Report Cards that demonstrate ac-
complishments related to diversity-related ini-
tiatives for patients, families, and the
community.
2. Quality Monitoring and Evaluation
a. Increased consumer satisfaction with care and
services particularly related to:
i. providers rated as being actively engaged with
the consumer/practitioner partnership, and,
ii. Increased time with providers during
primary care visits.
b. Improvements in health and wellness status
in the service area, particularly related to
underserved populations.
c. Improved public safety in the service area.
d. Increased compliance with treatment plans.
e. Decreased medical errors related to informed
consent and wrong patient, wrong site/side
surgeries or procedures.
3. Communication
a. Documented use of trained medical inter-
preters and/or use of language telephone in-
terpretation services for patients who do not
understand the primary language of care used
within the organization.
b. Documented use of patient education materi-
als that are culturally sensitive and reflect the
health literacy level and language proficiency
of the patient/family.
70 Foundations for Cultural Competence
2780_Ch04_060-073 16/07/12 11:38 AM Page 70

c. Documented use of critical documents, such
as consent forms and patient education mate-
rials that have been translated into the most
frequent languages represented by the demo-
graphic data of the service area.
d. Documentation systems that include cultural
health assessment data and the integration of
assessment findings into a transdisciplinary
plan of care.
4. Education
a. Cultural competency performance criteria that
are integrated into performance appraisals for
all levels of job descriptions.
b. Learning outcomes that reflect culturally, eth-
nically, linguistically, and spiritually relevant
health-care interventions, plans of care, and
clinical evaluation strategies.
5. Services
a. Increased access to services by diverse, under-
served, and vulnerable populations.
b. Increase in cultural- and language-related
services and programs provided in response to
community needs assessment date.
◗ In the organization where you work/go to
school, are food pyramids and food selections
available and reflective of the patients’ and
staffs’ languages and culture?
6. Community Involvement
a. Community leaders represented among key
organizational decision making and stake-
holder groups, such as Board of Trustees,
Governing Board, Diversity Council, Patient
Education Committee, and Ethics Committee.
7. Access
a. Increased use of preventive services with re-
sultant decreased use in Emergency Depart-
ment visits for nonemergent health needs.
8. Health Outcomes
a. Decrease in racial and ethnic health disparities
in the service area.
9. Financial Stability/Viability
a. Decreased health-care costs chiefly related to
decreased length of stay (LOS), decreased
complications, issues of “noncompliance,” de-
creased Emergency Department visits for non-
emergent health issues, and decreased
readmissions and recidivism.
b. Increased revenue principally related to in-
creased use of services by underserved popula-
tions and increased throughout related to
decreased LOS.
c. Decreased litigation and malpractice.
10. Data Management
a. Decreased disparities related to the access and
use of health-care services or in received
and/or recommended treatment.
b. Review and analysis of consumer satisfaction
with care and services data and evidence that
information has been used to influence the
design/redesign of strategic initiatives and
services.
Resources to Support Culturally
Competent Health-Care
Organizations
Many governmental, regulatory, and professional
agencies provide useful information that can assist with
the design of an organizational infrastructure that sup-
ports cultural competency. The World Health Organi-
zation provides technical support to assist countries
and regions in addressing priority health issues and en-
gages in partnerships to establish health and care
norms and standards; policy, program, and human re-
sources development; and the prevention and control
of major communicable diseases (WHO, 2010).
The U.S. Office of Minority Health (OMH) develops
health policies and programs that are aimed at protect-
ing the health of minority populations through the
elimination of health disparities among vulnerable pop-
ulations (OMH, 2001). The OMH developed the CLAS
Standards in Health Care to guide health-care delivery
systems toward meeting the culture care needs of con-
sumers within their respective service areas. The Insti-
tute of Medicine (IOM) serves as an independent
advisor for health and science policy development. The
IOM established Core Competencies for Health Care
Professionals that encourage patient-centered care, col-
laborative interprofessional teams, evidence-based prac-
tice, quality improvement, and informatics (IOM, 2002).
The Joint Commission is a U.S. agency with an
international affiliate that is aimed at continuously
improving the safety and quality of care provided to
the public through the accreditation of health-care
facilities. The Joint Commission developed evaluation
strategies in support of culturally competent organiza-
tions. Organizational cultural competency evaluation
strategies include the following:
1. Allocating resources to initial and ongoing team-
building and cultural training and educational
programs, such as the development of interdisci-
plinary cultural diversity committees and out-
reach programs to minority nursing and medical
organizations.
2. Integrating cultural diversity initiatives into and
cited cultural competency standards within all lev-
els of the organization, such as vision and mission
statements, strategic objectives, learning outcomes,
clinical performance criteria, policies and proce-
dures, documentation systems, and research.
3. Assessing the cultural composition of the staff
as compared with the demographics of the
community.
Organizational Cultural Competence 71
2780_Ch04_060-073 16/07/12 11:38 AM Page 71

4. Developing hiring practices, promotion strategies,
and outreach programs that underscore diversity
as a priority.
5. Assessing and integrating patient satisfaction,
staff satisfaction, quality improvement, and
health outcomes data related to cultural, spiritual,
and linguistic diversity into all levels of the orga-
nizational strategic planning.
6. Utilizing only trained medical interpreters and
translators.
7. Integrating patients’ health and illness values and
traditions into written plans of care and progress
notes.
8. Assessing patient/family understanding of teach-
ing and discharge instructions (Joint Commission,
2011).
The Transcultural Nursing Society (2012) is a pro-
fessional nursing organization that is committed to
enhancing the quality of culturally congruent care
provided by nurses prepared in transcultural nursing
that supports improved health and wellness for people
worldwide. The Society developed a certification
process for nurses and other health-care professionals
that ensures competency in providing culturally
competent care. The International Council of Nurses
(ICN) (2010) promotes healthy lifestyles, healthy
workplaces, and healthy communities by working
closely with the national nursing associations repre-
senting 130 countries. The Council supports programs
that mitigate poverty, pollution, and other underlying
causes of illness, includes care strategies that address
meeting spiritual and emotional needs, and advocates
that prevention, care, and cure are the rights of every
human being.
The American Organization of Nurse Executives
(AONE) (2011) developed the AONE Guiding Prin-
ciples for Diversity in Health Care Organizations and
the AONE Diversity for Health Care Organizations
Toolkit to assist health-care organizations to establish
a healthy practice and work environment that reflects
the diversity through a commitment to inclusivity, tol-
erance, and governance structures.
The Future of Culturally
Competent Health-Care
Organizations
Global geographic migrations resulting in wide-reaching
demographic variations are anticipated to grow over
the next several decades. These demographic changes
amplify the importance of addressing cultural, ethnic,
racial, linguistic, and spiritual health disparities. Mi-
nority populations that are currently experiencing
poorer health status are expected to grow more rap-
idly, particularly in industrialized countries. Govern-
ments and health-care organizations are focusing
more on reducing health disparities by ensuring the
cultural competency of the health-care system and its
providers.
Successful culturally competent health-care organi-
zations utilize evidence-based organizing frameworks
that articulate well with one another to ensure the in-
tegrity and reliability of diversity-related initiatives. The
triangulated framework used in this chapter to illustrate
the critical elements of organizational cultural compe-
tency included the CLAS Standards, the Purnell Model,
and the Cultural Assessment Profile. Collectively, the
components provide the road map and guideposts for
the delivery of culturally and linguistically appropriate
health-care services to diverse consumers.
In summary, hallmark characteristics of culturally
competent health-care organizations include the fol-
lowing (Marrone, 2010):
• An organizational infrastructure that respects and
celebrates diversity as reflected in the vision, mis-
sion, values, strategic plan, standard operating pro-
cedures (policies and procedures), quality initiatives,
education plan, employee competencies, and clinical
and operational performance outcomes
• The design, implementation, and evaluation of a
well-structured strategic plan that ensures the provi-
sion of culturally, spiritually, and linguistically ap-
propriate services consistent with the demographics
of the service area
• Retention, recruitment, and promotion strategies
that attract and retain health-care professionals
prepared in transcultural concepts at all levels of
the organization that are representative of the con-
sumer demographics in the service area
• Availability of diversity-related resources at the
point of care
• Education programs that ensure that all levels of
staff receive initial and ongoing learning and skill
acquisition related to the culture care needs of the
consumer demographics in the service area
• Evidence-based assessment strategies that reliably
measure access to care, quality of care, health
outcomes, and patient and staff satisfaction, and
stratify data related to the demographics of the
service area
• A network of active partnerships with community
leaders and consumer groups that reflect the demo-
graphics of the service area who assist the organiza-
tion in the assessment, planning, implementation,
and evaluation of diversity-related initiatives
Finally, essential to the provision of safe, quality
language services, culturally competent health-care or-
ganizations must develop systems and processes that
ensure ongoing self-assessments to determine if con-
sumers are receiving care in their preferred language,
maintain a current organizational language data bank
that reflects the dynamic changes in languages spoken
within the service area, employ trained and validated
72 Foundations for Cultural Competence
2780_Ch04_060-073 16/07/12 11:38 AM Page 72

medical interpreters and translators to provide lan-
guage assistance services at all points of care and
across the continuum of care at no cost to the con-
sumers, and have in place retention and recruitment
strategies for diverse staff at all levels of the organiza-
tion represented in the service area.
Culturally competent organizations must provide
patients and visitors with written notices of their right
to receive language assistance services; maintain sig-
nage in the major languages spoken by consumers, in-
cluding sign language for the deaf/hearing impaired
and Braille for the blind/visually impaired; establish
and maintain partnerships with key formal and infor-
mal community leaders; safeguard that interpretation
and translation services are efficient and accessible at
the point of care throughout the continuum of care;
and utilize subject matter experts and specialists in
transcultural care and cultural competency to guide
the language services product development
R E F E R E N C E S
American Association of Critical Care Nurses. (2003). Safeguarding
the patient and the profession: The value of critical care nurse
certification. American Journal of Critical Care, 12, 154–164.
American Association of Critical Care Nurses. (2008). AACN
standards for establishing and sustaining healthy work environ-
ments. Retrieved from http://www.aacn.org/wd/hwe/content/
resources.pcms?menu=practice American Organization of Nurse
Executives. (2011). Guidelines and toolkit for diversity in
health care organizations. Retrieved from http://www.nursezone.
com/nursing-news-events/more-news/AONE-Releases-Online-
Tool-Kit-To-Support-Diversity_32546.aspx
Andrews, M.M. (1998). A model for cultural change: Nurse lead-
ers must realize the importance of transculturally based ad-
ministrative practices. Nursing Management, 29, 62–66.
Betancourt, J.R., Green, A.R., Carrillo, J.E., & Ila, O.A. (2003).
Defining cultural competence: A practical framework for
addressing racial/ethnic disparities in health and health care.
Public Health Reports, 118, 293–302.
Coleman-Miller B. (2000). A physician’s perspective on minority
health. Health Care Financing Review, 21, 45–56.
Cooper-Patrick, L., Gallo, J.J., Powe, N.R., Steinwachs, D.M.,
Eaton, W.W., & Ford, D.E.. (1999). Mental health service uti-
lization by African Americans and Whites: The Baltimore epi-
demiological catchment area follow-up. Medical Care, 37(10),
1034–1045.
Cornelio, M. (2004). Quality translation in health care: Kaiser
Permanente—Meeting the challenge. Apuntes, 12(4), 14–15.
Einbinder, L.C., & Schulman, K.A. (2000). The effect of race on
the referral process for invasive cardiac procedures. Medical
Care Research and Review, 1, 162–177.
Europa. (2010). Commission takes steps to promote patient safety
in Europe [Press release]. Retrieved from http://europa.eu/
rapid/press ReleasesAction.do?reference=IP/08/1973&format=
HTML&aged=0&language=EN&guiLanguage=en
Health Resources and Services Administration. (2002). Indica-
tors of cultural competence in health care delivery organiza-
tions: An organizational cultural competence assessment
profile. U.S. Department of Health and Human Resources.
Retrieved from http://www.hrsa.gov/CulturalCompetence/
healthdlvr
Institute of Medicine. (2002). Unequal treatment: Confronting
racial and ethnic disparities in health care. Washington, DC:
National Academies Press.
International Council of Nurses. (2010). Vision statement. Re-
trieved from http://www.icn.ch/visionstatement.htm
Joint Commission. (2011). Patient safety: About hospitals, lan-
guage, and culture. Retrieved from www.jointcommission.org/
assets/1/6/hlc_paper
Marrone, S.R. (2008). Factors that influence critical care nurses’
intentions to provide culturally congruent care to Arab
Muslims. Journal of Transcultural Nursing, 19, 8–15.
Marrone, S.R. (2010). Organizational cultural competency. In
M. Douglas & D. Pacquiao (Eds.), Core curriculum in transcul-
tural nursing and health care. Thousand Oaks, CA: Sage.
Morales, L.S., Cunningham, W.E., Brown, J.A., Liu, H., & Hays,
R.D. (1999). Are Latinos less satisfied with communication by
healthcare providers? Journal of General Internal Medicine, 14,
409–417.
Office of Minority Health. (2001). National standards for culturally
and linguistically appropriate services. Retrieved from http://
minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15
Office of Minority Health. (2002). Eliminating racial and ethnic
disparities in health: Overview. Retrieved from http://www.
raceandhealth.hhs.gov/sidebars/sbinitover.htm
Public Health Reports. (2003). Defining cultural competence:
A practical framework—301. Public Health Reports. July–August,
Volume 118.
Purnell, L., Davidhizar, R., Giger, G., Fishman, D., Strickland,
O., & Allison, D. (2011). A guide to developing a culturally
competent organization. Journal of Transcultural Nursing,
(22)1, 5–14.
Purnell, L.D., & Paulanka, B.J. (2008). Transcultural health care:
A culturally competent approach (3rd ed.). Philadelphia:
F.A. Davis.
Robert Wood Johnson Foundation. (2011). Getting minority
patients’ points of view about cultural barriers to health care.
Retrieved from http://www.rwjf.org/reports/grr/055258.htm
Saha, S., Komaromy, M., Koepsell, T.D., & Bindman, A.B. (1999).
Patient-physician racial concordance and the perceived quality
and use of health care. Archives in Internal Medicine, 159,
997–1004.
Saha, S., Taggart, S.H., Komaromy, M., & Bindman, A.B. (2000).
Do patients choose physicians of their own race? Health
Affairs, 19, 76–83.
Tang, G. (2010) Organizational cultural competency: Interpreta-
tion services. In M. Douglas & D. Pacquiao (Eds.), Core cur-
riculum in transcultural nursing and health care. Thousand
Oaks, CA: Sage.
Tartaglia, A., McMahon, B.T., West, S.L., Belongia, L., & Shier
Beach, L. (2007). Workplace discrimination and healthcare:
The national EEOC ADA research project. Journal of Voca-
tional Rehabilitation, 27, 163–169.
Thornicroft, G., Brohan, E., Kassam, A., & Lewis-Holmes, E.
(2008). Reducing stigma and discrimination: Candidate interven-
tions. International Journal of Mental Health Systems, 2, 1–7.
Transcultural Nursing Society. (2012). Mission, vision, philosophy,
and values. Retrieved from http://www.tcns.org
World Health Organization. (2010). Role of WHO in public health.
Retrieved from http://www.who.int/en/
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
Organizational Cultural Competence 73
2780_Ch04_060-073 16/07/12 11:38 AM Page 73

74
Chapter 5
Perspectives on Nursing
in a Global Context
Linda C. Baumann and Laurie B. Hartjes
Overview
The global context of health addresses circumstances
that affect populations worldwide, such as quantity and
nutritional value of food, air, and water quality; expo-
sure to infectious diseases and environmental toxins;
access to essential medications; and gender inequalities.
Viewing health without geographic boundaries is a shift
from an international health perspective that has em-
phasized exchanges between national governments.
This global perspective affects nursing practice. Glob-
alization has led to a growing interdependence of the
world’s population and involves the integration of
economies, cultures, technologies, and governance
(Chapman, 2009). In addition, global health affected
by climate change is of such importance to the world’s
future that all governments must understand the issues
and become part of the solution (Gostin, 2008;
Narayan, Ali, & Koplan, 2010).
Health is a global priority for a number of reasons:
• Most of the public has been sensitized to the po-
tential for infectious diseases to spread rapidly in a
world with extensive travel, human migration,
global commerce, and transmission routes that
include food, insects, animals, and other vectors.
• There are shared concerns about the societal bur-
dens imposed by an increase in chronic diseases
requiring long-term management such as diabetes,
cardiovascular disease, and cancer.
• The threat of bioterrorism necessitates surveillance
for suspicious clusters of symptoms for popula-
tions at a global level.
• Unhealthy populations can destabilize economies,
and economic insecurity creates the conditions for
poor health.
• Ethical and humanitarian considerations support
addressing health from a global perspective
(Gostin, 2007). Significant trends that will
influence the work of nurses in the decades ahead
are the shift in health conditions from an acute
care focus to chronic care, and the increasing
number of elderly health consumers (Pruitt &
Epping-Jordan, 2005).
Definitions of Health, Global
Health, One Health, and Global
Nursing
The Preamble to the Constitution of the World
Health Organization (WHO) defined health as a state
of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity
(WHO, 1946). The Institute of Medicine (IOM) de-
fined global health as health problems, issues, and
concerns that transcend national boundaries, may be
influenced by circumstances or experiences in other
countries, and are best addressed by cooperative ac-
tions and solutions (IOM, 1997). A revised definition
of global health has been proposed based on the evo-
lution of philosophy, attitude, and practice over the
past decade:
Global health is an area for study, research, and practice
that places a priority on improving health and achieving
equity in health for all people worldwide. Global health
emphasizes transnational health issues, determinants,
and solutions; involves many disciplines within and be-
yond the health sciences and promotes interdisciplinary
collaboration; and is a synthesis of population-based
prevention with individual-level clinical care. (Koplan,
Bond, Merson, Reddy, Rodriquez, & Sewankambo, 2009,
p. 1995)
Global nursing is the adoption of a global health
perspective by nursing professionals interested in seek-
ing collaborative and sustainable solutions to health
problems irrespective of national boundaries. These so-
lutions and innovations involve both the professional
2780_Ch05_074-088 16/07/12 11:39 AM Page 74

development of individuals and capacity building in
nursing systems at national, regional, and international
levels (International Council of Nurses, 2009). This
work requires respect for differences in language, cul-
ture, customs, and health beliefs. Equally important is
the need to approach health issues in partnership with
communities by mutually identifying expectations, re-
sources, and strategies for capacity building that are
best suited to the specific context (SNV & UNDP,
2009).
The One Health Initiative supports the integration
of human medicine, veterinary medicine, and environ-
mental science for the purpose of improving the lives
of all species—both human and nonhuman. This
recognition of the interconnectedness of all life sys-
tems offers new avenues for collaboration and for re-
search questions that will extend our understanding
of the dynamic nature of biologic relationships.
Global Health Frameworks
The 1978 World Assembly of the United Nations at
Alma-Ata adopted a framework of Health for All by
the Year 2000 with an emphasis on poverty reduction,
social justice, and the expansion of primary health-care
services. The declaration noted that health was a
human right and that countries have the obligation to
ensure that all people have access to primary health care
(i.e., universal access). This framework identified the es-
sential elements of primary health care (Table 5-1) and
endorsed the reallocation of resources to communities
to reduce health-care inequality worldwide (WHO &
UNICEF, 1978).
Although primary health care has been successfully
implemented as a national health policy in some coun-
tries, the Alma-Ata declaration failed to achieve its
goals in others due to lack of political will, lack of
basic resources, and lack of measurable objectives
with which to monitor goal achievement. In response
to the challenges of implementing universal access to
primary health care, the World Development Report
(World Bank, 1993) identified the need to invest in
health as a cost-effective investment in national devel-
opment. This report also highlighted the role of the
private sector in improving the welfare of populations
worldwide.
This philanthropic call to action stimulated foun-
dations and global health leaders to work together to
fill a resource gap not otherwise being met. Although
there are over 50 philanthropic health organizations
with over $96 million in annual donations, the Bill and
Melinda Gates Foundation, created in 2000, is among
the largest of all the transparently operated charitable
foundations in the world, with annual donations of
over $2 billion (Health Grants Information Center,
2009). The Gates Foundation was inspired to some de-
gree by the philanthropic history of the Rockefeller
Foundation dating back to 1891. Rockefeller dona-
tions have targeted substantial global health and wel-
fare problems, such as large United Nations projects
and the ambitious (although ultimately unsuccessful)
worldwide goal of eradicating yellow fever and
malaria. In 2006, Warren Buffet pledged more than
$30 billion in stocks to the Gates Foundation, while
encouraging other wealthy individuals to give more to
charitable causes.
A subsequent framework for addressing the root
causes of global health disparities was adopted at the
World Assembly in 2000, known as the Millennium
Declaration (WHO, 2011). Eight Millennium Devel-
opment Goals (MDGs) were identified in this decla-
ration to be achieved by 2015 (Table 5.2).
These goals include specific target objectives and
measurable indicators. Together these goals aim to re-
duce poverty, hunger, and ill health and to promote eq-
uitable educational opportunities and environmentally
sustainable practices. Critics of the MDG framework
note that these goals fail to address chronic conditions,
disabilities, or unintentional injuries (Fuster & Voute,
2005). Although monitoring has shown that some
goals have been partially achieved in some countries,
most will fall short of the 2015 targets (WHO, 2011).
The 2006 World Health Report identified shortages of
Perspectives on Nursing in a Global Context 75
❙❙◗ Table 5-1 Essential Elements of Primary
Health Care
1. Education concerning prevailing health problems and
methods of prevention and control
2. Promotion of the food supply and proper nutrition
3. The provision of safe water and basic sanitation
4. Maternal and child health care, including family planning
5. Immunization against the major infectious diseases
6. Prevention and control of locally endemic diseases
7. Appropriate treatment of common diseases and injuries
8. Provision of essential drugs
World Health Organization and UNICEF. (1978). Primary health care: Report
of the International Conference on Primary Health Care. Alma-Ata USSR.
September 6–12, 1978. Geneva: WHO.
❙❙◗ Table 5-2 Millennium Development Goals
Goal 1 Eradicate extreme hunger and poverty
Goal 2 Achieve universal primary care
Goal 3 Promote gender equality and empower women
Goal 4 Reduce child mortality
Goal 5 Improve maternal health
Goal 6 Combat HIV/AIDS, malaria, and other diseases
Goal 7 Ensure environmental sustainability
Goal 8 Develop a global partnership for development
World Health Organization. (2011) 2015 millennium development goals. Re-
trieved from http://www.un.org/millenniumgoals/
2780_Ch05_074-088 16/07/12 11:39 AM Page 75

human resources as a critical obstacle to the achieve-
ment of the MDGs (WHO, 2006). Despite the chal-
lenges and shortcomings, the MDG framework
supports an integrated database and a road map for
monitoring goal achievement using core targets that
are measured locally and nationally, and then shared
globally.
Finally, a framework entitled Smart Global Health
Policy has been proposed to guide the U.S. global
health agenda (CSIS, 2010). The following five-point
agenda was developed to leverage U.S. influence and
past successes to create a healthier and safer world:
1. Maintain the commitment to the fight against
HIV/AIDS, malaria, and tuberculosis.
2. Prioritize women and children in U.S. global
health efforts.
3. Strengthen prevention and capabilities to manage
health emergencies.
4. Ensure that the United States has the capacity to
match our global health ambitions.
5. Make smart investments in multilateral
institutions.
These three frameworks provide guidance for the de-
velopment of nursing curricula and practice standards
that view health needs, resources, and interventions
through a global lens in a world that is increasingly
interconnected.
Global Health Organizations
An important role for world governments is to provide
health services. When governments lack the resources
or political will to meet basic health, welfare, and safety
needs, there are hundreds of thousands of national and
international organizations that have coalesced to re-
duce the associated suffering. The organizations focus-
ing on global health issues are often classified as
bilateral, multilateral, and nongovernmental.
Bilateral organizations use funding from one gov-
ernment to improve health and welfare elsewhere. The
U.S. Agency for International Development (USAID)
is a major bilateral organization in the United States
that was created in 1961 as an independent federal
government agency under the direction of the secre-
tary of state. Objectives of USAID are to assist coun-
tries with disaster relief, antipoverty programs, and the
implementation of democratic reforms. The Presi-
dent’s Emergency Plan for AIDS Relief (PEPFAR)
and the President’s Malaria Initiative are both USAID
programs. More recently, these USAID health pro-
grams have become part of an overarching program
called the “whole-of-government” umbrella under the
Global Health Initiative (GHI) (USAID: Health,
2009). The GHI coordinates U.S. government global
health efforts, with $63 billion committed over six
years (2009–2014) to help partner countries reform
their health systems.
Multilateral (or intergovernmental) organizations
are those that receive funding from multiple govern-
ments as well as nongovernmental sources, with fund-
ing distributed to many different countries. The major
multilateral organizations were created by the United
Nations (UN) and remain under the UN organiza-
tional umbrella, such as the World Health Organiza-
tion (WHO), the World Bank, the United Nation
Children’s Fund (UNICEF), and the United Nations
Development Programme (UNDP). Other highly vis-
ible examples of multilateral organizations are the
World Trade Organization (WTO), the European
Union (EU), and the Organization for Economic
Cooperation and Development (OECD).
Nongovernmental organizations (NGOs) make sig-
nificant contributions nationally and internationally
based on their unique missions. By definition, NGOs
are independent from government influence, and they
are often in a unique position to address issues not ad-
dressed by governments. NGOs were given Consulta-
tive Status in 1945 as part of Article 71 of Chapter X
of the United Nations Charter. Although new NGOs
are being created daily, some have become very large
and influential. The Bangladesh Rural Advancement
Committee (BRAC) has 120,000 employees, the ma-
jority of whom are women, as well as microfinance
and education programs in Asia and Africa that reach
more than 110 million people. World Vision, a Chris-
tian humanitarian organization, is an NGO with an
annual budget in the billions of dollars, enough to
match the gross domestic products of some countries.
Other faith-based organizations also play a role in
mitigating threats to health through their support of
public health measures to ensure access to safe food,
water, and sanitation; housing; direct health services;
and schools. Table 5-3 provides brief descriptions of
major bilateral, multilateral, and NGO organizations.
Sigma Theta Tau International (STTI) is a profes-
sional nursing honor society that strives to connect
nurses worldwide to collaborate on issues of common
interest. STTI has 469 chapters in 86 countries and a
mission of using knowledge, scholarship, service, and
learning to improve the health of all. STTI partnerships
have yielded a series of think tank conferences, as well
as reports such as the Competency Framework for Inter-
national Health Consultants, Practice Innovations at
Magnet health-care facilities, and the Global Standards
for the Initial Education of Professional Nurses and Mid-
wives written in partnership with the WHO.
The International Council of Nurses (ICN) is an-
other nursing organization with a global focus. ICN
is a federation of more than 130 national nurses asso-
ciations representing more than 13 million nurses.
Founded in 1899, ICN is the oldest and largest organ-
ization serving health professionals. Its mission is to
ensure quality nursing care for all, sound health poli-
cies globally, the advancement of nursing knowledge,
76 Foundations for Cultural Competence
2780_Ch05_074-088 16/07/12 11:39 AM Page 76

Perspectives on Nursing in a Global Context 77
❙❙◗ Table 5-3 Examples of International Health Organizations
Bilateral Organizations
Peace Corps U.S. government agency that places volunteers in 139 countries to work on issues ranging from AIDS
education to information technology and environmental preservation, and to foster cultural under-
standing. www.peacecorps.gov
U.S. Agency for U.S. government agency that provides economic, development and humanitarian assistance to
International countries for reasons of poverty, conflict and natural disaster, and to support populations engaging in
Development democratic reforms. www.usaid.gov
(USAID)
Multilateral Organizations
Food and UN agency that provides international leadership for combating world hunger. FAO helps countries
Agricultural improve agriculture, forestry, and fisheries practices to ensure good nutrition for all. www.fao.org
Organization
Pan American UN agency focused on improving the health of the countries of the Americas. Also serves as the
Health Regional Office of the Americas for the World Health Organization. www.paho.org
Organization
United Nations UN agency that advocates for children in the areas of nutrition, environment, education, gender equity,
Children’s Fund health, and public policy. www.unicef.org
United Nations UN agency to protect the rights and well-being of refugees. www.unhcr.org
High Commissioner
for Refugees (UNHCR)
United Nations UN partnership that strives to ensure universal access to services for HIV prevention, treatment, care
Program on and support. www.unaids.org
HIV/AIDS (UNAIDS)
World Bank UN-affiliated intergovernmental financial institution that provides low-interest loans, interest-free cred-
its, and grants to developing countries to invest in areas such as education, health, infrastructure, and re-
source management. www.worldbank.org
World Health UN-affiliated intergovernmental agency responsible for shaping the health research agenda, setting
Organization (WHO) norms and standards, articulating evidence-based policy options, providing technical support to
countries, and monitoring and assessing health trends. www.who.int/en/
Nongovernmental Organizations
CARE International Relief and development organization that identifies underlying causes of global poverty. Operating in
more than 70 countries, CARE responds to emergencies by delivering aid and helping people rebuild
their lives. www.care-international.org
Health Volunteers A network of health-care providers who aim to increase health-care access in low-resource countries.
Overseas They work to improve access through clinical training and education programs. HVO train, mentor, and
support health-care providers in more than 25 countries. www.hvousa.org
Human Rights Watch Investigates and exposes human rights violations and holds oppressors accountable for their crimes.
Dedicated to upholding freedom and preventing discrimination. www.hrw.org
International Medical Dedicated to relieving suffering through health-care training and relief and development programs.
Corps Builds capacity in underserved communities. www.internationalmedicalcorps.org
International Red Based primarily on the Geneva Conventions of 1864 and 1949, ensures humanitarian protection and
Cross assistance for victims of war and armed violence and other emergencies. The goal of ICRC’s Health
Unit activities is to give people affected by conflict access to basic preventive and curative health care
that meets universally recognized standards. www.icrc.org
Médecins sans Provides life-saving medical and technical assistance to people affected by natural or man-made
Frontières (Doctors disasters and armed conflict. Field staff deliver direct care in more than 60 countries, often in very
without Borders) difficult conditions. www.msf.org
Oxfam International Group of 14 international organizations that work with other local organizations in 98 countries to
fight poverty and injustice. Oxfam objectives are guided by the belief that respect for human rights is
the key to lifting people from poverty. www.oxfam.org
Partners in Health Strives to create solidarity in health by partnering with poor communities to combat disease and
poverty by using a comprehensive and community based approach.
Projects are ongoing in 12 countries. www.pih.org
Project Hope Since 1958, has delivered direct healthcare services and health education to people in more than
35 countries, with a goal of creating sustainable approaches. www.projecthope.org
Continues on page 78
2780_Ch05_074-088 16/07/12 11:39 AM Page 77

78 Foundations for Cultural Competence
❙❙◗ Table 5-3 Examples of International Health Organizations Continued from page 77
Nongovernmental Organizations
World Vision Christian humanitarian organization that serves close to 100 million people in over 100 countries. Sup-
port children, families and communities to help all people reach their full potential by fighting poverty
and injustice. www.worldvision.org
Other Organizations
The Gates Foundation Philanthropic foundation created by Bill and Melinda Gates. Provides key resources to promote health
and education in the United States and globally through innovative approaches to pressing problems.
www.gatesfoundation.org
The Rockefeller First U.S. philanthropic foundation with global perspective, established by John Rockefeller in 1913.
Foundation Funded the first global initiative to eradicate malaria and yellow fever in the 1940-1950s.
www.rockefellerfoundation.org
The Global Fund Unique international financing partnership between governments, private sector businesses and af-
fected communities that aims to finance programs addressing HIV/AIDS, tuberculosis and malaria.
www.theglobalfund.org
President’s Emergency U.S. government initiative to save the lives of those suffering from HIV/AIDS around the world.
Plan for AIDS Relief Provides the largest commitment by any nation to combat a single disease internationally.
(PEPFAR) www.pepfar.gov
and the presence worldwide of a respected nursing
profession and a competent and satisfied nursing
workforce.
Forces Shaping Global Health
and Nursing
Policy and National Economies
Government policies determine how health services
and health research are financed and how health-care
services are distributed. Governments also control the
licensing and regulation of nurses, globally the largest
group of health-care providers. A high national burden
of disease results in lost productivity and incurs treat-
ment expenses, as demonstrated by the substantial eco-
nomic impact of HIV/AIDS, malaria, and tuberculosis
in countries with high prevalence (Audibert, Motel, &
Drabo, 2010). Failure to prevent or to provide early in-
tervention for noncommunicable diseases (NCDs) sim-
ilarly has a significant negative impact on national
health budgets (Lancet NCD Action Group, 2011).
Although high-income countries perform better
across many measures of health, there is no direct re-
lationship between the two. The Organization for Eco-
nomic Cooperation and Development (OECD) tracks
and reports annually on more than 1200 health system
measures across 34 industrialized countries. U.S.
health-care spending was significantly higher than
other industrialized countries, both per capita and as
a percentage of gross domestic product (Anderson, &
Squires, 2010), yet the United States ranks in the bot-
tom quartile in life expectancy among OECD coun-
tries. Such gaps between investment and health
outcomes suggest that efficiencies and cost controls
are needed by health-care systems in countries across
all income levels.
Population Trends
Demographic transition refers to a documented global
pattern characterized by a population with high birth
and death rates shifting over time to one of lower birth
and death rates, resulting in a higher percentage of
older adults. Another transition is the shift from pre-
dominantly communicable disease to NCDs. This in-
crease in NCDs creates a need for health-care systems
and a nursing workforce that can provide continuous
monitoring and services that address prevention meas-
ures such as lifestyle modifications, especially healthy
diets and regular physical activity (WHO, 2002).
Chronic diseases account for 60 percent of all
deaths worldwide, and 80 percent of these deaths
occur in low-middle-income countries, where they dis-
proportionately affect youth to middle-age individuals
who are in the prime productivity period of life (Daar
et al., 2007). It is projected that by 2030 the four lead-
ing causes of burden of disease will be related to
HIV/AIDS, unipolar depressive disorders, ischemic
heart disease, and road traffic accidents (WHO, 2004).
HIV/AIDS is estimated to be the leading cause of bur-
den of disease in middle- and low-income countries
by 2015 (Mathers & Loncar, 2006).
The global burden of disease is measured using a
composite indicator called “disability adjusted life
years,” or DALY, to measure premature death and loss
due to illness and disability in a population. DALY
data are reported for communicable diseases; maternal
and perinatal conditions; nutrition; NCD; injuries and
self-inflicted injuries; and violence (World Bank,
1993). The 10 leading risk factor causes of DALYs by
country income group (i.e., low, middle, and high in-
come) are shown in Table 5-4. Critics of the DALY
measure point out that this objective measure pays lit-
tle attention to local and cultural conditions. Further,
2780_Ch05_074-088 16/07/12 11:39 AM Page 78

DALYs do not account for the subjective experience
of someone with a disability and how this might
change over time; they do not account for how disabil-
ity may affect a household or family; and they fail to
account for the true burden of disability beyond lost
productivity (Nichter, 2008).
Environmental Factors
The forces of globalization, urbanization, and indus-
trialization underlie the rising prevalence of chronic
conditions. These phenomena have radically affected
dietary patterns, physical activity behaviors, and key
behavioral determinants of NCDs (Beaglehole &
Yach, 2003; Narayan et al., 2010). Across nations,
food choices and levels of physical activity are becom-
ing more homogeneous, characterized by widespread
access to calorie-rich but nutrient-poor foods, built en-
vironments that pose barriers to active modes of
transportation, and occupational trends toward
sedentary work (Lancet NCD Group, 2011). It is es-
timated that 70 percent of the world’s population will
be urban residents by 2050, resulting in both benefits
and challenges (United Nations, 2007).
Through practice and research, nurses are respond-
ing to the health threats posed by environmental
exposures (Clarke & Butterfield, 2011; Sattler, 2011).
This includes the development of new systems to doc-
ument exposures and health status changes postexpo-
sure. On a broader scale, nurses and other health
providers are pushing for public policies to mitigate
the health-impairing effects of climate change and
other ecosystem disruptions such as the depletion of
natural resources, including clean air and water.
Figure 5-1 provides a framework developed by the
Intergovernmental Panel on Climate Change that
depicts health as part of the dynamic interactions be-
tween the earth’s ecosystems and human-scale social
and economic systems. This IPCC framework is com-
patible with a One Health approach in which all
parts of a system are considered when doing re-
search and comparing policy alternatives. It is the
complexity of dynamic systems that lends support
for adhering to the precautionary principle to avoid
irreversible and potentially catastrophic changes.
This principle states that if an action or policy has
a suspected risk of causing harm to the public or to
Perspectives on Nursing in a Global Context 79
❙❙◗ Table 5-4 Ranking of Selected Risk Factors: 10 Leading Risk Factor Causes of DALYS by
Income Group, 2004
DALYs Percentage of
Risk Factor (millions) total
World
1 Childhood underweight 91 5.9
2 Unsafe sex 70 4.6
3 Alcohol use 69 4.5
4 Unsafe water, sanitation, 64 4.2
hygiene
5 High blood pressure 57 3.7
6 Tobacco use 57 3.7
7 Suboptimal breastfeeding 44 2.9
8 High blood glucose 41 2.7
9 Indoor smoke from 41 2.7
solid fuels
10 Overweight and obesity 36 2.3
Middle-income countries*
1 Alcohol use 44 7.6
2 High blood pressure 31 5.4
3 Tobacco use 31 5.4
4 Overweight and obesity 21 3.6
5 High blood glucose 20 3.4
6 Unsafe sex 17 3.0
7 Physical inactivity 16 2.7
8 High cholesterol 14 2.5
9 Occupational risks 14 2.3
10 Unsafe water, sanitation, 11 2.0
hygiene
*Countries grouped by 2004 gross national income per capita—low income (US $825 or less) high income (US $10,066 or more)
Source: World Health Organization. (2009). Global health risks: mortality and burden of disease attributable to selected major risks. Geneva, Switzerland: WHO.
DALYs Percentage of
Risk Factor (millions) total
Low-income countries*
1 Childhood underweight 82 9.9
2 Unsafe water, sanitation, 53 6.3
hygiene
3 Unsafe sex 52 6.2
4 Suboptimal breastfeeding 34 4.1
5 Indoor smoke from solid 33 4.0
fuels
6 Vitamin A deficiency 20 2.4
7 High blood pressure 18 2.2
8 Alcohol use 18 2.1
9 High blood glucose 16 1.9
10 Zinc deficiency 14 1.7
High-income countries*
1 Tobacco use 13 10.7
2 Alcohol use 8 6.7
3 Overweight and obesity 8 6.5
4 High blood pressure 7 6.1
5 High blood glucose 6 4.9
6 Physical inactivity 5 4.1
7 High cholesterol 4 3.4
8 Illicit drugs 3 2.1
9 Occupational risks 2 1.5
10 Low fruit and vegetable 2 1.3
intake
2780_Ch05_074-088 16/07/12 11:39 AM Page 79

the environment, in the absence of scientific consen-
sus that the action or policy is harmful, the burden
of proof that it is not harmful falls on those taking
the action.
Access to Technology
Access to technology is rapidly changing globally.
Even in communities where an infrastructure for re-
liable electricity and phone service does not exist,
cell phone penetration is virtually universal. Cell
phones and smart phones are being used to deliver
health-care services, such as monitoring blood sugar
(Cavalcanti, Shirinzadeh, & Kretly, 2008); delivering
health education and peer support for healthy be-
haviors (Piette, 2007, Piette, et al., 2010); and diag-
nosing diseases that are prevalent in areas with
limited access to health-care services, such as
malaria. The expansion of Internet access and the
development of low-cost health technologies can
promote more equitable distribution of health serv-
ices worldwide. Additionally, electronic health
records and integrated systems for sharing health in-
formation will increase efficiencies regardless of the
site of delivery. The ability to access information
anywhere and anytime reduces barriers to the
achievement of many global health objectives.
The Global Nursing Workforce
Even though an estimated 35 million nurses and mid-
wives make up the greater part of the global health-
care workforce, the demand for nurses currently
exceeds supply, and chronic shortages are character-
istic of the global nursing workforce (WHO, 2009). It
is estimated that there is a global shortage of about
4 million health-care workers (WHO, 2006), and the
situation is especially dire in sub-Saharan Africa. Staff
shortages in low-resource countries can be attributed
to three major forces: (1) an insufficient supply of ap-
propriately trained workers and financially strapped
health-care systems that have difficulty with recruitment
and retention; (2) substantial numbers of health-care
providers who are affected by HIV/AIDS personally
and professionally, which has increased the demand
for services and has reduced health-care workforce
availability, especially in sub-Sahara Africa; and
(3) migration patterns that have affected access to
health services as more nurses are moving from rural
to urban areas, from public health-care systems to pri-
vate health-care organizations, and from clinical to
nonclinical jobs (Laurent, 2011).
The global shortage of nurses is also related to an
unprecedented aging of the world population. The
older population is growing faster than the total
80 Foundations for Cultural Competence
EARTH SYSTEMS
HUMAN SYSTEMS
Climate Change
Temperature
change
Precipitation
change
Sea level
rise
Extreme
events
Impacts and
Vulnerability
Ecosystem Water
resources
Food
security
Human
healthSettlements
and society
Socio-Economic
Development
Literacy
Governance Health
Technology
Trade Equity
Population
Socio-cultural
preferencesProduction and
consumption patterns AdaptationMitigation
Concentrations
Emissions
AerosoisGreenhouse
gases
Climate Process Drivers
Figure 5-1 Anthropogenic (human-derived) climate change drivers, impacts, and responses. (Intergovernmental Panel on Climate Change.
(2007). Climate change 2007: Synthesis report. Geneva: IPCC. World Health Organization. (2010). Global atlas of the health workforce. Retrieved from
http://www.who.int/hrh/workforce_mdgs/en/index.html)
2780_Ch05_074-088 16/07/12 11:39 AM Page 80

population in virtually all world regions, with a pro-
jected doubling of the proportion of older persons by
2050 (United Nations, 2010). In some countries, more
than 40 percent of the population will be over 60 years
of age in 2050. This change in age demographics will
produce profound societal changes that include polit-
ical representation; family living arrangements; de-
mand for health services; and economic dynamics
related to investment, consumption, labor markets,
and intergenerational transfers.
The nursing workforce is also aging, with the aver-
age age of nurses in the United States at 46 years
(American Association of Colleges of Nursing, 2011).
The World Health Organization has proposed a model
of task shifting to address nurse shortages that are
worsened by this aging of the workforce. Task shifting
is the delegation of specific tasks to trained nonpro-
fessional health-care providers (WHO, 2008). Tasks
can be shifted from physicians to clinical officers, med-
ical assistants, nurses, or community health workers
as appropriate. Task shifting has been successful in
providing cost-effective, quality care with high patient
satisfaction (Holzemer, 2008).
The uneven ratio of health-care providers to pop-
ulation on a global scale is a significant problem
(Figure 5-2). The average nurse-to-population ratio
in Europe, the region with the highest ratios, is
10 times that of the lowest regions in Africa and
Southeast Asia (Buchan, Kingma, & Lorenzo, 2005).
The low availability of nurses in many less developed
Perspectives on Nursing in a Global Context 81
Uzbekistan
Kyrgyz Republic
Dem People’s Rep of Korea
Tajikistan
Soa Tome and Principe
Nigeria
Solomon Islands
Uganda
Myanmar
Vietnam
Lao People’s Dem Rep
Kenya
Pakistan
Ghana
Cambodia
Yemen
Comoros
Zimbabwe
Benin
Mauritania
Burkina Faso
Zambia
Afghanistan
Nepal
Dem Rep of the Congo
Eritrea
Cote d’lvoire
Gambia
Guinea-Bissau
Papua New Guinea
Bangladesh
Central African Republic
Senegal
Madagascar
Rwanda
Haiti
Mozambique
Togo
Chad
Malawi
Liberia
Mali
Ethiopia
Tanzania
Burundi
Sierra Leone
Niger
Somalia
Guinea
134
80
74
70
24
20
15
14
13
13
13
13
12
11
10
10
9
9
8
8
8
8
7
7
6
6
6
6
6
6
6
66
5
5
5
5
5
4
3
3
3
3
3
3
3
2
2
2
2
3
3
1
0 20 40 80 100 120 1406040
Critical threshold = 23 doctors, nurses
and midwives per 10,000 population
Doctors, nurses and midwives per 10,000 population
Figure 5-2 Density of doctors, nurses,
and midwives in 49 priority countries.
(World Health Organization. (2010). Global
atlas of the health workforce. Retrieved from
http://www.who.int/hrh/workforce_mdgs/en/
index.html)
2780_Ch05_074-088 16/07/12 11:39 AM Page 81

countries is exacerbated by geographic maldistribu-
tion with fewer nurses available in rural and remote
areas. Without planned and sustained interventions,
these wide variances in access to nursing care will un-
dermine attempts to improve health outcomes of
world populations.
International Migration
Migration is recognized as a normal activity of a global
society. In 1995, almost 100 million (1.8 percent of the
world’s population) lived outside their countries of
birth compared to 175 million (2.9 percent) in 2000
(United Nations, 2004). By 2010, it was estimated that
214 million (3.2 percent) people lived outside their
country of origin (United Nations, 2011). International
migration has more than doubled from 75 million in
1965 to an estimated 175 million in 2003; (Buchan,
Kingma, & Lorenzo, 2005). The United States has the
largest professional nurse workforce in the world.
It is expected that the migration of nurses to the
United States and other high-resource countries will
continue, as well as the need for U.S. nurses to under-
stand health-care systems and health problems beyond
their borders.
Career mobility and a desire to improve one’s liv-
ing conditions are motivators for migration. Push
factors that make nursing practice less desirable in
one’s home country include poor compensation,
under-resourced facilities, few career development
options, and sociopolitical instability. Pull factors in-
clude opportunities for increased pay, working in a
different culture, and improvement in one’s quality
of life (Kingma, 2006). Further, remittances sent to
families back home represent a significant propor-
tion of the gross national product in many develop-
ing nations.
Brain drain is a term used to describe recruitment
and migration of health-care providers, usually from
low-income countries to developed countries, for im-
proved career options. Foreign-educated nurses work-
ing in Australia, Canada, the United Kingdom, and
the United States comprise 5 to 10 percent of each
country’s nursing workforce (Kingma, 2008). In some
regions of Africa, over 80 percent of medical school
graduates migrate out of the country within five years
of graduation. Internal brain drain occurs when those
who stay in the home country work in the private sec-
tor or for foreign nongovernmental organizations.
However, brain drain sometime occurs because there
is no work available in the home country and because
of bankrupt health-care systems that cannot pay
workers. Some positive results of nursing migration
are when resources are sent back to the home country
or health-care providers return with advanced training
and experience (Kirk, 2007).
Challenges associated with international migration
include unethical recruitment practices where nurses
are misled about working conditions and remunera-
tion and benefits, the need to become familiar with a
foreign language and culture, a different health-care
system, and drugs and technologies used in other
countries. Foreign nurses may be discriminated
against based on concern about language proficiency
as it relates to patient safety. Gender-based discrimi-
nation may be an issue because nursing is often
viewed as a female occupation.
Trade and Mutual Recognition Agreements
The nursing workforce in the United States has been
affected by the 1994 trilateral trade bloc known as the
North American Trade Agreement (NAFTA). NAFTA
provides for the movement of goods and services across
the borders of Canada, Mexico, and the United States.
Health professionals included under the agreement in-
clude nurses, clinical laboratory specialists, and physical
and occupational therapists.
Squires (2011) explored the effects of NAFTA on
the development of Mexican nursing. A thematic
analysis was conducted using interviews with 48 Mex-
ican nurses and information from 410 primary and
secondary sources. Findings revealed that NAFTA
was associated with improvements to the educational
and regulatory infrastructures for Mexican nurses
without contributing to a mass migration of nurses to
the United States and Canada. However, the eco-
nomic instability caused by the peso crisis of 1995
slowed the implementation of nursing workforce re-
forms, and later political actions reduced nurses’ job
security by reducing wages and minimizing access to
full-time positions with benefits. This study reaffirms
the need to monitor the effects of trade agreements
over time, since implementation may contribute
to unintended effects that negatively affect front-
line workers such as nurses, as well as the health
consumers they serve.
In 2001, the Pan American Health Organization
(PAHO) and the Caribbean Program Coordination
office conducted a review of the scope and impact of
nurses’ migration in the Caribbean. The strategy that
resulted is the Managed Migration Program (MMP)
of the Caribbean, with a goal of retaining competent
nursing personnel to deliver health programs and serv-
ices to Caribbean nationals (Salmon, Yan, Hewitt, &
Guisinger, 2007). This collaborative effort identified
two foundational values: nurses have the right as in-
dividuals to freedom of movement within and beyond
the region, and all people have the right of access to
high-quality health services and programs. The MMP
encourages governments and other stakeholders to be
more aware of and responsive to six critical nursing
workforce issues: terms and conditions of work; re-
cruitment, retention, and training; value of nursing;
utilization and deployment; management practices;
and policy development.
82 Foundations for Cultural Competence
2780_Ch05_074-088 16/07/12 11:39 AM Page 82

When considering nursing migration from an even
broader perspective, the ICN has developed a creden-
tialing framework that uses Mutual Recognition
Agreements (MRAs). These bilateral, international,
and regional agreements permit qualifications and cre-
dentials to be recognized and accepted across borders.
The work to streamline credentialing standards and
processes is ongoing to ensure that more MRAs
will be available in the future. There is also an effort
to reach new global nursing markets in China and
Southeast Asia, where the nursing workforce of over
2 million nurses in their twenties can partially alleviate
the global shortage of nurses (Nichols, Davis, &
Richardson, 2011). In the United States, the nonprofit
Commission on Graduates of Foreign Nursing
Schools (CGFNS) serves as a clearinghouse for infor-
mation on international nursing education and licen-
sure. CGFNS is the authorized provider of certification
for nurses and other health-care providers seeking
employment in the United States.
Nursing Education
The preparation and practice standards for nurses vary
significantly by country. Baccalaureate programs are
becoming more common, with more than 46 countries
requiring the baccalaureate degree as entry level for
nursing practice. The baccalaureate degree has not yet
been established as the entry-level education for regis-
tered nurses universally, despite long-standing advocacy
by the ICN and the American Nurses Association to
standardize educational pathways. In the United States,
there are three educational pathways to achieve a
registered nurse level: a two-year associate degree, a
three-year diploma, and a baccalaureate degree.
The United Kingdom has the two pathways of a nurs-
ing diploma or a degree. The Philippines, Denmark,
Ireland, New Zealand, and Spain all have one university-
based educational pathway to become a registered
nurse, even though the required number of credit hours
varies among countries.
To promote greater uniformity in the United States,
the American Association of Colleges of Nursing
(AACN) developed an Essentials series that provides
recommendations for baccalaureate, masters, and doc-
toral curricula. Thus, the achievement of global stan-
dards for the education of nurses that has been an
ICN vision for more than 100 years has yet to be
accomplished.
Because of these multiple paths, if you pick any two
countries, you will find problems. Why does nursing
preparation in Germany and the United States, or
China and the United States, for example, produce a
variable skill mix, particularly with the expansion of
the role of advanced practice nurses (WHO, 2010)?
The goal of global standards for nursing practice is to
establish educational criteria to ensure outcomes
based on evidence and competency, to promote
lifetime learning, and to support nurse competencies
that will promote positive population-based health
outcomes (WHO, 2009).
Nursing curricula are being shaped by institutional
and organizational initiatives that address global
health issues. The American Academy of Nursing’s
(AAN) Expert Panel on Global Nursing and Health
white paper (Rosenkoetter & Nardi, 2005) examined
critical issues such as recruiting international nurses
to nursing positions in high-resource countries, faculty
and student exchanges, effects of U.S. Citizenship and
Immigration Law, and laws governing nursing practice
within the public domain. The panel recommended
expanding the number of international conferences
and exchanges, as well as opportunities and support
for collaborative research. This group supports mov-
ing curricular references to international nursing into
the context of global nursing and health and using
technology to increase access to educational materials
from any location.
U.S. Nursing Workforce Recommendations
The Future of Nursing: Leading Change, Advancing
Health provides a vision of U.S nursing education,
regulation, and practice. An appendix to this report
entitled International Models of Nursing (Nichols
et al., 2011) contains six recommendations to address
a national and global nursing workforce (Table 5-5).
Nursing education and continued professional devel-
opment are key elements for addressing global nursing
workforce shortages. This has been supported by a push
to make academic degrees and quality standards more
comparable across countries and to encourage the
pursuit of graduate degrees in nursing.
Nurse educators in the United States are increas-
ingly engaged in international partnerships to pro-
mote curriculum innovation that is shared across a
global faculty network.
Perspectives on Nursing in a Global Context 83
❙❙◗ Table 5-5 Recommendations for the Future
U.S. Nursing Workforce
1. Promote targeted educational investment in foreign edu-
cated nurses in the United States
2. Promote baccalaureate education for entry into practice in
the United States
3. Harmonize nursing curricula
4. Add global health as subject matter to undergraduate and
graduate nursing curricula
5. Establish a national system that monitors and tracks the in-
flow of foreign nurses, their countries of origin, the settings
in which they work, and their education and licensure to
ensure a proper skill mix for the U.S. nursing workforce
6. Create an international body to coordinate and recom-
mend national and international workforce policies
Adapted from Institute of Medicine. (2011). The future of nursing: Leading
change, advancing health. Washington, DC: The National Academies Press.
Appendix J, International Models of Nursing,
2780_Ch05_074-088 16/07/12 11:39 AM Page 83

These relationships support the development of
course content that would include a description of
health systems worldwide and information on global
patterns of disease, practice conditions, and profes-
sional migration.
The formulation of health-care policy can be sig-
nificantly influenced by a comprehensive database that
could assist governmental and private organizations
in health planning and policy development by track-
ing the education, skill mix, and practice and migra-
tion patterns of nurses.
In summary, nurses share a common professional
history, yet, internationally, education, preparation,
regulation, and practice are largely diverse. Market
forces have created the demand for a globalized nurs-
ing workforce. The WHO developed a set of global
standards for competency-based educational criteria
and outcomes for the Initial Education of Nurses and
Midwives. These evidence-based standards were de-
veloped for promoting positive health outcomes, and
they acknowledge the progressive nature of education
and lifelong learning (WHO, 2009). These standards
serve as guidelines for professional nursing regardless
of the specific location of the educational program or
practice, and they ease the burden placed on nurses
who migrate to other countries to practice.
Ethical, Safety, and Health
Considerations When Studying
or Working Abroad
This final section provides some food for thought for in-
dividuals who are planning to study or practice abroad.
The increasing numbers of students, faculty, clinicians,
and researchers who are pursuing their interests in di-
verse locations has raised both ethical and practical
questions about how to best prepare individuals for
work and study in settings that cross national and soci-
ocultural borders. The Working Group on Ethics
Guidelines for Global Health Training (WEIGHT) has
developed guidelines for institutions, trainees, and spon-
sors of field-based global health training on ethics and
best practices (Crump, Sugarman, & the WEIGHT,
2010). The WEIGHT guidelines encourage institutions
to develop structured programs among international
partners, including an accounting of the costs and re-
ciprocal benefits associated with these partnerships.
Other discussion points are how long-term partnerships
can mitigate possible short-term adverse consequences;
the characteristics of suitable trainees and supervisors;
and how participants should be prepared, including
attitudes and risk reduction education. The WEIGHT
recommendations include the following actions for
global health trainees:
• Recognize that the purpose is learning and possible
service. Develop goals and expectations for the
experience, and communicate this to the receiving
institution or mentor.
• Obtain necessary language skills and become
informed about the local social-cultural, political,
and historical aspects of the host community.
• Demonstrate cultural competency through per-
sonal dress, respect privileged communication, be
cognizant of alternate meanings of gestures and
body language, and seek a more in-depth under-
standing of gender and traditional health beliefs in
the host setting.
• Meet licensing standards, visa policies, and all
other program requirements.
• Follow accepted international guidelines regarding
the donation of medication, technology, and other
supplies.
• If publications are a possibility, discuss plans for
authorship of publications early to determine the
degree of collaboration and how it will be credited.
• Be prepared to provide feedback on the training
experience and follow-up information on career
development.
It’s helpful to assess personal attributes so that
strengths can be exploited and vulnerabilities ac-
knowledged and compensated for. Good listening
skills and an awareness of nonverbal cues are very im-
portant in new settings. These will be needed along
with good observational skills in general to learn
about how various communities perceive the world
and approach problems. The ability to weigh options
and engage in informed risk-taking is important for
making safe decisions while still being able to extend
one’s experiential base in unfamiliar settings. Finally,
the personal characteristics of patience and flexibility
will be needed, along with the recognition that feelings
of frustration may be cultural in origin. For this
reason, an awareness of personal values and cultural
assumptions is vital and will need to be reexamined
over time.
Venues for learning more about global nursing are
the ICN journal International Nursing Review and the
STTI publication Journal of Nursing Scholarship. For
students and faculty wishing to study, teach, and con-
duct research abroad, Fulbright scholarships are an
option. The Fulbright Program is the flagship inter-
national educational exchange program sponsored by
the U.S. government. It is named after the late senator
J. William Fulbright (1905–1995), who was the longest
serving chair of the Senate Foreign Relations Com-
mittee. There have been 300,000 past participants ful-
filling its mission to increase mutual understanding
between the U.S. citizens and the people of other
countries. The Fogarty International Center (FIC) is
the U.S. National Institutes of Health (NIH) agency
that provides grants and fellowships focused on global
health training and research. The FIC mission is to
84 Foundations for Cultural Competence
2780_Ch05_074-088 16/07/12 11:39 AM Page 84

foster partnerships between health research institu-
tions in the United States and abroad while training
the next generation of scientists to address global
health needs. The FIC was created in 1968 and is
named after Representative John E. Fogarty, who was
an outspoken advocate for the NIH budget and U.S.
global outreach in the health sciences.
When planning to work abroad as a nurse, a travel
health consultation is advised to assess risks related
to a specific destination and to receive individualized
counseling and advice about personal protection
practices. This will include a risk assessment to deter-
mine the need for immunizations; chemoprophylaxis
for malaria; precautions about food and water safety;
and personal safety, particularly in countries where
roads, vehicles, and infrastructure may be in disrepair
(Panosian, 2010). Rabies risk may be substantially
higher in some destinations, requiring special precau-
tions and a plan for how to proceed if confronted
with a possible exposure. Emergency evacuation in-
surance is highly recommended, since out-of-pocket
costs may vary from a few thousand dollars to over
$100,000, depending on the circumstances. Without
insurance, this fee must be paid before the evacuation
is undertaken.
Nurses globally have more commonalities than dif-
ferences as they seek to solve problems that range
from straightforward to highly complex. The role of
a professional nurse, regardless of location, includes
advocating for equitable access to health services and
essential medication; questioning discriminatory prac-
tices based on differences such as age, gender, race,
culture, or religion; providing care to the most vulner-
able members of society; and providing the education
and coaching that empower individuals and families
to care for themselves. Although the manner in which
nursing advocacy is accomplished will vary depending
on local resources, technology, governmental policies,
and culture, the goal remains the same: to provide
competent and compassionate nursing services based
on the best evidence available.
Perspectives on Nursing in a Global Context 85
R E F L E C T I V E E X E R C I S E 5 . 1
Rachel Cooper is a nurse practitioner who is departing in two
months for an assignment with a Haitian Non-Governmental
Organization (NGO) that delivers health-care services within
the capital of Port-au-Prince and several neighboring commu-
nities. Rachel’s preparation began online when she reviewed
the CDC recommendations for humanitarian aid workers, as
well as specific advice for relief workers going to Haiti. She fol-
lowed links to the U.S. State Department and the CIA World
Factbook to read about the Haitian government and health-
care system; crime prevention; stress management; heatstroke;
and diseases such as hepatitis, typhoid, rabies, tuberculosis,
R E F L E C T I V E E X E R C I S E 5 . 2
Dr. Lily Lee is a professor of nursing who will spend a
semester sabbatical in Kampala, Uganda, to work in
diabetes management and to assist with the development
of diabetes educational materials. She chose Uganda be-
cause over the past five years she has taken nursing and
other health science students there for a 3-week immersion
experience focused on an over view of health-care, culture,
and the environment. While in Uganda, she wants to be
par t of a recognized organization that can assist her with
licensing and credentials requirements, housing, and
developing a work plan. She decides to explore a Non-
Governmental Organization (NGO) called Health Volun-
teers Overseas (HVO; www.hvousa.org). She finds the
mission statement that describes HVO as a private non-
profit organization dedicated to improving the availability
and quality of health care in developing countries through
the training and education of local health-care providers.
Even though there was no posted volunteer oppor tunity
for a nurse in diabetes education, Professor Lee decided to
state her specific interest in her application because one of
the guiding principles of HVO is not only education about
diseases and treatments but to focus on prevention. She
was pleased that her application was accepted and now
needs to finalize her plans.
leptospirosis, HIV, and mosquito-borne malaria and dengue.
She plans to avoid travel at night, bring a bike helmet, and reg-
ister with the U.S. Embassy. She is shopping around for evacua-
tion insurance because the NGO does not provide it. Today
Rachel consulted with a travel health specialist for a detailed
risk assessment. She was asked about her daytime and night-
time activities; whether the dormitory housing provided air
conditioning, window/door screens, or bed nets; and personal
health status. Rachel received vaccinations and a prescription
for a weekly antimalarial medication. Precautions for food- and
water-borne diseases (e.g., cholera) and injury prevention
(e.g., traffic accidents, falls, drowning, and violence) were dis-
cussed in detail. Rachel is looking forward to this new experi-
ence and feels prepared for the health risks she will face in Haiti.
1. What resources are available to U.S. travelers to learn
about travel health risks and prevention strategies?
2. For how long after returning to the United States should
a traveler be concerned that new symptoms could be
related to a travel exposure (i.e., days, weeks, months,
years)?
3. What are Rachel’s options for emergency evacuation
insurance? How much does it cost to be evacuated
for health or safety reasons when individuals do not
purchase insurance?
4. What cultural issues will Rachel need to be sensitive to
while working as a nurse volunteer in Haiti?
Continued
2780_Ch05_074-088 16/07/12 11:39 AM Page 85

R E F E R E N C E S
American Association of Colleges of Nursing. (2011). Nursing
shortage fact sheet. Washington, DC: AACN.
Anderson, G.F., & Squires, D.A. (2010). Measuring the U.S. health
care system: A cross-national comparison. Washington, DC:
The Commonwealth Fund.
Audibert, M., Motel, P.C., & Drabo, A. (2010). Global burden of
disease and economic growth. Clermont-Ferrand, France: Cen-
tre d’Etudes et de Recherches sur le Developpement Interna-
tional (CERDI).
Beaglehole, R., & Yach, D. (2003). Globalisation and the preven-
tion and control of non-communicable disease: the neglected
chronic diseases of adults. Lancet, 362(9387), 903–908.
Buchan, J., Kingma, M., & Lorenzo, F. (2005). International mi-
gration of nurses: Trends and policy implications. Geneva: ICN.
Cavalcanti, A., Shirinzadeh, B., & Kretly, L.C. (2008). Medical
nonrobotics for diabetes control. Nanomedicine, 4(2), 127–138.
Chapman, A.R. (2009). Globalization, human rights, and the
social determinants of health. Bioethics, 23, 97–111.
Clarke, P.N., & Butterfield, P. (2011). Nursing as if the future
matters. Nursing Science Quarterly, 24(126), 126–129.
Crump, J.A., Sugarman, J., & and the Working Group on Ethics
Guidelines for Global Health Training. (2010). Global health
training: Ethics and best practice guidelines for training expe-
riences in global health. American Journal of Tropical Medicine
and Hygiene, 83(6), 1178–1182.
CSIS Commission on Smart Global Health Policy. (2010). Smart
global health policy. Washington, DC: Center for Strategic and
International Studies.
Daar, A.S., Singer, P.A., Persad, D.L., Pramming, S.K., Matthews,
D.R., Beaglehole, R., et al. (2007). Grand challenges in chronic
non-communicable diseases. Nature, 450, 494–496.
Fuster, V., & Voute, J. (2005). MDGs: Chronic diseases are not on
the agenda (Comment). Lancet, 366, 1512–1514.
Gostin, L.O. (2007). Meeting basic survival needs of the world’s
least healthy people: Toward a framework convention on
global health. Georgetown Law Journal, 96(2), 331–392.
Health Grants Information Center. (2009). Retrieved from
http://healthgrants.wordpress.com/category/major-philanthropic-
foundations/
Holzemer, W.L. (2008). Building a qualified global nursing work-
force. Nursing Care Continuum-Framework and Competencies.
Geneva: International Council of Nurses.
Institute of Medicine (IOM) & Board on International Health.
(1997). America’s vital interest in global health: Protecting our
people, enhancing our economy, and advancing our international
interests. Washington, DC: National Academy Press.
International Council of Nurses. (2009). Reducing the gap and im-
proving the interface between education and service: A framework
for analysis and solution generation. Geneva: ICN.
Kingma, M. (2006). Nurses on the move: Migration and the global
health care economy. Ithaca: ILR Press (Cornell University
Press).
Kingma, M. (2008). Nurses on the move: Historical perspective
and current issues. OJIN: The Online Journal of Issues in Nurs-
ing, 13(2), Manuscript 1.
Kirk, H. (2007). Towards a global nursing workforce: The “brain
circulation.” Nursing Management, 13(10), 26–30.
Koplan, J.P., Bond, T.C., Merson, M.H., Reddy, K.S., Rodriguez,
M.H., Sewankambo, N.K., et al. (2009). Towards a common
definition of global health. Lancet, 373, 1993–1995.
Lancet NCD Action Group. (2011). Priority actions for the non-
communicable disease crisis. Lancet, published online April 6,
2011. DOI:10.1016/S0140-6736(11)60393-0.
Laurent, C. (2011). Scaling up HIV treatment in resource-limited
countries: The challenge of staff shortages. Journal of Public
Health Policy, 1–8. DOI:10.1057/jphp.2011.8.
Mathers, C.D., & Loncar, D. (2006). Projections of global mortal-
ity and burden of disease from 2002 to 2030. PLOS Medicine,
3(11), 2011–2030.
Narayan, K.M.V., Ali, M.K., & Koplan, J.P. (2010). Global non-
communicable diseases: Where worlds meet. New England
Journal of Medicine, 363(13), 1196–1198.
Nichols, B.L., Davis, C.R., & Richardson, J.D. (2011). Interna-
tional models of nursing. In Institute of Medicine (Ed.), The
future of nursing: Leading change, advancing health (Appendix J).
Washington, DC: National Academies Press.
Nichter, M. (2008). Global health. Tucson, AR: Arizona Press.
Panosian, C. (2010). Courting danger while doing good—protecting
global health workers from harm. New England Journal of Med-
icine, 363(26), 2484–2485.
Piette, J. (2007). Interactive behavior change technology to sup-
port diabetes self-management: Where do we stand? Diabetes
Care, 30(10), 2425–2432.
Piette, J.D., Mendoza-Avelares, M.O., Milton, E.C., Lange, I., &
Fajardo, R. (2010). Access to mobile communication technol-
ogy and willingness to participate in automated telemedicine
calls among chronically ill patients in Honduras. Telemedicine
Journal and e-Health, 16(10), 1030–1041.
Pruitt, S.D., & Epping-Jordan, J.E. (2005). Preparing the 21st
century global healthcare workforce. British Medical Journal,
330(7492), 637–639.
Rosenkoetter, M., & Nardi, D. (2007). American Academy of
Nursing expert panel on global nursing and health: White
paper on global nursing and health. Journal of Transcultural
Nursing, 18(4), 305–315.
Salmon, M., Yan, J., Hewitt, H., & Guisinger, V. (2007). Man-
aged migration: The Caribbean approach to addressing nurs-
ing services capacity. Health Services Research, 42(3),
1354–1372.
Sattler, B. (2011). The greening of a major medical center. American
Journal of Nursing, 111(4), 60–62.
SNV Netherlands Development Organization & United Nations
Development Programme (2009). Going local to achieve the
millennium development goals: Stories from eight countries.
New York: United Nations.
Squires, A. (2011). The North American Free Trade Agreement
(NAFTA) and Mexican nursing. Health policy and planning,
26(2), 124–132.
86 Foundations for Cultural Competence
1. What more would Professor Lee want to know about this
organization before making a commitment to volunteer
for a semester?
2. Once you’ve visited the Web site, do you think HVO is a
good match with Professor Lee’s objectives?
3. How will serving as an HVO volunteer be different from
her prior visits as a faculty member with students repre-
senting her university?
4. What strategies could Professor Lee use to increase the
sustainability of her Ugandan project after she is gone?
2780_Ch05_074-088 16/07/12 11:39 AM Page 86

United Nations. (2004). International migration trends. New York:
Population Division, Department of Economic and Social
Affairs.
United Nations. (2007). World urbanization prospects: The 2007
revision (executive summary). New York: Department of
Economic and Social Affairs.
United Nations. (2010). World population aging 2009. New York:
Population Division, Department of Economic and Social
Affair.
United Nations. (2011). Migration and human rights. United Nations
human rights. Retrieved from http://www.ohchr.org/EN/
Issues/Migration/Pages/MigrationAndHumanRightsIndex.aspx
USAID: Health. (2009). Fact sheet: The U.S. government ‘s
global health initiative. Retrieved from http://www.usaid.gov/
ghi/factsheet.html
World Bank. (1993). World development report 1993: Investing in
health.
Washington, DC: World Bank.
World Health Organization. (1946). Preamble to the Constitution
of the World Health Organization as adopted by the Interna-
tional Health Conference, New York: WHO.
World Health Organization. (2002). Innovative care for chronic
conditions: Building blocks for action. Geneva: WHO.
World Health Organization. (2004). The global burden of disease:
2004 update. Geneva: WHO.
World Health Organization. (2006). World health report 2006.
Geneva: WHO.
World Health Organization. (2008). Task shifting: Global recom-
mendations and guidelines. Geneva: WHO.
World Health Organization. (2009). Global standards for the initial
education of professional nurses and midwives. Geneva: WHO.
World Health Organization. (2010). Global atlas of the health work-
force. Retrieved from http://www.who.int/hrh/workforce_mdgs/
en/index.html
World Health Organization. (2011). 2015 millennium development
goals. Geneva: WHO.
World Health Organization and UNICEF. (1978). Primary health
care: Report of the International Conference on Primary Health
Care. Alma-Ata USSR. September 6–12, 1978. Geneva: WHO.
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
Perspectives on Nursing in a Global Context 87
2780_Ch05_074-088 16/07/12 11:39 AM Page 87

2780_Ch05_074-088 16/07/12 11:39 AM Page 88

UNIT 2
AGGREGATE DATA
FOR CULTURAL-
SPECIFIC GROUPS
2780_Ch06_089-114 16/07/12 11:40 AM Page 89

2780_Ch06_089-114 16/07/12 11:40 AM Page 90

91
Chapter 6
People of African American
Heritage
Josepha Campinha-Bacote
Overview, Inhabited Localities,
and Topography
Overview
African Americans are the second largest minority
population in the United States, with the Hispanic/
Latino population being the largest (U.S. Department
of Health and Human Services, 2009). The population
of African Americans, including those of more than
one race, was estimated at 40.7 million, comprising
13.5 percent of the total population as of July 1, 2007,
according to the Census Bureau (U.S. Department of
Commerce, Census Bureau, 2010). This number is
projected to rise to 65.7 million (15 percent) of the
total population by the year 2050.
African Americans are mainly of African ancestry,
but many have non-African ancestors due to the fact
that the slave trade resulted in a diaspora from West
and Central Africa to many parts of the world, includ-
ing the West Indies, South America, Central America,
and the United States. Over the centuries, in all of
parts of the world, the African has mixed with other
local ethnic groups. In America this intermixing has
largely been with American Indians and European
Americans. Although African Americans and African
immigrants in the United States share some similari-
ties in respect to phenotype features and experience
with racism, discrimination, and prejudices, there
are major differences that vary in regard to such
factors as sociopolitical history, languages, cultural
beliefs, and family life (Chin, 2009, p. 15). Because of
the significant diversity that exists among African
Americans, health-care providers must be aware of the
intracultural variations that exist within this ethnic
group.
African Americans have been identified as “Negro,”
“colored,” “black,” “black American,” “Afro-American,”
and “people of color.” Depending on their cohort
group, some African Americans may prefer to identify
themselves differently. For example, younger blacks
may prefer the term African American, whereas elderly
African Americans may use the terms Negro and col-
ored. In contrast, middle-aged African Americans refer
to themselves as black or black American. Although the
term Negro is not a commonly used today, and many
African Americans are offended by its use, the U.S.
Census Bureau still included the term Negro on the
2010 U.S. Census, along with the terms black and
African American. These different descriptors can cause
confusion for those who are attempting to use the po-
litically correct term for this ethnic group. In addition,
organizational titles as the National Black Nurses
Association, National Center for the Advancement of
Blacks in the Health Professions, the National Associ-
ation for the Advancement of Colored People, and the
United College Negro Fund still exist, which clearly de-
pict the differences in how African Americans prefer to
be identified. Therefore, it is culturally responsive to ask
African Americans what they prefer to be called.
Heritage and Residence
African Americans are largely the descendants of
Africans who were brought forcibly to this country as
slaves between 1619 and 1860. The literature contains
many conflicting reports of the exact number of slaves
that arrived in this country. Varying estimates reveal that
from 3.5 to 24 million slaves landed in the Americas dur-
ing the slave trade era. Many slaves who were brought
to the American colonies and early United States came
from the west coast of Africa, from the Kwa- and Bantu-
speaking people. The legacy of African American her-
itage and history of slavery is often passed on from
generation to generation through African American
folktales and lived experiences (Taulbert, 1969).
African American slaves were settled mostly in south-
ern states. In 2007, 56 percent of African Americans still
2780_Ch06_089-114 16/07/12 11:40 AM Page 91

live in the South; 19 percent live in the North and
Northeast, 9 percent in the West, and 19 percent in the
Midwest. In 2008, the 10 states with the largest black
populations were New York, Florida, Texas, Georgia,
California, North Carolina, Illinois, Maryland, Virginia,
and Michigan (U.S. Department of Health and Human
Services, 2009). Louisiana is no longer in the top 10 as
a result of Hurricane Katrina in 2005. Combined, these
10 states represented 59 percent of the total African
American population. Of the 10 largest places in the
United States with populations of 100,000 or more,
Gary, Indiana, has the largest proportion of blacks—
83 percent—followed by Detroit with 82 percent (U.S.
Department of Health and Human Services, 2009).
Reasons for Migration and Associated Economic
Factors
The Civil War ended slavery in 1865, and particularly
in the state of South Carolina, the Reconstruction Act
allowed blacks the right to vote and participate in state
government. However, most African Americans in the
South were denied their civil rights and were segre-
gated. Thus, African Americans lived in poverty and
encountered many hardships. After the Civil War,
more African Americans migrated from southern
rural areas to northern urban areas. Blacks migrated
because of a lack of security for life and property.
They were unable to get out of debt and support their
families despite being successful farmers. Also, World
War II was a major catalyst in fostering migration to
urban and northern areas, which provided greater eco-
nomic opportunities and brought African Americans
and European Americans into close contact for the
first time. Jaynes and Williams (1989) reported that
during the 1940s, a net outmigration from the South
totaled approximately 1.5 million African Americans
(15 percent of the South’s black population). Although
the migration was viewed as a positive move, many
African Americans encountered all the problems of
fragmented urban life, racism, poverty, and covert
segregation.
Educational Status and Occupations
Before 1954, educational opportunities for African
Americans were compromised. School systems were
segregated, and blacks were victims of inferior facili-
ties. In fact, in 1910, almost one-third of all blacks
were illiterate (Blum et al., 1981). However, in 1954,
the Supreme Court decision in Brown v. Board of Ed-
ucation of Topeka ruled against the segregation of
blacks and whites in the public school systems. Co-
nant (1961) described the plight of African Americans
in segregated schools and, to some extent, predicted
the long-term social consequences of such a system.
His predictions have been borne out as inadequate job
opportunities and poor wages, resulting in poverty.
Poverty has had a ripple effect on African American
communities, often leading to poorly educated indi-
viduals, high dropout rates from school, and drug and
alcohol misuse (Ladner & Gourdine, 1992). In many
African American communities, this oppressive envi-
ronment contributes to the existing alcohol and drug
problems and the high dropout rate among African
Americans, which has been reported as high as 61 percent
(Braithwaite, Taylor, & Austin, 2000).
Despite these devastating occurrences, most African
American families place a high value on education. In
2008, 81 percent of African Americans age 25 and
older had a high school diploma (U.S. Department of
Commerce, Bureau of the Census, 2008). The African
American family views education as the process most
likely to ensure work security and social mobility.
Families often make great sacrifices so at least one
child can go to college. In African American families,
it is not uncommon to see cooperative efforts among
siblings to assist one another financially to obtain a
college education. For example, as the older child
graduates and becomes employed, that child then as-
sists the next sibling, who, in turn, assists the next one.
This continues until all of the children who attend
college have graduated. Before the civil rights move-
ment, a major emphasis for African Americans in
higher education was vocational. The thinking was
that if African Americans could learn a trade or vo-
cation, they could become self-sufficient and improve
their economic well-being. Preparation for vocational
careers is evidenced in the name, mission, and goals
of two of the renowned, historically black institutions,
Hampton University and Tuskegee University, for-
merly known as Hampton Institute and Tuskegee
Normal and Industrial Institute.
Although African Americans have successfully com-
pleted a variety of majors in universities, significant dif-
ferences exist in the ethnic, racial, and gender makeup
of those obtaining higher degrees. In 2008, 18 percent
of African Americans had a bachelor’s degree or higher,
which is 10 percent age points lower than the national
average (U.S. Department of Commerce, Bureau of the
Census, 2008). Today, African Americans continue to
be underrepresented in managerial and professional po-
sitions. In addition, the representation of many African
Americans and other ethnic groups in the health pro-
fessions is far below their representation in the general
population (Sullivan, 2004). Increasing racial and ethnic
diversity among health professionals is critical because
evidence indicates that diversity is associated with im-
proved access to care for racial and ethnic minority pa-
tients, greater patient choice and satisfaction, and better
educational experiences for all students (IOM, 2004).
African Americans represent a large segment of
blue-collar workers employed in service occupations
(Low-wage labor market, 2006). One reason for this
disproportionate representation in professional and
managerial positions is believed to be discrimination
92 Aggregate Data for Cultural-Specific Groups
2780_Ch06_089-114 16/07/12 11:40 AM Page 92

in employment and job advancement. In 1961, President
John F. Kennedy established the Committee on Equal
Employment Opportunity to protect minorities from
discrimination in employment. However, most African
Americans still believe that job discrimination is a
major variable contributing to problems they en-
counter in obtaining better jobs or successful career
mobility. With the dismantling of affirmative-action
programs, based on misinterpretation of their pur-
pose, this view will, perhaps, continue to gain support.
Most working-class African Americans do not typ-
ically advance to the higher socioeconomic levels.
Because they are overrepresented in the working class,
they are more likely to be employed in hazardous oc-
cupations, resulting in occupation-related diseases and
illnesses. For example, Michaels (1993) reported that
African American males are at a higher risk for devel-
oping cancer, which is related to their high represen-
tation in the steel and tire industries. According to
Clark (1999), genetic factors of greatest importance
in the work environment are probably race and gen-
der. Implications are that health-care providers must
not only assess African American patients for occu-
pation-related diseases such as cancer and stress-
related diseases such as hypertension but must also be
familiar with the government’s Healthy People 2010
goals for the health and safety of individuals in the
work environment (U.S. Department of Health and
Human Services, 1997).
Communication
Dominant Language and Dialects
The dominant language spoken among African
Americans is English. Some African Americans use a
language that sociolinguists refer to as African American
English (AAE). According to Green (2002) AAE in-
cludes the variations of an ethnic and social dialect
spoken by African Americans who are members of
the working class, street culture, and hip-hop or rap.
The two main hypotheses about the origin of AAE are
the dialect hypothesis and the Creole hypothesis. The
dialect hypothesis supports the position that African
slaves, upon arriving in the United States, picked up
English very slowly and learned it incorrectly. In turn,
these inaccuracies have been passed down through
generations. The Creole hypothesis maintains that
AAE is the result of a Creole derived from English
and various West African Languages.
The major problem that AAE speakers face is prej-
udice. Most people believe that AAE is inferior to
Standard American English (SAE). At times, African
Americans who use AAE are misinterpreted as being
uneducated. However, it is common for educated
African Americans who are extremely articulate in
SAE to use AAE when conversing with one another.
Thompson, Craig, and Washington (2004) referred to
this ability as dialect-shifting. The literature suggests
that AAE provides African Americans with a frame-
work for communicating unique cultural ideas and
also serves as a way to symbolize racial pride
and identity (Allender & Spradley, 2001; Murray &
Zentner, 2001).
Over the years, a number of names have been used
to describe the different varieties or dialects of AAE.
Some of the more common terms are Black Dialect,
Black Folk Speech, Black English, Ebonics, Black
Vernacular English (BEV), and African American
Vernacular English (AAVE) (Bland-Stewart, 2005;
Green, 2002). Much controversy exists regarding the
use of these labels. In December 1996, the Oakland
School Board in Oakland, California, passed a reso-
lution to recognize Ebonics as the primary language
of African American children and take it into ac-
count in their language arts lessons and classrooms
(Rickford, 1999). This resolution sparked national de-
bate, and in April 1997, the Oakland School Board
dropped the word Ebonics from their implementation
proposals. Obvious problems occur with defining a
language racially because not all African Americans
speak these varieties, and some non–African Americans
speak them as well.
Cultural Communication Patterns
African American communication has been described
as high-context (Cokley, Cooke, & Nobles, 2005). The
volume of African Americans’ voices is often louder
than those in some other cultures; therefore, health-
care providers must not misunderstand this attribute
and automatically assume this increase in tone is re-
flecting anger. African American speech is dynamic
and expressive, and they communicate more interac-
tively than European Americans. Wood (2009) states
that this may explain why some African Americans
shout out responses such as “Tell it,” “All right,” and
“Keep talking” during speeches or church sermons.
While many European Americans may consider these
comments as an interruption, some African Americans
regard it as complimentary participation in commu-
nication. Body movements are involved when commu-
nicating with others. Facial expressions can be very
demonstrative. African Americans are reported to be
comfortable with a closer personal space than other
ethnic groups. Touch is another form of nonverbal
communication seen when African Americans are in-
teracting with relatives and extended family members.
When interacting with African Americans, the power
of touching should not be underestimated for its heal-
ing powers (Cokley et al., 2005).
In communicating among themselves, African
Americans place a strong value on oral tradition. Oral
tradition is the face-to-face transmittal of elements of
the African American culture from one generation to
another by the spoken word (NMAETC, 2006). One
People of African American Heritage 93
2780_Ch06_089-114 16/07/12 11:40 AM Page 93

example of this form of communication is story-
telling. These stories convey important values and
morals on how to live life.
Humor is a form of communication that can serve
as a tool to release angry feelings and to reduce stress
and ease racial tension. The dozens, a social game in
which African Americans use humor, is a joking rela-
tionship between two African Americans in which
each in turn is, by custom, permitted to tease or make
fun of the other (Campinha-Bacote, 1993). Fre-
quently, humor is used among the African American
population as a preventive mechanism to ward off an
anticipated attack. Often, the joking is loud and can
be mistaken for aggressive communication if not un-
derstood within the context of the African American
culture. Being aware of and understanding the func-
tion that humor serves in the African American cul-
ture can assist health-care providers to formulate
culturally responsive health-care interventions. For
example, Campinha-Bacote (1993; 1997) documented
the effective use of culturally specific humor groups
with African American patients with psychiatric
disorders.
Many African Americans mistrust health-care
providers and express their feelings only to trusted
friends or family. What transpires within the family is
viewed as private and not appropriate for discussion
with strangers. A common phrase that reflects this
perspective is “Don’t air your dirty laundry in public.”
Health-care providers must be sensitive to this form
of communication in that older and more traditional
African Americans may not embrace “talk therapy.”
Temporal Relationships
In general, African Americans tend to be more present-
than past- or future-oriented. However, the past or
future may be valued in specific subgroups of African
Americans, such as the elderly, who place greater
emphasis on the past than on the present. In contrast,
younger and middle-aged African Americans are more
present oriented, with evidence of becoming more
future oriented, as indicated by the value placed on
education.
Some African Americans are more relaxed about
time and may not be prompt for their appointments.
Within this context, it is more important for them to
show up for an appointment than to be on time. What
they see as important is the fact that they are there, even
though they may arrive 1 or 2 hours late. Therefore,
flexibility in timing appointments may be necessary for
African Americans, who have a circular sense of time
rather than the dominant culture’s categorically imper-
ative linear sense of time (Murray & Zentner, 2001).
Format for Names
Most African Americans prefer to be greeted formally
as Dr., Reverend, Pastor, Mr., Mrs., Ms., or Miss. They
prefer their surname because the family name is highly
respected and connotes pride in their family heritage.
However, African Americans do not use such formal
names when they interact among themselves. An
African American youth commonly addresses an unre-
lated African American who lives in the community as
Uncle, Aunt, or Cousin. Adult African Americans may
also be called names different from their legal names.
Until invited to do otherwise, greet African American
patients by using their last name and appropriate title.
Family Roles and Organization
Head of Household and Gender Roles
Although today it is common to find a patriarchal sys-
tem in African American families, a high percentage of
families still have a matriarchal system. The head of the
household can be a single mother, grandmother, or
aunt. A single head of household is accepted without
associated stigma in African American families. When
women are unable to provide emotional and physical
support for their children, grandmothers, aunts, the
church, and extended or augmented families readily pro-
vide assistance or take responsibility for the children.
One important trend noted today is that a growing num-
ber of African American grandparents are functioning
in primary parental roles. For example, 44 percent of all
children living with grandparents today are African
American. Approximately 66 percent of these children
have grandparents as the primary caregivers.
Ladner and Gourdine (1992) state, “Single parenting
and poverty are viewed as the causal factors in destabi-
lizing the African American family” (p. 208). The
poverty rate for African Americans reached 25.8 percent
in 2009 (U.S. Department of Commerce, Bureau of the
Census, 2008). Forty-one percent of single-mother
African American families are living in poverty. Anther
contributing factor undermining the African American
94 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 6 . 1
Kesia Crawford, a 6-year-old African American female, is
brought into the ER by her grandmother, Mrs. Elvenia Thomas,
for vaginal bleeding. The nurse, in an attempt to establish rap-
port with the grandmother, states, “Shirley, I know you must be
very concerned that your granddaughter is experiencing this
bleeding.” The grandmother immediately becomes defensive in
her subsequent responses to the nurse’s questions.
1. What are some reasons for Kesia Crawford’s vaginal
bleeding?
2. How would you conduct a culturally sensitive skin
assessment with Kesia Crawford?
3. What may explain why Mrs. Thomas became defensive in
her responses to the nurse?
2780_Ch06_089-114 16/07/12 11:40 AM Page 94

family is the absence of African American males due to
high unemployment rates, low life expectancy, and in-
carceration. Overall, African American men are incar-
cerated at 6.5 times the rate of white men (U.S.
Department of Justice Office of Justice Programs, 2008)
Gender roles and child-rearing practices in the
African American family vary widely depending on eth-
nicity, socioeconomic class, rural versus urban location,
and educational achievement. The diverse family struc-
ture extends the care of family members beyond the
nuclear family to include relatives and nonrelatives.
Similar to the pattern in the general society, dual em-
ployment of many middle-class African American fam-
ilies requires cooperative teamwork. Many family tasks
such as cooking, cleaning, child care, and shopping are
shared, requiring flexibility and adaptability of roles.
Because many African American families, especially
those with a single head of household, are matrifocal in
nature, the health-care provider must recognize women’s
importance in decision making and disseminating
health information. Also, the health-care provider
must focus on, and work with, the strengths of African
American families, especially single-parent families. Hill
(1997) stated that although many African American
families headed by single women are economically dis-
advantaged, they should not be compared or equated
with broken or intact families.
Prescriptive, Restrictive, and Taboo Roles
for Children and Adolescents
Given African Americans’ strong work and achieve-
ment orientation, they value self-reliance and educa-
tion for their children. A dichotomy might exist here,
because many parents do not expect to get full benefit
from their efforts because of discrimination. Thus,
families tend to be more protective of their children
and act as a buffer between their children and the
outside world.
Respectfulness, obedience, conformity to parent-
defined rules, and good behavior are stressed for
children. The belief is that a firm parenting style,
structure, and discipline are necessary to protect the
child from danger outside of the home. In violence-
ridden communities, mothers try to keep young chil-
dren off the streets and encourage them to engage in
productive activities. Adolescents are assigned house-
hold chores as part of their family responsibility or
seek employment for pay when they are old enough,
thus learning “survival skills.”
Although there has been a decline in the incidence of
teen pregnancy, it continues to be a problem in the
African American community because of poor preg-
nancy outcomes such as premature and low-birth-weight
infants and obstetric complications. Furthermore, the
teenage mother is expected to assume primary responsi-
bility for her child, whereas the extended family becomes
a strong support system. Premarital teenage pregnancy
is not condoned in African American families but rather
is accepted after the fact. In other instances, the infant
may be informally adopted, and someone other than the
mother may become the primary caregiver.
Family Roles and Priorities
African American families share a wide range of char-
acteristics, family values, goals, and priorities. An exam-
ple of a strong family value is the level of respect
bestowed upon the elders in the African American com-
munity. In this community, the elders, especially grand-
mothers, are respected for their insight and wisdom. The
role of the grandmother is one of the most central roles
in the African American family. Grandmothers are fre-
quently the economic support of African American
families, and they often play a critical role in child care.
It is common to see African American children raised
by grandparents; this has contributed to an increase in
the number of skipped-generational families seen in the
African American community.
Understanding the role of the extended family in
the lives of African Americans is essential. Several
African American extended-family models exist.
Billingsley (1968) divided them into four major types:
subfamilies, families with secondary members, aug-
mented families, and nonblood relatives. Subfamily
members include nieces, nephews, cousins, aunts, and
uncles. Secondary members consist of peers of the pri-
mary parents, older relatives of the primary parents,
and parents of the primary parents. In an augmented
family, the head of the household raises children who
are not his or her own relatives. Nonblood relatives
are individuals who are unrelated by blood ties but
who are closely involved with the family functioning.
Nonblood relatives are also referred to as “fictive kin.”
As a result of long-standing relationships with the
family, fictive kin may be serving as the primary care-
givers or even as the substitute decision makers and
sometimes may be more involved than the related fam-
ily members (Curriculum Ethnogeriatrics, 2001) Stud-
ies have found that African American families exhibit
about 70 diverse structural formations versus about
40 among white families (Barbarin, 1983). Barbarin
adds that this comparison points to the variability of
the African American family structure and to the flex-
ibility of family roles.
Social status is important within the African
American community. Certain occupations receive
higher esteem than others. For example, African
American physicians and dentists tend to have privi-
leged positions. Ministers and clergy also receive re-
spect in the African American community. They have
historically held a high status in African American
communities and are critical “First Responders”
(Cokley et al., 2005).
African Americans who move up the socioeco-
nomic ladder often find themselves caught between
People of African American Heritage 95
2780_Ch06_089-114 16/07/12 11:41 AM Page 95

two worlds. They have their roots in the African
American community, but at times they find them-
selves interacting more within the European American
community. Other African Americans refer to these
individuals as “oreos”—a derogatory term that means
“black on the outside, but white on the inside.” In
Frazier’s (1957) seminal and controversial publication
Black Bourgeoisie, he highly criticized middle-class
blacks. He argued that African American families who
achieve upper-middle-class and middle-class status—
the so-called black bourgeoisie—perpetuate a myth of
“Negro society.” According to Frazier, this term de-
scribes behavior, attitudes, and values of a make-
believe world created by middle- and upper-class
African Americans in order to escape feelings of
inferiority in American society.
Alternative Lifestyles
Lesbian and gay relationships undoubtedly occur as
frequently among African Americans as in other eth-
nic groups. A review of the literature reveals that
African Americans are less supportive of homosexu-
ality than other racial and ethnic groups, but the rea-
sons have more to do with religion than race. African
Americans are markedly more religious on a variety
of measures than the U.S. population as a whole,
including level of affiliation with a religion, atten-
dance at religious services, frequency of prayer, and
religion’s importance in life (The Pew Forum on
Religion & Public Life, 2009). Negy and Eisenman
(2005) reported that while initial results of their study
suggested that African Americans had modestly
higher homophobia and homonegativity scores than
whites, these differences did not hold after controlling
for frequency of church attendance, religious commit-
ment, and socioeconomic status. For both ethnic
groups, religiosity significantly predicted homophobia
and homonegativity.
Acceptance of same-sex relationships varies be-
tween and among families. Personal disclosure to
friends and family may jeopardize relationships,
thereby forcing some to remain closeted. Debate is on-
going about the pros and cons of legitimizing lesbian
and gay families, especially when children are involved.
Opponents of this family form believe that parental
behavior has a profound effect on children’s gender
identities and establishing family values (Bender, 1998).
Single parenting and other alternative lifestyles are dis-
cussed in other sections in this chapter.
Workforce Issues
Culture in the Workplace
Although the African American value system reflects
a strong emphasis on spirituality, there is also an
economic-driven emphasis on materialism. African
Americans feel a need to acculturate into mainstream
society in order to successfully survive in the work-
force. However, this survival is often met with ethnic
or racial tension. Ethnic or racial tension can be de-
fined as a negative workplace atmosphere motivated
by prejudicial attitudes about cultural background
and/or skin color. Watts (2003) asserts that race is an
issue for African Americans, and “the black experi-
ence” in America is markedly different from that of
other immigrants, specifically in terms of the ex-
tended period of the institution of slavery and the
issue of skin color as a means for dehumanization of
black persons. Watts concludes that matters of race,
racism, and racial discrimination persist throughout
contemporary American life.
In 2007, the unemployment rate for African
Americans was twice that for non-Hispanic whites
(8 percent and 4 percent, respectively). This finding
was consistent for both men (9 percent compared
with 4 percent) and women (8 percent compared with
4 percent) (U.S. Department of Health and Human
Services, 2009). Research reveals that African Americans
have a long history of workforce disadvantage. While
some work organizations are making strides in
their efforts to fight against discrimination, African
Americans continue to encounter challenges imposed
on them through the multifaceted interactions of
racially motivated negative attitudes and actions of in-
dividual and organizational policies and practices
that are not encountered by European Americans.
These major problems include such issues as employ-
ment process biases, channeling into “minority”
positions, lack of access to network and mentors, pro-
motion and advancement difficulties, and emotional
and psychological maltreatment (Parks-Yancy, 2010;
Queralt, 1996).
African Americans are underrepresented in highly
skilled and managerial positions and overrepresented in
low-status positions. Middle-class African Americans
who hold higher-paying jobs often experience the
“glass ceiling” effect, in which access to higher posi-
tions is blocked (Bigler & Averhart, 2003). However,
Barack Obama, a biracial man born of an African fa-
ther and European American mother, has instilled
hope in African Americans as the first person of color
to be elected president of the United States in 2008.
Although his presidency appears to demonstrate that
the “American Dream” is within reach for African
Americans, authors such as Kwate and Meyer (2010)
maintain that the problem still persists: “Opportu-
nities are not equally distributed and are not allotted
solely by meritocratic criteria” (p. 1831). Health-care
providers must increase their sensitivity and aware-
ness of cultural nuances and issues that create ethnic
or racial tension in the workplace environment, for
these factors can have an impact on such stress-
related conditions as mental health disorders and
hypertension.
96 Aggregate Data for Cultural-Specific Groups
2780_Ch06_089-114 16/07/12 11:41 AM Page 96

Issues Related to Autonomy
Some African American men may experience a diffi-
cult time in taking direction from European American
supervisors or bosses. This difficulty stems from the
era of slavery when African Americans were consid-
ered the property of their masters. Many African
Americans continue to be frustrated at their lower-
level positions and the absence of African American
leadership in many workplaces. Lowenstein and
Glanville (1995) found that along with historical
circumstances, culture and politics affect the employ-
ment of African Americans in the health-care indus-
try, often relegating African Americans to nonskilled
roles. Today, a large number of African Americans
continue to work as nursing assistants, licensed
practical nurses (LPNs), or technicians. Thus, if the
professional nurse who directs and supervises nonpro-
fessional workers lacks cultural sensitivity toward other
ethnic groups, the stage is set for cultural conflict.
Because the dominant language of African
Americans is English, they usually have no difficulty
communicating verbally with others in the workforce.
However, some people may inaccurately view African
Americans who exclusively speak AAE as poorly
educated or unintelligent. This misinterpretation may
affect employment and job promotion where verbal
skills are more valued. In addition, the nonverbal
communication style (e.g., strong intonation and ani-
mated body movements) of some African Americans
is often misunderstood and labeled as more aggressive
than assertive in comparison with that of other
cultural groups.
Biocultural Ecology
Skin Color and Other Biological Variations
African Americans encompass a gene pool of over
100 racial strains. Therefore, skin color among
African Americans can vary from light to very dark.
As health-care providers, we are trained in the art of
using alterations in skin color and deviations from an
individual’s normal skin tone to aid in our diagnoses.
For example, jaundice is a sign of a liver disorder; pink
and blue skin changes are associated with pulmonary
disease; ashen or gray color signals possible cardiac
disease; copper skin tone indicates Addison’s disease;
and a nonblanchable erythema response signifies the
presence of a stage I pressure ulcer (Salcido, 2002). We
commonly use these alterations in skin color as poten-
tial signals of pathology because we can visualize
changes such as the increased blood flow (erythema)
that signals such problems as inflammation. However,
these acquired assessment skills are based on a Euro-
centric rather than a melanocentric approach to
skin assessment (Campinha-Bacote, 2007). Sommers
(2011) urges health-care providers to cultivate color
awareness in regard to assessing the skin of African
Americans. Color awareness recognizes that skin color
is relevant to health and should not be ignored.
Furthermore, by applying color awareness to health
assessment, health-care providers can more appropri-
ately manage skin conditions among patients of all
skin colors and help reduce disparities in health-care
delivery.
Assessing the skin of most African American pa-
tients requires clinical skills different from those for
assessing people with white skin. For example, pallor
in dark-skinned African Americans can be observed
by the absence of the underlying red tones that give
the brown and black skin its “glow” or “living color.”
Lighter-skinned African Americans appear more
yellowish-brown, whereas darker-skinned African
Americans appear ashen. Assessing such conditions
as inflammation, cyanosis, jaundice, and petechiae in
African Americans may require natural light and the
use of different assessment skills. African Americans
exhibiting inflammation or petechiae must be assessed
by palpation of the skin for warmth, edema, tightness,
or induration. If feasible, do not to wear gloves to per-
form the skin assessment, because they have a ten-
dency to diminish sensitivity to skin temperature
changes. To assess for cyanosis in dark-skinned
African Americans, the health-care provider needs to
observe the oral mucosa or conjunctiva. Jaundice is
assessed more accurately in dark-skinned persons by
observing the sclera of the eyes, the palms of the
hands, and the soles of the feet, which may have a yel-
low discoloration. In performing a skin assessment it
may also be helpful to ask the patient, family, signifi-
cant other, or caregiver to point out an area of normal
skin color, temperature, and texture to serve as a
baseline (Sommers, 2011).
Researchers studying forensic sexual assault exam-
inations found data suggesting African American
women had a lower incidence of genital injury after
rape when compared to European American women
(Sommers et al., 2008). However, they maintain that
the difference in reported injury prevalence was not
related to race or ethnicity but rather due to reduced
visibility of injury in dark-skinned women. Their re-
search demonstrated that skin color explained the dif-
ferences in the numbers of genital injuries than race
or ethnicity, concluding that the prevalence of genital
injuries in dark-skinned women has likely been underre-
ported because of difficulty seeing the injuries. Sommers
(2011) argues that these findings are important given
the role of forensic evidence in the criminal justice sys-
tem; women whose injuries are documented during
the forensic examination have better judicial outcomes
than women without documented injuries.
The literature also confirms that health-care
providers are not doing an adequate job of detecting
and reducing pressure ulcer risk in African Americans.
According to recent studies, African Americans are at
People of African American Heritage 97
2780_Ch06_089-114 16/07/12 11:41 AM Page 97

higher risk for developing more severe pressure ulcers
and associated mortality and morbidity (Salcido,
2002). The National Healthcare Disparities Report
(AQHR, 2005) revealed that in both 2002 and 2003,
the proportion of high-risk, long-stay, and short-stay
residents who had pressure sores was higher among
African Americans and Hispanics when compared
with non-Hispanic whites. Salcido (2002) asserted that
it may be due to our lack of ability to make an early
diagnosis of skin in jeopardy of breaking down. Cur-
rently, researchers are testing a variety of devices that
could be used to detect and diagnose alterations in
blood flow, regardless of the color of the patient’s
skin. These devices include visible and near-infrared
spectroscopy, pulse oximetry, laser Doppler, and ul-
trasound (Matas et al., 2001; Salcido, 2002; Sowa,
Matas, Schattka, & Mantsch, 2002).
Several skin disorders are found among the African
American population. The major skin disorder is
postinflammatory hyperpigmentation, which is the
darkening of the skin after resolution of skin trauma,
lesions of a dermatosis, or as a result of treatments
administered for skin disorders. Hypopigmentary
changes have also been noted in these instances.
African Americans also have a tendency toward the
overgrowth of connective tissue associated with the
protection against infection and repair after injury.
Keloid formation is one example of this tendency.
Diseases such as lymphoma and systemic lupus ery-
thematosus occur in African Americans secondary to
this overgrowth of connective tissue.
Certain skin conditions are gender-specific among
some African Americans. Pseudofolliculitis barbae
(“razor bumps”) is more common among African
American males. This skin condition results from
curved hairs growing back into the skin, causing itchy
and painful bumps. African American males should
be counseled regarding the best shaving method to
keep this disorder to a minimum. Suggestions include
the use of electric clippers, a triple-bladed razor, a de-
pilatory, or laser therapy. Melasma (“the mask of
pregnancy”) is more common among darker-skinned
African American females during pregnancy. This con-
dition is characterized by brown spots or patches on
the face. Also noted among African American women
is alopecia (hair loss) related to the use of chemicals to
straighten/relax the hair or from braiding.
African Americans, in general, also experience a
disproportionate amount of pigment discoloration,
with vertiligo (white patches) being the most common.
This autoimmune disease manifests as white patches
on the skin and causes skin discoloration and is also
associated with diabetes and thyroid disorders. Birth-
marks are more prevalent in African Americans, oc-
curring in 20 percent of the African American
population compared with 1 to 3 percent in other eth-
nic groups. One example is mongolian spots, which
are found more often in African American newborns
but disappear over time.
African Americans must also be screened for skin
cancer. Skin cancer comprises 1 to 2 percent of all
cancers in African Americans (Gloster & Neal,
2006). Whereas squamous cell carcinoma is the sec-
ond most common type of skin cancer in white pa-
tients, it is the most common type in patients of
African and Asian Indian descent. Basal cell cancer
is the second most common skin cancer of African
Americans and is associated with chronic sun expo-
sure. This type of skin cancer is more aggressive in
African Americans than in whites. While melanoma
is uncommon in African Americans, it is often
terminal. The overall melanoma survival rate for
African Americans is only 77 percent, as compared
with 91 percent for whites (Ries et al., 2008). Many
African Americans believe that they are not at risk
for skin cancer because of their higher concentra-
tion of melanin; however, health-care providers
must help to dispel this myth and educate African
Americans regarding skin cancer protection.
Diseases and Health Conditions
Underwood and colleagues (2005) asserted that
African Americans experience an “excessive burden
of disease.” When examining the relationship of social
characteristics such as education, income, and occu-
pation to health indicators, African Americans have
worse indicators when compared with those of whites
(Navarro, 1997). African Americans are at greater risk
for many diseases, especially those associated with
low-income, stressful life conditions, lack of access to
primary health care, and negating health behaviors
such as violence, poor dietary habits, lack of exercise,
and lack of importance placed on seeking primary
health care early. The Institute of Medicine (IOM)
98 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 6 . 2
Abu Jemison, a 43-year-old African American man, has been
admitted to the psychiatric unit with a provisional diagnosis of
schizophrenia. His admitting history states that he is having
auditory hallucinations (hearing voices from God), exhibiting
paranoid behavior, and is aggressive. Mr. Jemison is started on
olanzapine (Zyprexa™) 10 mg once a day.
1. What are the cultural factors that may explain his para-
noid behavior, auditory hallucinations, and aggressive
behavior?
2. What factors must be considered when confirming a
diagnosis of schizophrenia?
3. What are the medication issues you must consider since
Mr. Jemison has been prescribed the antipsychotic drug
Zyprexa™?
2780_Ch06_089-114 16/07/12 11:41 AM Page 98

report provides health-care providers with overwhelm-
ing evidence documenting the severity of health dis-
parities among African Americans (Smedley, Stith, &
Nelson, 2002). Whereas previous research attributed
the problem of health disparities among African
Americans and other minority groups to access-
related factors, income, age, comorbid conditions, in-
surance coverage, socioeconomic status, and expres-
sions of symptoms, the IOM’s report cites racial
prejudice and differences in the quality of health as
possible reasons for increased disparities (Burroughs,
Mackey, & Levy, 2002).
In 2007, the leading causes of death in the African
American population were heart disease, malignant
neoplasms (cancer), cerebral vascular diseases (strokes),
unintentional injuries, diabetes mellitus, homicide,
nephritis, nephrotic syndrome and nephrosis, chronic
lower respiratory diseases, human immunodeficiency
virus (HIV) disease, and septicemia (U.S. Department
of Health and Human Services, Center for Disease
Control and Prevention National Center for Health
Statistic, 2010). Although progress has been noted re-
garding an increase in the life expectancy among
African Americans, they continue to fall behind statis-
tics of European Americans. African American men’s
life expectancy is 70 years compared with 75.9 years for
white men, while African American women’s life ex-
pectancy is 76.8 years compared with 80.8 years for
white women (U.S. Census Bureau, Statistical Abstract
of the United States, 2011).
Hypertension is the single largest risk factor for car-
diovascular disease and heart attack among African
Americans. Current statistics reveal that 39 percent of
African American men and 43 percent of African
American women are diagnosed with hypertension (U.S.
Department of Health and Human Services, Centers
for Disease Control (CDC) and Prevention National
Center for Health Statistic, 2010). Compared with hy-
pertension in other ethnic groups, hypertension among
African Americans is more severe, is more resistant to
treatment, begins at a younger age, and results in signifi-
cantly worse target organ damage (Brewster, van Mont-
frans, & Kleijnen 2005; Moore, 2005). The literature
suggests that the pathophysiology of hypertension in
African Americans is related to volume expansion, de-
creased renin, and increased intracellular concentration
of sodium and calcium. Genetic cardiovascular
researchers have hypothesized that there might be a
“hypertensive-heart failure genotype” (Moore, 2005).
However, it is more likely that the etiology of hyperten-
sion among African Americans is multifaceted, includ-
ing genetics, diet, lifestyle, stress, environment, and
socioeconomic status (Moore, 2005; Saunders, 1997).
African American adults are 1.7 times as likely as
their European American counterparts to have a
stroke, while African American males are 60 percent
more likely to die from a stroke when compared with
European Americans. In addition, analysis from a
CDC health interview survey reveals that African
American stroke survivors were more likely to become
disabled and have difficulty with activities of daily liv-
ing than their non-Hispanic white counterparts.
African Americans also experience higher rates of
diabetes. The incidence of type 2 diabetes in African
Americans is among the highest in the world (Sow-
ers, Ferdinand, Bakris, & Douglas, 2002). Compared
with white adults, the risk of diagnosed diabetes
was 77 percent higher among African Americans
(National Diabetes Information Clearinghouse,
2011). African Americans experience double the
prevalence of complications related to their diabetes.
These complications include higher occurrence of
lower-limb amputations, end-stage renal disease, eye
disease, and higher rates of hospitalization for dia-
betes when compared with whites. African Americans
also have a higher rate of obesity, which puts them
at risk for diabetes. African Americans tend to carry
upper-body obesity, an additional risk factor for di-
abetes (Base-Smith & Campinha-Bacote, 2003).
African Americans are 15 percent more likely to
suffer from obesity than European Americans. Na-
tional statistics report that 36 percent of African
American men and 53 percent of African American
women are obese (U.S. Department of Health and
Human Services, Centers for Disease Control and Pre-
vention, National Center for Health Statistics, 2010).
More than 40 percent of African American teenagers
are overweight. There are serious health implications
related to obesity in African American children, in-
cluding increased risk for developing heart disease,
type 2 diabetes, stroke, orthopedic problems, and
asthma (The HSC Foundation, 2007). In an address
to the National Association for the Advancement of
Colored People (NAACP), Michelle Obama, America’s
first African American First Lady, shared the following
personal remarks regarding obesity in the African
American community:
And there’s no doubt that this is a serious problem. It’s
one that is affecting every community across this country.
But just like with so many other challenges that we face
as a nation, the African American community is being hit
even harder by this issue. We are living today in a time
where we’re decades beyond slavery, we are decades
beyond Jim Crow; when one of the greatest risks to our
children’s future is their own health. African American
children are significantly more likely to be obese than are
white children. Nearly half of African American children
will develop diabetes at some point in their lives. People,
that’s half of our children. (The White House, Office of
the First Lady, 2010).
African Americans have the highest death rate and
shortest survival of any racial and ethnic group in the
United States for most cancers. Although the overall
racial disparity in cancer death rates is decreasing,
People of African American Heritage 99
2780_Ch06_089-114 16/07/12 11:41 AM Page 99

in 2007, the death rate for all cancers combined con-
tinued to be 32 percent higher in African American
men and 16 percent higher in African American
women than in white men and women, respectively
(American Cancer Society, 2010). While African
American women have a slightly lower incidence of
breast cancer than that of white women, their mortal-
ity rate is 32 percent higher (Morgan et al., 2006).
African American women are less likely to participate
in regular breast cancer screening, which is a major
factor for this disparity (Spurlock & Cullins, 2006).
Unfortunately, this results in breast cancer being dis-
covered in the later stages when it is less responsive to
treatment. Once African American women are diag-
nosed with breast cancer, they tend to cope with the
diagnosis by relying on God and seeking help from in-
formal supportive networks such as family members
and friends (Morgan et al., 2006). Health-care
providers must recognize the role of spirituality and
informal support systems when developing interven-
tion strategies to have an impact on breast cancer
treatment among African American women.
African American women have the highest rate of
infant mortality among all ethnic groups (Mathews
& MacDorman, 2010). They have 2.3 times the in-
fant mortality rate of non-Hispanic whites and are
almost 4 times as likely to die from causes related to
low birth weight. African American mothers are
also 2.5 times as likely as non-Hispanic white moth-
ers to begin prenatal care in the third trimester or to
not receive prenatal care at all. In addition, African
American women have 1.8 times the sudden infant
death syndrome (SIDS) mortality rate as non-
Hispanic whites.
Because African Americans are concentrated in
large inner cities, they are at risk for being victims of
violence. Violence is a major cause of death among
African Americans, with homicide being the leading
cause of death among young African American males
between the ages of 15 and 34. Brownstein (1995) in-
dicated that young black men are murdered by other
black men at 10 times the rate of white men between
the ages of 20 and 29. This violence has been referred
to as “black-on-black” violence. Gangs may be more
prevalent in larger cities, which only increases the likeli-
hood of the occurrence of violence in African American
communities.
Living in urban industrial or substandard housing
also exposes African Americans to the risk for devel-
oping diseases associated with environmental hazards.
For example, the risk of asthma and allergies is in-
creased by such environmental factors as exposure to
house dust mite allergen and cockroach allergen.
These allergens and respiratory tract irritants are com-
monly found in substandard housing, which has been
related to the development of asthma in children
(Asthma and Allergy Foundation, 2006).
Asthma is a top health problem for African American
children. More than 3 million African Americans have
asthma. African Americans go to the hospital emer-
gency room more than whites because of asthma and
are almost three times more likely to die from asthma-
related causes than whites. Other causes of asthma in
the African American population are exposure to sec-
ondhand tobacco smoke, poverty, lack of education,
and not being able to get to a doctor (The National
Women’s Health Information, U.S. Department of
Health and Human Resources, Office on Women’s
Health, 2011).
Lead exposure is another environmental threat for
poorer African American communities. African
American and urban children are most often exposed
to this environmental hazard. Specifically, African
American and low-income children suffer lead poison-
ing at highly disproportionate rates and are at higher
risk of exposure to unsafe levels of lead in the home
environment. The American Academy of Pediatrics
(1998) reports that the prevalence of elevated blood
lead levels for African American children ages 1 to
5 years is approximately five times higher than the
prevalence among white children in the same age
range. During the 1990s, high levels of lead in the
blood were found in 4.4 percent of all U.S. children
and in 22 percent of African American children
(American Public Health Association, 2004).
In addition to the exposure to harmful environmen-
tal conditions, African Americans suffer from certain
genetic conditions. Sickle cell disease is the most com-
mon genetic disorder among the African American
population, affecting 1 in every 500 African Americans,
and represents several hemoglobinopathies including
sickle cell anemia, sickle cell hemoglobin C disease, and
sickle cell thalassemia. Sickle cell disease is also found
among people from geographic areas in which malaria
is endemic, such as the Caribbean, the Middle East, the
Mediterranean region, and Asia. In addition to sickle
cell disease, glucose-6-phosphate dehydrogenase defi-
ciency, which interferes with glucose metabolism, is an-
other genetic disease found among African Americans.
Urethral prolapse is a rarely diagnosed condition
that occurs most commonly in African American girls
younger than 10 years, with an average age at presen-
tation of 4 years (Fleisher & Ludwig, 2010). Urethral
prolapse is a circular protrusion of the distal urethra
through the external meatus, with vaginal bleeding
being the most common presenting symptom. Because
urethral prolapse is so rare, the prevalence of misdiag-
nosis is high. This uncommon condition in prepubes-
cent African American girls should not be confused
with other causes of vaginal bleeding, the most impor-
tant being sexual abuse. Increased health-care provider
awareness and recognition of urethral prolapse among
African American girls will avoid misdiagnosis and un-
necessary anxiety to both the patient and family.
100 Aggregate Data for Cultural-Specific Groups
2780_Ch06_089-114 16/07/12 11:41 AM Page 100

Finally, in addition to environmental hazards and
genetic conditions, AIDS contributes to lower life ex-
pectancy of African Americans when compared with
European Americans. HIV/AIDS continues to be a
devastating epidemic with African American commu-
nities carrying the brunt of the impact (Williams,
Wyatt, & Wingood, 2010). Although African Americans
make up only 13 percent of the total U.S. population,
they accounted for 49 percent of HIV/AIDS cases in
2007. African Americans also continue to experience
higher rates of sexually transmitted infections (STIs)
than any other race/ethnicity in the United States. In
a national study concerning African American views
of the HIV/AIDS epidemic, African Americans were
asked why they were not tested for this disease. Fifty-
four percent responded that they felt they were not at
risk for HIV/AIDS, and 11 percent stated that they
did not know where to go to get tested (Kaiser Family
Foundation, 2001). A knowledge deficit about HIV/
AIDS was also revealed in this report. African Americans
believed that kissing, sharing a drinking glass, or
touching a toilet seat posed a risk of infection.
In summary, health conditions and health status for
most African Americans are well below average.
Health-care providers must provide culturally relevant
health education, prevention practices, and screening
aimed at improving the disparities in their health sta-
tus and reducing their risks.
Variations in Drug Metabolism
Research conducted at the University of Maryland re-
vealed that African Americans and other minorities do
not always respond to drugs in the same manner as
European Americans (Saunders, 1997). Examples of
drugs that African Americans respond to or metabolize
differently are psychotropic drugs, immunosuppres-
sants, antihypertensives, cardiovascular drugs, and
antiretroviral medications.
Glazer, Morganstern, & Douchette (1993) reported
from their research that African Americans are twice
as likely to develop tardive dyskinesia than their white
counterparts when placed on specific neuroleptics. For
example, Campinha-Bacote (1991) reported that
African American psychiatric patients experience a
higher incidence of extrapyramidal effects with
haloperidol decanoate than that found in European
Americans. African Americans are also more suscepti-
ble to tricyclic antidepressant (TCA) delirium than are
European Americans. Strickland, Lin, Fu, Anderson,
and Zheng (1995) reported that for a given dose of a
TCA, African Americans show higher blood levels
and a faster therapeutic response. As a result, African
Americans experience more toxic side effects from a
TCA than do European Americans. In addition,
African Americans have a higher risk of lithium tox-
icity and side effects related to less efficient cell mem-
brane lithium-sodium transport and increased lithium
red blood cell to plasma ratio (Herrera, Lawson, &
Sramek, 1999). Some African Americans have a lower
baseline leukocyte count (benign leukopenia), which
puts them at risk for side effects of specific antipsy-
chotic drugs, such as clozapine, which can cause agran-
ulocytosis. Health-care providers must make extended
efforts to observe African American patients for
side effects related to TCAs and other psychotropic
medications.
Dirks, Huth, Yates, and Melbohm (2004) reported
ethnic differences in the pharmacokinetics of immuno-
suppressants among African Americans and European
Americans. They found that the oral bioavailability
of these drugs in African Americans was 20 and
50 percent lower than in non–African Americans. This
finding suggests that there is a need for higher dose re-
quirements in African Americans to maintain average
concentrations of specific immunosuppressants. Dirk
and colleagues (2004) maintained that recognition
of these findings has the potential to improve post-
transplant immunosuppressant therapy among African
Americans.
African Americans may differ in their response to
beta-blockers, angiotensin-converting enzyme (ACE) in-
hibitors, angiotensin receptor blocking agents, and di-
uretics used either alone or in combination for the
treatment of hypertension (Burroughs, Mackey, & Levy,
2002). In 0.1 to 0.5 percent of patients, ACE inhibitors
induce a rapid swelling in the nose, throat, larynx,
mouth, glottis, lips, and/or tongue (angioedema), but
African Americans have a 4.5 times greater risk of ACE
inhibitor-induced angioedema (Brunton, Goodman,
Blumenthal, & Buxman, 2008). Studies report that
African Americans do not respond as readily to the
beta-blocker propanolol as European Americans do.
However, their response to the diuretic hydrochloroth-
iazide is greater when taken alone or with a calcium
channel blocker. Diuretics, alone or in combination with
another antihypertensive agent, are reported to coun-
teract increases in salt retention noted among African
Americans. Although there has been much discussion
about the best type of antihypertensive drug to admin-
ister in African Americans, health-care providers must
remember “There is no specific class of antihypertensive
drugs that categorically should not be used based on
race” (Burroughs, Mackey, & Levy, 2002, p. 18).
In 2005, the Food and Drug Administration (FDA)
approved the drug BiDil (NitroMed) as adjunct stan-
dard therapy in self-identified black patients for heart
failure (Ferdinand, 2006). This drug is based on the
chemical nitric oxide, found naturally in the body,
which dilates the blood vessels, allowing the blood to
flow more easily and thus easing the burden on the
heart. Although this drug was initially considered a
drug failure in 2003, when the results were reexamined
by race, it was found that a significant percentage of
the 400 black patients in the trial seemed to respond.
People of African American Heritage 101
2780_Ch06_089-114 16/07/12 11:41 AM Page 101

It was postulated that heart failure in African Americans
is somehow associated with how they produce and
metabolize nitric oxide. Specifically, African Americans
may produce less nitric oxide and destroy it too
quickly (National Women’s Health Report, 2005). The
approval of BiDil for “blacks only” is a highly contro-
versial subject. Schwartz (2001) argued that labeling
a drug based on race is “racial profiling” and is of no
proven value in treating an individual patient. How-
ever, Ferdinand (2006) contended, “While controver-
sial, the FDA approval of BiDil does offer evidence
that this therapy may be useful in the black popula-
tion” (p. 157). An obvious question is, in a world of
mixed heritages, how do health-care providers deter-
mine a person’s race? Many contend that racial cate-
gories are more a societal construct than a scientific
one. Health-care providers must be cautious in pro-
moting drugs for specific ethnic groups, since it could
easily lead to stereotyping and discrimination.
Whereas race and ethnicity are important for public
health issues, they are not true biological or genetic
categories (Ferdinand, 2006). One solution is the de-
signing of drugs that target specific genes, eliminating
the need to rely on race.
Research has identified the possibility that a genetic
mutation may make antiretroviral treatment less effec-
tive in Africans and African Americans (Schaeffeler
et al., 2001). The P-glycoprotein (PGP) membrane
protein appears to transport antiretroviral drugs out
of cells, thus making the drugs less effective. A double
mutation of the gene that encodes this protein (C/C
genotype) leads to an increased amount of the PGP
protein. Schaeffeler and colleagues (2001) examined
the frequency of the C/C genotype in 537 Caucasians,
142 Ghanaians (from West Africa), 50 Japanese, and
41 African Americans. The C/C genotype was found
in 83 percent of the Ghanaians and 61 percent of the
African Americans, and only 34 percent of the Japanese
and 26 percent of the Caucasians. It was hypothesized
that certain antiretroviral drugs may not be as effective
in people with the C/C genotype. Considering that
African Americans account for half of the diagnosed
HIV/AIDS cases, this finding has serious implications
in efforts to treat the AIDS epidemic among the
African American population.
Cultural factors, such as a health-care provider’s
personal beliefs and biases about a specific ethnic
group, may lead to unequal treatment, misdiagnosis,
and overmedication (Levy, 1993; Smedley et al., 2002).
For example, African Americans are at a higher risk
of misdiagnosis for psychiatric disorders and, there-
fore, may be treated inappropriately with drugs. Stud-
ies have found that African Americans are more likely
to be overdiagnosed with having a psychotic disorder
and more liable to be treated with antipsychotic drugs,
regardless of diagnosis. DelBello and colleagues
(1999) found that in a study with adolescents,
although there were no differences in psychotic symp-
toms (14 percent of the African Americans and
18 percent of the whites were diagnosed as having psy-
chotic symptoms), those who were African American,
despite not being more psychotic, received more
antipsychotic medications. Specifically, among white
patients, 43 percent received antipsychotic medica-
tions, and among nonwhite patients, 68 percent
received antipsychotic medications. There are several
possible explanations. DelBello and colleagues con-
tended that one plausible explanation is that clinicians
perceived African Americans to be more aggressive and,
thus, more psychotic, and prescribed the antipsychotics.
Studies by Lawson (1999); Strakowski, McElroy, Keck,
and West, (1996); and Strickland, Ranganath, Lin,
Poland, Mendoza, and Smith (1991) also found that
African Americans were more likely to be diagnosed
with schizophrenia and more likely to be prescribed
antipsychotics.
Access to pain medication is an issue for African
Americans and other minority groups. African Amer-
icans with severe pain are less likely than whites to be
able to obtain commonly prescribed pain medication
because pharmacies in predominantly nonwhite com-
munities do not sufficiently stock opiates (Burroughs
et al., 2002). Morrison, Wallenstein, Natale, Senzel,
and Huang (2000) examined the percentage of phar-
macies in New York City stocked with adequate opi-
oid medications and found that pharmacies in
predominantly minority neighborhoods were much
less likely to stock opioid medications. Only 25 percent
of the pharmacies in minority neighborhoods had an
ample supply of opioid medications to treat severe
pain, compared with 72 percent of pharmacies in pre-
dominantly white neighborhoods.
Eye color is another genetic variation related to dif-
ference in response to a specific drug. For example,
light eyes dilate wider in response to mydriatic drugs
than do dark eyes. This difference in response to a my-
driatic drug must be taken into consideration when
treating African Americans.
Malnutrition can also influence drug response. Pro-
tein, vitamin, and mineral deficiencies can hinder the
function of metabolic enzymes and alter the body’s
ability to absorb or eliminate a psychotherapeutic
drug. This may pose a problem for newly arriving
refugees from Ethiopia/Eritrea and other East African
countries where malnutrition is considered a major
medical problem. In addition, psychotherapeutic med-
ications, such as antidepressants, that require fat in
order to be absorbed are not as effective in patients
with exceptionally low body fat or differing fat metab-
olism (Wandler, 2003). This is a factor to consider
when caring for Ghanaians, who may differ in fat me-
tabolism as compared to Americans (Banini et al.,
102 Aggregate Data for Cultural-Specific Groups
2780_Ch06_089-114 16/07/12 11:41 AM Page 102

2003). When there are unexplained variations in a pa-
tient’s response to a medication, it is imperative for the
health-care provider to assess the patient’s dietary
habits (Campinha-Bacote, 2007).
High-Risk Behaviors
Smoking is a serious high-risk behavior in the African
American population. Compared with European
Americans, African Americans are at increased risk
for lung cancer even though they smoke about the
same amount. Twenty-six percent of African Ameri-
can men and17 percent of African American women
18 years and over smoke (U.S. Department of Health
and Human Services, Centers for Disease Control
and Prevention National Center for Health Statis-
tic, 2010). Other high-risk health behaviors among
African Americans can be inferred from the high
incidences of HIV/AIDS and other STIs, teenage
pregnancy, violence, unintentional injuries, smoking,
alcoholism, drug abuse, sedentary lifestyle, and
delayed seeking of health care.
Community health workers can have a significant
impact on these detrimental practices by providing
health education at community affairs located in
African American communities. The goals of health
education are to change high-risk health behaviors and
improve decision making (Edleman & Mandel, 1998).
Examples of effective methods for changing behaviors
are mutual goal setting and behavior contracts. An-
other strategy for changing high-risk behaviors is
a teaching module using a culturally appropriate
Afrocentric approach to early screening for breast and
cervical cancer (Baldwin, 1996).
Efforts to change high-risk behaviors are not al-
ways successful. According to Edleman and Mandel
(1998), health-care providers must understand influ-
ential factors affecting decision making regarding
health behaviors. These factors include values, atti-
tudes, beliefs, religion, previous experiences with the
health-care system, and life goals.
Health-Care Practices
Because a significant proportion of African Americans
are poor and live in inner cities, they tend to concen-
trate on day-to-day survival. Health care often takes
second place to the basic needs of the family, such as
food and shelter. In addition, the role of the family has
an impact on the health-seeking behaviors of African
Americans. African Americans have strong family ties;
when an individual becomes ill, that individual is fre-
quently taught to seek health care from the family
rather than from health-care professionals. This cul-
tural practice may contribute to the failure of African
Americans to seek treatment at an early stage. Screen-
ing programs may best be initiated in community and
church activities in which the entire family is present.
Nutrition
Meaning of Food
Historically, African American rites revolved around
food. Eating foods identified with slavery has provided
many African Americans with a sense of their identity
and tradition. Special meaning is attached to the soul
food diet, a southern tradition handed down from
generation to generation. The term soul food comes
from the need for African Americans to express the
group feeling of soul, and as a result, soul foods are
seen to nourish not only the body but also the spirit.
Although African Americans have incorporated soul
foods into their diets, these foods are more commonly
consumed for occasions such as special events, holi-
days, and birthdays. Therefore, the everyday diet of
African Americans may more closely resemble the
“American” diet, based on convenience and cost.
Common Foods and Food Rituals
Chitterlings (pig intestines often either fried or boiled
with hot peppers, onions, and spices), okra, ham
hocks, corn, pork fat, and sweet potato pie are foods
uniquely identified as Southern African American
foods. Common ways for African Americans to pre-
pare food include frying, barbecuing, and using gravy
and sauces. African American diets are typically high
in fat, cholesterol, and sodium. African Americans eat
more animal fat, less fiber, and fewer fruits and veg-
etables than the rest of American society. Traditional
breads of Southern African Americans are cornbread
and biscuits, and the most popular vegetables are
greens such as mustard, collard, or kale. Vegetables
are preferred cooked rather than raw, with some type
of fat, such as salt pork, fatback, and bacon or fat
meat. Salt pork is a key ingredient in the diet of many
African Americans. Salt pork is inexpensive and,
therefore, more frequently purchased.
Infant feeding methods may vary among African
Americans. African American parents may be encour-
aged by their elders to begin feeding solid foods, such
as cereal, at an early age (usually before 2 months).
The cereal is mixed with the formula and given to the
infant in a bottle. African Americans believe that giv-
ing only formula is starving the baby and that the in-
fant needs “real food” to sleep through the night.
Cultural-specific interventions are needed to educate
African American parents regarding the potential
harmful effects of giving infants solid foods at an early
age. Black, Siegel, Abel, and Bentley (2001) conducted
a study with first-time African American adolescent
mothers living in multigenerational households. The
intervention focused on reducing the cultural barriers
to the acceptance of the recommendations of the
American Academy of Pediatrics and World Health
Organization on complementary feeding. Culturally
People of African American Heritage 103
2780_Ch06_089-114 16/07/12 11:41 AM Page 103

specific interventions included nonfood strategies for
managing infant behavior and mother–grandmother
negotiation strategies.
Dietary Practices for Health Promotion
Some African Americans believe that a healthy person
is one who has a good appetite. Foods such as milk,
vegetables, and meat are referred to as strength foods.
In the African American community, individuals who
are at an ideal body weight are commonly viewed as
“not having enough meat on their bones” and, there-
fore, unhealthy. African Americans believe that it is
important to carry additional weight in order to be
able to afford to lose weight during times of sickness.
Therefore, being slightly overweight is seen as a sign
of good health.
One common belief among Southern African
Americans is the concept of “high blood” and “low
blood.” The healthy state is when the blood is in
balance—neither too high nor too low. High blood is
viewed as more serious than low blood. High blood is
often interchangeable with high blood pressure. High
blood is believed to be a condition in which the blood
expands in volume or moves higher in the body, usu-
ally to the head. Some African Americans believe that
rich foods or foods red in color, especially red meat,
are considered the primary cause of high blood. Some
African Americans believe that the treatment of high
blood is to drink vinegar or eat pickles to “thin” the
blood. Garlic is also seen as a health food. Garlic
water is consumed to treat hypertension as well as hy-
perlipidemia in the African American population. In
contrast, low blood is believed to be caused by eating
too many acidic foods. Low blood is believed to be the
cause of anemia. Treatment is aimed at trying to
thicken the blood by eating rich foods and red meats.
Another treatment for anemia, as well as for malnu-
trition, is to drink “pot liquor,” the liquid that remains
after a pot of greens has been cooked.
Nutritional Deficiencies and Food Limitations
The calcium consumption in African American
women is particularly low. Williams (2005) cites that
the diets of older African Americans are also ex-
tremely low in calcium. The National Health and
Nutrition Examination Surveys (NHANES II) re-
ported that the intake levels for African American
women 55 to 74 years of age were 460/mg, the lowest
among all age and ethnic groups (Williams, 2005,
p. 89). One factor that may explain the low calcium
intake among African Americans is the lack of aware-
ness of the health risks associated with this deficiency.
Another factor is the high level of lactose intolerance
in this population. Lactose intolerance occurs in
75 percent of the African American population. Low
levels of thiamine, riboflavin, vitamins A and C, and
iron are noted among African Americans and are
mostly associated with a poor diet secondary to a low
socioeconomic status.
Many African Americans are Protestant and have
no specific food restrictions. However, a significant
number of African Americans are members of religious
groups who have dietary restrictions. These may in-
clude Seventh-Day Adventists, Muslims, and Jehovah’s
Witnesses. For example, a Muslim halal diet forbids
pork or pork products. Muslims also refuse pork-based
insulin. They consider these products to be filthy. In ad-
dition, some African Americans, especially those from
Jamaica and other parts of the Caribbean, may be
Rastafarians. Their religious beliefs mandate that they
follow a clear dietary restriction, which includes eating
fresh foods of vegetable origin and avoiding meat, salt,
and alcohol. The health-care provider must always ask
about any religious or cultural prohibitions on types of
food consumed.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Historically, African American families have been
large, especially in rural areas. A large family was
viewed as an economic necessity, and African Ameri-
can parents depended on their children to support
them when they could no longer work. However, as
families moved to cities, they soon found that large
families could become an economic burden. To some
extent, this shifted attention to family planning.
Although oral contraceptives may be the most pop-
ular choice of birth control among African Americans,
religious beliefs also play a role in choices made. For
example, African American Catholics may choose the
rhythm method over other forms of birth control.
African American communities also hold many views
on the issue of pregnancy versus abortion. Many
104 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 6 . 3
Donna White, a 59-year-old African American woman,
presents to her local community health clinic for a physical
examination. Selected physical findings reveal that she is 5 feet,
4 inches tall; weighs 278 pounds; has a blood pressure of
160/96; and has a total cholesterol of 297.
1. What cultural factors may have contributed to her
hypertension?
2. What environmental factors may have contributed to her
obesity?
3. Discuss some culturally relevant interventions when
rendering care for Mrs. White’s hypertension, obesity,
and hyperlipidemia.
2780_Ch06_089-114 16/07/12 11:41 AM Page 104

African Americans who oppose abortion do so be-
cause of religious or moral beliefs. Others oppose
abortion because of moral, cultural, or Afrocentric
beliefs. Such beliefs may cause a delay in making a de-
cision so that having an abortion is no longer safe.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
African American women usually respond to preg-
nancy in the same manner as women in other ethnic
groups, based on their satisfaction with self, economic
status, and career goals. The elders in the family pro-
vide advice and counseling about what should and
should not be done during pregnancy. The African
American family network guides many of the practices
and beliefs of the pregnant woman, including pica.
Pica is the eating of nonnutritive substances such
as clay, dirt (geophagia), sand, laundry starch, burnt
matches, plastic, paint chips and plaster, lightbulbs,
needles, coffee grounds, and string. Women have re-
ported that these items reduce nausea and cause an
easy birth. One theory of geophagia is that this natu-
ral craving alleviates several mineral deficiencies and
that the unborn child “needs” this supplement. How-
ever, geophagia can lead to a potassium deficiency,
constipation, and anemia. Although it is a common
practice among many African Americans, independ-
ent of socioeconomic or educational level, some are
unaware that the practice exists.
Certain practices are believed to be taboo during
pregnancy. For example, some African Americans
believe that pregnant women should not take pic-
tures because it may cause a stillbirth, nor should
they have their picture taken because it captures their
soul. Some also believe that it is not wise to reach
over their heads if they are pregnant because the
umbilical cord will wrap around the baby’s neck.
Another taboo concerns the purchase of clothing for
the infant.
Many African American women expect to experi-
ence cravings during pregnancy. Several beliefs related
to the failure to satisfy this food craving exist. Some
African Americans claim that if the mother does not
consume the specific food craving, the child can be
birthmarked, or, more seriously, it can result in a still-
birth. Caribbean food beliefs during pregnancy focus
on pregnancy outcomes and eating specific food
groups. For example, consuming milk, eggs, tomatoes,
and green vegetables is believed to result in a large
baby, whereas drinking too many liquids will drown
the baby.
Snow (1993) reported several home practices re-
lated to initiating labor in pregnant African American
women. Taking a ride over a bumpy road, ingesting
castor oil, eating a heavy meal, or sniffing pepper are
all thought to induce labor. If a baby is born with the
amniotic sac (referred to as a “veil”) over its head or
face, the neonate is thought to have special powers. In
addition, certain children are thought to have received
special powers from God: those born after a set of
twins, those born with a physical problem or disability,
or a child who is the seventh son in a family.
The postpartum period for the African American
woman can be greatly extended. Some believe that
during the postpartum period, the mother is at greater
risk than the baby. She is cautioned to avoid cold air
and is encouraged to get adequate rest to restore the
body to normal. Postpartum practices for child care
can involve the use of a bellyband or a coin. When
placed on top of the infant’s umbilical area, these ob-
jects are believed to prevent the umbilical area from
protruding outward.
Death Rituals
Death Rituals and Expectations
Death rituals for African Americans may vary owing to
the diversity in their religious affiliations, geographic lo-
cation, educational level, and socioeconomic back-
ground. African Americans are very family oriented,
and it is important that family members and extended
family stay at the bedside of the dying patient in the hos-
pital. They desire to hold on to their loved ones for as
long as possible, and as a result may avoid signing Do
Not Resuscitate (DNR) orders or making preparations
for death (Lobar, Youngblut, & Brooten, 2006, p. 47).
Lobar and colleagues (2006) conducted a qualita-
tive study regarding cross-cultural beliefs, ceremonies,
and rituals surrounding death of a loved one and
found that African American participants described
the importance of giving their loved one a “big send-
off.” This practice involved elaborate financial deci-
sions concerning the type of coffin to buy and the
vehicle for carrying the coffin.
Johnson, Elbert-Avila, and Tulsky (2005, p. 711)
maintained that spirituality is an important part of
African American culture and is often the rationale
for more aggressive treatment preferences of some
African Americans at the end of life. Specifically,
Americans are more likely to prefer life-sustaining
treatments than do other ethnic groups (Fairrow,
McCallum, & Messinger-Rapport, 2004; Welch, Teno,
& Mor, 2005). African Americans do not believe in
rushing to bury the deceased. Therefore, it is common
to see the burial service held 5 to 7 days after death.
Allowing time for relatives who live far away to attend
the funeral services is important. Visual display of the
body is also important. Southern and rural blacks ob-
serve the custom of having the deceased’s body remain
in the house the evening before the funeral (Lobar
et al., 2006). This practice allows the extended family
time to “pay respect” to their deceased loved one.
African Americans believe that the body must be
kept intact after death. For example, it is common to
People of African American Heritage 105
2780_Ch06_089-114 16/07/12 11:41 AM Page 105

hear an African American say, “I came into this world
with all my body parts, and I’ll leave this world with
all my body parts!” Based on this belief, African
Americans are less likely to donate organs or consent
to an autopsy. Health-care providers must be aware
that talking about organ donation may be considered
an insult to the family.
For most African Americans, death does not end the
connection among people, especially family. They be-
lieve the deceased is in God’s hands and that they will
be reunited in heaven after death. Relatives communi-
cating with the deceased’s spirit is one example of this
endless connection. Snow (1993) studied African
American families in the southern United States and
noted interesting rituals regarding spirits of the de-
ceased. For example, if one passes an infant over the
casket of the deceased who has died a sudden or vio-
lent death, this protects the infant from the deceased’s
“haunting spirits.”
Responses to Death and Grief
Grieving and death rituals of African Americans are
often influenced by religion. Descendants from the
Caribbean may practice a blend of Catholicism and
African religion known as Voudoun, also spelled
Voodoo, Vodoun, and Vodun. The name has its roots
in an ancient African Yoruban word for “spirit.” Some
African Americans believe in “voodoo death,” which
is a belief that illness or death may come to an indi-
vidual via a supernatural force (Campinha-Bacote,
1992). Voodoo is more commonly known as “root
work,” “hex,” “fix,” “conjuring,” “tricking,” “mojo,”
“witchcraft,” “spell,” “black magic,” or “hoodoo.”
One response to hearing about a death of a family
member or close member in the African American
culture is “falling out,” which is manifested by sudden
collapse, paralysis, and the inability to see or speak.
However, the individual’s hearing and understanding
remain intact. Health-care providers must understand
the African American culture to recognize this condi-
tion as a cultural response to the death of a family
member or other severe emotional shock and not as a
medical condition requiring emergency intervention.
Some African Americans are less likely to express
grief openly and publicly. However, they do express
their feelings openly during the funeral. Funeral serv-
ices encourage emotional expression, such as crying,
screaming, and wailing.
Several studies suggest that African Americans are
less likely to complete advance directives such as DNR
orders or living wills (Curriculum Ethnogeriatrics,
2001; Waters, 2000). This may be due to their feeling
that if they choose DNR orders, it would give the
health-care system the legal authorization to provide
substandard care or give up on them. Another factor
may be the role of religious beliefs. Many African
Americans believe that God is in ultimate control of
the timing of death. Research has also found that
African Americans use end-of-life services at a con-
siderable lower rate than whites. Washington, Bickel-
Swenson, and Stephens (2008) conducted an in-depth
review of the literature regarding the underuse of hos-
pice services by African Americans and found the
following six factors:
1. Lack of awareness of hospice services
2. Mistrust of the health-care system
3. Anticipated lack of ethnic minority employees in
hospice agencies
4. Personal or cultural values in conflict with
hospice philosophy
5. Concerns about burdening the family
6. Economic factors
An example of a conflict with hospice philosophy
focused on religious beliefs. Specifically, accepting the
terminality of their loved one’s life meant giving up
on God’s power to heal. Implications of these findings
suggest a need for culturally relevant discussion and
education in the African American community re-
garding advance directives and end-of-life services.
Spirituality
Dominant Religion and Use of Prayer
Religion and religious behavior are integral parts of
the African American community. African American
churches have played a major role in the development
and survival of African Americans. As eloquently
stated by Lincoln (1974, pp. 115–116):
To understand the power of the black Church, it must first
be understood that there is no disjunction between the
black Church and the black community. . . . Whether one
is a church member or not is beside the point in any
assessment of the importance and meaning of the black
Church.
106 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 6 . 4
Rena Broadnaux, a 74-year-old African American woman, has
been unexpectedly diagnosed with terminal lung cancer. She
does not have any advance directives in place. The health-care
team plans to discuss do not resuscitate (DNR) orders and
palliative care, such as hospice, with the family. When the
physician told Mrs. Broadnaux’s two daughters about the
pending death of their mother, one daughter suddenly
collapsed and could not speak.
1. What could explain the daughter’s sudden collapse and
inability to communicate?
2. What are some of the cultural beliefs you might
encounter when discussing DNR orders with the family?
3. What potential barriers must you consider when offering
such services as hospice care to the family?
2780_Ch06_089-114 16/07/12 11:41 AM Page 106

African Americans take their religion seriously, and
they expect to receive a message in preaching that
helps them in their daily lives. Brown and Gary (1994)
found that religious involvement is associated with
positive mental health. Furthermore, most African
Americans expect to take an active part in religious
activities. In reviewing the literature, Johnson and col-
leagues (2005, p. 712) found that African Americans
“participate more often in organizational (attendance
at religious services) and nonorganizational (prayer or
religious study) religious activities and endure higher
levels of intrinsic religiosity (personal religious com-
mitment) than do Caucasians.” In addition, research
has noted that church attendance was an important
correlate of positive health-care practices (Aaron,
Levine, & Burstin 2003).
Most African American Christians are affiliated with
the Baptist and Methodist denominations. In 1990,
50 percent of African Americans considered themselves
Baptist. However, that percentage dropped to 45 per-
cent by 2008 (Black Demographics.com, 2011). There
is also a substantial decrease in the percentage of
Methodist and Orthodox from 12 percent in 1990 to
7 percent in 2008 (Black Demographics.com, 2011).
Many other denominations and distinct religious
groups are also represented in African American com-
munities in the United States. These include African
Methodist, Episcopalian, Jehovah’s Witnesses, Church
of God in Christ, Seventh-Day Adventists, Pentecostal,
Apostolic, Presbyterian, Lutheran, Roman Catholic,
Nation of Islam, and Islamic sects, as well as nonde-
nominational and evangelical churches.
African Americans strongly believe in the use of
prayer for all situations they may encounter. They also
pray for the sake of others who are experiencing prob-
lems. According to Roberson (1985), “Prayers reflect
the trust and faith one has in God.” African Americans
also believe in the laying on of hands while praying.
The belief is that certain individuals have the power to
heal the sick by placing hands on them. African Amer-
icans may pray in a language that is not understood by
anyone but the person reciting the prayer. This expres-
sion of prayer is referred to as speaking in tongues.
Meaning of Life and Individual Sources
of Strength
Most African Americans’ inner strength comes from
trusting in God and maintaining a biblical worldview
of health and illness. Some African Americans believe
that whatever happens is “God’s will.” Because of this
belief, African Americans may be perceived to have a
fatalistic view of life. For example, Snow (1993) re-
ported that African Americans trust in “Doctor
Jesus,” and some believe that sickness and pain are
forms of weakness that come directly from Satan.
Therefore, for African Americans, having faith in God
is a major source of inner strength. Frameworks such
as Campinha-Bacote’s (2005) Biblically Based Model
of Cultural Competence in the Delivery of Healthcare
Services can provide health-care providers with strate-
gies for implementing culturally specific interventions
for African Americans who share a biblical worldview
of health and illness.
Spiritual Beliefs and Health
Spiritual beliefs strongly direct many African Americans
as they cope with illness and the end of life. In a review
of the literature on spiritual beliefs and practices of
African Americans, Johnson and colleagues (2005)
noted the following recurrent themes: “spiritual beliefs
and practices are a source of comfort, coping, and
support and are the most effective way to influence
healing; God is responsible for physical and spiritual
health; and the doctor is God’s instrument.” African
Americans consider themselves spiritual beings, and
God is thought to be the supreme healer. Health-care
practices center on religious and spiritual activities
such as going to church, praying daily, laying on of
hands, and speaking in tongues. Drayton-Brooks and
White (2004) conducted a qualitative study to explore
health-promoting behaviors among African American
women with faith-based support. They concluded that
“health beliefs, attitudes, and behaviors are not devel-
oped outside of social systems; therefore, the facilita-
tion of healthy lifestyle behaviors may be best
addressed and influenced within a context of recipro-
cal social interaction such as a church.”
As health-care providers develop culturally specific
interventions for African Americans, it is important
to understand that the church community can serve
as a viable support system in developing health-
promoting behaviors. Underwood and Powell (2006)
further added that considerable improvements can
occur in the health status of African Americans if
health education and outreach efforts are presented
and promoted through religious, spiritual and faith-
based efforts. Musgrave, Allen, and Allen (2002)
cautioned public health not to “use” faith communi-
ties or the spirituality of individuals to its own end.
Instead, there must be a partnership between public
health and faith communities in which the central
undertaking of faith is respected.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Spirituality, communalism, oral tradition, internal
strength, resolve, and respect for elders are central values
that guide the health-seeking beliefs and behaviors
among the traditional African American culture
(NMAETC, 2006). Spirituality depicts an inner strength
that comes from trusting in God for good health. Com-
munalism reflects a strong history of collective group
orientation that includes personal relationships, social
People of African American Heritage 107
2780_Ch06_089-114 16/07/12 11:41 AM Page 107

support systems, and shared resources over individual-
ism in maintaining health. Oral tradition is an impor-
tant tool for African Americans in sharing knowledge
about health behaviors and practices. Internal strength
and resolve originates from survival skills learned
through challenging conditions and slavery. Respect for
elders refers to African American elders who are revered
for their experience and wisdom in areas concerning
health and well-being.
According to Snow (1974), many African Ameri-
cans are pessimistic about human relationships and
believe that it is more natural to do evil than to do
good. Snow concluded that some African Americans’
belief systems emphasize three major themes:
1. The world is a very hostile and dangerous place
to live.
2. The individual is open to attack from external
forces.
3. The individual is considered to be a helpless per-
son who has no internal resources to combat such
an attack and, therefore, needs outside assistance.
Because many African Americans tend to be suspi-
cious of health-care providers, they may see a physi-
cian or nurse only when absolutely necessary. Some
older African Americans continue to use the Farmers’
Almanac to choose what are thought to be good times
for medical and dental procedures.
Some African Americans, particularly those of
Haitian background, may believe in sympathetic
magic. Sympathetic magic assumes everything is inter-
connected and includes the practice of imitative and
contagious magic. Contagious magic is the belief that
once an entity is physically connected to another, it
can never be separated; what one does to a specific
part, they also do to the whole. This type of belief is
seen in the practice of voodoo. An individual will take
a piece of the victim’s hair or fingernail and place a
hex, which they believe will cause the person to
become ill (voodoo illness). Imitative magic is the
belief that “like follows like” (Campinha-Bacote, 1992).
For example, a pregnant woman may sleep with a
knife under her pillow to “cut” the pains of labor.
Another example is the use of a doll or a picture of
an individual to inflict harm on that person. Whatever
harm is done to the picture is also simultaneously done
to the person.
Responsibility for Health Care
The African American population believes in natu-
ral and unnatural illnesses. Natural illness occurs in
response to normal forces from which individuals
have not protected themselves. Unnatural illness is
the belief that harm or sickness can come to you via
a person or spirit. In treating an unnatural illness,
African Americans seek clergy or a folk healer or
pray directly to God. In general, health is viewed as
harmony with nature, whereas illness is seen as a
disruption in this harmonic state owing to demons,
“bad spirits,” or both.
African Americans may use home remedies to
maintain their health and treat specific health condi-
tions as well as seek health care from Western health-
care providers. When taking prescribed medications,
African Americans commonly take the medications
differently from the way prescribed. For example, in
treating hypertension, African Americans may take
their antihypertensive medication on an “as-needed”
basis. To provide services that are effective and cultur-
ally acceptable to African Americans, health-care
providers must conduct thorough cultural assessments
and become partners with the African American com-
munity. Strategies such as focus groups can provide
health-care providers with insight into health-care
practices acceptable to African Americans.
Folk and Traditional Practices
African Americans, like most ethnic groups, engage in
folk medicine. The history of African American folk
medicine has its origin in slavery. Slaves had a limited
range of choices in obtaining health care. Although they
were expected to inform their masters immediately when
they were ill, slaves were reluctant to submit themselves
to the harsh prescriptions and treatments of eighteenth-
and nineteenth-century European American physicians
(Savitt, 1978). They preferred self-treatment or treat-
ment by friends, older relatives, or “folk doctors.”
This led to a dual system: “white medicine” and “black
medicine” (Savitt, 1978). Snow (1993) studied hundreds
of folk practices used by African Americans. One
example is the belief that drinking a mixture of an
alcoholic beverage and fish blood can cure alcoholism.
This is believed to give an undesirable taste and cause
nausea and vomiting when subsequent alcoholic drinks
are taken.
Traditionally, African Americans have practiced heal-
ing with botanicals. A botanical is a plant or plant part
valued for its medicinal or therapeutic properties, flavor,
and/or scent. A secondary analysis conducted of a na-
tionally representative cross-sectional sample of 2107
adult African Americans living in the United States in
1979 and 1980 found that 69.6 percent reported that
their families used home remedies and 35.4 percent re-
ported that they used home remedies themselves
(Boyd, Taylor, Shimp, & Semler, 2000). However,
newer research suggests that the use of botanicals
among African Americans has decreased (Gunn &
Davis, 2011; Kelly, Kaufman, Kelley, Rosenberg, &
Mitchell, 2006). In a study of contemporary use of
herbal/natural supplements in the largest racial/ethnic
groups in the United States, it was noted that use was
lowest among African Americans, with a decline in re-
cent years (Kelly et al., 2006). One possible reason
cited in the literature is the continued strong belief in
108 Aggregate Data for Cultural-Specific Groups
2780_Ch06_089-114 16/07/12 11:41 AM Page 108

God as healer and maintainer of health (Gunn &
Davis, 2011).
Barriers to Health Care
Healthy People 2010 defined health literacy as “the de-
gree to which individuals have the capacity to obtain,
process, and understand basic health information and
services needed to make appropriate health decisions”
(U.S. Department of Health and Human Services,
2002). Research shows that health literacy is the single
best predictor of health status. Low health literacy af-
fects older people, immigrants, the impoverished, and
minorities. Low health literacy affects 40 percent of
African Americans and is considered a barrier to re-
ceiving optimal health care. Low health literacy is also
driven by poor patient-provider communication.
Health-care providers can reduce low health literacy
by limiting the amount of information provided at
each visit, avoiding medical jargon, using pictures or
models to explain important health concepts, ensuring
understanding with the “show-me” technique, and en-
couraging patients to ask questions.
Negative attitudes from health-care professionals can
greatly affect African Americans’ decision to seek med-
ical attention (McNeil, Campinha-Bacote, Tapscott, &
Vample, 2002). McNeil and colleagues maintained
that the attitude of the health-care provider is one of
the most significant barriers to the care of African
Americans (p. 132). One study reported that 12 percent
of African Americans, compared with 1 percent of
whites, felt that health-care providers treated them
unfairly or disrespectfully because of their race (Kaiser
Family Foundation, 2001). Kennedy, Mathis, and
Woods (2007) reported that African Americans feel that
just receiving health care is very often a demeaning and
humiliating experience.
Some African Americans may experience economic
and geographic barriers to health-care services.
Needed health-care services may not be accessible or
affordable for African Americans in lower socioeco-
nomic groups. Although some services may be avail-
able, accessible, and affordable for other African
Americans, they may not be culturally relevant. For
example, a health-care provider may prescribe a strict
American Diabetic Association diet to a newly diag-
nosed diabetic African American patient without tak-
ing into consideration this person’s dietary habits.
Therefore, therapeutic interventions developed by
health-care providers may be underused or ignored.
Underrepresentation of ethnic minority health-care
providers is an additional barrier to health care for
many minorities. In the absence of adequate represen-
tation, minority populations are less likely to access
and use health-care services. Research investigated
doctor–patient race concordance and its impact on
predicting greater health-care utilization and satisfac-
tion among minorities (LaVeist & Carroll, 2002;
LaVeist & Nuru-Jeter, 2002). LaVeist and Nuru-Jeter
found that patients who were race-concordant with
their physician reported greater satisfaction with their
physician compared with respondents who were not
race-concordant. These authors concluded that efforts
must be made to increase the number of minority
physicians, as well as improve the ability of physicians
to interact with patients who are not of their own
race. These findings are relevant for all health-care
providers.
Another barrier that many African Americans face
in obtaining health care is inadequate health insurance
coverage. In 2009, 19 percent of African Americans
did not have health insurance. Having access to health
insurance is a critical factor in reducing the current
health disparities that exit among African Americans.
In an attempt to reduce these disparities, the Afford-
able Care Act was passed in 2010. This health insur-
ance reform legislation includes a series of measures
to guarantee that insurance companies will no longer
be able to deny coverage to anyone with preexisting
conditions, a significant benefit for the many African
Americans who are plagued with higher rates of
chronic diseases, illnesses, and comorbidity (Cord,
2010). The Affordable Care Act also expands access to
preventive care, a needed service to reduce health dis-
parities for millions of African Americans by helping
to prevent many diseases that have a disproportionate
impact on this group.
Cultural Responses to Health and Illness
To understand the African American responses to
health and illness, it is important to first understand
their worldview. The literature discusses an Afrocen-
tric, or African-centered, worldview held by some
African Americans (Carroll, 2010; Dixon, 1971).
Within an Afrocentric worldview, the highest value of
African Americans lies in interpersonal relationships.
Therefore, it is key to establish a rapport early on in
the patient–health-care provider interaction. African
Americans come to knowledge affectively, or through
feelings (Nichols, 1987). This worldview maintains
that one can discover knowledge and truth through
feelings or emotions. It is not uncommon for an
African American patient to say, “It doesn’t feel right”
when asked questions regarding compliance issues.
Afrocentric logic highlights seeing the union of oppo-
sites (diunital logic). For example, an African American
patient may be both optimistic and pessimistic about
the future at the same time and see no conflict in this
view. An Afrocentric worldview asserts that one
should live in harmony with nature, and spirituality
must hold the most significance place in life. Cooper-
ation, collective responsibility, and interdependence
are the central values to which all should aspire. The
Afrocentric worldview is a circular one, in which all
events are tied together with one another. Therefore,
People of African American Heritage 109
2780_Ch06_089-114 16/07/12 11:41 AM Page 109

it may be challenging for health-care providers to
isolate specific health problems when taking a patient
history.
African Americans often perceive pain as a sign of
illness or disease. Therefore, it is possible that if they
are not experiencing severe and/or immediate pain, a
regimen of regularly prescribed medicine may not be
followed. For example, African Americans may take
their antihypertensive drugs or diuretics only when
they experience head or neck pain. This cultural prac-
tice interferes with successful and effective treatment of
hypertension. In other cases, some African Americans
believe, as part of their spiritual and religious founda-
tion, that suffering and pain are inevitable and must
be endured, thus contributing to their high tolerance
levels for pain. Prayers and the laying on of hands are
thought to free the person from all suffering and pain,
and people who still experience pain are considered to
have little faith.
In addition to religious beliefs, low educational levels
among African Americans may limit their access to in-
formation about the etiology and treatment of mental
illness. Some African Americans hold a stigma against
mental illness. The high frequency of misdiagnosis
among African Americans contributes to their reluc-
tance to trust mental health professionals. For example,
Adebimpe (1981) reported that over the years, a major
diagnostic issue has been the high frequency of the
diagnosis of schizophrenia among African American
patients. Specifically, African Americans are more likely
to report hallucinations when suffering from an affec-
tive disorder, which may lead to the misdiagnosis of
schizophrenia.
Close family and spiritual ties within the African
American family allow one to enter the sick role with
ease. Extended and nuclear family members willingly
care for sick individuals and assume their role respon-
sibilities without hesitation. Sickness and tragedy
bring African American families together, even in the
presence of family conflict.
Blood Transfusions and Organ Donation
Blood transfusions are generally accepted in the
African American patient. However, some religious
groups, such as Jehovah’s Witnesses, do not permit
this practice. In addition, Jehovah’s Witnesses
believe that any blood that leaves the body must be
destroyed, so they do not approve of an individual
storing her or his own blood for a later autologous
transfusion.
A low level of organ donation among African
Americans has been cited (Plawecki & Plawecki, 1992).
This reluctance is associated with a lack of information
about organ donation, religious fears and beliefs, dis-
trust of health-care providers, fear that organs will be
taken before the patient is dead, and concern that
proper medical attention will not be given to patients
if they are organ donors. However, in regard to kidney
donations, it must be noted that African Americans
donate in proportion to their share of the population.
African Americans, for example, represent about
13 percent of the population and account for 12 percent
of kidney donors. It may appear that there is a low
level of kidney donation among the African American
community because they are disproportionately repre-
sented (35 percent) on the kidney waiting list. Their
rate of organ donation does not keep pace with the
number of those needing transplants. This increased
need for organ donors led the Congress of National
Black Churches to make organ and tissue donation a
top-priority health issue.
Health-Care Providers
Traditional Versus Biomedical Providers
Physicians are recognized as heads of the health-care
team, with nurses having lesser importance. However,
as nurses are becoming more educated and operating
in advanced practice roles, both African American
males and female are holding them in higher regard.
For example, Wehbe-Alamah and colleagues (2011)
found that African American men receiving primary
care in a nurse-managed clinic reported that that they
felt nurse practitioners (NPs) spent more time with
patients and demonstrated more caring behaviors.
Similar studies revealed that African Americans re-
ported that NPs provided nonjudgmental care,
showed more care than physicians, spent more time
with them than physicians to explain things, were
trusted more, and rendered a holistic approach to find
the best treatment (Benkert & Tate, 2008; Gunn &
Davis, 2011; Wehbe-Alamah, McFarland, Macklin, &
Riggs, 2011). These findings suggest that some African
Americans are able to develop a strong and trusting
relationship with health-care providers despite their
long history of distrust.
Whereas some African Americans may prefer a
health-care provider of the same gender for urolog-
ical and gynecological conditions, generally gender
is not a major concern in the selection of health-care
provider. Men and women can provide personal care
to the opposite sex. On occasion, young men may
prefer that another man or an older woman give per-
sonal care. With the current emphasis on women’s
health and the responses of women to illness and
treatment regimens, some African American women
prefer female primary-care providers. Health-care
providers should respect these wishes when possible.
Among the African American community, traditional/
folk practitioners can be spiritual leaders, grandpar-
ents, elders of the community, voodoo doctors, or
priests. For example, the pastor in the African
American church is noted to be “a healer of the
sick” (Drayton-Brooks & White, 2004, p. 86).
110 Aggregate Data for Cultural-Specific Groups
2780_Ch06_089-114 16/07/12 11:41 AM Page 110

Status of Health-Care Providers
Western health-care providers do not generally regard
folk practitioners with high esteem. However, as
homeopathic and alternative medicine increases in im-
portance in preventive health, these practitioners are
gaining more recognition, respect, and utilization.
Folk practitioners are respected and valued in
the African American community and frequently used
by African Americans of all socioeconomic levels. Many
African Americans perceive health-care providers as
outsiders, and they resent them for telling them what
their problems are or telling them how to solve them
(Underwood, 1994). Generally, most African Americans
are suspicious and cautious of health-care providers
they have not heard of or do not know. Because inter-
personal relationships are highly valued in this group,
it is important to initially focus on developing a
sound, trusting relationship.
R E F E R E N C E S
Aaron, K., Levine, D., & Burstin, H. (2003). African American
church participation and health care practices. Journal of General
Internal Medicine, 18(11), 908–913. Retrieved from http://www.
ncbi.nlm.nih.gov/pmc/articles/PMC1494942/
Adebimpe, V. (1981). Overview: White norms in psychiatric diag-
nosis of Black American patients. American Journal of Psychi-
atry, 138(3), 279–285.
Agency for Healthcare Research and Quality (AHRQ). (2005,
December). National Healthcare Disparities Report. AHRQ
Publication No. 06-0017. Retrieved from http://www.ahrq.gov/
qual/nhdr05/nhdr05
Allender, J., & Spradley, B. (2001). Community health nursing:
Concepts and practice. Philadelphia: Lippincott.
American Academy of Pediatrics. (1998). Screening for elevated
blood levels. Pediatrics, 101(6), 1072–1078.
American Cancer Society. (2010). Cancer facts and figures for
African Americans 2011–2012. Retrieved from http://www.
cancer.org/acs/groups/content/@epidemiologysurveilance/
documents/document/acspc-027765
American Public Health Association. (1999). More research needed
to guide policy on environmental justice. Nation’s Health, 29(3), 4.
American Public Health Association. (2004). Eliminating Dispar-
ities: Communities moving from statistics to solutions—Toolkit.
National Public Health Week, April 5–11, 2004. Washington,
DC: Author. Retrieved from http://www.nphw.org/2005/toolkit/
Toolkit-PHW04-LR
The Asthma and Allergy Foundation of America and the Na-
tional Pharmaceutical Council. (2006). Ethnic disparities in the
burden and treatment of asthma. Washington, DC: Author.
Retrieved from http://www.scribd.com/doc/7514016/ethnic-
disparities-in-the-burden-and-treatment-of-asthma
Baldwin, D. (1996). Model for describing low-income African-
American women’s participation in breast and cervical cancer
early detection and screening. Advances in Nursing Science
19(2), 21–42.
Banini, A., Allen, J., Boyd, L., & Lartey, A. (2003). Fatty acids,
diet, and body indices of type II diabetic American whites and
blacks and Ghanaians. Nutrition, 19(9), 722–726.
Barbarin, O. (1983). Coping with ecological transitions by Black
families: A psycho-social model. Journal of Community Psy-
chology, 11(4), 308–322.
Base-Smith, V., & Campinha-Bacote, J. (2003). The culture of obe-
sity. Journal of the National Black Nurses Association, 14(1),
52–56.
Bender, D. (1998). The family: Opposing viewpoints. San Diego,
CA: Greenhaven Press.
Benkert, R., & Tate, N. (2008). Trust of nurse provider and physi-
cians among African Americans with hypertension. Journal of
the American Academy of Nurse Provider, 20(5), 273–280.
Bigler, R., & Averhart, C. (2003). Race and the workforce:
Occupational status, aspirations, and stereotyping among
African American children. Developmental Psychology,
39(3), 572–580.
Billingsley, A. (1968). Black families in White America. Upper
Saddle River, NJ: Prentice Hall.
Black, M., Siegel, E., Abel, Y., & Bentley, M. (2001). Home and
videotape intervention delays early complementary feeding
among adolescent mothers. Pediatrics, 107(5). Retrieved
from http://pediatrics.aappublications.org/cgi/content/full/
107/5/e67
Black Demographics.com. African American Religion. Retrieved
from http://www.blackdemographics.com/religion.html
Bland-Stewart, L. (2005). Difference or deficit in speakers of
African American English. What every clinician should know.
ASHA Leader, 10(6), 6–7, 30–31.
Blum, J., Morgan, E., Rose, W., Schlesinger, A., Stampp, K., &
Woodward, C. (1981). The national experience. New York:
Harcourt Brace Jovanovich.
Boyd, E., Taylor, S., Shimp L., & Semler, C. (2000). An assessment
of home remedy use by African Americans. Journal of the Na-
tional Medical Association, 92(7), 341–353. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2608585/pdf/
jnma00343-0057
Braithwaite, R., Taylor, S., & Austin, J. (2000). Building health
coalitions in the black community. Thousand Oaks, CA: Sage
Publications.
Brewster, L., van Montfrans, G., & Kleijnen, J. (2005). Systematic
review: Antihypertensive drug therapy in Black patients. Annals
of Internal Medicine, 14(18), 614–627.
Brown, D., & Gary, L. (1994). Religious involvement and health
status among African-American males. Journal of the National
Medical Association, 86(11), 825–831.
Brownstein, R. (1995, November 6). Why are so many black men
in jail? Numbers in debate equal a paradox. Los Angeles Times,
p. A5.
Brunton, L., Goodman, L., Blumenthal, D., & Buxman, L. (2008).
Goodman & Gillman’s manual of pharmacology and therapeutics.
New York: McGraw-Hill Companies.
Burroughs, V., Mackey, M., & Levy, R. (2002). Racial and ethnic
differences in response to medicines: Towards individualized
pharmaceutical treatment. Journal of the National Medical
Association, 94(10), 1–20.
Campinha-Bacote, J. (1991). Community mental health services
for the underserved: A culturally specific model. Archives of
Psychiatric Nursing, 5(4), 29–35.
Campinha-Bacote, J. (1992). Voodoo illness. Perspectives in
Psychiatric Nursing, 28(1), 11–19.
Campinha-Bacote, J. (1993). Soul therapy: Humor and music with
African American patients. Journal of Christian Nursing, 10(2),
23–26.
People of African American Heritage 111
2780_Ch06_089-114 16/07/12 11:41 AM Page 111

Campinha-Bacote, J. (1997). Humor therapy for culturally diverse
psychiatric patients. Journal of Nursing Jocularity, 7(1), 38–40.
Campinha-Bacote, J. (2005). A biblically based model of cultural
competence in the delivery of healthcare services. Cincinnati,
OH: Transcultural C.A.R.E. Associates.
Campinha-Bacote, J. (2007). The Process of cultural competence
in the delivery of healthcare services: The journey continues.
Cincinnati, OH: Transcultural C.A.R.E. Associates.
Carroll, K. (2010). A genealogical analysis of the worldview
framework in African-centered psychology. The Journal of Pan
African Studies, 3(8), 109–143.
Chin, J. (2009). Diversity in mind and action. Volume 2. Dispari-
ties and competence: Service delivery, education and employ-
ment contexts. Santa Barbara CA: Praeger/ABC-CLIO.
Clark, M.J. (1999). Nursing in the community: Dimensions of com-
munity health nursing. Stamford, CT: Appleton & Lange.
Cokley, K., Cooke, B., & Nobles, W. (2005, September 29). Guide-
lines for providing culturally appropriate services for people of
African ancestry exposed to the trauma of Hurricane Katrina.
Washington, DC: The Association of Black Psychologists.
Retrieved from http://www.abpsi.org/index.php/the-news/133-
guidelines-for-providing-culturally-appropriate-services
Conant, J. (1961). Slums and suburbs. New York: New American
Library Publishers.
Cord, J. (2010). What health-care reform means for African
Americans. The Root. Retrieved from http://www.theroot.com/
views/what-health-care-reform-means-african-americans
Curriculum Ethnogeriatrics. (2001). Core curriculum and ethnic
specific modules: African American. Retrieved from http://www.
stanford.edu/group/ethnoger/
DelBello, M., Soutullo, C., Ochsner, J., McElroy, J., Keck, P.,
Strakowski, S., et al. (1999, May 18). Racial differences in the
treatment of adolescents with bipolar disorder, New Research
379. Presented at the 152nd annual meeting of the American
Psychiatric Association. Washington, DC.
Dirks, N., Huth, B., Yates C., & Melbohm, B. (2004). Pharmaco-
kinetics of immunosuppressants: A perspective on ethnic dif-
ference. International Journal of Clinical Pharmacology and
Therapeutics, 42(12), 719–723.
Dixon, V. (1971). African-oriented and Euro-American-oriented
worldviews: Research methodologies and economics. Review
of Black Political Economy, 7(2), 119–156.
Drayton-Brooks, S., & White, N. (2004). Health promoting behav-
iors among African American women with faith-based sup-
port. The ABNF Journal, 15(5), 84–90.
Edleman, C., & Mandel, C. (1998). Health promotion throughout
the lifespan (3rd ed.). St. Louis, MO: C. V. Mosby.
Fairrow, A., McCallum, T., & Messinger-Rapport, B. (2004). Pref-
erences of older African-Americans for long-term tube feeding
at end of life. Aging & Mental Health, 8(6), 530–534.
Ferdinand, K. (2006). The isosorbide-hydralazine story: Is there
a case for race-based cardiovascular medicine? The Journal of
Clinical Hypertension, 8(3), 156–158.
Fleisher, G., & Ludwig, S. (2010). Textbook of pediatric emergency
medicine. PA: Lippincott Williams & Wilkins.
Frazier, E. (1957). Black bourgeoisie. New York: Collier Books.
Glazer, W.M., Morganstern, H., & Doucette, J.T. (1993). Predict-
ing the long-term risk of tardive dyskinesia in outpatients
maintained on neuroleptic medications. Journal of Clinical Psy-
chiatry, 54(4), 133–139.
Gloster, H. & Neal, K. (2006). Skin cancer in skin of color. Journal
of American Academy of Dermatology, 55(5), 741–760.
Green, L. (2002). African American English: A linguistic introduc-
tion. United Kingdom: Cambridge University Press.
Gunn, J., & Davis, S. (2011). Beliefs, meanings, and practices of
healing with botanicals re-called by elder African American
women in the Mississippi Delta. Online Journal of Cultural
Care in Nursing and Healthcare, 1(1), 37–49.
Herrera, J., Lawson, W., & Sramek, J. (1999). Cross-cultural psy-
chiatry. New York: John Wiley & Sons.
Hill, R. (1997, July 7). Sociologist taught strength of black family.
Baltimore Sun Times, p. 2B.
The HSC Foundation. (2007). Preventing childhood obesity in lower-
income communities: A focus group report of African-American
and Latino families’ understanding of healthy lifestyles, barriers
and challenges. Washington, DC: Author.
Institute of Medicine (IOM). (2004). In the nation’s compelling in-
terest: Ensuring diversity in the health care workforce. Washington,
DC: Author.
Jaynes, D., & Williams, R. (1989). A common destiny: Blacks and
American society. Washington, DC: National Academy Press.
Johnson, K., Elbert-Avila, K., & Tulsky, J. (2005). The influence
of spiritual beliefs and practices on the treatment preferences
of African Americans: A review of the literature. Journal of
the American Geriatrics Society, 53(4), 711–719.
Kaiser Family Foundation. (2001). African Americans view of the
HIV/AIDS epidemic at 20 years. Menlo Park, CA: Author.
Kelly, J., Kaufman, D., Kelley, K., Rosenberg, L., & Mitchell, A.
(2006). Use of herbal/natural supplements according to
racial/ethnic group. The Journal of Alternative and Complemen-
tary Medicine, 12(6), 555–561.
Kennedy, B., Mathis, C., & Woods, A., (2007). African Americans
and their distrust of the health care system: Healthcare
for diverse populations. Journal of Cultural Diversity, 14(2),
56–60.
Kwate, N., & Meyer, I. (2010). The myth of meritocracy and
African American health. American Journal of Public Health,
100(10), 1831–1834.
Ladner, J., & Gourdine, R. (1992). Adolescent pregnancy in the
African-American community. In R. Braithwaite & S. Taylor
(Eds.), Health issues in the black community (pp. 206–221). San
Francisco, CA: Josey-Bass.
LaVeist, T., & Carroll, T. (2002). Race of physician and satisfac-
tion with care among African American patients. The Journal
of the National Medical Association, 94(11), 937–943.
LaVeist, T., & Nuru-Jeter, A. (2002). Is doctor-patient concor-
dance associated with greater satisfaction with care? Journal of
Health and Social Behavior, 43(3), 296–306.
Lawson, W. (1999, May 19). Ethnicity and treatment of bipolar dis-
order. Presented at the 152nd annual meeting of the American
Psychiatric Association. Washington, DC.
Levy, R. (1993). Ethnic and racial differences in response to med-
icines: Preserving individualized therapy in managed pharma-
ceutical programmes. Pharmaceutical Medicine, 7, 139–165.
Lincoln, C. (1974). The Black church since Frazier. New York:
Schocken Books.
Lobar, S., Youngblut, J., & Brooten, D. (2006). Cross-cultural be-
liefs, ceremonies, and rituals surrounding death of a loved one.
Pediatric Nursing, 32(1), 44–55.
Low-wage labor market. (2006). Retrieved from http://aspe.hhs.
gov/hsp/lwlm99/henly.htm
Lowenstein, A., & Glanville, C.L. (1995). Cultural diversity and
conflict in the health care workplace. Nursing Economics, 13(4),
203–209.
Matas, A., Sowa, M., Taylor, V., Taylor, G., Schattka, B., &
Mantsch, H. (2001). Eliminating the issue of skin color in as-
sessment of the blanch response. Advances in Skin Wound Care,
14, 180–8.
112 Aggregate Data for Cultural-Specific Groups
2780_Ch06_089-114 16/07/12 11:41 AM Page 112

Mathews, T., & MacDorman, M. (2010). Infant mortality statis-
tics from the 2006 period linked birth/infant death data set. Na-
tional Vital Statistics Report, 58(17), 1–32. Retrieved from
http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_17
McNeil, J., Campinha-Bacote, J., Tapscott, E., & Vample, G.
(2002). BESAFE: National minority AIDS education and train-
ing center cultural competency model. Washington, DC:
Howard University Medical School.
Michaels, D. (1993). Occupational cancer in the black population:
The health effects of job discrimination. Journal of the
National Black Medical Association, 75, 1014–1018.
Moore, J. (2005). Hypertension: Catching the silent killer. Nurse
Provider, 30(10), 16–18, 23–24, 26–27.
Morgan, P., Barnett, K., Perdue, B., Fogel, J., Underwood, S.,
Gaskins, M., & Brown-Davis, C. (2006). African American
women with breast cancer and their spouses’ perception of care
received from physicians. The ABNF Journal, 17(1), 32–37.
Morrison, R., Wallenstein, S., Natale, D., Senzel, R., & Huang L.
(2000). “We don’t carry that”—failure of pharmacies in
predominantly nonwhite neighborhoods to stock opioid anal-
gesics. New England Journal of Medicine, 342, 1023–1026.
Murray, R., & Zentner, J. (2001). Health promotion strategies
through the lifespan. Upper Saddle River, NJ: Prentice Hall.
Musgrave, C., Allen, C., & Allen, G. (2002). Rural health and
women of color: Spirituality and health for women of color.
American Journal of Public Health, 92(4), 557–560.
National Diabetes Information Clearinghouse. National Diabetes
Statistics, 2011. Bethesda, MD: Author. Retrieved from
www.diabetes.niddk.nih.gov
National Women’s Health Information (2011). U.S. Department
of Health and Human Resources, Office on Women’s Health:
Overweight and obesity. Retrieved from http://www.4women.
gov/minority/africanamerican/obesity.cfm
National Women’s Health Report. (2005). African-American
women & heart health. National Women’s Health Report,
27(10), 6.
Navarro, V. (1997). Race or class versus race and class: Mortality
differentials in the U.S. In P. R. Lee & C. L. Estes (Eds.), The
nation’s health (pp. 32–36). Sudbury, MA: Jones & Barlett.
Negy, C., & Eisenman, R. (2005). A comparison of African American
and white college students’ affective and attitudinal reactions to
lesbian, gay, and bisexual individuals: An exploratory study. The
Journal of Sex Research, 42(4), 291–298).
Nichols, E. (1987). Nichols’ Model of the Philosophical Aspects of
Cultural Difference. Unpublished paper. Contact: Nichols and
Associates, Inc.; 1523 Underwood Street, NW; Washington,
DC, 20012.
NMAETC. (2006). African American/Black fact sheet. Washington,
DC: Author.
Parks-Yancy, R. (2010). Equal work, unequal career: African Americans
in the workforce. Boulder, CO: First Forum Press.
The Pew Forum on Religion and Public Life. (2009). A religious por-
trait of African Americans. http://pewforum.org/A-Religious-
Portrait-of-African-Americans.aspx
Plawecki, H., & Plawecki, J. (1992). Improving organ donation
rates in the black community. Journal of Holistic Nursing,
10(1), 34–46.
Queralt, M. 1996. The social environment and human behavior: A
diversity perspective. Needham Heights, MA: Allyn & Bacon.
Rickford, J. (1999). The Ebonics controversy in my backyard: A
sociologist’s experiences and reflections. Journal of Sociolin-
guistics, 3(2), 267.
Ries, L., Melbert, D., Krapcho, M., Mariotto, A., Miller, B.,
Feuer, E., Clegg, L., Horner, M., Howlader, N., Eisner, M.,
Reichman, M, & Edwards, B. (Eds). (2008). SEER Cancer Sta-
tistics Review, 1975–2004, National Cancer Institute. Bethesda,
Retrieved from http://seer.cancer.gov/csr/1975_2004/results_
merged/sect_16_melanoma . Based on November 2006
SEER data submission.
Roberson, M. (1985). The influence of religious beliefs on health
choices of Afro-Americans. Topics in Clinical Nursing, 7(3),
57–63.
Salcido, S. (2002). Finding a window into the skin. Advances in
Skin and Wound Care, 15(3), 100.
Saunders, E. (1997). High blood pressure: A call to action for
African-Americans. Baltimore Sun, p. A3.
Savitt, T. (1978). Medicine and slavery. Chicago: University of
Illinois Press.
Schaeffeler, E., Eichelbaum, M., Brinkmann, U., Penger, A.,
Asante-Poku, S., Zanger, U., & Schwab, M. (2001). Frequency
of C3435T polymorphism of gene in African people. The
Lancet, 358(9279), 383–384.
Schwartz, R. (2001). Racial profiling in medical research. New
England Journal of Medicine, 344, 1392–1393.
Smedley, B., Stith, A., & Nelson, A. (2002). Unequal treatment:
Confronting racial and ethnic disparities in healthcare.
Washington, DC: National Academy Press.
Snow, L. (1974). Folk medical beliefs and their implications for
care of patients. Annals of Internal Medicine, 81, 82–96.
Snow, L. (1993). Walkin’ over medicine. Boulder, CO: Westview
Press.
Sommers, M. (2011). Color awareness: A must for patient assess-
ment. American Nurse Today. 6(1). Retrieved from http://www.
americannursetoday.com/Article.aspx?id=7434&fid=7360
Sommers, M., Zink, T., Fargo, J., Baker, R.B., Buschur, C.,
Shambley-Ebron, D.Z., & Fisher, B.S. (2008). Forensic sexual
assault examination and genital injury: Is skin color a source
of health disparity? American Journal of Emergency Medicine, 26,
857–866.
Sowa, M., Matas, A., Schattka, B., & Mantsch, H. (2002). Spec-
troscopic assessment of cutaneous hemodynamics in the pres-
ence of high epidermal melanin concentration. Clinica Chimica
Acta, 317, 203–212.
Sowers, J., Ferdinand, K., Bakris, G., & Douglas, J. (2002).
Hypertension-related disease in African Americans. Postgraduate
Medicine, 112(4), 24–48.
Spurlock, W., & Cullins, L. (2006). Cancer fatalism and breast
cancer screening in African American women. The ABNF
Journal, 17(10), 38–43.
Strakowski, S., McElroy, S., Keck P., & West, S. (1996). Racial in-
fluence on diagnosis in psychotic mania. Journal of Affect
Disorders, 39(2), 157–162.
Strickland, T.I., Lin, K.M., Fu, P., Anderson, D., & Zheng, Y.
(1995). Comparison of lithium ratio between African-American
and Caucasian bipolar patients. Biological Psychiatry, 37(5),
325–330.
Strickland, T.L., Ranganath, V., Lin, K.M., Poland, R.E., Mendoza,
R., & Smith, M.W. (1991). Psychopharmacologic considerations
in the treatment of black American populations. Psychopharma-
cology Bulletin, 27(4), 441–448.
Sullivan, L. (2004). Missing persons: Minorities in the health
professions: A report of the Sullivan Commission on diversity in
the healthcare workforce. Battle Creek, MI: W. K. Kellogg
Foundation.
Taulbert, C. (1969). Once upon a time when we were colored. Tulsa,
OK: Counsel Oak Books.
The White House, Office of the First Lady. (2010). Remarks by the
first lady to the NAACP national convention in Kansas City,
People of African American Heritage 113
2780_Ch06_089-114 16/07/12 11:41 AM Page 113

Missouri. Retrieved from http://www.whitehouse.gov/the-
press-office/remarks-first-lady-naacp-national-convention-
kansas-city-missouri
Thompson, C., Craig, H., & Washington, J. (2004). Variable pro-
duction of African American English across oral and literary
contexts. Language, Speech, and Hearing in Schools, 35(3), 269–
282.
Underwood, S. (1994). Increasing the participation of minorities
and other at-risk groups in clinical trials. Innovations in Oncol-
ogy Nursing, 10(4), 106.
Underwood, S., Buseh, A., Canales, M., Powe, B., Dockery, B,
Kather, T., & Kent, N. (2005). Nursing contributions to the
elimination of health disparities among African Americans:
Review and critique of a decade of research (part II). Journal
of National Black Nurses Association, 16(10), 31–47.
Underwood, S., & Powell, R. (2006). Religion and spirituality: In-
fluence on health/risk behavior and cancer screening behavior
of African Americans. The ABNF Journal, 17(10), 20–31.
Underwood, S., Berry, M., & Haley, S. (2009). Promoting health
and wellness of African American brethren: Because we are
our brother’s keeper. The ABNF, 20(2), 53–59.
U.S. Census Bureau, Statistical Abstract of the United States: 2011.
(2011). Births, deaths, marriages, and divorces. Retrieved from
http://www.census.gov/compendia/statab/2011/tables/11s0103
U.S. Department of Commerce, Bureau of the Census. (1993). We
the American blacks. Washington, DC: U.S. Government Print-
ing Office.
U.S. Department of Commerce, Bureau of the Census. (2006).
www.census.gov.
U.S. Department of Commerce, Bureau of the Census. (2008).
American community survey. Retrieved from http://www.
census.gov/acs/www/
U.S. Department of Commerce, Bureau of the Census. (2010).
Retrieved from http://2010.census.gov/2010census/
U.S. Department of Health and Human Services. (1997). Healthy
People 2010: National health promotion and disease prevention
objectives. Washington, DC: Author.
U.S. Department of Health and Human Services. (2002). Healthy
PEOPLe 2010: Understanding and improving health (2nd ed.).
Washington, DC: Author.
U.S. Department of Health and Human Services. (2009). Office
of Minority Health: African American Profile. Washington,
DC: Author. Retrieved from http://minorityhealth.hhs.gov/
templates/browse.aspx?lvl=2&lvlID=51
U.S. Department of Health and Human Services, Center for Dis-
ease Control and Prevention National Center for Health Sta-
tistics (2010). Health, United States, 2010. Washington, DC:
Author.
U.S. Department of Justice Office of Justice Programs. (2008).
Prison and jail inmates at midyear 2006. Bureau of Justice Statistics
Bulletin. Retrieved from http://bjs.ojp.usdoj.gov/content/pub/
pdf/pjim06
Wandler, K. (2003). Psychopharmacology of patients with eating
disorders. Remuda Review, 2(1), 1–7.
Washington, K., Bickel-Swenson, D., & Stephens, N. (2008). Bar-
riers to hospice use among African Americans: A systematic
review. Health & Social Work, 33(4), 267–274.
Waters, C. (2000). End-of-life directives among African Americans:
A need for community-centered discussion and education. Journal
of Community Health Nursing, 17(1), 25–37.
Watts, R. (2003, January). Race consciousness and the health of
African Americans. Online Journal of Nursing, 8(1), Manu-
script 3. Retrieved from http://www.nursingworld.org/Main-
MenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/
TableofContents/Volume82003/No1Jan2003/RaceandHealth.aspx
Wehbe-Alamah, H., McFarland, M., Belanger, B., Bender, J.,
Brandon, C., Gensel, B., & Ross, L. (2011). The lived experi-
ence of African American Men receiving primary care in a
nurse managed clinic within an urban context. Online Journal
of Cultural Competence in Nursing and Healthcare, 1(1), 54.
Wehbe-Alamah, H., McFarland, M., Macklin, J., & Riggs, N.
(2011). The lived experiences of African American women re-
ceiving care from nurse provider leave as practitioner in an
urban nurse-managed clinic. The Online Journal in Cultural
Competence in Nursing and Healthcare, 1(1), 15–26.
Welch, L., Teno, J., & Mor, V. (2005). End-of-life care in black and
white: Race matters for medical care of dying patients and their
families. Journal of the American Geriatrics Society, 53(7),
11154–11161.
Williams, B. (2005). Older African Americans and calcium-
deficient diets: What rehabilitation specialists need to know.
Topic in Geriatric Rehabilitation, 21(1), 88–92.
Williams, J., Wyatt, G., & Wingood, G. (2010). The four Cs of HIV
prevention with African Americans: Crisis, condoms, culture,
and community. Current HIV/AIDS Report, 7(4), 185–193.
Wood, J. (2009). Communication in our lives. Boston, MA:
Wadsworth Cengage Learning.
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
114 Aggregate Data for Cultural-Specific Groups
2780_Ch06_089-114 16/07/12 11:41 AM Page 114

115
Chapter 7
The Amish
Anna Frances Z. Wenger and Marion R. Wenger
Overview, Inhabited Localities,
and Topography
Overview
As dusk gathers on the hospital parking lot, a man
first ties his horse to the hitching rack and then helps
down from the carriage a matronly figure who is
wrapped in a shawl as dark as his own greatcoat. On
their mother’s heels, a flurry of children dressed like
undersized replicas of their parents turn their wide
eyes toward the fluorescent-lit glass façade of the re-
ception area, a glimmering beacon from the world of
high-technology health care. Their excitement is
muted by their father’s soft-spoken rebuke in a lan-
guage more akin to German than English, and in a
hush, the Amish family crosses a cultural threshold—
into the workaday world of health-care providers.
This Amish family appears to come from another
time and place. Those familiar with the health-care
needs of the Amish know the profound cultural dis-
tance they have bridged in seeking professional help.
Others, only marginally acquainted with Amish ways,
may ask why this group dresses, acts, and talks like vis-
itors to the North American cultural landscape of the
21st century. Amish are “different” by intention and
by conviction. That is to say, for most of the ways in
which they depart from the norm for contemporary
American culture, they cite a reason related to their
understanding of the biblical mandate to live a life
separated from a world they see as unregenerate or
sinful.
As noted in the variant cultural characteristics in
the introduction to cultural diversity in Chapter 1, dis-
similar appearance, behavior, or both may signal
deeper underlying differences in the Amish culture.
Noting these differences does not, of necessity, lead
to better acceptance or deeper understanding of atti-
tudes and behaviors. Appearances can be misleading.
For example, the Amish family’s arrival at the hospital
by horse and carriage might suggest a general taboo
against modern technological conveniences. In fact,
most Amish homes are not furnished with electric and
electronic labor-saving devices and appliances. But
that does not preclude the Amish’s openness to using
state-of-the-art medical technology if it is perceived
as necessary to promoting their health.
This minority group’s exotic features of dress and
language may disguise true motivations regarding
health-seeking behaviors, which they share in com-
mon with the larger, or majority, culture. To enable
such patients to attain their own standard of health
and well-being, health-care providers need to look be-
yond the superficial appearance and to listen more
carefully to the cues they provide.
Heritage and Residence
It is as important to locate the Amish topographically
according to cultural and religious coordinates as well
as to the geographical areas they inhabit. The hospital
visit scene just portrayed could have taken place in any
one of a number of towns spanning the American
Midwest from the eastern seaboard, but the basic cir-
cumstances surrounding the interaction with profes-
sional caregivers and the cultural assumptions
underlying it are basically similar. For the Amish,
seeking help from health-care providers requires them
to go outside their own people and, in so doing, to
cross over a significant “permeable boundary” that de-
limits their community in cultural-geographic terms.
Today’s Amish live in rural areas in a band of over
20 states stretching westward from Pennsylvania,
Ohio, and Indiana as far as Montana, with some scat-
tered settlements as far south as Florida and as far
north as the province of Ontario, Canada (Huntington,
2001) as well as other parts of the United States.
About 75 percent of their estimated total population
of over 175,000 is concentrated in Pennsylvania, Ohio,
and Indiana (Kraybill & Hostetter, 2001; C.N. Hostet-
ter, personal communication). The Old Order Amish,
so-called for their strict observance of traditional ways
that distinguishes them from other, more progressive
“plain folk,” are the largest and most notable group
2780_Ch07_115-136 16/07/12 11:41 AM Page 115

among the Amish. As such, they constitute an eth-
noreligious cultural group in modern America with
roots in Reformation-era Europe.
Reasons for Migration and Associated
Economic Factors
The Amish emerged after 1693 as a variant of one
stream of the Anabaptist movement that originated in
Switzerland in 1525 and spread to neighboring lands
to the east, north, and northwest, especially along the
Rhine River, to the Netherlands. The Amish em-
braced, among other essential Anabaptist tenets of
faith, the baptism of adult believers as an outward
sign of membership in a voluntary community with
an inner commitment to live peaceably with all. The
Amish parted ways with the larger Anabaptist group,
now known as Mennonites, over the Amish propensity
to strictly avoid community members whom they ex-
cluded from fellowship in their church (Hostetler,
1993). The Amish name is derived from the surname
of Jacob Ammann, a 17th-century Anabaptist who
led the Amish division from the Anabaptists in 1693
(Hüppi, 2000). Similarly, the name Mennonite is de-
rived from the given name of Menno Simons, a former
Catholic priest, who was a key leader of the Anabaptist
movement in Europe.
Anabaptists were disenfranchised and deported,
and their goods expropriated for their refusal to bear
arms as a civic service and to accept the authority of
the state church in matters of faith and practice. Their
attempts at radical discipleship in a “free church,” fol-
lowing the guidelines of the early church as set forth
in the New Testament, resulted in conflict with
Catholic and Protestant leaders. After experiencing se-
vere persecution and martyrdom in Europe, the
Amish and related groups emigrated to America in the
17th and 18th centuries. No Amish live in Europe
today, the last survivors having been assimilated into
other religious groups (Hostetler, 1993). As a result,
the Amish, unlike many other ethnic groups in the
United States, have no larger reference group in their
former homeland to which their customs, language,
and lifeways can be compared.
Denied the right to hold property in their home-
lands, the Amish sought not only religious freedom
but also the opportunity to buy farmland where they
could live out their beliefs in peace. In their commu-
nities, the Amish have transplanted and preserved a
way of life that bears the outward dress of preindustrial
European peasantry. In modern industrial America,
they have persisted in social isolation based on reli-
gious principles, a paradoxically separated life of
Christian altruism. Living for others entails a caring
concern for members of their in-group, a community
of mutuality, but it also calls them to reach out to oth-
ers in need outside their immediate Amish household
of faith (Hostetler, 1993).
Although the Amish value inner harmony, mutual
caring, and a peaceable life in the country, it would be
a mistake to see Amish society as an idyllic, pastoral
folk culture, frozen in time and serenely detached from
the dynamic developments all around them. Since the
mid-19th century, Amish communities have experi-
enced inner conflicts and dissension as well as outside
pressures to conform and modernize. Over time, the
Amish have continued to adapt and change, but at
their own pace, accepting innovations selectively.
One cost of controlled, deliberate change has been
the loss of some members through factional divisions
over “progressive” motivations, both religious and ma-
terial. The influence of revivalism led to religious re-
form variants, which introduced Sunday schools,
missions, and worship in meetinghouses instead of
homes. Others who were impatient to use modern
technology, such as gasoline-powered farm machinery,
telephones, electricity, electronic devices, and automo-
biles, also split off from the main body of the most
conservative traditionalists, now called the Old Order
Amish. Some variant groups were named after their
factional leaders (e.g., Egli and Beachy Amish); some
were called Conservative Amish Mennonites, and oth-
ers The New Order Amish. Today, these progressives
stand somewhere between the parent body, the
Mennonites, and the Old Order Amish (technically
Old Order Amish Mennonites), hereafter simply re-
ferred to as the Amish (Hostetler, 1993). This latter
group, the (Old Order) Amish, which has been widely
researched and reported on, provides the observa-
tional basis for this present culture study.
Educational Status and Occupations
The controversy over schooling of Amish children is
a good example of a policy issue that attracts public
attention. Amish parents assume primary responsibil-
ity for child rearing, with the constant support of the
extended family and the church community to rein-
force their teachings. On the family farm, parents and
older siblings model work roles for younger siblings.
Corporate worship and community religious practices
nurture and shape their faith. Learning how to live
and to prepare for death is more important in the
Amish tradition than acquiring special skills or
knowledge through formal education or training
(Hostetler & Huntington, 1992).
The mixed-grade, one-room schoolhouses (Fig. 7-1),
typical of rural America before 1945, were acceptable
to the Amish because the schools were more amenable
to local control. With the introduction of consolidated
high schools, however, the Amish resisted secondary
education, particularly compulsory schooling man-
dated by state and federal agencies, and raised objec-
tions both on principle and on scale. To illustrate the
latter, the amount of time required by secondary ed-
ucation and the distances required to bus students out
116 Aggregate Data for Cultural-Specific Groups
2780_Ch07_115-136 16/07/12 11:41 AM Page 116

of their home communities were cited as problems.
But probably more crucial was the understanding that
the high school promised to socialize and instruct the
young in a value system that was antithetical to the
Amish way of life. For example, in the high school, in-
dividual achievement and competition were pro-
moted, rather than mutuality and caring for others in
a communal spirit. On pragmatic grounds, Amish
parents objected to “unnecessary” courses in science,
advanced math, and computer technology, which
seemed to have no place and little relevance in their
tradition (Meyers, 1993).
The Amish response to this perceived threat to their
culture was to build and operate their own private el-
ementary schools. Their right to do so was litigated
but finally upheld in the U.S. Supreme Court in the
1972 Wisconsin v. Yoder ruling. Today, school-age chil-
dren are encouraged to attend only eight grades, but
Amish parents actively support local private and
public elementary schools.
The Amish rejection of higher learning for their
children means that only the rare individual may pur-
sue professional training and still remain Amish.
Health-care providers, by definition, are seen as out-
siders who mediate information on health promotion,
make diagnoses, and propose therapies across cultural
boundaries. To the extent that they do so with sensi-
tivity and respect for Amish cultural ways, they are re-
spected, in turn, and valued as an important resource
by the Amish.
As the 20th century drew to a close, important
changes were underway among the Amish in North
America, whose principal and preferred occupations
have long been agricultural work and farm-related
enterprises (Fig. 7-2). They had typically settled on
good farmland from their earliest immigration some
250 years ago. As cultivatable land at an affordable
price became an increasingly scarce commodity near
centers of Amish settlements, the trend toward other
work away from home led to a reshaping of the Amish
family. Income from goods and services once delivered
for internal domestic consumption came increasingly
from cottage industry production for the retail market
and wage-earning with nearby employers. The alter-
native, seeking new farmland at a distance, has led to
community resettlement as far away from Pennsylvania
as Montana.
Young women who have learned quantity cookery
at the many church and family get-togethers may find
jobs in restaurants and catering, or skills learned in
household chores may be exchanged for wages in child
care or housecleaning. Young men who bring skills
from the farm may practice carpentry or cabinetmak-
ing in the trades and construction industry. This, in
turn, brings a change in family patterns, since “lunch-
box daddies” are absent during daylight workday
hours and the burden for parenting is borne more by
stay-at-home mothers. The bonds of family and
church have proved resilient but are clearly experienc-
ing more tension in the current generation.
In summary, jobs away from home, an established
majority culture pattern, and increased contacts with
non-Amish people test the strength of sociocultural
bonds that tie young people to the Amish culture.
Given the enticements of the majority culture to change
and to acculturate, it is noteworthy that so many young
Amish find their way back to full membership in the
ethnoreligious culture that nurtured them.
Communication
Dominant Languages and Dialects
Like most people, the Amish vary their language usage
depending on the situation and the individuals being ad-
dressed. American English is only one of three language
varieties in their repertoire. For the Amish, English is
the language of school, of written and printed commu-
nications, and, above all, the language used in contacts
The Amish 117
Figure 7-1 A one-room Amish schoolhouse in Indiana.
(Photograph by Joel Wenger.)
Figure 7-2 An Amish farm. The windmill in the background is
used to pump water. (Photograph by Joel Wenger.)
2780_Ch07_115-136 16/07/12 11:42 AM Page 117

with most non-Amish outsiders, especially business
contacts. Because English serves a useful function as
the contact language with the outside world, Amish
schools all use English as the language of instruction,
with the strong support of parents, because elemen-
tary schooling offers the best opportunity for Amish
children to master the language. But within Amish
homes and communities, use of English is discouraged
in favor of the vernacular Deitsch, or Pennsylvania
German. Because all Amish except preschool children
are literate in their second language, American English,
language usage helps to define their cultural space
(Hostetler, 1993).
The first language of most Amish is Deitsch, an
amalgamation of several upland German dialects that
emerged from the interaction of immigrants from the
Palatinate and Upper Rhine areas of modern France,
Germany, and Switzerland. Their regional linguistic
differences were resolved in an immigrant language
better known in English as “Pennsylvania German”
(also known as “Pennsylvania Dutch”). Amish immi-
grants who later moved more directly from the Swiss
Jura and environs to midwestern states (with minimal
mixing in transit with Deitsch-speakers) call their home
language Düütsch, a related variety with marked Upper
Alemannic features. Today, Deitsch and Düütsch both
show a strong admixture of vocabulary borrowed
from English, whereas the basic structure remains
clearly nonstandard German. Both dialects have prac-
tically the same functional distribution (Meyers &
Nolt, 2005; Wenger, 1970).
Deitsch is spoken in the home and in conversation
with fellow Amish and relatives, especially during
visiting, a popular social activity by which news is dis-
seminated orally. It is important to note that Deitsch
is primarily a spoken language. Some written material
has been printed in Pennsylvania German, but Amish
seldom encounter it in this form. Even Amish publi-
cations urging the use of Deitsch in the family circle
are printed in English, by default the print replace-
ment for the vernacular, the spoken language (What
is in a language?, 1986).
Health-care providers can expect all their Amish
patients of school age and older to be fluently bilin-
gual. They can readily understand spoken and written
directions and answer questions presented in English,
although their own terms for some symptoms and ill-
nesses may not have exact equivalents in Deitsch and
English. Amish patients may be more comfortable
consulting among themselves in Deitsch, but generally
they intend no disrespect for those who do not under-
stand their mother tongue.
Although of limited immediate relevance for
health-care considerations, the third language used by
the Amish deserves mention in this cultural profile to
complete the scope of their linguistic repertoire.
Amish proficiency in English varies according to the
type and frequency of contact with non-Amish, but it
is increasing. The use of Pennsylvania German is in
decline outside the Old Order Amish community. Its
retention by Amish, despite the inroads of English,
has been related to their religious communities’
persistent recourse to Hochdeitsch, or Amish High
German, their so-called third language, as a sacred
language (Huffines, 1994).
Amish do not use Standard Modern High German,
but an approximation, which gives access to texts
printed in an archaic German with some regional vari-
ations. Rote memorization and recitation for certain
ceremonial and devotional functions, and for selected
printed texts from the Bible, from the venerable
“Ausbund” hymnbook, and from devotional literature
are a part of public and private prayer and worship
among the Amish. Such restricted and nonproductive
use of a third language hardly justifies the term “trilin-
gual” because it does not encompass a fully developed
range of discourse. However, Amish High German
does provide a situational-functional complement to
their other two languages (Enninger & Wandt, 1982).
Its retention is one more symbol of a consciously sep-
arated way of life that reaches back to its European
heritage.
Within a highly contextual subculture like the
Amish, the base of shared information and experience
is proportionately larger. As a result, less overt verbal
communication is required than in the relatively low-
contextual American culture, and more reliance is
placed on implicit, often unspoken understandings.
Amish children and youth may learn adult roles in
their society more through modeling, for example,
than through explicit teaching. The many and diverse
kinds of multigenerational social activities on the
family farm provide the optimal framework for this
kind of enculturation. Although this may facilitate the
transmission of traditional, or accepted, knowledge
and values within a high-context culture, this same in-
formation network may also impede new information
imparted from the outside, which entails some behav-
ior changes. Wenger (1988; 1991c) suggested that
nurses and other health-care providers should con-
sider role modeling as a teaching strategy when work-
ing with Amish patients. Later, a brief example of the
promotion of inoculation is presented to illustrate
how public-health workers can use culture-appropri-
ate information systems to achieve fuller cooperation
among the Amish.
In a final note on language and the flow of verbal
information, health-care providers should be aware
that much of what passes for “general knowledge” in
our information-rich popular culture is screened, or
filtered, out of Amish awareness. The Amish have se-
verely restricted their own access to print media, per-
mitting only a few newspapers and periodicals. Most
have also rejected the electronic media, beginning with
118 Aggregate Data for Cultural-Specific Groups
2780_Ch07_115-136 16/07/12 11:42 AM Page 118

radio and television, but also including entertainment
and information applications of film and computers.
Conversely, the Amish are openly curious about the
world beyond their own cultural horizons, particularly
regarding a variety of literature that deals with health
and quality-of-life issues. They especially value the
oral and written personal testimonial as a mark of the
efficacy of a particular treatment or health-enhancing
product or process. Wenger (1988; 1994) identified tes-
timonials from Amish friends and relatives as a
key source of information in making choices about
health-care providers and products.
Cultural Communication Patterns
Fondness and love for family members are held deeply
but privately. Some nurses have observed the cool, al-
most aloof behavior of Amish husbands who accom-
pany their wives to maternity centers, but it would be
presumptuous to think that it reflects a lack of
concern. The expression of joy and suffering is not
entirely subdued by dour or stoic silence, but Amish
are clearly not outwardly demonstrative or exuberant.
Amish children, who can be as delightfully animated
as any other children at play, are taught to remain
quiet throughout a worship service lasting more than
two hours. They grow up in an atmosphere of re-
straint and respect for adults and elders. But privately,
Amish are not so sober as to lack a sense of humor
and appreciation of wit.
Beyond language, much of the nonverbal behavior
of Amish is also symbolic. Many of the details of
Amish garb and customs were once general charac-
teristics without any particular religious significance
in Europe, but in the American setting, they are
closely regulated and serve to distinguish the Amish
from the dominant culture as a self-consciously sepa-
rate ethnoreligious group (Kraybill, 2001).
It is precisely in the domain of ideas held to be nor-
mative for the religious aspects of Amish life that they
find their English vocabulary lacking. The key source
texts in Hochdeitsch and the oral interpretation of
them in Deitsch are crucial to an understanding of two
German values, which have an important impact on
Amish nonverbal behavior. Demut, German for “hu-
mility,” is a priority value, the effects of which may be
seen in details such as the height of the crown of an
Amish man’s hat, as well as in very general features
such as the modest and unassuming bearing and de-
meanor usually shown by Amish people in public.
This behavior is reinforced by frequent verbal warn-
ings against its opposite, hochmut, which means
“pride” or “arrogance,” and should be avoided
(Hostetler, 1993).
The second term, gelassenheit, is embodied in be-
havior more than it is verbalized. Gelassenheit is treas-
ured not so much for its contemporary German
connotations of passiveness, even of resignation, as it
is for its earlier religious meanings, denoting quiet ac-
ceptance and reassurance, encapsulated in the biblical
formula “godliness with contentment” (1 Tim. 6:5).
The following Amish paradigm for the good life flows
from the calm assurance found through inner yielding
and forgoing one’s ego for the good of others:
1. One’s life rests secure in the hands of a higher
power.
2. A life so divinely ordained is therefore a good gift.
3. A godly life of obedience and submission will be
rewarded in the life hereafter (Kraybill, 2001).
A combination of these inner qualities; an unpreten-
tious, quiet manner; and modest outward dress in plain
colors lacking any ornament, jewelry, or cosmetics pres-
ents a striking contrast to contemporary fashions, both
in clothing styles and in personal self-actualization.
Amish public behavior is consequently seen as deliber-
ate rather than rash, deferring to others instead of
being assertive or aggressive, avoiding confrontational
speech styles and public displays of emotion in general.
Health-care providers should greet Amish patients
with a handshake and a smile. Amish use the same
greeting both among themselves and with outsiders,
but little touching follows the handshake. Younger
children are touched and held with affection, but older
adults seldom touch socially in public. Therapeutic
touch, conversely, appeals to many Amish and is prac-
ticed informally by some individuals who find com-
munal affirmation for their gift of warm hands. This
concept is discussed further in the section on health-
care practices.
In public, the avoidance of eye contact with non-
Amish may be seen as an extension, on a smaller scale,
of the general reserve and measured larger body
movements related to a modest and humble being. But
in one-on-one clinical contacts, Amish patients can be
expected to express openness and candor with unhesi-
tating eye contact.
Among their own, Amish personal space may be
collapsed on occasions of crowding together for group
meetings or travel. In fact, Amish are seldom found
alone, and a solitary Amish person or family is the ex-
ception rather than the rule. But Amish are also prag-
matic, and in larger families, physical intimacy cannot
be avoided in the home, where childbearing and care
of the ill and dying are accepted as normal parts of
life. Once health-care providers recognize that Amish
prefer to have such caregiving within the home and
family circle, providers will want to protect modest
Amish patients who feel exposed in the clinical setting.
Temporal Relationships
So much of current Amish life and practice has a tradi-
tional dimension reminiscent of a rural American
past that it is tempting to view the Amish culture as
“backward-looking.” In actuality, Amish self-perception
The Amish 119
2780_Ch07_115-136 16/07/12 11:42 AM Page 119

is very much grounded in the present, and historical an-
tecedents or reasons for current consensus have often
been lost to common memory. Conversely, the Amish
existential expression of Christianity focused on today
is clearly seen as a preparation for the afterlife. One may
say that Amish are also future-oriented, at least in a
metaphysical sense, although not as it relates to modern,
progressive, or futuristic thought.
After generations of rural life guided by the natural
rhythms of daylight and seasons, the Amish manage
the demands of clock time in the dominant culture.
They are generally punctual and conscientious about
keeping appointments, although they may seem some-
what inconvenienced by not owning a telephone or
car. These communication conveniences, deemed es-
sential by the dominant American culture, are viewed
by the most conservative Amish as technological
advances that could erode the deeply held value of
community, in which face-to-face contacts are easily
made. Therefore, telephones and automobiles are gen-
erally owned by nearby non-Amish neighbors and
used by Amish only when it is deemed essential, such
as for reaching health-care facilities.
Because the predominant mode of transportation
for the Amish is horse and carriage, travel to a doctor’s
office, a clinic, or a hospital requires the same adjust-
ment as any other travel outside their rural community
to shop, trade, or attend a wedding or funeral. The
latter three reasons for travel are important means of
reinforcing relationship ties, and on these occasions,
the Amish may use hired or public transportation, ex-
cluding flying. Taking time out of normal routines for
extended trips related to medical treatments is not
uncommon, such as a visit to radioactive mines in the
Rocky Mountains or to a laetrile clinic in Mexico to
cope with cancer (Wenger, 1988).
Format for Names
Using first names with Amish people is appropriate,
particularly because generations of intermarriage have
resulted in a large number of Amish who share only a
limited number of surnames. So it is preferable to use
John or Mary during personal contacts rather than
Mr. or Mrs. Miller, for example. In fact, within Amish
communities, with so many Millers, Lapps, Yoders,
and Zooks, given names like Mary and John are over-
used to the extent that individuals have to be identified
further by nicknames, residence, a spouse’s given
name, or a patronymic, which may reflect three or
more generations of patrilineal descent. For example,
a particular John Miller may be known as “Red John,”
or “Gap John,” or “Annie’s John,” or “Sam’s Eli’s
Roman’s John” (Hostetler, 1993).
During an interview with an Amish mother and her
5-year-old son, Wenger (1988) asked the child where he
was going that day. The boy replied that he was going
to play with Joe Elam John Dave Paul, identifying his
age-mate Paul with four preceding generations. This lit-
tle boy was giving useful everyday information, while
at the same time, unknown to him, keeping oral history
alive. The patronymics also illustrate the cultural value
placed on intergenerational relationships and help to
create a sense of belonging that embraces several gen-
erations and a broad consanguinity. Thus, one can see
that medical record keeping can be a challenge when
serving an extensive number of Amish patients.
Family Roles and Organization
Head of Household and Gender Roles
From the time of marriage, the young Amish man’s
role as husband is defined by the religious community
to which he belongs. Titular patriarchy is derived from
the Bible: Man is the head of the woman as Christ is
the head of the church (I Cor. 3). This patriarchal role
in Amish society is balanced or tempered by realities
within the family, in which the wife is accorded high
status and respect for her vital contributions to the suc-
cess of the family. Practically speaking, husband and
wife may share equally in decisions regarding the
family farming business. In public, the wife may assume
a retiring role, deferring to her husband, but in private,
they are typically partners. However, it is best to listen
to the voices of Amish women themselves as they re-
flect on their values and roles within Amish family and
their shared ethnoreligious cultural community.
Traditionally, the highest priority for the parents is
child rearing, an ethnoreligious expectation in the
Amish culture. With a completed family averaging
seven children, the Amish mother contributes physi-
cally and emotionally to the burgeoning growth in the
Amish population. She also has an important role in
providing family food and clothing needs, as well as a
major share in child nurturing. Amish society expects
the husband and father to contribute guidance, serve
as a role model, and discipline the children. This
shared task of parenting takes precedence over other
needs, including economic or financial success in the
family business. On the family farm, all must help as
needed, but in general, field and barn work and ani-
mal husbandry are primarily the work of men and
boys, whereas food production and preservation,
clothing production and care, and management of the
household are mainly the province of women.
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Children and youth represent a key to the vitality of
the Amish culture. Babies are welcomed as a gift from
God, and the high birth rate is one factor in their pop-
ulation growth. Another is the surprisingly high reten-
tion of youth, an estimated 75 percent or more, who
choose as adults to remain in the Amish way. Before
and during elementary school years, parents are more
120 Aggregate Data for Cultural-Specific Groups
2780_Ch07_115-136 16/07/12 11:42 AM Page 120

directive as they guide and train their children to as-
sume responsible, productive roles in Amish society.
Young people over age 16 may be encouraged to
work away from home to gain experience or because
of insufficient work at home or on the family farm,
but their wages are still usually sent home to the
parental household because of the cultural value that
the whole family contributes to the welfare of the fam-
ily. Some experimentation with non-Amish dress and
behavior among Amish teenagers is tolerated during
this period of relative leniency, but the expectation is
that an adult decision to be baptized before marriage
will call young people back to the discipline of the
church, as they assume adult roles.
In recent years, the media have been fascinated with
this period of Amish teenage life as Americans in gen-
eral have learned more about the Amish as a distinc-
tive culture. Meyers and Nolt (2005) contended that
although some Amish teenagers do experiment with
behaviors that are incongruent with Amish beliefs and
values, they do so in a distinctive Amish way. Amish
teenagers are aware of the dominant American cul-
ture, and when they choose to participate in behaviors,
some of which may involve the legal system, they do
so in distinctive Amish ways, not in ways more com-
mon to American teenagers in general. For example,
Amish youth will usually experiment within an Amish
context and with other Amish youth, rather than with
non-Amish teenagers.
Family Goals and Priorities
The Amish family pattern is referred to as the freind-
schaft, the dialectical term used for the three-generational
family structure. This kinship network includes con-
sanguine relatives consisting of the parental unit and
the households of married children and their off-
spring. All members of the family personally know
their grandparents, aunts, uncles, and cousins, with
many Amish knowing their second and third cousins
as well.
Individuals are identified by their family affiliation.
Children and young adults may introduce themselves
by giving their father’s first name or both parents’
names so they can be placed geographically and
genealogically. Families are the units that make up
church districts, and the size of a church district is
measured by the number of families rather than by the
number of church members. This extended family pat-
tern has many functions. Families visit together fre-
quently, thus learning to anticipate caring needs and
preferences. Health-care information often circulates
through the family network, even though families may
be geographically dispersed. Wenger (1988) found that
informants referred to freindschaft when discussing
the factors influencing the selection of health-care op-
tions. “The functions of family care include maintain-
ing freindschaft ties, bonding family members together
intergenerationally, and living according to God’s will
by fulfilling the parental mandate to prepare the
family for eternal life” (Wenger, 1988, p. 134).
As grandparents turn over the primary responsibil-
ity for the family farm to their children, they continue
to enjoy respected status as elders, providing valuable
advice and sometimes material support and services
to the younger generation. Many nuclear families live
on a farm with an adjacent grandparent’s cottage,
which promotes frequent interactions across genera-
tions. Grandparents provide child care and help in
rearing grandchildren and, in return, enjoy the respect
generally paid by the next generations. This emotional
and physical proximity to older adults also facilitates
elder care within the family setting. In an ethnonurs-
ing study on care in an Amish community, Wenger
(1988) reported that an informant discussed the recip-
rocal benefits of having her grandparents living in
the attached daadihaus and her own parents living in
a house across the road. Her 3-year-old daughter
could go across the hall to spend time with her great-
grandfather, which, the mother reported, was good for
him in that he was needed, whereas the small child ben-
efited from learning to know her great-grandfather,
and the young mother gained some time to do chores.
There is no set retirement age among the Amish, and
grandmothers also continue in active roles as advisers
and assistants to younger mothers.
Assuming full adult membership and responsibility
means the willingness to put group harmony ahead of
personal desire. In financial terms, it also means an
obligation to help others in the brotherhood who are
in need. This mutual aid commitment also provides a
safety net, which allows Amish to rely on others for
help in emergencies. Consequently, the Amish do not
need federal pension or retirement support; they have
their own informal “social security” plan. Amish of
varying degrees of affluence enjoy approximately the
same social status, and extremes of poverty and
wealth are uncommon. Property damage or loss and
unusual health-care expenses are also covered to a
large extent by an informal brotherhood alternative to
commercial insurance coverage. The costs of high-
technology medical care present a new and severe test
of the principle of mutual aid or “helping out,” which
is almost synonymous with the Amish way of life.
Alternative Lifestyles
There is little variation from the culturally sanctioned
expectations for parents and their unmarried children
to live together in the same household while maintain-
ing frequent contact with the extended family. Unmar-
ried children live in the parents’ home until marriage,
which usually takes place between the ages of 20 and 30.
Some young adults may move to a different commu-
nity to work and live as a boarder with another Amish
family. Being single is not stigmatized, although almost
The Amish 121
2780_Ch07_115-136 16/07/12 11:42 AM Page 121

all Amish do marry. Single adults are included in the
social fabric of the community with the expectation
that they will want to be involved in family-
oriented social events.
Individuals of the same gender do not live together
except in situations in which their work may make it
more convenient. For example, two female school-
teachers may live together in an apartment or home
close to the Amish school where they teach. There are
no available statistics on the incidence of homosexual-
ity in Amish culture. Isolated incidents of homosexual
practice may come to the attention of health providers,
but homosexual lifestyles do not fit with the deeply
held values of Amish family life and procreation.
Pregnancy before marriage does not usually occur,
and it is viewed as a situation to be avoided. When it
does occur, in most Amish families, the couple would
be encouraged to consider marriage. If they are not
yet members of the church, they need to be baptized
and to join the church before being married. Although
not condoning pregnancy before marriage, the fami-
lies and the Amish community support the young cou-
ple about to have a child. If the couple chooses not to
marry, the young girl is encouraged to keep the baby
and her family helps raise the child. Abortion is an un-
acceptable option. Adoption by an Amish family is an
acceptable alternative.
Workforce Issues
Culture in the Workplace
In every generation except the present one, the Amish
have worked almost exclusively in agriculture and farm-
related tasks. Their large families were ideally suited to
labor-intensive work on the family farm. As the number
of family farms has been drastically reduced because
of competition from agribusinesses that use mecha-
nized and electronically controlled production meth-
ods, few options are available for Amish youth.
Traditionally, the Amish have placed a high value
on hard work, with little time off for leisure or recre-
ation. Productive employment for all is the ideal, and
the intergenerational family provides work roles ap-
propriate to the age and abilities of each person. But
prospects began to narrow with the increased concen-
tration of family farms in densely settled Amish com-
munities as their population increased.
In addition, several cultural factors combine to
limit the opportunities for young Amish to adapt to
new work patterns. Amish children, who are encour-
aged to attend school through only eight grades, have
a limited basis for vocational training in many work
areas other than agriculture. Amish avoidance of com-
promising associations with “worldly” organizations,
such as labor unions, restricts them to nonunion work,
which often pays lower hourly rates. Work off the fam-
ily farm, at one time a good option for unmarried
youth, has become an economic necessity for some
parents, although it is considered less acceptable for
social reasons. Fathers who “work away,” sometimes
called “lunchpail daddies,” have less contact with chil-
dren during the workday, which in turn has an impact
on the traditional father’s modeling role and places
more of the responsibility for child rearing on stay-at-
home mothers. This shift in traditional parental roles
is a source of some concern, although the effects are
not yet clear.
Another concern for the Amish culture in relation
to the workplace is the use of technologies that may
be of concern for them. Hurst and McConnell (2010)
describe survey results of Amish in Holmes County,
Ohio, where 9 out of 10 persons “believe there are
some technologies that are harmful to the stability and
integrity of Amish culture, regardless of how they are
used” (p. 210). Computers, Internet, and TV were
mentioned the most. These technologies seem to be so
pervasive in non-Amish lifestyles and workplaces. For
the Amish, their concern is the difficulty in using these
technologies in healthy ways that uphold Amish be-
liefs and values.
Issues Related to Autonomy
As described previously, external and internal factors
have converged in the early 21st century to cause
doubt about the continued viability of compact
Amish farming communities. Exorbitant land prices
triggered group outmigrations and resettlement in
states to the west and south. The declining availability
of affordable prime arable land in and around the cen-
ters of highest Amish population density is due in part
to their non-Amish neighbors’ land-use practices,
especially in areas of suburban sprawl. A powerful in-
ternal force is at work as well in the population growth
rate among the Amish, now well above the national
average. So, contrary to popular notions that such a
“backward” subculture is bound to die out, the Amish
today are thriving.
Population growth continues even without a steady
influx of new immigrants from the European homeland
or significant numbers of new converts to their religion
or way of life (Kraybill, 2001). The Young Center for
Anabaptist and Pietist Studies at Elizabethtown College
(2010) reported, “In the 20-year period from 1991 to
2010, the Amish in North America (adults and chil-
dren) doubled in population, increasing from 123,500
in 1991 to 249,000 in 2010, an overall growth of
102 percent.” This population growth has been attrib-
uted largely to the size of families and the retention rate
of young adults.
The resulting pressures to control the changes in
their way of life while maintaining its religious basis,
particularly the high value placed on in-group har-
mony, have challenged the Amish to develop adaptive
strategies. One outcome is an increasingly diversified
122 Aggregate Data for Cultural-Specific Groups
2780_Ch07_115-136 16/07/12 11:42 AM Page 122

employment base, with a trend toward cottage indus-
tries and related retail sales, as well as toward wage
labor to generate cash needed for higher taxes and in-
creasing medical costs. Another recent development
includes a shift from traditional multigenerational
farmsteads, as some retirees and crafts workers em-
ployed off the farm have begun to relocate to the
edges of country towns. In summary, pressures to se-
cure a livelihood within the Amish tradition have
heightened awareness of the tension field within which
the Amish coexist with the surrounding majority
American culture.
Because English is the language of instruction in
schools and is used with business contacts in the out-
side world, there is generally no language barrier for
the Amish in the workplace. English vocabulary that
is lacking in their normative ideas for religious aspects
of Amish life is rarely a concern in the workplace.
Biocultural Ecology
Skin Color and Other Biological Variations
Most Amish are descendants of 18th-century Southern
German and Swiss immigrants; therefore, their physical
characteristics vary, as do those of most Europeans,
with skin variations ranging from light to olive tones.
Hair and eye colors vary accordingly. No specific
health-care precautions are relevant to this group.
Diseases and Health Conditions
Since 1962, several hereditary diseases have been iden-
tified among the Amish. The major findings of the ge-
netic studies have been published by Dr. Victor
McKusick (1978) of the Johns Hopkins University.
Because Amish tend to live in settlements with rela-
tively little domiciliary mobility, and because they
keep extensive genealogical and family records, genetic
studies are more easily done than with more mobile
cultural groups. Many years of collaboration between
the Amish and a few geneticists from the Johns
Hopkins Hospital have resulted in mutually beneficial
projects (Hostetler, 1993). The Amish received printed
community directories, and geneticists compiled com-
puterized genealogies for the study of genetic diseases
that continue to benefit society in general.
The Amish are essentially a closed population with
exogamy occurring very rarely. However, they are not
a singular genetically closed population. The larger
and older communities are consanguineous, meaning
that within the community the people are related
through bloodlines by common ancestors. Several
consanguine groups have been identified in which rel-
atively little intermarriage occurs between the groups.
“The separateness of these groups is supported by
the history of the immigration into each area, by
the uniqueness of the family names in each commu-
nity, by the distribution of blood groups, and by the
different hereditary diseases that occur in each of
these groups” (Hostetler, 1993, p. 328). These diseases
are one of the indicators of distinctiveness among the
groups.
Hostetler (1993) cautioned that although inbreed-
ing is more prevalent in Amish communities than in
the general population, it does not inevitably result in
hereditary defects. Through the centuries in some so-
cieties, marriages between first and second cousins
were relatively common without major adverse effects.
However, in the Amish gene pool are several recessive
tendencies that in some cases are limited to specific
Amish communities in which the consanguinity
coefficient (degree of relatedness) is high for the spe-
cific genes. Of at least 12 recessive diseases, 4 should
be noted here (Hostetler, 1993; McKusick, 1978;
Troyer, 1994).
Dwarfism has long been recognized as obvious in
several Amish communities. Ellis–van Creveld syn-
drome, known in Europe and named for Scottish and
Dutch physicians, is especially prevalent among the
Lancaster County, Pennsylvania, Amish (McKusick,
Egeland, Eldridge, & Krusen, 1964). This syndrome
is characterized by short stature and an extra digit on
each hand, with some individuals having a congenital
heart defect and nervous system involvement, result-
ing in a degree of mental deficiency. The Lancaster
County Amish community, the second largest Amish
settlement in the United States, is the only one in
which Ellis–van Creveld syndrome is found. The line-
age of all affected people has been traced to a single
ancestor, Samuel King, who immigrated in 1744
(Troyer, 1994).
Cartilage hair hypoplasia, also a dwarfism syn-
drome, has been found in nearly all Amish communi-
ties in the United States and Canada and is not unique
to the Amish (McKusick, Eldridge, Hostetler, Ruan-
quit, & Egeland, 1965). This syndrome is character-
ized by short stature and fine, silky hair. There is no
central nervous system involvement and, therefore, no
mental deficiency. However, most affected individuals
have deficient cell-mediated immunity, thus increasing
their susceptibility to viral infections (Troyer, 1994).
Pyruvate kinase anemia, a rare blood cell disease,
was described by Bowman and Procopio in 1963. The
lineage of all affected individuals can be traced to
Jacob Yoder (known as “Strong Jacob”), who immi-
grated to Mifflin County, Pennsylvania, in 1792
(Hostetler, 1993; Troyer, 1994). This same genetic dis-
order was found later in the Geauga County, Ohio,
Amish community. Notably, the families of all those
who were affected had migrated from Mifflin County,
Pennsylvania, and were from the “Strong Jacob” lin-
eage. Symptoms usually appear soon after birth, with
the presence of jaundice and anemia. Transfusions
during the first few years of life and eventual removal
of the spleen can be considered cures.
The Amish 123
2780_Ch07_115-136 16/07/12 11:42 AM Page 123

Hemophilia B, another blood disorder, is dispropor-
tionately high among the Amish, especially in Ohio.
Ratnoff (1958) reported on an Amish man who was
treated for a ruptured spleen. It was discovered that
he had grandparents and 10 cousins who were hemo-
philiacs; 5 of the cousins had died from hemophilia.
Research studies on causative mutations indicated a
strong probability that a specific mutation may ac-
count for much of the mild hemophilia B in the Amish
population (Ketterling, Bottema, Koberl, Setsuko, &
Sommer, 1991).
Through the vigilant and astute observations of
some public-health nurses known to these authors, a
major health-care problem was noted in a northern
Indiana Amish community. A high prevalence of
phenylketonuria (PKU) was found in the Elkhart-
Lagrange Amish settlement (Martin, Davis, & Askew,
1965). Those affected are unable to metabolize the
amino acid phenylalanine, resulting in high blood levels
of the substance and, eventually, severe brain damage
if the disorder is untreated. Through epidemiological
studies, the health department found that 1 in 62 Amish
were affected, whereas the ratio in the general popula-
tion was 1 in 25,000 at that time. Through the leader-
ship of these nurses, the county and the state improved
case funding for PKU and health-care services for af-
fected families throughout Indiana, which was followed
by improved health services in Amish communities in
other states as well.
In recent years, a biochemical disorder called glutaric
aciduria has been studied by Dr. Holmes Morton, a
Harvard-educated physician who has chosen to live
and work among the Amish in Lancaster County,
Pennsylvania. Morton made house calls, conducted
research at his own expense because funding was not
forthcoming, and established a clinic in the Amish
community to screen, diagnose, and educate people to
care for individuals afflicted with the disease (Allen,
1989). By observing the natural history of glutaric
aciduria type I, the researchers postulated that the
onset or progression of neurological disease in Amish
patients can be prevented by screening individuals at
risk; restricting dietary protein; and thus limiting
protein catabolism, dehydration, and acidosis during
illness episodes.
Dr. Morton was well received in the Amish com-
munity, with many people referring friends and rela-
tives to him. When he noted the rapid onset of the
symptoms and the high incidence among the Amish,
he did not wait for them to come to his office. He went
to their homes and spent evenings and weekends
driving from farm to farm, talking with families, run-
ning tests, and compiling genealogical information
(Wolkomir & Wolkomir, 1991). In 1991, he built a
clinic with the help of donations, in part the result of
an article in the Wall Street Journal about the need for
this nonprofit clinic. Hewlett-Packard donated the
needed spectrometer that cost $80,000; local compa-
nies provided building materials, and an Amish couple
donated the building site. Although volunteers helped
to build the clinic, a local hospital provided temporary
clinic space lease-free because the community recog-
nized the very important contribution Morton was
making, not only to the Amish and the advancement
of medical science but also to the public health of the
community.
A countywide screening program is now in place.
Health-care providers are able to recognize the onset
of symptoms. Research continues on this metabolic
disorder, its relationship to cerebral palsy in the Amish
population, and the biochemical causes and methods
of preventing spastic paralysis in the general popula-
tion. However, education remains a highly significant
feature of any community health program. Nurses
and physicians need to plan for family and community
education about genetic counseling, screening of new-
borns, recognition of symptoms during aciduric crises
in affected children, and treatment protocols. In The
New York Times Magazine (Belkin, 2005), Dr. Morton
was called “a doctor for the future”’ because he prac-
tices what is now referred to as genetic medicine,
which recognizes genetics as part of all medicine. But
to the Amish, he is their friend who cares about their
children, knows their families by name, and comes to
their homes to see how they are able to cope with the
manifestations of these genetically informed diseases.
Extensive studies of manic-depressive illnesses have
been conducted in the Amish population. At first,
there seemed to be evidence of a link between the
Harvey-ras-1 oncogene and the insulin locus on chro-
mosome 11. Studies on non-Amish families (Foroud,
Casteluccio, Kollar, Edenberg, Miller, & Boman,
2000) and more extensive studies on Amish families
have revealed new information on the genome, al-
though the locus for the bipolar disorder has not yet
been found (Ginns, Egeland, Allen, Pauls, & Falls,
1992; Kelsoe, Ginns, & Egeland, 1989; Kelsoe et al.,
1993; Law, Richard, Cottingham, Lathrop, Cox, &
Meyers, 1992; Myers, 1992; Pauls, Morton, &
Egeland, 1992). Attempts have been made to gain
knowledge about the affective response the Amish
have to their ethnoreligious cultural identity and
experience. Reiling (1998) studied the relationship
between Amish self-identity and mental health.
The incidence of alcohol and drug abuse, which can
complicate psychiatric diagnoses, is much lower
among the Amish than in the general North American
population, thus contributing to the importance of
the Amish sample. Although the incidence of bipolar
affective disorder is not found to be higher in the
Amish, some large families with several affected mem-
bers continue to contribute to medical science by
being subjects in the genetic studies. Because the Old
Order Amish descend from 30 pioneer couples whose
124 Aggregate Data for Cultural-Specific Groups
2780_Ch07_115-136 16/07/12 11:42 AM Page 124

descendants have remained genetically isolated in
North America, have relatively large kindred groups
with multiple living generations, and generally live in
close geographic proximity, they are an ideal popula-
tion for genetic studies (Kelsoe et al., 1989).
Variations in Drug Metabolism
No drug studies specifically related to the Amish were
found in the literature. However, given the genetic dis-
orders common among selected populations of
Amish, this is one area in which more research needs
to be conducted.
High-Risk Behaviors
Amish are traditionally agrarian and prefer a lifestyle
that provides intergenerational and community sup-
port systems to promote health and mitigate against
the prevalence of high-risk behaviors. Genetic studies
using Amish populations are seldom confounded by
the use of alcohol and other substances. However,
health providers should be alert to potential alcohol
and recreational drug use in some Amish communi-
ties, especially among young, unmarried men. When
young adult men exhibit such behavior as straying
from the Amish way of life and “sowing their wild
oats” before becoming baptized church members and
before marriage, it is tolerated. Although this may be
considered a high-risk behavior, it is not prevalent in
all communities, nor is it promoted in any. Parents
confide in each other and sometimes in trusted out-
siders that this errant behavior causes many
heartaches, although at the same time, they try to be
patient and keep contact with the youth so the latter
may choose to espouse the Amish lifeways.
Another lifestyle pattern that poses potential health
risks is nutrition. Amish tend to eat high-carbohydrate
and high-fat foods with a relatively high intake of
refined sugar. Wenger (1994) reported that in an eth-
nonursing study on health and health-care percep-
tions, informants talked about their diet being too
high in “sweets and starches” and knowing they
should eat more vegetables. The prevalence of obesity
was found to be greater among Amish women than
for women in general in the state of Ohio (Fuchs,
Levinson, Stoddard, Mullet, & Jones, 1990). In this
major health-risk survey of 400 Amish adults and
773 non-Amish adults in Ohio, the authors found that
the pattern of obesity in Amish women begins in the
25-year-old and older cohort, with the concentration
occurring between the ages of 45 and 64. An explana-
tion for the propensity for weight gain among the
Amish may be related to the central place assigned to
the consumption of food in their culture and the
higher rates of pregnancy throughout their childbear-
ing years (Wenger, 1994). However, in recent studies
related to eating behaviors, obesity, and diabetes,
the Old Order Amish cohorts showed some significant
differences from other whites in the majority culture.
Hsueh and colleagues (2002) reported in the Third
National Health and Nutrition Examination Survey
that the Old Order Amish sample evidenced diabetes
approximately half as frequently as did other whites
in the survey. Another important difference was the
level of daily physical activity, which was reported to
be higher among both Amish men and women than
among other white cohorts (Bassett, 2004).
Health-Care Practices
Most Amish are physically active, largely owing to
their chosen agrarian lifestyle and farming as a pre-
ferred occupation. Physical labor is valued, and men
as well as women and children help with farmwork.
Household chores and gardening, generally consid-
ered to be women’s work, require physical exertion,
particularly because the Amish do not choose to use
electrically operated appliances in the home or ma-
chinery, such as riding lawn mowers, that conserve
human energy. Nevertheless, many women do contend
with a tendency to be overweight. In recent years, it is
not uncommon to find Amish women seeking help for
weight control from Weight Watchers® and similar
weight control support groups.
Farm and traffic accidents are an increasing health
concern in communities with a dense Amish popula-
tion. In states such as Indiana, with relatively high con-
centrations of Amish who drive horse-drawn vehicles
(Fig. 7-3), blinking red lights and large red triangles are
required by law to be attached to their vehicles. Jones
(1990) reported on a study of trauma by examining
hospital records of Amish patients admitted to one
hospital in mideastern Ohio. Transportation-related
injuries were the largest group, with many of those in-
volving farm animals. Falls from ladders and down hay
The Amish 125
Figure 7-3 Amish buggies parked outside a home. Note the
reflective safety triangle attached to the back of the rightmost
buggy in the picture. These are usually required by law in areas
that have large Amish populations. (Photograph by Joel Wenger.)
2780_Ch07_115-136 16/07/12 11:42 AM Page 125

holes resulted in orthopedic injuries, but no deaths.
Amish families need to be encouraged to monitor their
children who operate farm equipment and transporta-
tion vehicles and to teach them about safety factors.
Concern about accidents is evident in Amish newslet-
ters, many of which have a regular column reporting
accidents and asking for prayers or expressing gratitude
that the injuries were not more severe, that God had
spared the person, or that the community had re-
sponded in caring ways (Wenger, 1988).
Nutrition
Meaning of Food
Among the Amish, food is recognized for its nutri-
tional value. Most Amish prefer to grow their own
produce for economic reasons and because for gener-
ations they have been aware of their connections with
the earth. They believe that God expects people to be
the caretakers of the earth and to make it flourish.
The Amish serve food in most social situations be-
cause food also has a significant social meaning. Be-
cause visiting has a highly valued cultural function,
occasions occur during most weeks for Amish to visit
family, neighbors, and friends, especially those within
their church district. Some of these visits are planned
when snacks or meals are shared, sometimes with the
guests helping to provide the food. Even if guests
come unexpectedly, it is customary in most Amish
communities for snacks and drinks to be offered.
Common Foods and Food Rituals
Typical Amish meals include meat; potatoes, noodles,
or both; a cooked vegetable; bread; something pickled
(e.g., pickles, red beets); cake or pudding; and coffee.
Beef is usually butchered by the family and then kept
in the local commercially owned freezer for which they
pay a rental storage fee. Some families also preserve
beef by canning, and most families have chickens and
other fowl, such as ducks or geese, which they raise
for eggs and for meat. Amish families still value grow-
ing their own foods and usually have large gardens. A
generation ago, this was an unquestioned way of life,
but an increasing number of families living in small
towns and working in factories and construction own
insufficient land to plant enough food for the family’s
consumption.
Snacks and meals in general tend to be high in fat
and carbohydrates. A common snack is large, home-
baked cookies about 3 inches in diameter. Commercial
non-Amish companies have recognized large, soft
cookies as a marketable commodity and have adver-
tised their commercially made products as “Amish”
cookies, even though no Amish are involved in
the production. Other common snacks are ice cream
(purchased or homemade), pretzels, and popcorn.
When Amish gather for celebrations such as wed-
dings, birthdays, work bees, or quiltings, the tables are
usually laden with a large variety of foods. The selec-
tion, usually provided by many people, includes sev-
eral casseroles, noodle dishes, white and sweet
potatoes, some cooked vegetables, few salads, pickled
dishes, pies, cakes, puddings, and cookies. Hostetler
(1993) provided a detailed ethnographic description
of the meaning and practices surrounding an Amish
wedding, including the food preparation, the wedding
dinner and supper, and the roles and functions of
various key individuals in this most important rite of
passage that includes serving food.
In communities in which tourists flock to learn
about the Amish, many entrepreneurs have used the
Amish love of wholesome, simple foods to market
their version of Amish cookbooks, food products, and
restaurants that more aptly reflect the Pennsylvania
German, commonly referred to as Pennsylvania
Dutch, influence of communities such as Lancaster
County, Pennsylvania. Many of these bear little re-
semblance to authentic Amish foods, and some even
venture to sell “Amish highballs” or “Amish sodas”
(Hostetler, 1993). Some Amish families help to satisfy
the public interest in their way of life by serving meals
in their homes for tourists and local non-Amish. But
most Amish view their foods and food preparation as
commonplace and functional, not something to be
displayed in magazines and newspapers. Because
many Amish are wary of outsiders’ undue interest,
health providers need to discuss nutrition and food as
a part of their lifeways to promote healthy nutritional
lifestyles.
In Amish homes, a “place at the table” is symbolic
of belonging (Hostetler, 1993). Seating is traditionally
arranged with the father at the head and boys seated
youngest to oldest to his right. The mother sits to her
126 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 7 . 1
In many communities, laws have been enacted that require
drivers under the influence (DUI) to complete a course on
safe driving and the use of alcohol and drugs. A culturally per-
ceptive social service agency in Brightville offered a separate
course for Amish offenders. The organizers first met with the
Amish bishops and deacons to ask for their assistance in learn-
ing more about Amish values and beliefs, while also describing
their intent to offer a separate course for the Amish. The
Agency made it known that they wanted to employ a young
Amish man to attend all the classes, assist with group discus-
sions, and assist the instructors in relating with the participants
in a culture congruent manner.
1. If you were one of the Agency leaders, how would you
guide your organization in crossing the Amish cultural
boundary?
2. How would you develop a plan to orient this young Amish
employee to his new job?
2780_Ch07_115-136 16/07/12 11:42 AM Page 126

husband’s left, with the girls also seated youngest to
oldest or placed so that an older child can help a
younger one. The table is the place where work, be-
havior, school, and other family concerns are dis-
cussed. During the busy harvesting season, preference
is given to the men and boys who eat and return to the
fields or barn. At mealtimes, all members of the
household are expected to be present unless they are
working away from home or visiting at a distance,
making it difficult to return home.
Sunday church services, which for the Old Order
Amish are held in their homes or barns, are followed by
a simple meal for all who attended church (Fig. 7-4).
The church benches, which are transported from
home to home wherever the church service is to be
held, are set up with long tables for serving the food.
In many communities, some of the benches are built
so they can quickly be converted into tables. Meals be-
come ritualized so the focus is not on what is being
served but rather on the opportunity to visit together
over a simple meal. In one community, an Amish in-
formant who had not attended services because of a
complicated pregnancy told the researcher that she
missed the meal, which in that community consisted
of bread, butter, peanut butter mixed with marshmal-
low creme and honey, apple butter, pickles, pickled red
beets, soft sugar cookies, and coffee (Wenger, 1988).
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Children are viewed as a gift from God and are wel-
comed into Amish families. Estimates place the average
number of live births per family at seven (Hostetler &
Huntington, 1992). The Amish fertility pattern has re-
mained constant during the past 100 years, while many
others have declined. Household size varies from
families with no children to couples with 15 or more
children (Huntington, 1988; Meyers & Nolt, 2005).
Even in large families, the birth of another child brings
joy because of the core belief that children are “a
heritage from the Lord,” and another member of the
family and community means another person to help
with the chores (Hostetler, 1993).
Having children has a different meaning in Old
Order Amish culture than in the dominant American
culture. In a study on women’s roles and family pro-
duction, the authors suggested that women in Amish
culture enjoy high status despite the apparent patriar-
chal ideology because of their childbearing role and
their role as producers of food (Lipon, 1985). A large
number of children benefit small labor-intensive
farms, and with large families comes an apparent need
for large quantities of food. Interpretation of this
pragmatic view of fertility should always be moder-
ated with recognition of the moral and ethical core
cultural belief that children are a gift from God, given
to a family and community to nurture in preparation
for eternal life.
Scholars and researchers of long-term acquain-
tance with Old Order Amish agree that the pervasive
Amish perception of birth control is that it interferes
with God’s will and thus should be avoided (Kraybill,
2001). Nevertheless, fertility control does exist, al-
though the patterns are not well known and very few
studies have been reported. Wenger (1980) discussed
childbearing with two Amish couples in a group in-
terview, and they conceded that some couples do use
the rhythm method. In referring to birth control, one
Amish father stated, “It is not discussed here, really. I
think Amish just know they shouldn’t use the pill”
(Wenger, 1980, p. 5). Three physicians and three nurses
were interviewed, and they reported that some Amish
do ask about birth control methods, especially those
with a history of difficult perinatal histories and those
with large families. Some Amish women do use in-
trauterine devices, but this practice is uncommon.
Most Amish women are reluctant to ask physicians
and nurses and, therefore, should be counseled with
utmost care and respect because this is a topic that
generally is not discussed, even among themselves.
Approaching the subject obliquely may make it pos-
sible for the Amish woman or man to sense the health
provider’s respect for Amish values and thus encour-
age discussion. “When you want to learn more about
birth control, I would be glad to talk to you” is a sug-
gested approach.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Amish tend to have their first child later than do non-
Amish. In a retrospective chart review examining
pregnancy outcomes of 39 Amish and 145 non-Amish
women at a rural hospital in southern New York, it
The Amish 127
Figure 7-4 Buggies parked in a field on an Amish farm where
people have gathered for a Sunday church service and noon
meal. (Photograph by Joel Wenger.)
2780_Ch07_115-136 16/07/12 11:42 AM Page 127

was found that Amish had their first child an average
of one year later than non-Amish couples (Lucas,
O’Shea, Zielezny, Freudenheim, & Wold, 1991). The
Amish had a narrower range of maternal ages and
had proportionately fewer teenage pregnancies. All
subjects received prenatal care, with the Amish receiv-
ing prenatal care from Amish lay midwives during the
first trimester.
In some communities, Amish have been reputed to
be reluctant to seek prenatal health care. Providers
who gain the trust of the Amish learn that they want
the best perinatal care, which fits with their view of
children being a blessing (Miller, 1997). However, they
may choose to use Amish and non-Amish lay mid-
wives who promote childbearing as a natural part of
the life cycle. In a study of childbearing practices as
described by Amish women in Michigan, Miller
(1997) learned that they prefer home births, they had
“limited formal knowledge of the childbirth process”
(p. 65), and health-care providers were usually con-
sulted only when there were perceived complications.
Although many may express privately their preference
for perinatal care that promotes the use of nurse-
midwifery and lay midwifery services, home deliveries,
and limited use of high technology, they tend to use
the perinatal services available in their community. In
ethnographic interviews with informants, Wenger
(1988) found that grandmothers and older women re-
ported greater preference for hospital deliveries than
did younger women. The younger women tend to have
been influenced by the increasing general interest in
childbirth as a natural part of the life cycle and the
deemphasis on the medicalization of childbirth. Some
Amish communities, especially those in Ohio and
Pennsylvania, have a long-standing tradition of using
both lay midwifery and professional obstetric services,
often simultaneously.
In Ohio, the Mt. Eaton Care Center developed as a
community effort in response to retirement of an
Amish lay midwife known as Bill Barb (identified by
her spouse’s name, as discussed in the section on com-
munication). She provided perinatal services, includ-
ing labor and birth, with the collaborative services of
a local Mennonite physician who believed in providing
culturally congruent and safe health-care services for
this Amish population. At one point in Bill Barb
Hochstetler’s 30-year practice, the physician moved
a trailer with a telephone onto Hochstetler’s farm
so that he could be called in case of an emergency
(Huntington, 1993). Other sympathetic physicians
also delivered babies at Bill Barb’s home. After state
investigation, which coincided with her intended re-
tirement, Hochstetler’s practice was recognized to be
in a legal gray area. The Mt. Eaton Care Center be-
came a reality in 1985 after careful negotiation with
the Amish community, Wayne County Board of
Health, Ohio Department of Health, and local physi-
cians and nurses. Physicians and professional nurses
and nurse-midwives, who are interested in Amish cul-
tural values and health-care preferences, provide low-
cost, safe, low-technology perinatal care in a homelike
atmosphere. In 1997, the New Eden Care Center,
modeled after the Mt. Eaton Care Center, was built in
LaGrange County in northern Indiana and, in recent
years, has had more than 400 births per year (Meyers
& Nolt, 2005).
Because the Amish want family involvement in
perinatal care, outsiders may infer that they are open
in their discussion of pregnancy and childbirth. In ac-
tuality, most Amish women do not discuss their preg-
nancies openly and make an effort to keep others from
knowing about them until physical changes are obvi-
ous. Mothers do not inform their other children of
the impending birth of a sibling, preferring for the
children to learn of it as “the time comes naturally”
(Wenger, 1988). This fits with the Amish cultural
pattern of learning through observation that assumes
intergenerational involvement in life’s major events.
Anecdotal accounts exist of children being in the
house, though not physically present, during birth.
Fathers are expected to be present and involved,
although some may opt to do farm chores that cannot
be delayed, such as milking cows.
Amish women do participate in prenatal classes,
often with their husbands. The women are interested
in learning about all aspects of perinatal care but may
choose not to participate in sessions when videos are
used. Prenatal class instructors should inform them
ahead of time when videos or films will be used so
they can decide whether to attend. For some Amish
in which the Ordnung (the set of unwritten rules pre-
scribed for the church district) is more prescriptive and
strict, the individuals may be concerned about being
disobedient to the will of the community. Even though
the information on the videos may be acceptable, the
type of media is considered unacceptable.
Amish have no major taboos or requirements for
birthing. Men may be present, and most husbands
choose to be involved. However, they are likely not to
be demonstrative in showing affection verbally nor
physically. This does not mean they do not care; it is
culturally inappropriate to show affection openly in
public. The laboring woman cooperates quietly, sel-
dom audibly expressing discomfort. Because many
women tend to be stoical with pain, the health-care
provider needs to assess vital signs that may indicate
the need for pain medicine.
Given the Amish acceptance of a wide spectrum of
health-care modalities, the nurse or physician should
be aware that the woman in labor might be using
herbal remedies to promote labor. Knowledge about
and a respect for Amish health-care practices alert the
128 Aggregate Data for Cultural-Specific Groups
2780_Ch07_115-136 16/07/12 11:42 AM Page 128

physician or nurse to a discussion about simultaneous
treatments that may be harmful or helpful. It is always
better if these discussions can take place in a low-
stress setting before labor and birth.
As in other hospitalizations, the family may want
to spend the least allowable time in the hospital. This
is generally related to the belief that birth is not a med-
ical condition and because most Amish do not carry
health insurance. In their three-generational family,
and as a result of their cultural expectations for caring
to take place in the community, many people are will-
ing and able to assist the new mother during the post-
partum period. Visiting families with new babies are
expected and generally welcomed. Older siblings are
expected to help care for the younger children and to
learn how to care for the newborn. The postpartum
mother resumes her family role managing, if not
doing, all the housework, cooking, and child care
within a few days after childbirth. For a primiparous
mother, her mother often comes to stay with the new
family for several days to help with care of the infant
and give support to the new mother.
The day the new baby is first taken to church serv-
ices is considered special. People who had not visited
the baby in the family’s home want to see the new
member of the community. The baby is often passed
among the women to hold as they become acquainted
and admire the newcomer.
Death Rituals
Death Rituals and Expectations
Amish customs related to death and dying have dual di-
mensions. On the one hand, they may be seen as
holdovers from an earlier time when, for most Americans,
major life events such as birth and death occurred in
the home. On the other hand, Amish retention of such
largely outdated patterns is due to distinctively Amish
understandings of the individual within and as an in-
tegral part of the family and community. Today, when
70 percent of elderly Americans die in hospitals and
nursing homes, some still reflect nostalgically on death
as it should be and as, in fact, it used to be, in the circle
of family and friends, a farewell with familiarity and
dignity. In Amish society today, in most cases, this
is still a reality. As physical strength declines, the ex-
pectation is that the family will care for the aging
and the ill in the home. Hostetler’s (1993) brief ob-
servation that Amish prefer to die at home is borne
out by research findings. Tripp-Reimer and Schrock
(1982) reported from their comparative study of the
ethnic aged that 75 percent of the Amish surveyed
expressed a preference for living with family, 25 per-
cent preferred living at home with assistance, and
none would choose to live in a care facility, even if
bedridden.
Clearly, these preferences are motivated by more
than a wish to dwell in the past or an unwillingness to
change with the times. The obligation to help others,
in illness as in health, provides the social network that
supports Amish practices in the passage from life to
death. In effect, it is a natural extension of caregiving
embraced as a social duty with religious motivation.
The Amish accept literally the biblical admonition to
“bear one another’s burdens,” and this finds expres-
sion in communal support for the individual, whether
suffering, dying, or bereaved. Life’s most intensely per-
sonal and private act becomes transformed into a
community event.
Visiting in others’ homes is, for the Amish, a nor-
mal and frequent reinforcement of the bonds that tie
individuals to extended family and community. As a
natural extension of this social interaction, visiting the
ill takes on an added poignancy, especially during an
illness believed to be terminal. Members of the imme-
diate family are offered not only verbal condolences
but many supportive acts of kindness as well. Others
close to them prepare their food and take over other
routine household chores to allow them to focus
their attention and energy on the comfort of the ailing
family member.
Responses to Death and Grief
Ties across generations, as well as across kinship and
geographic lines, are reinforced around death as chil-
dren witness the passing of a loved one in the intimacy
of the home. Death brings many more visitors into the
home of the bereaved, and the church community
takes care of accommodations for visitors from a dis-
tance as well as funeral arrangements. The immediate
family is thus relieved of responsibility for decision
making, which otherwise may add distraction to grief.
In some Amish settlements, a wake-like “sitting up”
through the night provides an exception to normal
visiting patterns. The verbal communication with the
bereaved may be sparse, but the constant presence
of supportive others is tangible proof of the Amish
commitment to community. The return to normal
life is eased through these visits by the resumption of
conversations.
Apart from the usual number of visitors who come
to pay their respects to both the deceased and the fam-
ily, the funeral ceremony is as simple and unadorned
as the rest of Amish life. A local Amish cabinetmaker
frequently builds a plain wooden coffin. In the past,
interment was in private plots on Amish farms, con-
trasting with the general pattern of burial in a ceme-
tery in the churchyard of a rural church. Because
Amish worship in their homes and have no church
buildings, they also have no adjoining cemeteries. An
emerging pattern is burial in a community cemetery,
sometimes together with other Mennonites.
The Amish 129
2780_Ch07_115-136 16/07/12 11:42 AM Page 129

Grief and loss are keenly felt, although verbal ex-
pression may seem muted, as if to indicate stoic ac-
ceptance of suffering. In fact, the meaning of death
as a normal transition is embedded in the meaning of
life from the Amish perspective. Parents are exhorted
to nurture their children’s faith because life in this
world is seen as a preparation for eternal life.
Spirituality
Dominant Religion and Use of Prayer
Amish religious and cultural values include honesty;
order; personal responsibility; community welfare;
obedience to parents, church, and God; nonresistance
or nonviolence; humility; and the perception of the
human body as a temple of God.
Amish settlements are subdivided into church dis-
tricts similar to rural parishes with 30 to 50 families
in each district. Local leaders are chosen from their
own religious community and are generally untrained
and unpaid. Authority patterns are congregationalist,
with local consensus directed by local leadership, des-
ignated as bishops, preachers, and deacons, all of
whom are male. No regional or national church hier-
archy exists to govern internal church affairs, although
a national committee may be convened to address
external institutions of government regarding issues
affecting the broader Amish population.
In addition to prayer in church services, silent
prayer is always observed at the beginning of a meal,
and in many families, a prayer also ends the meal.
Children are taught to memorize prayers from a
German prayer book for beginning and ending meals
and for silent prayer. The father may say an audible
“amen” or merely lift his bowed head to signal the
time to begin eating.
Meaning of Life and Individual Sources
of Strength
Outsiders, who are aware of the Amish detachment
from the trappings of our modern materialistic
culture, may be disappointed to discover in their “oth-
erworldliness” something less than a lofty spirituality.
Amish share the earthy vitality of many rural peasant
cultures and a pragmatism born of immediate life ex-
periences, not distilled from intellectual pursuits such
as philosophy or theology. Amish simplicity is inten-
tional, but even in austerity, there is a relish of life’s
simpler joys rather than a grim asceticism.
If death is a part of life and a portal to a better life,
then individuals are well advised to consider how their
lives prepare them for life after death. Amish share the
general Christian view that salvation is ultimately in-
dividual, preconditioned on one’s confession of faith,
repentance, and baptism. These public acts are under-
taken in the Amish context as part of preparing to
fully assume one’s adult role in a community of faith.
In contrast with the ideals of American individualism,
however, the Amish surrender much of their individ-
uality as the price of full acceptance as members of a
community. In practical, everyday terms, the reli-
giously defined community is inextricably intertwined
with a social reality, which gives it its distinctive shape.
For the Amish, the importance of conformity to
the will of the group can hardly be exaggerated. To
maintain harmony within the group, individuals often
forgo their own wishes. In terms of faith-related be-
havior, outsiders sometimes criticize this “going along
with” the local congregational group as an expression
of religiosity, rather than spirituality. The frequent
practice of corporate worship, including prayer and
singing, helps to build this conformity. It is regularly
tested in “counsel” sessions in the congregational as-
sembly in which each individual’s commitment to the
corporate religious contract is reviewed before taking
communion (Kraybill, 2001).
Non-Amish occasionally are baffled at reports of
the Amish response to grave injury or even loss of life
at the hands of others. Owing to deeply held commu-
nity values, and especially constrained by love for oth-
ers, Amish often eschew retaliatory or vengeful
attitudes and actions when the majority culture might
justify such means. Amish are socialized to sustain
such injuries, grieve, and move on without fixing
blame or seeking redress or punishment for the per-
petrator. The felt need to forgive is for the Amish as
strong as others perceive a need to bring wrongdoers
to justice. The need to forgive is considered to be
“second nature” in the Amish community. It does not
indicate moral superiority or a heroic strength of for-
bearance in the face of adversity, but flows consis-
tently from a biblical mandate to express love, even for
an apparent adversary, as a practical application of
the “The Golden Rule” (Matt. 7:12). A current exam-
ple, claiming both national and international atten-
tion, was the Amish response of forgiveness in the face
of the Nickel Mines, Pennsylvania, tragedy when
10 Amish schoolgirls were held hostage and 5 of the
girls were shot to death on October 2, 2006 (Complete
Coverage of Nickel Mines Tragedy Web site at http://
local.lancasteronline.com/1/91). Forgiveness in such
situations may not come easily for many persons.
Krabill, Nolt, and Weaver-Zercher (2007) contend
that for the Amish, forgiveness is part of the Anabap-
tist “habits” begun in the sixteenth century that con-
tinue to undergird Old Order Amish culture even
today. Amish “values incorporate a willingness to
place tragedy in God’s hands without demanding
divine explanation for injustice” (p. 71).
Spiritual Beliefs and Health-Care Practices
As seen in earlier sections on communication among
Amish and their socioreligious provenance, many sym-
bols of Amish faith point to the separated life, which
130 Aggregate Data for Cultural-Specific Groups
2780_Ch07_115-136 16/07/12 11:42 AM Page 130

they live in accordance with God’s will. Over time,
they have chosen to embody their faith rather than
verbalize it. As a result, they seldom proselytize
among non-Amish and nurture among themselves a
noncreedal, often primitive form of Christianity that
emphasizes “right living.” Their untrained religious
leaders offer unsophisticated views of what that en-
tails based on their interpretation of the Bible. Most
members are content to submit to the congregational
consensus on what right living means, with the as-
sumption that it is based on submission to the will of
a loving, benevolent God, an aspect of their spiritu-
ality that is seldom articulated (Kraybill, 2001).
Although the directives of religious leaders are nor-
mative for many types of decisions, this appears not
to be the case for health-care choices (Wenger, 1991a).
When choosing among health-care options, families
usually seek counsel from religious leaders, friends,
and extended family, but the final decision resides with
the immediate family. Health-care providers need to
be aware of the Amish cultural context and may need
to adjust the normal routines of diagnosis and therapy
to fit Amish patients’ socioreligious context.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
The Amish believe that the body is the temple of God
and that human beings are the stewards of their bod-
ies. This fundamental belief is based on the Genesis
account of creation. Medicine and health care should
always be used with the understanding that it is God
who heals. Nothing in the Amish understanding of
the Bible forbids them from using preventive or cura-
tive medical services. A prevalent myth among health-
care providers in Amish communities is that Amish
are not interested in preventive services. Although it
is true that many times the Amish do not use main-
stream health services at the onset of recognized
symptoms, they are highly involved in the practices of
health promotion and illness prevention.
Although the Amish, as a people, have a reputation
for honesty and forthrightness, they may withhold im-
portant medical information from medical providers
by neglecting to mention folk and alternative care
being pursued at the same time. When questioned,
some Amish admit to being less than candid about
using multiple therapies, including herbal and chiro-
practic remedies, because they believe that “the doctor
wouldn’t be interested in them.” Making choices
among folk, complementary, and professional health-
care options does not necessarily indicate a lack of
confidence or respect for the latter, but rather reflects
the belief that one must be actively involved in seeking
the best health care available (Wenger, 1994).
Responsibility for Health Care
The Amish believe that it is their responsibility to be
personally involved in promoting health. As in most
cultures, health-care knowledge is passed from one
generation to the next through women. In the Amish
culture, men are involved in major health-care deci-
sions and often accompany the family to the chiro-
practor, physician, or hospital. Grandparents are
frequently consulted about treatment options. In one
situation, a scheduled consultation for a 4-year-old
was postponed until the maternal grandmother was
well enough after a cholecystectomy to make the
three-hour automobile trip to the medical center.
A usual concern regarding responsibility for health
care is payment for services. Many Amish do not carry
any insurance, including health insurance. However,
in most communities, there is some form of agreement
for sharing losses caused by natural disasters as well
as catastrophic illnesses. Some have formalized mutual
aid, such as the Amish Aid Society. Wenger (1988)
found that her informants were opposed to such for-
malized agreements and wanted to do all they could
to live healthy and safe lives, which they believed
would benefit their community in keeping with their
Christian calling. Many hospitals have been as-
tounded by the Amish practice of paying their bills
despite financial hardship. Because of this generally
positive community reputation, hospitals have been
willing to set up payment plans for the larger bills.
Active participation was found to be a major theme
in Wenger’s (1991a; 1994; 1995) studies on cultural con-
text, health, and care. The Amish want to be actively
involved in health-care decision making, which is a part
of daily living. “To do all one can to help oneself ” in-
volves seeking advice from family and friends, using
herbs and other home remedies, and then choosing
from a broad array of folk, alternative, and professional
The Amish 131
R E F L E C T I V E E X E R C I S E 7 . 2
The Nickle Mines tragedy in Pennsylvania, where 10 Amish
schoolgirls were held hostage in an Amish elementary school,
and 5 of the girls were killed, claimed national and interna-
tional attention. One of the most frequent questions asked by
non-Amish was how and why did Amish forgived the perpe-
trator so readily. A representative group of Amish even went
to visit the widow of the perpetrator and his family to express
their condolences to her for the loss of her husband and to in-
vite her to the funerals of some of the young Amish girls.
1. What have you learned about Amish ethnoreligious values
and beliefs that might explain forgiveness as practiced fol-
lowing that tragedy?
2. Krabill, Nolt, and Weaver-Zercher (2007) spoke with many
Amish following the tragedy who said that “forgiveness is
hard work that never ends” (p. 113). Describe what is
meant by that statement based on the Amish worldview.
2780_Ch07_115-136 16/07/12 11:42 AM Page 131

health-care services. One informant, who visited an
Amish healer while considering her physician’s recom-
mendation that she have a computerized axial tomogra-
phy (CAT) scan to provide more data on her continuing
vertigo, told the researcher, “I will probably have the
CAT scan, but I am not done helping myself, and this
[meaning the healer’s treatment] may help and it won’t
hurt.” In this study, health-care decision making was
found to be influenced by three factors: type of health
problem, accessibility of health-care services, and per-
ceived cost of the service. When the Amish use profes-
sional health-care services, they want to be partners in
their health care and want to retain their right to choose
from all culturally sanctioned health-care options.
Caring within the Amish culture is synonymous
with being Amish. “It’s the Amish way” translates into
the expectation that members of the culture be aware
of the needs of others and thus fulfill the biblical in-
junction to bear one another’s burdens. Caring is a
core value related to health and well-being. Care is ex-
pressed in culturally encoded expectations that they
can best describe in their dialect as abwaarde, meaning
“to minister to someone by being present and serving
when someone is sick in bed.” A more frequently used
term for helping is achtgewwe, which means “to serve
by becoming aware of someone’s needs and then to
act by doing things to help.” Helping others is ex-
pressed in gender-related and age-related roles, freind-
schaft (the three-generational family), church district,
community (including non-Amish), Amish settle-
ments, and worldwide. No outsiders or health-care
providers can be expected to fully understand this
complex, caring network, but health-care providers
can learn about it in the local setting by establishing
trust in relationships with their Amish patients.
When catastrophic illness occurs, the Amish com-
munity responds by being present, helping with
chores, and relieving family members so that they can
be with the afflicted person in the acute care hospital.
Some do opt to accept medical advice regarding the
need for high-technology treatment, such as trans-
plants or other high-cost interventions. The patient’s
family seeks prayers and advice from the bishop and
deacons of their church and their family and friends,
but the decision is generally a personal or family one.
Amish engage in self-medication. Although most
Amish regularly visit physicians and use prescription
drugs, as indicated previously, they also use herbs and
other nonprescription remedies, often simultaneously.
When discussing the meaning of health and illness,
Wenger (1988; 1994) found that her Amish informants
considered it their responsibility to investigate their
treatment options and to stay personally involved in
the treatment process rather than to relegate their care
to the judgment of the professional physician or nurse.
Consequently, they seek testimonials from other fam-
ily members and friends about what treatments work
best. They may also seek care from Amish healers and
other alternative-care practitioners, who may suggest
nutritional supplements. One informant told how she
would take “blue cohosh” pills with her to the hospital
when she was in labor because she believed they would
speed up the labor.
Because of the Amish practice of self-medication,
it is essential that health-care providers inquire about
the full range of remedies being used. For the Amish
patient to be candid, the provider must develop a con-
text of mutual trust and respect. Within this context,
the Amish patient can feel assured that the provider
wants to consider and negotiate the most advanta-
geous yet culturally congruent care.
Folk and Traditional Practices
The Amish, like many other cultures, have an elaborate
health-care belief system that includes traditional reme-
dies passed from one generation to the next. They
also use alternative health care that is shared by other
Americans, though often not sanctioned by medical and
other health-care providers. Although the prevalence of
specific health-care beliefs and practices, such as use of
chiropractic, Western medical and health-care science,
reflexology, iridology, osteopathy, homeopathy, and
folklore, is influenced mainly by freindschaft (Wenger,
1991b), variations depend on geographic region and the
conservatism of the Amish community.
Herbal remedies include those handed down by
successive generations of mothers and daughters. One
elderly grandmother showed the researcher the cup-
board where she kept some cloths soaked in a herbal
remedy and shared the recipe for it. She stated that the
cupboard was where she remembered her grand-
mother keeping those same remedies when her grand-
mother lived in the daadihaus, the grandparents’
cottage attached to the family farmhouse where her
daughter and son-in-law lived. She also confided that,
although she prepared the herb-soaked cloths for her
daughters when they married, she thought they opted
for more modern treatments, such as herb pills and pre-
scription drugs. This is a poignant example of the effect
of modern health care on a highly contextual culture.
“Of all Amish folk health care, brauche has claimed
the most interest of outsiders, who are often puzzled
by its historical origins and contemporary applica-
tion” (Wenger, 1991b, p. 87). Brauche is a folk-healing
art that was practiced in Europe around the time of
the Amish immigration to North America and is not
unique to the Amish, but is a common healing art
used among Pennsylvania Germans. As with some
other European practices, the Amish have retained
brauche in some communities. In other communities,
the practice is considered suspect, and it has been the
focus of some church divisions.
Brauche is sometimes referred to as sympathy cur-
ing or pow-wowing. It is unrelated to American
132 Aggregate Data for Cultural-Specific Groups
2780_Ch07_115-136 16/07/12 11:42 AM Page 132

Indian pow-wowing, and the use of this English term
to refer to the German term brauche is unclear. In
most literary descriptions of sympathy curing, it refers
to the use of words, charms, and physical manipula-
tions for treating some human and animal maladies.
In some communities, the Amish refer to brauche as
“warm hands,” the ability to feel when a person has a
headache or a baby has colic. Informants describe
situations in which some individuals can “take” the
stomachache from the baby into their own bodies in
what is described by researchers as transference.
Wenger (1991a; 1994) stated that all informant
families volunteered information about brauche,
using that term or “warm hands” to describe folk
healing. One informant asked the author if she
could “feel” it, too.
A few folk illnesses have no Western scientific
equivalents. The first is abnemme, which refers to a
condition in which the child fails to thrive and appears
puny. Specific treatments given to the child may in-
clude incantations. Some of the older people remem-
ber these treatments, and some informants remember
having been taken to a healer for the ailment. The sec-
ond is aagwachse, or livergrown, meaning “hide-
bound” or “grown together,” once a common ailment
among Pennsylvania Germans (Hostetler, 1993).
Symptoms include crying and abdominal discomfort
that is believed to be caused by jostling in rough buggy
rides. Wenger (1988) reported accompanying an in-
formant with her newborn baby to an Amish healer,
and the woman carried the baby on a pillow because
she believed the baby to be suffering from aagwachse.
As stated previously, Amish patients are more likely
to discuss folk beliefs and practices with providers if
the nurse or physician gives cues that it is acceptable
to do so.
Barriers to Health Care
Barriers to health care include delay in seeking pro-
fessional health care at the onset of symptoms, occa-
sional overuse of home remedies, and a prevailing
perception that health-care providers are not inter-
ested in, or may disapprove of, the use of home reme-
dies and other alternative treatment modalities. In
addition, some families may live far from professional
health-care services, making travel by horse and buggy
difficult or inadvisable. Because in some Amish com-
munities, such as the Old Order Amish, telephones are
not permitted in the home, there may be delays in
communication with Amish patients. Finally, the cost
of health care without health insurance can deter early
access to professional care, which could result in more
complex treatment regimens.
Cultural Responses to Health and Illness
The Amish are unlikely to display pain and physical
discomfort. The health-care provider may need to
check changes in vital signs for pain and remind the
Amish patient that medication is available for pain
relief if they choose to accept it.
Community for the Amish means inclusion of people
who are chronically ill or “physically or mentally dif-
ferent.” Amish culture approaches these differences as
a community responsibility. Children with mental or
physical differences are sometimes referred to as “hard
learners,” who are expected to go to school and be
incorporated into the classes with assistance from
other student “scholars” and parents. A culturally
congruent approach is for the family and others to
help engage those with differences in work activities,
rather than to leave them sitting around and getting
more anxious or depressed.
Hostetler (1993) stated that “Amish themselves
have developed little explicit therapeutic knowledge to
deal with cases of extreme anxiety” (p. 332). They do
seek help from trusted physicians, and some are
admitted to mental health centers or clinics. However,
the mentally ill are generally cared for at home when-
ever possible. Studies of clinical depression and
manic-depressive illness were discussed in the section
on biocultural ecology.
As previously mentioned, when individuals are sick,
other family members take on additional responsibil-
ities. Little ceremony is associated with being sick, and
members know that to be healthy means to assume
one’s role within the family and community. Caring
for the sick is highly valued, but at the same time, re-
ceiving help is accompanied by feelings of humility.
Amish newsletters abound with notices of thanks
from individuals who were ill. A common expression
is “I am not worthy of it all.” A care set identified in
one research study is that “giving care involves privi-
lege and obligation, and receiving care involves expec-
tation and humility” (Wenger, 1991a). The sick role is
mediated by very strong values related to giving and
receiving care.
The Amish culture also sanctions time out for ill-
ness when the sick are relieved of their responsibilities
by others who minister to their needs. A good analogy
to the communal care of the ill is found in the support
offered by family and church members at the time of
bereavement, as noted in the section on dying. The in-
formal social support network is an important factor
in the individual’s sense of well-being. An underlying
expectation, however, is that healthy individuals will
want to resume active work and social roles as soon
as their recovery permits. With reasonable adjust-
ments for age and physical ability, it is understood that
a healthy person is actively engaged in work, worship,
and social life of the family and community (Wenger,
1994). Work and rest are kept in balance, but for the
Amish, the accumulation of days or weeks of free time
or time off for vacation outside the framework of nor-
mal routines and social interactions is a foreign idea.
The Amish 133
2780_Ch07_115-136 16/07/12 11:42 AM Page 133

In a study of Amish women’s construction of health
narratives, Nelson (1999) found that the “collective de-
scriptions [of] health included a sense of feeling well
and the physical ability to complete one’s daily work
responsibilities” (p. vi). Women’s health traditions in-
cluded the use of herbal and other home remedies and
consulting lay practitioners. In general, health values
and beliefs are influenced by cultural group member-
ship and personal developmental history.
Blood Transfusions and Organ Donation
No cultural or religious rules or taboos prohibit
Amish from accepting blood transfusions or organ
transplantation and donation. In fact, with the genetic
presence of hemophilia, blood transfusion has been a
necessity for some families. Anecdotal evidence is
available regarding individuals who have received
heart and kidney transplants, although no research re-
ports or other written accounts were found. Thus,
some Amish may opt for organ transplantation after
the family seeks advice from church officials, extended
family, and friends, but the patient or immediate fam-
ily generally makes the final decision.
Health-Care Providers
Traditional Versus Biomedical Providers
Amish usually refer to their own healers by name
rather than by title, although some say brauch-doktor
or braucher. In some communities, both men and
women provide these services. They may even special-
ize, with some being especially good with bed-wetting,
nervousness, women’s problems, or livergrown. Some
set up treatment rooms, and people come early in the
morning and wait long hours to be seen. They do not
charge fees but do accept donations. A few also treat
non-Amish patients. In some communities, Amish
folk healers use a combination of treatment modali-
ties, including physical manipulation, massage,
brauche, herbs and teas, and reflexology. A few have
taken short courses in reflexology, iridology, and var-
ious types of therapeutic massage. In a few cases, their
practice has been reported to the legal authorities by
individuals in the medical profession or others who
were concerned about the potential for illegal practice
of medicine. Huntington (1993) chronicled several
cases, including those of Solomon Wickey and Joseph
Helmuth, both in Indiana. Both men continue to prac-
tice with some carefully designed restrictions.
Status of Health-Care Providers
For the Old Order Amish, health-care providers are
always outsiders because, thus far, this sect has been
unwilling to allow their members to attend medical,
nursing, or other health-related professional schools or
to seek higher education in general. Therefore, the Old
Order Amish must learn to trust individuals outside
their culture for health care and medically related sci-
entific knowledge. Hostetler (1993) contended that the
Amish live in a state of flux when securing health-care
services. They rely on their own tradition to diagnose
and sometimes treat illnesses, while simultaneously
seeking technical and scientific services from health-
care providers.
Most Amish consult within their community to
learn about physicians, dentists, and nurses with whom
they can develop trusting relationships. For more
information on this practice, see the Amish informants’
perceptions of caring physicians and nurses in
Wenger’s (1994; 1995) chapter and article on health
and health-care decision making. Amish prefer health-
care providers who discuss their health-care options,
giving consideration to cost, need for transportation,
family influences, and scientific information. They also
like to discuss the efficacy of alternative methods of
treatment, including folk care. When asked, many
Amish, like others from diverse cultures, claim that
health-care providers do not want to hear about non-
traditional health-care modalities that do not reflect
dominant American health-care values.
Amish hold all health-care providers in high regard.
Health is integral to their religious beliefs, and care is cen-
tral to their worldview. They tend to place trust in people
of authority when they fit their values and beliefs. Be-
cause Amish are not sophisticated in their knowledge of
physiology and scientific health care, the health-care
provider who gains their trust should bear in mind that
because the Amish respect authority, they may unques-
tioningly follow orders. Therefore, health-care providers
134 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 7 . 3
In an ethno-nursing research study, Wenger (1991c, p. 106), de-
scribed culture congruent caring among the Amish as a care set:
Giving care involves both obligation and privilege.
Receiving care involves both expectation and humility.
Explain how each of the following statements relates to the
care set:
1. Amish will experience acts of caring within the Amish
community throughout their lifetime.
2. Amish describe one of the benefits of caring for others as
“feeling good.”
3. In Amish newsletters, notices of appreciation for having re-
ceived care may include the closing phrase “I’m so unwor-
thy of it all.”
4. Amish social networks expressed in various visiting pat-
terns provide an opportunity for persons to learn about
one another’s caring needs.
5. Personal submission and obedience to God includes a
consideration of others before oneself.
2780_Ch07_115-136 16/07/12 11:42 AM Page 134

should make sure that their patients understand instruc-
tions. Role modeling and other concrete teaching strate-
gies are recommended to enhance understanding.
R E F E R E N C E S
Allen, F. (1989, September 20). Country doctor: How a physician
solved the riddle of rare disease in children of Amish. Wall
Street Journal, pp. 1, A16.
Bassett, D.R. (2004, January). Old-Time fitness in Old-Order
Amish: Why are we less fit than our ancestors? Amish offer
clues. Medicine and Science in Sports and Exercise, (36), 79–85.
Belkin, L. (2005, November 6). A doctor for the future. New York
Times WSJ Magazine, 68–115.
Bowman, H.S., & Procopio, J. (1963). Hereditary non-sperocytic
hemolytic anemia of the pyruvate kinase deficient type. Annals
of Internal Medicine, 58, 561–591.
Elizabeth Town College. (2010). The Young Center for Anabaptist
and Pietist Studies at Elizabethtown College. Retrieved from
http://www.etown.edu/centers/young-center/
Enninger, W., & Wandt, K.-H. (1982). Pennsylvania German in
the context of an Old Order Amish settlement. Yearbook of
German-American Studies, 17, 123–143.
Foroud, T., Casteluccio, P., Kollar, D., Edenberg, H., Miller, M.,
& Boman, L. (2000). Suggestive evidence of a locus on chro-
mosome 10p using the NIMH genetics initiative bipolar affec-
tive disorder pedigrees. American Journal of Medical Genetics,
96(1), 18–23.
Fuchs, J.A., Levinson, R., Stoddard, R., Mullet, M., & Jones, D.
(1990). Health risk factors among Amish: Results of a survey.
Health Education Quarterly, 17(2), 197–211.
Ginns, E.D., Egeland, J., Allen, C., Pauls, D., & Falls, K. (1992).
Update on the search for DNA markers linked to manic-
depressive illness in the Old Order Amish. Journal of Psychi-
atric Research, 26(4), 305–308.
Hostetler, J.A. (1993). Amish society (4th ed.). Baltimore, MD:
Johns Hopkins University Press.
Hostetler, J.A., & Huntington, G.E. (1992). Amish children: Edu-
cation in the family, school, and community (2nd ed.). Dallas,
TX: Harcourt Brace Jovanovich.
Hsueh W.C., Mitchell B.D., Aburomia R., Pollin T., Sakul, H.,
Gelder Ehm M., Michelsen B.K., Wagner, M.J., St. Jean, P.L.,
Knowler, W.C., Burns, D.K., Bell, C.J., & Shuldine A.R.
(2002). Diabetes in the Old Order Amish: Characterization and
heritability analysis of the Amish Family Diabetes Study.
American Journal of Clinical Nutrition, 75(6), 1098–1106.
Huffines, M.L. (1994). Amish languages. In J.R. Dow, W. Enninger,
& J. Raith (Eds.), Internal and external perspectives on Amish and
Mennonite life. 4: Old and new world Anabaptist studies on the
language, culture, society and health of Amish and Mennonites
(pp. 21–32). Essen, Germany: University of Essen.
Huntington, G.E. (1988). The Amish family. In C. Mindel &
R. Haberstein (Eds.), Ethnic families in America (3rd ed.).
(pp. 367–399). New York: Elsevier.
Huntington, G.E. (1993). Health care. In D.B. Kraybill (Ed.), The
Amish and the state. Baltimore, MD: Johns Hopkins University
Press.
Huntington, G.E. (2001). Amish in Michigan. East Lansing, MI:
Michigan State University Press.
Hüppi, J. (2000). Research note: Identifying Jacob Ammann.
Mennonite Quarterly Review, 74(10), 329–339.
Hurst, C.E., & McConnell, D.L. (2010). An Amish paradox:
Diversity and change in the world’s largest Amish community.
Baltimore, MD: The Johns Hopkins University Press.
Jones, M.W. (1990). A study of trauma in an Amish community.
Journal of Trauma, 30(7), 899–902.
Kelsoe, J.R., Ginns, E.D., & Egeland, J.A. (1989). Re-evaluation
of the linkage relationship between chromosome 11p loci and
the gene for bipolar affective disorder in the Old Order Amish.
Nature, 342, 338–342.
Kelsoe, J.R., Kristobjanarson, H., Bergesch, P., Shilling, S., Attirad,
S., Mirow, A., Moises, H., Gillin, J., & Egeland, J. (1993). A
genetic linkage study of bipolar disorder and 13 markers on
chromosome 11, including the D2 dopamine receptor.
Neuropsychopharmocology, 9(4), 293–307.
Ketterling, R.P., Bottema, C.D., Koberl, D.D., Setsuko. I, & Sommer,
S.S. (1991). T296M, a common mutation causing mild hemo-
philia B in the Amish and others: Founder effect, variability in
factor IX activity assays, and rapid carrier detection. Human
Genetics, 87, 333–337.
Kraybill, D.B. (2001). The riddle of Amish culture (rev. ed.). Balti-
more, MD: Johns Hopkins University Press.
Kraybill, D.B., & Hostetter, C.N. (2001). Anabaptist World USA.
Scottdale, PA: Herald Press.
Krabill, D.B., Nolt, S.M., & Weaver-Zercher, D.L. (2007). Amish
grace: How forgiveness transcended tragedy. San Francisco, CA:
John Wiley and Sons.
Law, A., Richard, C.W., Cottingham, R.W., Lathrop, M.G., Cox,
D.R., & Meyers, R.M. (1992). Genetic linkage analysis of
bipolar affective disorder in an Old Order Amish pedigree.
Human Genetics, 88, 562–568.
Lipon, T. (1985). Husband and wife work roles and the organiza-
tion and operation of family farms. Journal of Marriage and
the Family, 47(3), 759–764
Lucas, C.A., O’Shea, R.M., Zielezny, M.A., Freudenheim, J.L., &
Wold, J.F. (1991). Rural medicine and the closed society. New
York State Journal of Medicine, 91(2), 49–52.
Martin, P.H., Davis, L., & Askew, D. (1965). High incidence of
phenylketonuria in an isolated Indiana community. Journal of
the Indiana State Medical Association, 56, 997–999.
McKusick, V.A. (1978). Medical genetics studies of the Amish: Se-
lected papers assembled with commentary. Baltimore, MD:
Johns Hopkins University Press.
McKusick, V.A., Egeland, J.A., Eldridge, D., & Krusen, E.E.
(1964). Dwarfism in the Amish I. The Ellis-van Creveld syn-
drome. Bulletin of the Johns Hopkins Hospital, 115, 306–330.
McKusick, V.A., Eldridge, D., Hostetler, J.A., Ruanquit, U., &
Egeland, J.A. (1965). Dwarfism in the Amish II. Cartilage hair
hypoplasia. Bulletin of the Johns Hopkins Hospital, 116, 285–326.
Meyers, T.J. (1993). Education and schooling. In D. Kraybill (Ed.),
The Amish and the state (pp. 87–106). Baltimore, MD: Johns
Hopkins University Press.
Meyers, T.J., & Nolt, S.M. (2005). An Amish patchwork: Indiana’s
Old Orders in a modern world. Bloomington, IN: Quarry
Books, Indiana University Press.
Miller, N.L. (1997). Childbearing practices as described by Old
Order Amish women. Doctoral dissertation, Michigan State
University. Dissertation Abstracts International, UMI 1388555.
Myers, R.M. (1992). Genetic linkage analysis of bipolar affective
disorder in an Old Order Amish pedigree. Human Genetics, 88,
562–568.
Nelson, W.A. (1999). A study of Amish women’s construction of
health narratives. Unpublished doctoral dissertation, Kent
State University, Kent, Ohio.
Pauls, D.L., Morton, L.A., & Egeland, J.A. (1992). Risks of af-
fective illness among first-degree relatives of bipolar and Old
Order Amish probands. Archives of General Psychiatry, 49,
703–708.
The Amish 135
2780_Ch07_115-136 16/07/12 11:42 AM Page 135

Ratnoff, O.D. (1958). Hereditary defects in clotting mechanisms.
Advances in Internal Medicine, 9, 107–179.
Reiling, D.M. (1998). An explanation of the relationship between
Amish identity and depression among Old Order Amish. Doc-
toral dissertation, Michigan State University. Dissertation
Abstracts International, UMI 9985454.
Tripp-Reimer, T., & Schrock, M. (1982). Residential patterns of
ethnic aged: Implications for transcultural nursing. In C. Uhl
& J. Uhl (Eds.), Proceedings of the Seventh Annual Transcul-
tural Nursing Conference (pp. 144–153). Salt Lake City, UT:
University of Utah, Transcultural Nursing Society.
Troyer, H. (1994). Medical considerations of the Amish. In J.R.
Dow, W. Enninger, & J. Raith (Eds.), Internal and external per-
spectives on Amish and Mennonite life 4: Old and new world An-
abaptist studies on the language, culture, society and health of
the Amish and Mennonites (pp. 68–87). Essen, Germany:
University of Essen.
Wenger, A.F. (1980, October). Acceptability of perinatal services
among the Amish. Paper presented at a March of Dimes sym-
posium, Future Directions in Perinatal Care, Baltimore, MD.
Wenger, A.F.Z. (1988). The phenomenon of care in a high-context
culture: The Old Order Amish. Doctoral dissertation, Wayne
State University. Dissertation Abstracts International, 50/02B.
Wenger, A.F.Z. (1991a). The culture care theory and the Old
Order Amish. In M.M. Leininger (Ed.), Cultural care diversity
and universality: A theory of nursing (pp. 147–178). New York:
National League for Nursing.
Wenger, A.F.Z. (1991b). Culture-specific care and the Old Order
Amish. Imprint, 38(2), 81–82, 84, 87, 93.
Wenger, A.F.Z. (1991c). The role of context in culture-specific
care. In P.L. Chinn (Ed.), Anthology of caring (pp. 95–110).
New York: National League for Nursing.
Wenger, A.F.Z. (1994). Health and health-care decision-making:
The Old Order Amish. In J.R. Dow, W. Enninger, & J. Raith,
(Eds.), Internal and external perspectives on Amish and Men-
nonite life 4: Old and New World Anabaptists studies on the lan-
guage, culture, society and health of the Amish and Mennonites
(pp. 88–110). Essen, Germany: University of Essen.
Wenger, A.F.Z. (1995). Cultural context, health and health-care
decision making. Journal of Transcultural Nursing, 7(1), 3–14.
Wenger, M.R. (1970). A Swiss German dialect study: Three linguis-
tic islands in Midwestern USA. Ann Arbor, MI: University
Microfilms.
What is in a language? (1986, February). Family Life, p. 12.
Wolkomir, R., & Wolkomir, J. (1991, July). The doctor who con-
quered a killer. Reader’s Digest, 139, 161–166.
For Reflective Exercises, review questions and additional
information, go to
http://davisplus.fadavis.com
136 Aggregate Data for Cultural-Specific Groups
2780_Ch07_115-136 16/07/12 11:42 AM Page 136

137
Chapter 8
People of Appalachian Heritage
Kathleen W. Huttlinger
Overview, Inhabited Localities,
and Topography
Overview
Appalachia consists of that large geographic expanse
in the eastern United States that is associated with the
Appalachian mountain system, a 205,000-square-mile
region that extends from the northeastern United States
in southern New York to northern Mississippi. It in-
cludes all of West Virginia and parts of Alabama,
Georgia, Kentucky, Maryland, Mississippi, New York,
North Carolina, Ohio, Pennsylvania, South Carolina,
Tennessee, and Virginia. This very rural area is charac-
terized by a rolling topography with very rugged ridges
and hilltops, some extending over 4000 feet high, with
remote valleys between them. The surrounding valleys
are often 2000 feet or more in elevation and give
one a sense of isolation, peacefulness, and separateness
from the lower and more heavily traveled urban areas.
This isolation and rough topography have contributed
to the development of secluded communities in the hills
and natural hollows or narrow valleys where people,
over time, have developed a strong sense of independ-
ence and family cohesiveness. These same isolated
valleys and rugged mountains can present accessibil-
ity issues for those who do not have access to private
transportation because public transportation is not
widely available, and even then only in the larger, more
urbanized areas.
Even though the Appalachian region includes sev-
eral large cities, most people live in small settlements
and in inaccessible hollows or “hollers” (Huttlinger,
Schaller-Ayers, & Lawson, 2004a). The rugged loca-
tion of many communities in Appalachia results in a
population that is isolated from the mainstream of
health-care services. In some areas, substandard sec-
ondary and tertiary roads, as well as limited public
bus, rail, and airport facilities, prevent easy access to
the area (Fig. 8-1). Difficulty in accessing the area is
partially responsible for continued geographic and
social isolation. In addition, the rugged terrain and
secondary roads can delay ambulance response times
and are deterrents to people who need emergency
health care. This is one area in which telehealth inno-
vations can and often do provide needed services
(University of Virginia, 2009).
Many of the approximately 24.8 million people
who live in Appalachia can trace their family roots
back 150 years or more, and it is common to find
whole communities comprising extended, related fam-
ilies (Appalachia Regional Commision (ARC), 2010).
The cultural heritage of the region is rich and reflected
by a distinctive music, art, and literature. Even though
family roots are strong, many of the region’s younger
residents have left the area to pursue job opportunities
and college in the larger urban cities of the North,
South, and West Coast. The remaining, older popu-
lation reflects a group that often has less than a high
school education, is frequently unemployed, may be
on welfare and/or disability, and is regularly uninsured
(20.4 percent) (ARC, 2010). In fact, 80 percent of
the population over age 65 is higher in Appalachia
(14.3 percent) than in the rest of the United States
(12.4 percent). The lack of education has often been
associated with nonparticipation in health promotion
activities (ARC, 2010; Graduate Medical Education
Consortium [GMEC], 2001). Completion of a high
school degree and matriculation to college are well
below average throughout central and southern
Appalachia. For example, in central Appalachia,
25 percent of the residents have attended college,
compared to 50 percent for the nation (ARC, 2010).
Graduation rates from high school in the year 2000
vary widely from 60.7 to 91.4 percent, with the lowest
number of graduates occurring in West Virginia,
southwestern Virginia, eastern Kentucky, and north-
eastern Tennessee (ARC, 2010; Haaga, 2004).
Heritage and Residence
Appalachians generally identify themselves by family
surname. At one time an individual’s country of origin—
Germany, Scotland, Ireland, and so on—was also
2780_Ch08_137-158 16/07/12 11:43 AM Page 137

included as an identification, but this tradition has gen-
erally disappeared, except for older adults who still deem
this aspect an important part of their residence. Germans,
Scots-Irish, Welsh, French, and British constitute the
primary groups who settled the region between the 17th
and 19th centuries. It is important to remember that
simply taking up residence in Appalachia does not make
one an “Appalachian,” since a significant value is held
for those whose roots are well identified within the re-
gion. Historically, the population has been predomi-
nantly white, although many maintain a strong family
identity with the American Indian tribes that once pop-
ulated the area (e.g., Cherokee, Choctaw) (Huttlinger,
Schaller-Ayers, Kenney, & Ayers, 2004b). In addition,
African Americans have been in Appalachia since the
1500s. Early Spanish and French explorers brought with
them African slaves, and free persons of color were
among the earliest settlers. While a plantation economy
never developed in the region, many wealthy mountain
people owned slaves who worked in stores and inns, log-
ging, and mining, as well as on farms. After the Civil
War, many freed African Americans bought land to
farm and lived rural lifestyles very similar to those of
their white neighbors (Watkins, 2011).
African American Appalachians have endured the
same kinds of racial problems that exist elsewhere.
While they recognize their ties to the larger African
American population, they also have a unique identifi-
cation with the region. Celebration of family heritage
through the collection of family memorabilia and atten-
dance at family reunions strengthens their separate iden-
tity as African American Appalachians (Watkins, 2011).
Appalachians in general cannot be distinguished
from other white cultural and ethnic groups by either
dress or physical appearance. However, similarities in
beliefs and practices, tempered by variant cultural
characteristics (see Chapter 1), give them a unique and
rich ethnic identity. Like many disenfranchised
groups, the people of Appalachia have been described
in stereotypically negative terms (e.g., “poor white
trash”) that in no way represent the people or the cul-
ture as a whole. They have also been called “moun-
taineers,” “hillbillies,” “rednecks,” and “Elizabethans.”
During the past 60 years, the media have perpetuated
the stereotypes with cartoon strips such as “Li’l
Abner” and “Snuffy Smith,” television programs such
as the Dukes of Hazzard, and stories of the feuding
Hatfields and McCoys and the Whites and Garrards.
Interestingly, these feuds were among wealthy families
over salt deposits and land and families who had high
political profiles. Failure of the courts to intervene and
a propensity of Appalachians to handle things them-
selves perpetuated the longevity of the feuds.
However, in recent times, works by popular authors
such as Sharon McCrumb, James Dickey, Lee Smith,
and John Ehle reflect values for deep-seated work
ethics, low cost of living, and a high quality of life that
permeate their Appalachian daily lives. All told,
Appalachians see themselves as loyal, caring, family-
oriented, religious, hardy, independent, honest, patri-
otic, and resourceful (Huttlinger et al., 2004a).
Other groups in the region who may identify with
Appalachian culture include American Indians,
African Americans, and Melungeons, who are of
mixed African American, American Indian, Middle
Eastern, Mediterranean, and white ethnic descent
(Costello, 2000; Kennedy, 1997). Although Melun-
geon heritage is often denied, there is, of late, a resur-
gence of identification of Melungeon ancestry. In fact,
annual Melungeon get-togethers are now held once a
year in Appalachia (Kennedy, 1997). With the increase
in immigration to the United States since the 1970s,
the Appalachian region is becoming more ethnically
and culturally diverse, and it is now very common to
observe other ethnic groups, including those of south-
east Asian, Chinese, and Hispanic heritage.
Reasons for Migration and Associated
Economic Factors
Approximately 300 years ago, people came to
Appalachia to seek religious freedom, land for them-
selves, and control over social interactions with the
outside world. Over the years, mining and timber re-
sources have become depleted, farmland has eroded,
and jobs have become scarce, which has resulted in an
out-migration of people, especially those of working
age, to larger urban areas of the North such as Cincin-
nati, Cleveland, and Louisville; to the South in cities
like Charlotte and Atlanta; and even to the Southwest
to places like Nevada and California (ARC, 2010).
This migration began after World War II and has re-
mained constant ever since (Obermiller & Brown,
2002). Those who move to urban areas often feel
alone and sometimes become depressed as they are
separated from family and friends. Many families fear
for their young family members and worry that they
138 Aggregate Data for Cultural-Specific Groups
Figure 8-1 Before the construction of the New River Gorge
bridge, many people were isolated from health care. (Courtesy
of West Virginia Division of Tourism and Parks.)
2780_Ch08_137-158 16/07/12 11:43 AM Page 138

will succumb to crime, drug use, and the other perils
of living in an urban environment. In spite of these
concerns, many of those who have remained in urban
settings have become bicultural, adapting to the cul-
ture of urban life while retaining, as much as possible,
their traditional Appalachian culture.
The limited opportunities for employment in
Appalachia often require wage earners to leave their
families to seek work elsewhere, returning home on
weekends and holidays or vacations to maintain their
close ties with kinfolk. Their migration pattern is
regional, where individuals from one area primarily
migrate to the same urban areas as their relatives and
friends—a pattern that is common with many
migrants. This practice helps decrease the occurrence
of depression and feelings of isolation and provides a
support network of family and friends that is so
important for members of the Appalachian culture.
Appalachian migration patterns reflect the eco-
nomic conditions found in the area, as well as some
of the cultural values of home, connection to the land,
and importance of the family. Working-age individu-
als move from Appalachia to make their living but
often return to their home hills and hollows in
Appalachia to retire. Because of these patterns,
Appalachia has one of the highest existing aging pop-
ulations (ARC, 2010; Haaga, 2004). The pattern of re-
turning home to retire has given rise to challenges for
health-care delivery. In fact, older people were once
able to rely on home care services, but severe budget
cuts in 1977 left home care health service unreliable
and ineffective. A study by Carter (2005) indicated
that Appalachian nursing homes served resident pop-
ulations with higher activities of daily living (ADL)
impairment levels, had a larger proportion of resi-
dents whose stays were reimbursed by Medicaid, and
had a lower proportion of residents who paid pri-
vately for their care. Carter noted that the long-term
care facilities located in Appalachia were more likely
to be hospital-based, reflecting hospital swing-bed
policies in rural areas, and were less likely to offer spe-
cialty beds designated for the care of residents with
Alzheimer’s disease. Although important differences
in operational and organizational characteristics were
found (potential indicators of the poor quality of
nursing home care), findings suggested that these did
not necessarily lead to higher deficiency citation rates
in Appalachia. Rather, Carter’s findings indicated that
facilities whose resident populations have higher levels
of ADL impairment have a greater proportion of
Medicaid- reimbursed stays, and a smaller proportion
of privately paid days received more deficiencies than
did otherwise similar facilities, holding other factors
constant. Lastly, her findings indicated that after ad-
justing for other factors, a clear pattern of fewer defi-
ciencies emerged across the Appalachian region that
cannot be fully unexplained by either urban-rural or
quality of care differences in the region, suggesting
most likely that other, unexplained but regionally dis-
tributed, factors are contributing to the number and
types of deficiencies found in nursing home facilities.
A recent perusal of local phone directories shows,
as of 2011, many private and community-based home
care services throughout the Appalachian region. In
the past, older people and the chronically ill had to rely
on options for short-term and expensive hospital care,
nursing homes, or no care at all (Hurley & Turner,
2000), whereas now they appear to have other options.
For generations, the region has been a symbol of
poverty in a land of wealth and opportunity. During
the 1960s, the Appalachian Regional Commission
(ARC) appropriated funds for building roads to at-
tract industry and provided loans for residents to start
their own businesses. In many areas of Central Ap-
palachia, the unemployment rate and the number of
people living in poverty have remained consistently
above the national average, while the per capita in-
come has remained below the national average. Eight
of the 13 states in Appalachia have an unemployment
rate higher than the national average, and the national
poverty rate of 12.6 percent is exceeded by 10 of the
13 states in Appalachia. During the recent recession,
Appalachia lost a disproportionate number of jobs
compared with some other states (ARC, 2010). The
average per capita income rate in Appalachia is
$20,434. Not one Appalachian state achieves the na-
tional per capita income of $25,470. Of 410 counties
in Appalachia, 77 are considered economically dis-
tressed, 81 are at risk, and 222 are transitional (ARC,
2010). Even though the cost of living in much of the
area is lower than that in many other parts of the
United States, costs for transportation of food, basic
living supplies, and transportation fuels rise, thus cre-
ating hardships for an area that is already economi-
cally stressed (ARC, 2010).
Educational Status and Occupations
Although many of the original immigrants to this area
were highly educated when they arrived, limited access
to more formal education resulted in the isolation of
later generations with fewer educational opportuni-
ties. Despite the value placed on education, a disparity
in the number and placement of educational facilities
exists throughout the region. Access to colleges and
universities has improved, but there is still a lack of
knowledge about life outside of Appalachia and the
educational opportunities available. Examples of uni-
versities and colleges in Appalachia include, but are
not limited to, West Virginia University, Appalachian
State, University of Virginia’s College at Wise, East
Tennessee State, Shawnee State, and the University of
North Alabama. A dichotomy between those who are
poorly educated and those who are extremely well
educated still exists today (Huttlinger et al., 2004a).
People of Appalachian Heritage 139
2780_Ch08_137-158 16/07/12 11:43 AM Page 139

Because isolation results in a cultural lag, IQ
scores of children from Appalachia are sometimes
lower than those in the populations outside of
Appalachia who have access to larger schools and
live in urban settings. However, with television
and the Internet now available throughout the area,
this cultural lag has been slowly improving. In fact,
U.S. representatives from many of the districts that
lie in Appalachia made it a priority to have broad-
band and Internet connections made accessible. Fac-
tors such as improved mobility, access to better
schools with qualified teachers, increased employ-
ment opportunities in some regions, and greater use
of technology are responsible for improving socioeco-
nomic conditions and better performance on standard
IQ tests (ARC, 2010). However, the mountainous ter-
rain often limits those services that require “line of
sight” and may include cell phone and advanced TV
technologies.
Although a value is placed on education, education
beyond high school is often viewed as not as impor-
tant as earning a living to help support the family.
Many Appalachian parents, and especially those who
belong to more conservative and secular religious
sects, do not want their children influenced by main-
stream middle-class American behaviors and actions.
However, fewer children drop out of school today than
in previous decades. One interesting fact is that several
states in Appalachia have laws that grant permanent
driving privileges only upon completion of high school,
which has lowered dropout rates significantly.
Parents who value higher education encourage their
children to seek quality education at the best institu-
tions possible. Despite this value, the graduation rate
from college is, at best, 27 percent compared with 45
percent for non-Appalachian counterparts (ARC,
2010). Unfortunately, the highly educated, including
health-care workers, who return to the area are often
unable to secure financially lucrative employment and
soon leave to seek employment elsewhere.
Because educational levels of individuals within the
Appalachian regions vary, it is essential for health-care
providers to assess the health literacy and basic under-
standing of health and disease of individuals when pro-
viding any kind of intervention. Educational materials
and explanations must be presented at literacy levels
that are consistent with patients’ understanding. If ma-
terials are presented at a level that is not understandable
to patients, providers may be seen as being “stuck-up,”
“putting on airs,” or “not understanding them and their
ways” (Huttlinger et al., 2004b) (see Chapter 1).
Communication
Dominant Language and Dialects
The dominant language of the Appalachian region is
English, with many words derived from 16th-century
Saxon and Gaelic. Because the Appalachian dialect
tends to be very concrete, continued exposure is nec-
essary to avoid misunderstandings. Negative interpre-
tations of Appalachian behaviors by non-Appalachian
health-care providers can be detrimental to positive
and facilitative working relationships.
Some of the more isolated groups in Appalachia
speak an Elizabethan English, which has its own dis-
tinct vocabulary and syntax and can cause communi-
cation difficulties for those who are not familiar with
it. Some examples of variations in pronunciation for
words are allus for “always” and fit for “fight.” Word
meanings that may be different include poke or sack
for “paper bag” and sass for “vegetables.” The Ap-
palachian region is also noted for its use of strong
preterits such as clum for “climbed,” drug for
“dragged,” and swelled for “swollen.” Plural forms of
monosyllabic words are formed like Chaucerian Eng-
lish, which adds es to the word—for example, “post”
becomes postes, “beast” becomes beastes, “nest” be-
comes nestes, and “ghost” becomes ghostes. Many
people, especially in the nonacademic environment,
drop the g on words ending in ing. For example,
“writing” becomes writin’, “reading” becomes readin’,
and “spelling” becomes spellin’. In addition, vowels
may be pronounced with a diphthong that can cause
difficulty to one unfamiliar with this dialect—hence,
poosh for “push,” boosh for “bush,” warsh for “wash,”
hiegen for “hygiene,” deef for “deaf,” welks for “welts,”
whar for “where,” hit for “it,” hurd for “heard,” and
your’n for “your.” However, when the word is written,
the meaning is apparent. Comparatives and superla-
tives are formed by adding a final er or est, making the
word “bad” become badder and “preaching” become
preachin’est (Wilson, 1989).
If health-care providers are unfamiliar with the
exact meaning of a word, it is best to ask patients to
explain. Otherwise, miscommunication can occur and
will probably result in incorrect diagnoses and/or other
poor health outcomes. A health-care provider may
want to ask the person to write the words (if the person
has writing skills) to help prevent errors in communi-
cation and to improve outcomes and following direc-
tions with health prescriptions and treatments.
Cultural Communication Patterns
Appalachians practice the ethic of neutrality, which
helps shape communication styles, their worldview,
and other aspects of the Appalachian culture. Four
dominant themes affect communication patterns in
the Appalachian culture: avoiding aggression and as-
sertiveness, not interfering with others’ lives unless
asked to do so, avoiding dominance over others, and
avoiding arguments and seeking agreement (Smith &
Tessaro, 2005).
Appalachians are often accepting of others and do
not want to pass judgment. This value is reflected in
140 Aggregate Data for Cultural-Specific Groups
2780_Ch08_137-158 16/07/12 11:43 AM Page 140

written and oral communications in which fewer ad-
jectives and adverbs are used. Thus, many Appalachi-
ans may be less precise in describing their emotions,
may be more concrete in conversations, and will
answer questions in a more direct manner. Accord-
ingly, a health-care provider may need to use more
open-ended questions when obtaining health informa-
tion and eliciting opinions and beliefs about health-care
practices, such as “What do you believe might be caus-
ing your illness?” Otherwise, Appalachian providers are
likely to give a yes or no answer without expanding or
clarifying their answers.
In general, Appalachians are a very private people
who do not want to offend others, nor do they easily
trust or share their thoughts and feelings with out-
siders. They are more likely to say what they think the
listener wants to hear rather than what the listener
needs to hear. In addition, because of past, and often
unfavorable, experiences with large mining and timber
companies, many Appalachians dislike authority
figures and institutions that attempt to control their
behavior. Individualism and self-reliant behavior are
idealized; personalism and individualism are admired;
and people are accepted on the basis of their personal
achievements, qualities, and family lineage.
Appalachians’ perceptions of themselves, their com-
munity, and their families influence many aspects of
their communication styles. Families are more than ge-
netic relationships and are described as including broth-
ers, sisters, aunts, uncles, parents, grandparents, cousins,
in-laws, and out-laws (those related by marriage). This
perception of family and community transcends the
concept of self as “I.” The use of the pronoun “we”
throughout speech patterns recognizes the concept of
self. Thus, “we can make it,” “we will survive,” or “we
will be there” may refer to only the person speaking.
An example of a typical interaction in an Ap-
palachian community may be illustrated by this state-
ment from a key informant in the Counts and Boyle
(1987) Genesis Project, which took place from 1985 to
1994. Miss Ruth, a 94-year-old native Appalachian,
was interviewed in the house in which she was born. In
fact, she had her appendix removed in the living room
of this same house by a traveling nurse. After returning
from a trip to Africa (she had a doctorate and liked to
travel, but always returned home), Miss Ruth described
the concept of “neighboring” as a double-edged sword.
The positive side is that when you are sick, everyone
comes around to take care of you; however, on the neg-
ative side, when you try to do something quietly, every-
one knows about it.
Appalachians may be sensitive to direct questions
about personal issues. Sensitive topics are best ap-
proached with indirect questions and suggestions and
without critical innuendo. Appalachians are taught to
deny anger and not complain. Information should be
gathered in the context of broader relationships with
respect for the ethic of equality, which implies more
horizontal than hierarchical relationships, allowing
cordiality to precede information sharing. Starting
with sensitive issues may invite ineffectiveness; thus,
the health-care provider may need to “sit a spell” and
“chat” before getting down to the business of collect-
ing health information. To establish trust, the health-
care provider must show interest in the community,
the patient’s family, and other personal matters; drop
hints instead of give orders; and solicit the patient’s
opinions and advice. These actions increase the pa-
tient’s self-worth and self-esteem and help to establish
the trust needed for an effective working relationship.
Traditional Appalachians value personal physical
space, so they are more likely to stand at a distance
when talking with people in both social and health-care
situations. This physical distancing has its origins in re-
ligious persecution endured by this group in their his-
tory and has been perpetuated by a social isolation that
has encouraged family members to become the main
social contact (Coyne, Demian-Popescu, & Friend,
2006). Therefore, many people may perceive direct eye
contact, especially from strangers, as an aggressive or
hostile act. Staring is considered bad manners.
To communicate effectively with Appalachian pa-
tients, nonverbal behaviors must be assessed within the
contextual framework of the culture. Many Appalachi-
ans are comfortable with silence, and when talking
with health-care providers who are outsiders, they are
likely to speak without emotion, facial expression, or
gestures and avoid telling unpleasant news to avoid
hurting someone’s feelings. Health-care providers who
are unfamiliar with the culture may interpret these
nonverbal communication patterns as not caring.
Within this context, the health-care provider needs to
allow sufficient time to develop rapport by dropping
hints instead of giving orders (Coyne et al., 2006). In
addition, to communicate effectively with traditional
Appalachians, health-care providers must not ignore
speech patterns; they must clarify any differences in
word meanings, translate medical terminology into
everyday language using concrete terms, explain not
only what is to be done but also why, and ask patients
to repeat or demonstrate instructions to ensure under-
standing. Adopting an attitude of respect and flexibil-
ity demonstrates interest and helps bridge barriers
imposed by health-care providers’ personal ideologies
and cultural values. Throughout history, Appalachians
have enjoyed storytelling, a practice that still continues;
accordingly, some individuals may respond better to
verbal instructions and education, with reinforcement
from videos rather than printed communications.
Temporal Relationships
The traditional Appalachian culture is “being”-
oriented (i.e., living for today) as compared with
“doing”-oriented (i.e., planning for the future).
People of Appalachian Heritage 141
2780_Ch08_137-158 16/07/12 11:43 AM Page 141

A being orientation not only opposes progress but
also may mean ignoring expert advice and “accepting
one’s lot in life.” With the potential for economic and
cultural lag, other problems may be more pressing,
and “just getting by” may be the most important ac-
tivity. Health-care providers must realize that the em-
phasis on illness prevention in our current society is
still relatively new for many Appalachians (GMEC,
2001). For those living in poverty and isolation, the
trend is to “live for today” and to rely on more tra-
ditional approaches for those things that cannot be
controlled. This worldview is common with present-
oriented societies, in which some higher power is in
charge of life and its outcomes, but it is a deterrent
to preventive health services. With a fatalistic view in
which individuals have little or no control over na-
ture, and the time of death is “predetermined by
God,” one frequently hears expressions such as “I’ll
be there, God willing and if the crick [creek] don’t
rise.” As communication systems such as televisions,
satellite dishes, and the Internet become more com-
monplace, temporal relationships are becoming more
future-oriented.
For the traditional Appalachian, life is unhurried
and body rhythms, not the clock, control activities.
One may come early or late for an appointment and
still expect to be seen. If individuals are not seen be-
cause they are late for an appointment and are asked
to reschedule, they are likely to not return because they
may feel rejected. Many Appalachians are hesitant to
make appointments because “somethin’ better might
come up” or they may not be sure of transportation
until the last minute.
Appalachians who live outside the area usually talk
about, and sometimes even dwell upon, “home” in a
nostalgic way. To some, this might seem like a glorifi-
cation of a past temporal orientation. However, these
authors believe that it is nostalgia for “the way things
used to be” as, in reality, most people do not want to
return to the harshness of the life experienced by past
generations.
Format for Names
Although the format for names in Appalachia follows
the U.S. standard given name plus family name, indi-
viduals address nonfamily members by their last
name. A common practice that denotes neighborliness
with respect is to call a person by his or her first name
with the title Mr. or Miss (pronounced “miz” similar
to “Ms.,” when referring to women, whether single or
married)—for example, Miss Lillian or Mr. Bill. Miss
Lillian may or may not be married. There is also a
need to provide a link with both families of origin.
Many times Appalachians refer to a married woman
as “she was [born] a . . . ,” thus linking the families and
enhancing the feeling of continuity.
Family Roles and Organization
Head of Household and Gender Roles
In previous decades, gender roles for Appalachian
men and women were more clearly defined. Men were
supposed to do physical work, to support the family
financially, and to provide transportation. Women
took care of the house and assumed responsibility for
child rearing. Self-made individuals and families, or
those who carried out their own subsistence and
depended little on outsiders, were idealized.
The traditional Appalachian household continues
to be patriarchal, although many families are becom-
ing more egalitarian in their beliefs and practices. This
is especially true if the woman makes more money
than the man. Women are generally the providers of
emotional strength, with older women having a lot of
clout in health-care matters. Older women are usually
responsible for preparing herbal remedies and folk
medicines and are sought out by family members and
neighbors for these preparations. Older women have
a higher status in the community than older men, who
in turn have a higher status than younger women.
With the advent of better access to education and im-
proved transportation throughout Appalachia, more
women are working outside the home, thus creating
an environment in which gender roles are becoming
more egalitarian.
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Children are important to the Appalachian culture
(Coyne et al., 2006). Large families are common, and
children are usually accepted regardless of whether
the parents are married. Parents may impose strict so-
cial conformity for family members in fear of commu-
nity censure and their own parental feelings of
inferiority. Permissive behavior at home is unaccept-
able, and hands-on physical punishment, to a degree
that some perceive as abuse, is common. For Ap-
palachian children who have problems with school
performance, the most effective approach to increase
performance is to provide individualized attention
rather than group support or attention, an approach
that is congruent with the ethic of neutrality. To be
effective in changing negative behavior, it is necessary
to emphasize positive points.
As children progress into their teens, mischievous
behavior is accepted but not condoned. Continuing
formal education may not be stressed because many
teens are expected to get a job to help support the
family. Children are seen as being important, and to
many, having a child, even at an early age (less than
18 years), means fulfillment. Motherhood increases
the woman’s status in the church and the community.
In previous generations, it was not uncommon for
142 Aggregate Data for Cultural-Specific Groups
2780_Ch08_137-158 16/07/12 11:43 AM Page 142

teenagers to marry by the age of 15, and some as early
as 13. Children, single or married, may return to their
parents’ home, where they are readily accepted, when-
ever the need arises.
Teens in Appalachia enter into a cultural dilemma
when exposed to other lifestyles outside the home
and family. Health-care providers can assist adoles-
cents and their family members in working through
these cultural differences by helping them resolve
personal conflicts resulting from being exposed to
different cultures and lifestyles. Some ways to pro-
mote a positive self-awareness that conveys a respect
for their culture are discussing personal parenting
practices and providing information about health
promotion and wellness; disease, illness, and injury
prevention; and health restoration and maintenance
in a culturally congruent way.
Family Goals and Priorities
Appalachian families take great pride in being inde-
pendent and doing things for themselves. Even though
economics may permit paying others to do some
tasks, great pride is taken in being able to do for one-
self. This is an area in which the editor (L. Purnell)
can still strongly relate to Appalachian roots. Even
though reaching a financial position at which he can
pay someone to do chores on home and farm, he con-
tinues to take pride in doing them for himself. For
many, family priorities include men getting a job and
making a living and, for women, bearing children.
Traditionally, nuclear and extended families are im-
portant in the Appalachian culture, so family mem-
bers frequently live in close proximity. Relatives are
sought for advice on child rearing and most other as-
pects of daily living.
Elders are respected and honored in the Ap-
palachian family. Grandparents frequently care for
grandchildren, especially if both parents work. This
form of child care is readily accepted and is an expec-
tation in large extended families. Elders usually live
close to or with their children when they are no longer
able to care for themselves. The physical structure of
the home is designed to assist aging parents. Many
adult children do not consider nursing home place-
ment because it is the equivalent of a death sentence.
Migration of children out of the home area may force
many older people to relocate outside their home area
to be with their children. A dilemma occurs because
they have an equally strong Appalachian value of at-
tachment to place and family. As a compromise, some
practice “snow birding”—leaving their home in the
winter and moving in with their children, then return-
ing to their home in the summer. It is not unusual for
adult children to drive 3 to 5 hours on days off work
to spend time with and help maintain their aging par-
ents at their homes in Appalachia.
One’s obligation to extended family outweighs the
obligations to school or work. The nuclear family feels
a personal responsibility for nieces and nephews and
readily takes in relatives when the need arises. This ex-
tended family is important regardless of the socioeco-
nomic level. Upon migration to urban areas, the
nuclear family becomes dominant because the ex-
tended family is usually left behind in Appalachia.
This strong sense of family, in which the family dis-
trusts outsiders and values privacy, can be a deterrent
to getting involved in community activities or joining
self-help group activities.
The Appalachian family network can be a rich
resource for the health-care provider when health
teaching and assistance with personalized care are
needed. For programs with Appalachians to be effec-
tive, support must begin with the family, specifically
the grandmothers, and immediate neighborhood ac-
tivities. The health-care provider must respect each
person as an individual and be nonbureaucratic in na-
ture. The family, rather than the individual, must be
considered as the basic treatment unit.
Social status is gained from having the respect of
family and friends. Formal education and position do
not gain one respect. Respect has to be earned by
proving that one is a good person and “living right.”
Living right is based on the ethic of neutrality and on
being a good “Christian person.” Having a job, re-
gardless of what the work might be, is as important as
having a prestigious position. Families are very proud
of their family members and let the entire community
know about their accomplishments. In some instances,
migration to the city may result in mixed views toward
one’s status. Monetary gain does not necessarily im-
prove one’s status in the family and community.
Rather, skills and character traits that allow one to
achieve financial comfort are given high status.
Alternative Lifestyles
Alternative lifestyles such as single and divorced par-
ents are usually readily accepted in the Appalachian
culture. Same-sex couples and families living together
are accepted and rarely discussed. Such acceptance is
congruent with the ethic of neutrality, the Appalachian
need for privacy, not interfering with others’ lives
unless asked to do so, avoiding arguments, and seeking
agreement, even though agreement may be implied
rather than spoken.
Workforce Issues
Culture in the Workplace
Because many Appalachians value family above all
else, reporting to work may become less of a priority
when a family member is ill or other family obliga-
tions are pressing. When family illnesses occur, many
People of Appalachian Heritage 143
2780_Ch08_137-158 16/07/12 11:43 AM Page 143

Appalachian individuals willingly quit their jobs to
care for family members. For some, the preferred work
pattern is to work for an extended period of time, take
some time off, and then return to work. Although
work patterns may change, a deep-seated work ethic
exists. Liberal leave policies for funerals and family
emergencies are seen as a necessary part of the work
environment.
Because personal space is important, many Ap-
palachians use a greater distance when communicat-
ing in the workplace. Close, face-to-face encounters;
hugs; and the like are rarely seen. A harmonious en-
vironment that fosters cooperation and agreement in
decision making is valued and desired. Health-care
providers who come from outside the area may have
some difficulty establishing rapport in the workplace
if they lack an understanding and appreciation for
Appalachian workplace etiquette.
Appalachian individuals usually wish to maintain
independent lifestyles and often frown upon or not
engage in the latest fads of the larger macroculture.
Although most people want progress, they also wish
to remain isolated from the mainstream. Thus, more
traditional Appalachians may be slower to assimilate
the values of middle-class society into their daily
work habits.
Issues Related to Autonomy
In general, a lack of leadership is not uncommon be-
cause ascribed status is more important than achieved
status and because there is an attempt to keep hierar-
chal relationships to a minimum (Coyne et al., 2006).
The Appalachian ethic of neutrality and the values of
individualism and nonassertiveness, with a strong peo-
ple orientation, may pose a dichotomous perception
at work for outsiders who may not be familiar with
the Appalachian way of life. However, when conflicts
occur, mutual collaboration for seeking agreement is
consistent with the ethic of neutrality. Because many
Appalachians align themselves more closely with hori-
zontal rather than hierarchical relationships, they are
sometimes reluctant to take on management roles.
When they do accept management roles, they take great
pride in their work and in the organization as a whole.
Most middle-class Americans gain self-actualization
through work and personal involvement with doing.
Appalachians seek fulfillment through kinship and
neighborhood activities of being. To foster positive
and mutually satisfying working relationships, organ-
izations should capitalize on individual strengths such
as independence, sensitivity, and loyalty, which are
recognized values in the Appalachian culture. Many
Appalachians prefer to work at their own pace, devis-
ing their own work rules and methods for getting the
job done. Some local factories, mines, lumber mills,
and health-care facilities that hire managers and ad-
ministrators from outside the region often provide
educational seminars about the Appalachians’ world-
view, work culture, and way of life in order to foster
cultural sensitivity and a general understanding of the
people with whom they work.
Biocultural Ecology
Skin Color and Other Biological Variations
Since its first settlement, the Appalachian region has
had a predominantly white population with little vari-
ation over time. Some individuals can trace their her-
itage to a mixture of white ancestry along with
Cherokee, Apalachee, Choctaw, and other indigenous
tribes of the region. A few blacks, a distinct minority
of 3.2 percent, may identify themselves as Appalachian,
and intermarriage with American Indians and white
settlers was not uncommon (ARC, 2006a). The influ-
ence of American Indians and blacks can be seen in
skin color along with pronounced epicanthic eye folds,
high cheekbones characteristic for American Indian an-
cestory, and darker skin tones and black, curly hair that
are characteristic in blacks.
Diseases and Health Conditions
Those Appalachians who have migrated and live in the
urban centers of the north are often exposed to poor
housing conditions that include inadequate sewage
and plumbing systems, lack of refrigeration, and var-
ious environmental problems stemming from indus-
trial pollution (Obermiller & Brown, 2002). Even
those who have remained and live in Appalachia are
often exposed to substandard housing where there is
a lack of safe potable water and sewage disposal
(ARC, 2010; GMEC, 2001).
Although national safety programs implemented by
the Occupational Safety and Health Administration
(OSHA) have been implemented throughout Ap-
palachia, many people are still exposed to the harmful
by-products of the predominant occupations in the re-
gion: farming, textile manufacturing, mining, furniture
making, and timbering (ARC, 2006a). Occupational
hazards include respiratory diseases such as black lung,
brown lung, emphysema, and tuberculosis. The inci-
dence of other health conditions including hypochromic
anemia, otitis media, cardiovascular diseases, female
obesity, non-insulin-dependent diabetes mellitus, and
parasitic infections is greater than the national norm
(GMEC, 2001; Huttlinger et al., 2004a). White Ap-
palachian residents may have a 20 percent greater
chance of dying from heart disease between the ages of
35 and 64 than other white Americans. This rate may be
due to limited access to healthy foods, a general lack and
use of recreational facilities, and a lack of access to med-
ical care (Centers for Disease Control and Prevention
(CDC), 2004; GMEC, 2001). Appalachia is one of the
areas in the United States with the highest rate of dis-
ability (Hurley & Turner, 2000).
144 Aggregate Data for Cultural-Specific Groups
2780_Ch08_137-158 16/07/12 11:43 AM Page 144

Children are at greater risk for sudden infant death
syndrome (SIDS), congenital malformations, and in-
fections. The infant mortality rate throughout the
Appalachian region varies greatly, with an overall rate
of 7.7 per 100 live births, which is lower than the na-
tional average of 7.9. However, the states of Alabama,
Mississippi, and North Carolina have an infant mor-
tality rate that exceeds the national rate (ARC, 2006a).
Only 70 percent of children are immunized, compared
with 90 percent for the nation as a whole. Childhood
injuries due to burns, trauma, poisoning, child neglect,
and abuse are also higher than the national average
(Voices of Appalachia, 2001).
Cancer, suicide, and accident rates in some parts of
Appalachia are significantly greater than the national
average. The higher rate of cancer in Appalachia
prompted the National Cancer Institute in 1999 to
create the Appalachian Leadership Initiative on
Cancer (ALIC) to help communities challenge cancer
at the grassroots level. Through ALIC, significant
progress has been made on screening for cervical
and breast cancer among low-income older women
(CDC, 2004).
In many parts of Appalachia, tooth decay re-
mains an unfortunate rite of childhood that may
lead to a lifetime of poor oral health. For example,
in West Virginia, dentists pulled an estimated 31,800
children’s teeth in 2006 (from a population of 1.8
million). By age 65, about 40 percent of the state’s
retirees have none of their natural teeth remaining.
Given the troubling scope and consequences of this
largely preventable problem across Appalachia, sev-
eral service organizations are attempting to more
clearly define the causes of poor oral health in the
region and develop practical, low-cost solutions
(Center for Oral Health Research in Appalachia
(COHRA), 2010). When prioritizing health and
other needs of the family, dental health often falls
last, and most people will simply “do without” or
rely upon home remedies and/or home extraction
(Fig. 8-2).
Educational information presented in a nonjudg-
mental manner can have a significant impact on the
health of Appalachian patients. Patients generally pre-
fer verbal rather than printed material to obtain
health-related information. In fact, an effective success
strategy used by ALIC is storytelling, a strong tradi-
tion in Appalachia and one in which people can relate.
Thus, the presentation of health and educational ma-
terial needs to include the entire family and be linked
with improvement in function in order to be taken
seriously.
People of Appalachian Heritage 145
R E F L E C T I V E E X E R C I S E 8 . 3
Coal mining comprises a major economic activity throughout
Appalachia. Many of the coal mining areas have been linked to
socioeconomic disadvantages among its residents. Appalachian
areas where economic disadvantage has been most persistent
over time are those characterized by low economic diversifica-
tion, low employment in professional services, and low educa-
tional attainment rates. Rural economies that are dependent
on sole-source resource extraction, such as mining, are
vulnerable to employment declines and market fluctuations.
The health costs due to illness and premature deaths in the
coal mining regions of Appalachia far outweigh the economic
benefits to the area from the coal industry (Hendryx & Ahern,
2009). Hendryx and Ahern state that throughout Appalachia,
“people in counties with no coal mining operations experience
better health, a cleaner environment, and greater economic pros-
perity than counties where mining takes place (p. 541).” The
authors maintain that while the coal mining industry had an
$8 billion economic impact on Appalachia, the costs (in terms
of health and shortened life span) ranged from $16 billion to
$84 billion in 2005. In fact, Appalachian coal mining areas have
almost 11,000 more deaths every year when compared with
areas elsewhere in the United States, and about 2300 of those
deaths were related to environmental factors such as air and
water pollution worsened by coal mining. A sad fact is that
“those who are falling ill and dying young are not just the coal
miners. Everyone who lives near the mines or processing plants
or transportation centers is affected by chronic socioeconomic
weakness that takes a toll in longevity and health (p. 543).”
1. What specific illnesses might you associate with the coal
mining industry?
2. How might a community’s water table be affected by
runoff from coal mines?
3. Many regions of Applachia are experiencing “mountaintop
removal” as a way to extract coal. What are the environ-
mental consequences of “mountaintop removal”? Can you
identifiy potential health risks involved with this approach?
Figure 8-2 Remote Area Medical. July 23, 2003. Dental clinic.
Wise, Virginia. 2003.
2780_Ch08_137-158 16/07/12 11:43 AM Page 145

Variations in Drug Metabolism
Current medical and research literature reports no
studies specific to the pharmacodynamics of drug in-
teractions among Appalachians. Given the diverse
gene pool of many residents, the health-care provider
needs to observe each individual for adverse drug
interactions.
High-Risk Behaviors
Compared with non-Appalachians, Appalachians
seem to be less concerned about their overall health
and risks associated with smoking (Huttlinger et al.,
2004a; 2004b). Their use of smokeless tobacco is the
highest in the country, and deaths from tobacco-
related uses are the highest in the nation (CDC, 2004).
Underage use of tobacco and alcohol is widespread
among teens.
The Appalachian definition of health encompasses
three levels: body, mind, and spirit. This definition
precludes viewing disease as a problem unless it inter-
feres with one’s functioning. Consequently, many con-
ditions are denied or ignored until they progress to the
point of decreasing function. (Nutrition practices are
covered more extensively later in the chapter.)
OxyContin has become one of the most widely
abused drugs in America. Dubbed “Hillbilly heroin,” it
has become the drug of choice for narcotic abusers in
Appalachia. Although chronic pain sufferers are finding
it increasingly difficult to obtain, elaborate OxyContin
underground transportation systems have developed to
sustain a lucrative drug trafficking business throughout
many mountain communities (Hays, 2004; Lubell,
2006). There has been a tremendous response from law-
makers and law enforcement agencies throughout the
region to curb the trafficking of OxyContin. The result
is that many physicians have become increasingly un-
willing to provide the drug, even to the cancer patients
and chronic pain sufferers who need it (Lubell, 2006).
One woman with cancer relates how she searched for
seven months before she found a specialist near Cincin-
nati, Ohio, who would prescribe OxyContin for her
(Hays, 2004).
Several states have tightened the control of
OxyContin. At least nine have limited Medicaid pa-
tients’ access to the drug. Virginia adopted a resolution
to study the use and abuse of OxyContin, whereas
Kentucky has legislation pending that would restrict
distribution of the drug. In Virginia, police have pro-
vided fingerprint kits to pharmacies for customers
wanting OxyContin (ARC, 2006b; Lubell, 2006).
Another high-risk behavior involves the prolifera-
tion of methamphetamine laboratories throughout
Appalachia. The seclusion of mountain hollows and
the number of remote and available barns and sheds
have contributed to the rise in methamphetamine pro-
duction. This highly addictive drug is made using
common ingredients such as over-the-counter (OTC)
cold medications, acetone, and rock salt. Setting up a
laboratory does not require a lot of room. Unfortu-
nately, ingredients and recipes are not hard to find. It
is cooked up in homemade laboratories using items
such as paint thinner, camping fuel, starter fluid, gaso-
line additives, mason jars, and coffee filters (U.S. Drug
Enforcement Agency (DEA), 2006a).
Marijuana abuse and trafficking are serious prob-
lems throughout the region and especially in the more
remote areas. Tennessee is a major supplier of domes-
tically grown marijuana. In fact, the DEA (2006b) re-
ported that Tennessee, along with West Virginia and
Kentucky, produces the majority of the United States’
supply of domestic marijuana. Prosecution of mari-
juana growers in the state has been extremely difficult
owing to a lack of intelligence and because many of
the domestic marijuana sites detected are so small that
146 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 8 . 1
Throughout Appalachia, general tooth decay is a problem for
children and adults. Many adults who receive little or no dental
care while children are faced with severe dental caries and
ultimate extraction in adulthood. Some estimates indicate that
by age 65, between 30 and 40 percent of the general popula-
tion throughout Appalachia have none of their natural teeth
remaining (National Institute of Dental and Craniofacial
Research, 2011). A survey conducted by Huttlinger and
colleagues in 2004 in southwestern Virginia indicated that
70 percent of the people surveyed (N = 1278) noted that
they “did without” dental care and that it was not part of their
overall medical priorities. In the same study, 48 percent of the
people surveyed stated that they relied heavily on over-the-
counter dental aids or other home treatment measures such
as poultices or rubs. Extraction was seen as a final but accept-
able remedy, and people who used this method performed
the extraction themselves or had someone in their family do it
for them. In addition, 31 percent of those surveyed related
that they knew of at least one household member who had
“cavities,” and 26 percent noted at least one household
member had lost one or more of their teeth.
All health-care providers should include a dental inspection
as part of their overall health assessment. Importantly, relatively
inexpensive measures such as tooth brushing and oral rinsing
as a child can prevent decay, chronic pain, and the social stigma
of having lost teeth throughout the lifetime.
1. What kinds of things might you observe on an oral exami-
nation of the mouth?
2. How would you respond to an individual who, during a
physical examination, requests that you help him (or her)
arrange to have all of her teeth pulled?
3. Identify at least three over-the-counter dental (OTC) aids
that people might use to assist them with their dental
problems?
2780_Ch08_137-158 16/07/12 11:43 AM Page 146

even if the owner/grower were identified, the U.S.
attorney general would be reluctant to prosecute
(DEA, 2006b).
Health-Care Practices
A 10-step pattern of health-seeking behaviors has
been identified among Appalachians:
1. At the onset of symptoms, Appalachians typi-
cally implement self-care practices that are
usually learned from mothers.
2. When the symptoms persist, they call their
mother, if she is available.
3. If the mother is unavailable, they call the female
in their kin network who is perceived as knowl-
edgeable regarding health. If a nurse is available,
they may seek the nurse’s advice.
4. If relief is not achieved, they use OTC medicine
they have seen advertised on television for symp-
toms that most closely match their own.
5. If that is ineffective, they use some of “Mable’s
medicine” (she lives down the road, had similar
symptoms, and did not finish her medicine).
6. Next, they ask the local pharmacist for a recom-
mendation; this usually marks the first encounter
with a professional health provider. (Of course,
they usually do not tell the pharmacist that they
tried Mable’s medicine.) The pharmacist may
strongly suggest that they see a health-care
provider; however, on their insistence, the
pharmacist may recommend another OTC
medication.
7. When no relief is achieved, they seek a local
health-care provider or utilize local emergency-
and urgent-care centers.
8. If the condition does not resolve itself, the local
health-care provider refers them to a specialist in
the area or to a larger urban area (e.g., Lexing-
ton, Cincinnati).
9. The specialist treats the condition to the best of
her or his ability.
10. If unsuccessful, the specialist refers him or her to
the closest tertiary medical center.
These 10 steps may not always follow the sequence
presented here; some steps may be skipped, and not
all steps are always completed. Moreover, the time
frame around these 10 steps may be several years.
Often by the time typical Appalachians are referred
for definitive treatment, compensatory reserves have
been depleted and they die at large medical centers.
The story is then passed on in the “holler”: “So-and-
so went to [Hospital X] and died.” This pattern leads
to a significant mistrust of large medical centers and
continued reluctance to use these facilities effectively.
Health-care providers can have a significant impact
on improving a patient’s health-seeking behaviors by
providing information early on in the pattern of
health-seeking behaviors. Nurses especially can help to
reverse this pattern because they are viewed, by the
clients they serve in Appalachia, as knowledgeable, non-
judgmental, and respectful of Appalachian lifestyles.
Nutrition
Meaning of Food
As with most ethnic and cultural groups, food has
meaning beyond providing nutritional sustenance.
To many Appalachians, wealth means having plenty
of food to share with family, friends, and at social
gatherings. It is generally believed that one should
drink plenty of fluids and eat plenty of good food
to have a strong body. A strong body is a healthy
body. Food and the sharing of food have broad so-
cial implications. Applalachians love to get together
with family members, friends, and neighbors for
meals. Weekend meals at a family member’s home
are common and serve as a mechanism to share in-
formation, community events and happenings, and
gossip. Church suppers are also commonplace, with
members contributing favorite dishes.
Common Foods and Food Rituals
Many Appalachians, and especially those living in the
more remote areas, include wild game in their diet.
Muskrat, groundhog, rabbit, squirrel, duck, turkey,
and venison commonly supplement “store-bought”
meats. Wild game traditionally has a lower fat content
than meat raised for commercial purposes. However,
consistent with traditional practices from previous
decades, most parts of both wild and domesticated
animals are eaten. High-cholesterol organ meats such
as tongue, liver, heart, lungs (called lights), and brains
are considered delicacies. Bone marrow is used to
make sauces, and stomach, intestines (chitterlings or
“chitlins”), pigs’ feet, tail, and ribs are also commonly
eaten. Low-fat game meat is usually breaded and fried
with lard or animal fat, negating the overall gains from
these low-fat meat sources. Most diets include sweet
prepackaged drinks, Kool-Aid with added sugar, very
sweet iced tea, and soda. In fact, “sweet tea” is a year-
round favorite, and most people keep a jar of it in the
refrigerator or on the porch in cooler weather.
Food preparation practices may increase dietary
risk factors for cardiac disease because many recipes
contain lard and meats that are preserved with
salt. Other common foods in particular regions of
Appalachia that may be unfamiliar to nonnative
Appalachians are sweet potato pie; molasses candy;
apple beer; gooseberry pie; pumpkin cake; and pick-
led beans, fruit, corn, beets, and cabbage, all of which
are high in sodium. Frying foods with bacon grease
or lard was once a common practice, but recent pub-
licity on the dangers of lard has initiated a cutback
in its use in cooking (Huttlinger et al., 2004a). Fried
People of Appalachian Heritage 147
2780_Ch08_137-158 16/07/12 11:43 AM Page 147

green tomatoes, biscuits, and thick gravies are ongo-
ing favorites.
Appalachians celebrate Thanksgiving, Christmas,
other national and religious holidays, and many other
occasions with food. In rural areas, people celebrate
with food when game and livestock are slaughtered be-
cause this is usually an extended-family or community
affair. The value of self-reliance is enhanced during the
“cannin” season when foodstuffs are preserved. Can-
ning becomes a social or family occasion and is an ex-
cellent avenue for health teaching if the health-care
provider is willing to participate and learn. Additional
celebrations with food occur during times of death and
grieving, when friends and participants bring dishes
specifically prepared for the occasion.
Dietary Practices for Health Promotion
Many Appalachians believe that good nutrition has an
effect on one’s health. In one study with rural Ap-
palachians, young mothers were asked what it meant to
eat well for good health. They referred to “taking fluids”
and “eating right,” but they were unable to describe
healthy eating patterns any further (Gainor, Fitch, &
Pollard, 2006). Because of health intervention programs,
publicity though television, magazines, newspapers, and
the Internet, residents of most Appalachian communi-
ties are aware of “good foods” and “bad foods” in terms
of general health. However, a lack of money and having
a meager budget that requires the use of food stamps
may limit choices.
Many believe that the sooner a baby can take food
other than milk, the healthier it will be. At one time,
babies from the first month were fed grease, sugar, and
coffee to promote hardiness, but the practice seems to
have fallen by the wayside with the younger genera-
tions of mothers. The editor (L. Purnell) fondly
remembers being fed teaspoons of bacon grease as a
child to be sure to grow up strong and healthy.
Another example is a family who saved the skin from
fried chicken for him to eat to increase his body
fat, because they believed that he was too thin. The
Special Supplemental Nutrition Program for Women,
Infants, and Children, commonly known as WIC, has
done much to change some of these practices. Health-
care providers have a rich opportunity to provide
education in healthy eating practices. Factual infor-
mation that describes health risks with early feeding
of solid foods may help prevent later nutritional
allergies in children.
An example of how a community intervention
can work is illustrated by the decrease in the inci-
dence of hypertension in one community. A local
health-care provider participated in the “cannin’” of
beans and showed the residents that the beans would
remain crisp with a “tige (a pinch) of vinegar” rather
than a “pile of salt.” It is essential for health-care
providers to assess specific food practices and food
preparation practices in order to provide effective
dietary counseling for health promotion and well-
ness. Health-care providers in clinics and school
settings have an excellent opportunity to have a pos-
itive impact on the nutritional status of individuals
and families. School breakfast and lunch programs,
Meals on Wheels, and church-sponsored meal plans
are some of the ways in which health-care providers
can encourage and support families to attain better
nutrition practices.
Nutritional Deficiencies and Food Limitations
A common practice for rural and urban Appalachian
children is to replace meals with snacks. The most
common snacks are candy, salty foods, desserts, and
carbonated beverages. Many adolescents skip break-
fast and lunch entirely, preferring to eat snack foods.
This pattern of snacking can result in deficiencies in
vitamin A, iron, and calcium.
There are no specific food limitations or enzyme de-
ficiencies associated with the people of Appalachia.
With subsistence farming and commercial farms from
nearby areas, all foods for a healthy diet are readily
available during the growing season. Even though the
climate is ideal for growing a large variety of vegeta-
bles, broccoli, cauliflower, or asparagus are rarely seen
as vegetables of choice in the mountainous regions of
Appalachia.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Birth outcomes in the more rural areas of Appalachia
are poorer than among middle-class white groups in
rural, suburban, and urban populations. In one study
that compared birth outcomes among rural, rural-
adjacent, and urban women, rural women had the
worst birth outcomes overall; rural-adjacent women
had the best birth outcomes of the three groups, yet
they were the youngest, least educated, least likely
to be married, and least likely to be privately insured
(Gainor et al., 2006). Contraceptive practices of
Appalachians follow the general pattern of the U.S.
population. Methods include birth control pills, con-
doms, and tubal ligation; abortion is an individual
choice. A popular belief among many is that taking
laxatives facilitates an abortion. As a group, a dispro-
portionate number of teenage pregnancies occur at a
younger age compared with non-Appalachians.
Fertility practices and sexual activity, both sensitive
topics for many teenagers, are topics in which outsiders
unknown to the family may be more effective than
health-care practitioners who are known to the family.
To be effective, counseling by the health-care provider
must be accomplished within the cultural belief pat-
terns of this group and must be approached in a
148 Aggregate Data for Cultural-Specific Groups
2780_Ch08_137-158 16/07/12 11:43 AM Page 148

nonhierarchical manner, preferably with a health-care
provider of the same gender.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Although the literature reports no specific research or
studies related to prescriptive, restrictive, or taboo
practices during pregnancy, the following are some of
the current beliefs:
• Pregnant women subscribe to the belief that to
have a healthy baby, they need to eat well and
take care of themselves.
• Boys are carried higher and the mother’s belly
appears pointy, whereas girls are carried low.
• The expectant mother should not have her picture
taken because it can cause a stillbirth.
• Reaching over one’s head can cause the cord to
strangle the baby.
• Wearing an opal ring during pregnancy may harm
the baby.
• Being frightened by a snake or eating strawberries
or citrus fruit can cause birthmarks.
• If the mother experiences a tragedy, a congenital
anomaly may occur.
• If the mother craves a particular food during her
pregnancy, then she should eat that food or the baby
will have a birthmark resembling the craved food.
Childbearing is a family affair. The birthing mother
is expected to accept childbirth as a short, intense, nat-
ural process that will bring her closer to the earth and
must be endured (Gainor et al., 2006).
The literature reports no specific studies on beliefs
related to postpartum practices. When a new baby is
born, relatives and extended family members gather
to assist the new mother with household chores until
she is able to complete them herself. Some newborns
wear a band around the abdomen to prevent umbilical
hernias and an asafetida bag around the neck to pre-
vent or ward off contagious diseases. The health-care
professional providing pregnancy counseling to the
Appalachian family needs to demonstrate an openness
to discuss cultural differences.
Death Rituals
Death Rituals and Expectations
When a death is expected, family and friends may stay
through the night and prepare food for the event and
provide comfort for family members. Because death is
such an important occasion in Appalachia, many em-
ployers give workers three days of funeral leave for
deaths of extended family members. After a death, ex-
tended family and friends may spend several nights with
the deceased’s immediate family to prevent loneliness.
Deaths in Ohio, Michigan, and other adjoining states
are frequently published in Appalachian newspapers
with a notice that the individual will be returned to their
mountain home for burial. Funeral services serve an im-
portant social function and are usually simple. This is a
time when extended family and friends come together
for services that can last for three hours or longer. The
length of time for a service varies according to the age
of the deceased. The service for an older person may be
longer than that for a younger person. The body is dis-
played for hours, either in the home or at the church, so
that all those who wish to view the body can do so. At
the end of the service, all who wish to can view the body
again, with the closest relative being the last. Many Ap-
palachian families go to funeral homes that specialize
in personal services to the Appalachian culture. Urban
Appalachian areas have funeral homes that specialize in
long-distance transport for burial and have become
familiar with Appalachian customs to meet culturally
specific requirements.
The deceased is usually buried in her or his best
clothes. Some individuals have a custom-made set of
clothes in which to be buried and may even design
their own funeral services long before their death. A
common practice is to bury the deceased with per-
sonal possessions. At the funeral home, the person’s
favorite chair, a picture of the deceased, or other per-
sonal items may be displayed. Flowers are more im-
portant than donations to a charity. Cremation is an
acceptable practice, and disposition of the ashes is a
personal decision. After the funeral services are com-
pleted, elaborate meals are served either in the home
or at the church. Services are accompanied by singing
before, during, and after the service. Cemeteries
throughout Appalachia show frequent visitations and
give a sense of place and relationship to the land. Plots
are carefully tended with displays of flowers, wreaths,
and flags. Other beliefs regarding burial practices in-
clude placing graveyards on hillsides for fear that
graves may be flooded out in low-lying areas. If the
body is exhumed and reburied, it is believed that the
person might not go to heaven.
Responses to Death and Grief
Clergy help families through the grieving process by
providing counseling and support to family members.
Family members, fellow church members, friends, a
nd community leaders often assist the bereaved. Typ-
ically, family members get together and reminisce
about their deceased loved one. Friends and neighbors
bring food for about a week and share memories of
the “one who passed on.”
Spirituality
Dominant Religion and Use of Prayer
The original inhabitants of Appalachia were mostly
Protestant and Episcopalian. In the early settlement
years, because central organization of churches was
People of Appalachian Heritage 149
2780_Ch08_137-158 16/07/12 11:43 AM Page 149

difficult to retain, people individualized their chosen
church structure. Today, the predominant religions in
the Appalachian region are Baptist, Methodist, Pres-
byterian, Holiness, Pentecostal, and Episcopalian. For
most Appalachians, the church is the center for social
and community activities. Some of the more reli-
giously devout pray daily whether or not they formally
attend church. Very often, religious beliefs are of a
spiritual nature and not tied to the tenets of any sin-
gular faith and reflect the harmony of the mountains
and being at one with life.
In addition to Protestant and Episcopalians, there are
congregations of Roman Catholics and Jehovah’s Wit-
nesses as well as other groups who, although they call
themselves Baptists, are not associated with the national
church organization. These Baptist sects are quite di-
verse and have important central beliefs, including the
belief in autonomy at the local level. As a result, many
divisions have occurred within and among churches to
accommodate more personal beliefs and philosophies.
Regardless of the denomination, most churches in the
region stress fundamentalism in religious practices and
use the King James Version of the Bible.
Many small churches have lay preachers instead of
trained ministers, and there is a belief that to be a
preacher, a person must have a divine calling. Thus, a
minister may or may not be ordained. Many of the
Baptist faiths believe that baptism must be done in a
river, pond, or lake so that the body can be submerged.
Another practice, feet washing, is believed to demon-
strate humility and occurs when men wash men’s feet
and women wash women’s feet. Many of the more fun-
damentalist churches segregate women and children
from men in the seating arrangement within the church;
men and older boys sit on one side, and women and
children sit on the opposite side. In some churches, men
sit on the right side of the church to represent the “right
hand of God,” while women sit on the left (Huttlinger,
personal communication, 2006).
Some denominations believe in divine healing, and
the region is full of examples to testify to its effective-
ness. Two or more weekly services are common, and
revival meetings are customary. Revivals tend to be
lively, allowing individuals to shout out when the spirit
moves them. Some denominations speak in tongues
and believe in visions. Stringed music is played in some
churches.
Some freewill churches—for example, the Holiness
Church—preach against attending movies, ball games,
and social functions where dancing occurs. Other sects
believe in handling poisonous snakes. Although the
practice is rare, it is believed that the snake will not
bite those who have faith. The common Bible verse
“And these signs shall follow them that believe; In my
name shall they cast out devils; they shall speak with
new tongues; They shall take up serpents; and if they
drink any deadly thing, it shall not hurt them; they
shall lay hands on the sick, and they shall recover”
(Mark 16:17–18) is usually associated with snake-
handling practices. A few people do get bitten by
snakes, and their usual course of action is to heal them-
selves rather than go to a hospital, even though deaths
occur each year following snake-handling rituals.
Another practice, the ingestion of strychnine in
small doses during religious services, is believed to in-
crease sensory stimuli. Needless to say, this practice
can precipitate convulsions if ingested in large enough
amounts. Fire-handling is still practiced by some
groups, again with the belief that the hot coals will not
burn those who have faith.
Prayer for many Appalachians is a primary source
of strength. Prayer is personally designed around spe-
cific church and religious beliefs and practices, which
vary widely throughout the region and between and
among churches of similar faith.
Meaning of Life and Individual Sources
of Strength
Meaning in life comes from the family and “living
right,” which is defined by each person and usually
means living right with God and in the beliefs of a
chosen church. Religion tends to be less focused on
institutional rituals and ceremonies and consists more
of personalized beliefs in God, Christ, and church.
Because life in the mountainous regions can often be
harsh, religious beliefs and faith make life worth living
in a grim situation. The church provides a way of cop-
ing with the hurts, pains, and disappointments of a
sometimes hostile environment and becomes a source
for celebration and a social outlet.
Common themes that give Appalachians strength
are family, traditionalism, personalism, self-reliance,
religiosity, a worldview of being, and not having undue
concern about things that one cannot control, such as
nature and the future. Appalachians believe that
rewards come in another life, in which God repays one
for kind deeds done on earth.
Spiritual Beliefs and Health-Care Practices
Within the context of fatalism comes the belief that
what happens to the individual is largely a result of
God’s will. Many Appalachians may not seek health
care until symptoms of illness are well advanced. This
practice is described more thoroughly under “High-Risk
Behaviors,” earlier in this chapter. Forming partnerships
between health-care providers and faith-related organi-
zations for health promotion and illness and disease pre-
vention has strong potential for improving the health
status of Appalachians. Health-care providers who are
aware of patients’ religious practices and spirituality
needs are in a better position to promote culturally com-
petent health care and to incorporate nonharmful prac-
tices into patients’ care plans. Health-care providers
must indicate an appreciation and respect for the dignity
150 Aggregate Data for Cultural-Specific Groups
2780_Ch08_137-158 16/07/12 11:43 AM Page 150

and spiritual beliefs of Appalachians without expressing
negative comments about differing religious beliefs and
practices.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Beliefs that influence health-care practices for many
Appalachians are derived from concepts such as
family, fatalism, traditionalism, self-reliance, individ-
ualism, and the ethic of neutrality. Even though many
Appalachians believe that health is God’s will, the
concept of self-reliance can foster good health prac-
tices through self-care. Many may not see formal bio-
medical health-care providers until self-medicating
and folk remedies have been exhausted. At one time,
Appalachians, compared with non-Appalachians,
were less likely to use the emergency room or to have
private physicians, but the trend has since changed,
and today emergency rooms and urgent-care centers
are communly used (GMEC, 2001; Obermiller &
Brown, 2002).
Health information on the Appalachian patient
should be gathered in the context of broader family re-
lationships and cordiality that precedes information
sharing, as the family rather than the individual is the
basic unit for treatment. Because direct approaches are
frowned upon, health-care providers need to learn to
approach sensitive topics, such as contraception and
alcohol and drug use, indirectly. Many Appalachians
expect the health-care provider to establish an advo-
cacy role and to understand and accept their cultural
differences; thus, it is best to involve professionals from
the same backgrounds, if they are available.
Huttlinger and colleagues (2004a) surveyed a large
sample of Appalachians from southwestern Virginia
and northeastern Tennessee to determine access to
health care. They also addressed factors related to
“good health.” Over 75 percent stated that their health
was “God’s will,” and over half stated that their fam-
ilies, church, and community played a vital role in
their overall health and well-being.
Responsibility for Health Care
When entering the biomedical health-care arena,
Appalachians might feel powerless to control their own
health. They often abdicate responsibility for their own
care and expect that the health-care provider will com-
pletely take over their care. Many have high expecta-
tions for their health-care provider, with an unrealistic
dependence on the system and an abandonment of
more self-reliance activities (Coyne et al., 2006).
One major health concern for many Appalachians
is the state of the blood, which is described as being
thick or thin, good or bad, and high or low; these con-
ditions can be regulated through diet (Huttlinger, per-
sonal communication, 2006; Obermiller & Brown,
2002). Venereal disease and Rh-negative blood fall
into the category of bad blood. Sour foods can also
cause bad blood. Appalachian men, in general, report
a greater number of backaches, with women reporting
a greater number of headaches, than the rest of
society (Coyne et al., 2006).
Self-care is a primary focus of health. Self-care is
primarily perceived as an individual responsibility, and
care is focused within the family rather than within the
community. Because many Appalachians value the
ability to respond to, and cope with, events of daily
life, home remedies, treatments, and active consulta-
tion with family members are sought before seeking
outside help (Huttlinger et al., 2004a). Good health is
feeling well and being able to meet one’s obligations.
Care within the medical system is used when the con-
dition is perceived as serious, does not respond to self-
care, or has a high potential for death. Furthermore,
because self-reliance activities and nature predominate
over people, many believe that it is best to let nature
heal. Health-care providers need to keep this in mind
when giving explanations and instructions to make
them more acceptable to patients and their families.
When older Appalachians go to a physician or an-
other health-care provider, they usually expect imme-
diate help. Physicians who dispense medications
in their offices are seen as helpful; providing prescip-
tions may be interpreted as rejection. The average
Appalachian patient does not understand the restric-
tions and limitations that are placed on physicians
and nurse practitioners with respect to dispensing
“sample” medications.
Health-care providers can assist Appalachian pa-
tients by reinforcing their preferred coping methods
and strategies when they are ill. The five most fre-
quently used coping methods are helping, thinking
positively, worrying about the problem, trying to find
out more about the problem, and trying to handle
things one step at a time. Coping strategies include
talking the problem over with friends, praying, think-
ing about the good things in life, trying to handle
things one step at a time, and trying to see the
good side of the situation (Hunsucker, Flannery, &
Frank, 2000). When establishing rapport, a health-
care provider can go a long way in achieving trust by
using churches, grange halls, and other community
places (e.g., libraries, schools) as meeting places for
the entire family to work with Appalachian families
at the community level.
Folk and Traditional Practices
A strong belief in folk medicine is a traditional part
of the Appalachian culture. Using herbal medicines,
poultices, and teas is common practice among indi-
viduals of all socioeconomic levels. Table 8-1 presents
a reference guide for the health-care provider with the
major ingredients and conditions for which the folk
People of Appalachian Heritage 151
2780_Ch08_137-158 16/07/12 11:43 AM Page 151

152 Aggregate Data for Cultural-Specific Groups
❙❙◗ Table 8-1 Health Conditions and Appalachian Folk Medicine Practices
Health Condition Folk Medicine Practices
Arthritis Make tea from boiling the roots of ginseng. Drink the tea or rub it on the arthritic joint.
Mix roots of ginseng and goldenseal in liquor and drink it. Ginseng is used heavily by many Koreans and was
exported to Korea in the 18th and 19th centuries.
Eat large amounts of raw fruits and vegetables.
Carry a buckeye around in a pocket.
Drink tea from the stems of the barbell plant.
Drink a mixture of honey, vinegar, and moonshine (or other liquor).
Drink tea made from alfalfa seeds or leaves.
Drink tea made from rhubarb and whiskey.
Place a magnet over the joint to draw the arthritis out of the joint.
Asthma Drink tea from the bark of wild yellow plum trees, mullein leaves, and alum. Take every 12 hours.
Combine gin and heartwood of a pine tree. Take twice a day.
Suck salty water up the nose.
Smoke or sniff rabbit tobacco.
Swallow a handful of spiderwebs.
Smoke strong tobacco until choking occurs.
Drink a mixture of honey, lemon juice, and whiskey.
Inhale smoke from ginseng leaves.
Bedbugs/chiggers Apply kerosene liberally to all parts of the body. Caution: Kerosene can cause significant irritation to sensitive
skin, especially when exposed to sunlight.
Bleeding Place a spiderweb across the wound. This is also used in rural Scotland.
Put kerosene oil on the cut.
Place soot from the fireplace into a cut. Be sure to wash out the soot after bleeding is stopped, or the area
will scar.
Apply a mixture of honey and turpentine on the bleeding wound.
Apply a mixture of soot and lard on the wound.
Place a cigarette paper over the wound.
Put pine resin over the cut.
Place kerosene oil on the wound. Caution: If used in large doses, kerosene will burn the skin.
Blood builders Drink tea from the bark of a wild cherry tree.
Combine cherry bark, yellowroot, and whiskey. Take twice each day.
Eat fried pokeweed leaves.
Blood purifiers Drink tea from burdock root.
Drink tea from spice wood.
Blood tonic Take a teaspoon of honey and a tiny amount of sulfur.
Take a teaspoon of molasses and a tiny amount of sulfur.
Drink tea made from bloodroot.
Soak nails in a can of water until they become rusty. Drink the rusty water.
Boils or sores Apply a poultice of walnut leaves or the green hulls with salt.
Apply a poultice of the houseleek plant.
Apply a poultice of rotten apples.
Apply a poultice of beeswax, mutton tallow, sweet oil, oil of amber, oil of spike, and resin.
Apply a poultice of kerosene, turpentine, petroleum jelly, and lye soap.
Apply a poultice of heart leaves, lard, and turpentine.
Apply a poultice of bread and milk.
Apply a poultice of slippery elm and pork fat.
Apply a poultice of flaxseed meal.
Apply a poultice of beef tallow, brown sugar, salt, and turpentine.
2780_Ch08_137-158 16/07/12 11:43 AM Page 152

People of Appalachian Heritage 153
❙❙◗ Table 8-1 Health Conditions and Appalachian Folk Medicine Practices Continued from page 152
Health Condition Folk Medicine Practices
Burns Apply a poultice of baking soda and water.
Place castor oil on the burn.
Apply a poultice of egg white and castor oil.
Place a potato on the burn.
Wrap the burn in gauze and keep moist with salt water.
Place linseed oil on the burn.
Apply a poultice of lard and flour.
Put axle grease on the burn. This is also a practice with some Germans in Minnesota.
Chapped hands Apply lard, grease, or tallow from pork or mutton.
and lips
Chest congestion Apply a poultice of kerosene, turpentine, and lard to the chest. Make sure the poultice is not applied directly
to the chest but rather on top of a cloth.
Apply mutton tallow directly to the chest.
Apply a warm poultice of onions and grease.
Rub pine tar on the chest.
Chew leaves and stems of peppermint.
Drink a combination of ginger and sugar in hot water.
Make a mixture of rock candy and whiskey. Take several teaspoons several times each day.
Drink tea made from ginger, honey, and whiskey.
Drink tea made from pine needles.
Put goose grease on the chest.
Drink red pepper tea.
Eat roasted onions.
Drink brine from pickles or kraut.
Make tea from boneset, rosemary, and goldenrod.
Make tea from butterfly weed.
Colic Make tea from calamus root and catnip. (Calamus is a suspected carcinogen.)
Tie an asafetida bag around the neck.
Drink baking soda and water.
Chew and swallow the juice of camel root.
Massage stomach with warm castor oil.
Drink ginseng tea.
Constipation Take two tablespoons of turpentine.
Combine castor oil and mayapple roots.
Take castor oil or Epsom salts.
Croup Have child wear a bib containing pine pitch and tallow.
Apply cloth to the chest saturated with groundhog fat, turpentine, and lamp oil.
Drink juice from a roasted onion.
Apply a poultice of mutton tallow and beeswax to the back.
Eat a spoonful of sugar with a drop of turpentine.
Eat honey with lemon or vinegar.
Eat onion juice and honey.
Diarrhea Drink tea from the ladyslipper plant.
Place soot in a glass of water, let the soot settle to the bottom of the glass, and drink the water.
Drink tea made from blackberry roots.
Drink tea from red oak bark.
Drink blackberry or strawberry juice.
Drink tea made from strawberry or blackberry leaves.
Drink tea made out of willow leaves.
Drink the juice from the bark of a white oak or a persimmon tree.
Continues on page 154
2780_Ch08_137-158 16/07/12 11:43 AM Page 153

154 Aggregate Data for Cultural-Specific Groups
❙❙◗ Table 8-1 Health Conditions and Appalachian Folk Medicine Practices Continued from page 153
Health Condition Folk Medicine Practices
Earache Place lukewarm salt water in the ear.
Put castor oil or sweet oil in the ear.
Put sewing machine oil in the ear.
Place a few drops of urine in the ear.
Place cabbage juice in the ear.
Blow smoke from tobacco in the ear.
Place a Vicks VapoRub–soaked cotton ball in the ear.
Eye ailments Place a few drops of castor oil in the eye.
Drop warm, salty water in the eye.
Drink tea made from rabbit tobacco or snakeroot.
Fever Drink tea made from butterfly weed, wild horsemint, or feverweed.
Mash garlic bulbs and place in a bag tied around the pulse points.
Drink water from wild ginger.
Headache Drink tea made of ladyslipper plants.
Tie warm fried potatoes around the head.
Take Epsom salts.
Tie ginseng roots around the head.
Place crushed onions on the head.
Rub camphor and whiskey on the head.
Heart trouble Drink tea made from heartleaf leaves or bleeding heart.
Eat garlic.
High blood Drink sarsaparilla tea.
pressure (not Drink a half cup of vinegar.
to be mistaken
for high blood)
Kidney trouble Drink tea made from peach leaves or mullein roots.
Drink tea made from corn silk or arbutus leaves.
Liver trouble Drink tea made from lion’s tongue leaves.
Drink tea made from the roots of the spinet plant.
Poison ivy Urinate on the affected area.
Take a bath in salt water and then apply petroleum jelly.
Wash the area with bleach.
Wash the area with the juice of the milkweed plant.
Apply a poultice of gunpowder and buttermilk.
Apply baking soda to wet skin.
Sore throat Gargle with sap from a red oak tree.
Eat honey and molasses.
Eat honey and onions.
Drink honey and whiskey.
Tie a poultice of lard of cream with turpentine and Vicks VapoRub to the neck.
Apply a poultice of cottonseed to the throat.
Swab the throat with turpentine.
treatments are used (Fig. 8-3). These treatments can
be adjusted to accommodate prescription therapies or
education regarding folk treatments. Information in
this table has been derived from the Foxfire series, the
authors’ backgrounds and experiences, and health-
care providers who practice in the area. Note that spe-
cific amounts are not given, and in many cases, the
amounts vary from person to person, according to the
geographic region and local family practices. Local
names are given rather than scientific names because
this is how the residents identify them. Folk and tra-
ditional practices were learned from the Cherokee and
Apalachee Indians living in the region and have been
passed down from generation to generation. Although
many of these home remedies are not harmful, some
may have a deleterious effect when used to the exclusion
2780_Ch08_137-158 16/07/12 11:43 AM Page 154

of, or in combination with, prescription medications.
This should be evident from the 10-step pattern
health-seeking behaviors among Appalachians pre-
sented in the section on health-care practices.
Because ingredients in some of these herbal medi-
cines can have serious side effects, especially if taken
in large quantities, health-care providers must become
familiar with folk medicines used by Appalachians as
part of patient assessments. Health-care providers
must ascertain whether individuals intend to use folk
medicines simultaneously with prescription medica-
tions and treatment regimens so that these remedies
can be incorporated into the plan of care and that di-
alogue can be undertaken to prevent adverse effects.
Health-care providers who integrate folk medicine
into allopathic prescriptions have a greater chance of
improving patients’ compliance with health prescrip-
tions and interventions. Health-care providers must
remember that today’s scientific medicine may be tra-
ditional or folk medicine to the next generation.
Barriers to Health Care
Barriers to health care for Appalachians are numerous
and center on accessibility, affordability, adaptability,
acceptability, appropriateness, and awareness. Bureau-
cratic, written forms foster fear and suspicion of
health-care providers, which can lead to confusion,
distrust, and negative stereotyping by both parties.
Some individuals fear “being cut on” or “going under
the knife” and feel that a hospital is a place where you
go only to give birth or die.
As noted earlier, the rugged terrain and distance to
health-care facilities and service is a deterrent to ac-
cessing services. Even though the ARC has sponsored
road-building campaigns in the mountainous regions
of Appalachia since 1965, transportation problems
continue to exist in parts of the region (see Fig. 8-1).
The high rate of unemployment in Appalachia means
that many people cannot afford basic health care. A
disproportionate number of Appalachians, especially
those who are self-employed, unemployed, or under-
employed, do not have health insurance. For some
who do not believe in owing money, seeing a health-
care provider may be postponed until the condition is
severe or until they have the money. If services can be
offered on a sliding scale, more people may be willing
to access them.
Health-care facilities are closing in some areas of
Appalachia. Most often, the closings are related to
People of Appalachian Heritage 155
Figure 8-3 American ginseng root.
R E F L E C T I V E E X E R C I S E 8 . 2
American ginseng (Panax Quinquefolius) is a therapeutic root
found throughout Appalachia. Known for its strong medicinal
value, ginseng (or locally known as “SANG”) is grown in
“patches” that are highly coveted and fiercely protected. The
American species of ginseng was discovered in the Appalachia
hills in the 1700s, and a significant trade for the root with
China was begun. An estimated 750,000 pounds or more of
wild ginseng roots were exported in 1822 (Pokladnik, 2009)
and at that time sold for 2 cents per pound. Today’s rates for
ginseng vary from $200 to $1500 per dry pound. By the early
1900s, it was recognized that unless the ginseng root was pro-
tected, Appalachia would soon become depleted of this valu-
able product. Wild ginseng root is currently protected under
Appendix II of the Convention of International Trade of En-
dangered Species, and the ginseng trade is closely monitored
by the U.S. Fish and Wildlife Services (Pokladnik, 2009).
Ginseng root is sold in health food stores throughout the
United States and is used to boost energy, relieve stress, im-
prove concentration, and enhance physical or cognitive per-
formance. Ginseng is also believed to act as a general
restorative or tonic, which have strengthening properties that
restore the body’s balance, enhance stamina, and increase re-
sistance to stress and disease. When compared to the Chinese
variety of ginseng, the American ginseng is thought to have a
more cooling or calming quality, as opposed to the Asian gin-
seng which is thought to have more heating or stimulating
properties. According to Traditional Chinese Medical (TCM)
theory, American ginseng is used to calm the ailing respiratory
or digestive systems and as therapy for diabetes or “thirsty”
syndromes. It also seems to be preferred by people who live
in warmer climates. Native Americans traditionally employed
American ginseng to help with childbirth and fertility and to
strengthen mental powers, and for a variety of ailments such
as respiratory disorders, headaches, and fevers.
1. How do you think the ginseng root is prepared for
consumption?
2. Go to a health food store and identify the ways in which
ginseng is prepared for sale (i.e., tablets, as a mixture
with other plants, etc.).
3. A patient wants to include ginseng with prescriptive
medication. What is your advice?
2780_Ch08_137-158 16/07/12 11:43 AM Page 155

decreasing availability of health-care providers and
the ability to pay competitive salaries, especially for
registered nurses (Huttlinger, personal communica-
tion, 2006). These changes have resulted in the reloca-
tion of highly educated and trained professionals of
all professions.
Recent studies have demonstrated that there is
not a lack of primary-care providers in Appalachia
(Huttlinger et al., 2004a); however, a large portion of
health-care being provided by nurse practitioners is
readily evident. There is, however, an acute shortage
of specialty providers and especially those for respi-
ratory and pulmonary diseases, oncology, dental serv-
ices, and ophthalmology. Those physicians who settle
in the region quickly learn that flexible fee schedules,
patience, and hands-on treatment approaches work
best. Referral to specialty care in the larger urban cen-
ters must be made with consideration of travel and
other expenses. For example, a referral to a pulmo-
nologist in Charlottesville, Virginia, for a person who
lives in Wise might require a 3-day trip because 2 days
are needed just to travel each way. Add to this the ex-
pense of gasoline, a relative taking off work to drive
the person, and two nights in a motel, and it becomes
something many Appalachians cannot afford.
Preventive health services have not been stressed in
the past and are not perceived as important by many
(GMEC, 2001). Even when services are available, peo-
ple may feel they are not delivered in an appropriate
manner. Outsider health-care providers may be seen as
disrespectful of Appalachian ways and self-care prac-
tices, and patients may see the health-care providers’
advice as criticism. If the health-care provider uses lan-
guage that the patient does not understand, the health-
care provider may be perceived as “stuck up.” Many
Appalachians do not like the impersonal care delivered
in large clinics and, therefore, shop around and ask
friends and family for suggestions for a private health-
care provider. “Sittin’ for a spell and engagin’ in small
talk” with the patient before an examination or treat-
ment will help ensure return visits for follow-up care.
When health-care facilities have limited hours or are
not adaptable, patients may not return for scheduled
appointments. For example, a mother may bring her
child in for an immunization. If the mother has a health
problem and perhaps needs a Pap smear, she may be
willing to have the test performed while having the child
examined. However, if she is given an appointment to
return at a later date, she may not keep the appointment
because it is too far to travel for a problem she sees as
nonurgent. If services are not available during evening
hours, people may be afraid of taking time off during
regular work hours for fear of losing their job.
Cultural Responses to Health and Illnesses
Appalachians take care of their own and accept a per-
son as a “whole individual.” Thus, those with mental
impairments or physical handicaps are generally
accepted into their communities and not turned away.
People with a mental handicap are not seen as “crazy”
but are seen as having “bad nerves,” “quite turned,”
or “odd turned.” Appalachians may label certain
behaviors as “lazy,” “mean,” “immoral,” “criminal,”
or “psychic” and will either recommend punishment
by either the social group or the legal system or toler-
ate these behaviors (Obermiller & Brown, 2002).
Traditional Appalachians believe that disability is
a natural and inevitable part of the aging process.
Their culture of being discourages the use of rehabil-
itation as an option. To establish trust and rapport
when working with Appalachian patients with chronic
diseases, health-care providers must avoid assump-
tions regarding health beliefs and provide health
maintenance interventions within the scope of
cultural customs and beliefs.
Individual responses to pain cannot be classified
among Appalachians. The Appalachian background
is too varied, and no studies regarding cultural beliefs
about pain could be found in the literature. For many
Appalachians, pain is something that is to be endured
and accepted stoically. However, when a person be-
comes ill or has pain, personal space collapses inward,
and the person expects to be waited on and to be cared
for by others. A belief among many is that if one
places a knife or axe under the bed or mattress of a
person in pain, the knife will help cut the pain. This
practice occurs with childbearing and other condi-
tions that cause pain. The editor (L. Purnell) is aware
of an Appalachian woman who requested to have a
knife or axe placed under the bed or mattress postop-
eratively to help cut (or decrease) the pain associated
with surgery. He offered a small pocketknife or butter
knife to place under the bed. Both were unacceptable
as the pocketknife was too small and the butter knife
was too dull to be of use. A sharp meat-cutting knife
from the kitchen was deemed appropriate because it
was both large enough and sharp enough to help cut
the pain.
Blood Transfusions and Organ Donation
Appalachians generally do not have any specific rules
or taboos about receiving blood, donating organs, or
undergoing organ transplantation. These decisions are
largely one’s own, but advice is usually sought from
family and friends.
Health-Care Providers
Traditional Versus Biomedical Providers
For decades, both lay and trained nurses have provided
significant health-care services, including obstetrics.
Granny midwives and more formally trained midwives
have provided obstetric services throughout the history
of Appalachia. Although many practitioners and
156 Aggregate Data for Cultural-Specific Groups
2780_Ch08_137-158 16/07/12 11:43 AM Page 156

herbalists are older women, men may also become
healers. Grannies and herb doctors are trusted and
known to the individual and the community for giving
more personalized care.
The entire Appalachian area has a shortage of
health personnel even though recent years have evi-
denced a good supply of primary-care providers,
thanks to government incentives for medical school
loans. As a result, nurse practitioners have delivered
the bulk of health care to some areas of Appalachia
(Huttlinger et al., 2004a; 2004b).
The Frontier Nursing Service, started by Mary
Breckenridge, is one of the oldest and most well-
known nurse-run clinics in the United States and is a
notable example of nurses, midwives, and nurse prac-
titioners taking the initiative to provide health care in
Appalachia. It was started in one of the most rural
areas of Appalachia in response to a lack of physi-
cians and the high birth and child mortality rates in
the area (Dawley, 2003; Jesse & Blue, 2004). Many
Appalachians prefer to go to insider health-care pro-
fessionals, especially in the more rural areas, because
the system of payment for services is accepted on a
sliding scale, and in some communities, even an ex-
change of goods for health services exists. One nurse
practitioner in private practice states that the only
time she locks her car is when the zucchini are “in.” If
she does not, when she gets in her car after a clinic
session, she has no room to drive because of all the
“presents” of the large vegetable.
Locally respected Appalachians are engaged to fa-
cilitate acceptance of outside programs and of the
staff who participate at the grassroots level in plan-
ning and initiating programs. For Appalachian pa-
tients to become more accepting of biomedical care,
it is important for health-care providers to approach
individuals in an unhurried manner consistent with
their relaxed lifestyle, to engage patients in decision
making and care planning, and to use locally trained
support staff whenever possible.
Status of Health-Care Providers
Most herbal and folk practitioners are highly re-
spected for their treatments, mostly because they are
well known to their people and trusted by those who
need health care. Physicians and other health-care
providers are frequently seen as outsiders to the Ap-
palachian population and are, therefore, mistrusted.
This initial mistrust is rooted in outsider behaviors
that exploited the Appalachian people and took their
land for timbering and coal mining in earlier genera-
tions. Trust for an outsider is gained slowly. Once the
person gets to know and trust the health-care
provider, the provider is given much respect. Trust and
respect for health-care providers depend more on per-
sonal characteristics and personal behavior than on
knowledge.
In terms of provider care, Appalachians seem to
prefer home-based nurses, health-care workers, and
social workers. To obtain full cooperation, the health-
care provider needs to ask clients what they consider
to be the problem before devising a plan of care. If the
provider begins with an immediate diagnosis without
considering the patient’s explanation, there is a good
chance that the provider’s treatment or recommenda-
tion will be ignored. Lastly, it is important to decrease
language barriers by decoding the jargon of the
health-care environment.
R E F E R E N C E S
Appalachian Regional Commission (ARC). (2006a). Contains
various articles on economics, population statistics, health-care
delivery, education, and general life in Appalachia. http://www.
arc.gov/
Appalachian Regional Commission (ARC). (2006b). Twenty-six
communities awarded seed grants to battle substance abuse in
Appalachia. News Brief. http://arc.gov/
Appalachian RegionalCommission (2010). The Appalachian Re-
gion. http://www.arc.gov/appalachian_region/TheAppalachian-
Region.asp
Carter, M. (2005). Nursing home quality of care in Appalachia.
Report to the Regional Research Institute. Morgantown, WV:
Regional Research Institute (West Virginia University).
Center for Oral Health Research in Appalachia. (2010). A Look at
oral health disparities in Appalachia. University of Pittsburgh.
Center for Oral Health Research.
Centers for Disease Control and Prevention (CDC). (2004). CDC
report shows cancer death rates in Applachia higher than
national. https://www.scienceblog.com/community
Costello, C. (2000, May 30). Beneath myth, Melungeons find roots
of oppression: Appalachian descendants embrace heritage. The
Washington Post, p. A4.
Counts, M. M., & Boyle, J. S. (1987). Nursing, health, and policy
within a community context. Advances in Nursing Science, 9(3),
12–23.
Coyne, C., Demian-Popescu, C., & Friend, D. (2006). Social and
cultural factors influencing health in southern West Virginia:
A qualitative study. Preventing Chronic Disease, 3(4), A. 124.
Dawley, K. (2003). Origins of nurse-midwifery in the United States
and its expansion in the 1940s. Journal of Midwifery and Womens’
Health, 48(2), 86–95.
Gainor, R., Fitch, C., & Pollard, C. (2006). Maternal diabetes and
perinatal outcomes in West Virginia Medicaid enrollees. West
Virginia Medical Journal, 102(1), 314–316.
Graduate Medical Education Consortium (GMEC). (2001, August).
Report to the board. Wise, VA: Graduate Medical Education
Consortium.
Haaga, J. (2004). The aging of Appalachia: Demographic and
socioeconomic change in Appalachia. Washington, DC:
Appalachian Regional Commission.
Hays, J. (2004). A profile of oxycontin addiction. Journal of Addictive
Disorders, 23(4), 1–9.
Hendryx, M., & Ahern, M. (2009). Mortality in Appalachian coal
mining regions: The value of statistical life lost. Public Health
Reports, 124(4), 541–546.
Hunsucker, S., Flannery, J., & Frank, D. (2000). Coping strategies
of rural families of critically ill patients. Journal of the Ameri-
can Academy of Nurse Practitioners, 12(4), 123–127.
People of Appalachian Heritage 157
2780_Ch08_137-158 16/07/12 11:43 AM Page 157

Hurley, J., & Turner, H.S. (2000). Development of a health service
at a rural community college in Appalachia. Journal of American
College Health, 48(4), 181–189.
Huttlinger, K., Schaller-Ayers, J., & Lawson, T. (2004a). Health
care in Appalachia: A population-based approach. Public
Health Nursing, 21(2), 103–110.
Huttlinger, K., Schaller-Ayers, J., Kenny, B., & Ayers, J. (2004b).
Rural, community health nursing, research and collaboration.
Online Journal of Rural Nursing and Health Care, 4(1).
www.rno.org
Jesse, D., & Blue, C. (2004). Mary Breckinridge meets Healthy
People 2010: A teaching strategy for visioning and building
healthy communities. Journal of Midwifery & Womens’ Health,
49(2), 126–131.
Kennedy, N. (1997). Melungeons. Macon, GA: Mercer University
Press.
Lubell, J. (2006). Virginia doctors report controlled substances.
Program targets substances with high potential for abuse.
Modern Healthcare, 36(26), 32.
National Institute of Dental and Craniofacial Research. (2010).
A look at oral health disparities in Appalachia. http://www.
nidcr.nih.gov/Research/ResearchResults/InterviewsOHR/
COHRA.htm Obermiller, P., & Brown, M. (2002, February).
Appalachian health status in greater Cincinnati: A research
overview. Urban Council Working Paper No. 18. Cincinnati,
OH: Urban Appalachian Council.
Pokladnik, R. (2009). Preserving an Appalachian treasure—American
ginseng. http://www.ecowatch.org/pubs/aug09/ginseng.htm
Smith, S., & Tessaro, I. (2005). Cultural perspectives on diabetes
in an Appalachian population. American Journal of Health
Behavior, 29(4), 291–301.
University of Virginia. (2009). Health Appalachia: Improving cancer
control through telehealth in Southwestern Virginia. http://
www.virginiacpac.org/PDFs/HealthyAppalachia_0909
U.S. Drug Enforcement Agency (DEA). (2006a, September 9).
DEA briefs and backgound drugs and drug abuse, drug descrip-
tions. News Release. Washington, DC: Drug Enforcement
Agency.
U.S. Drug Enforcement Agency (DEA). (2006b, November 29).
National methamphetamine awareness day events represent
largest single-day education effort in the dangers of methamphet-
amine. News Release. Washington, DC: Drug Enforcement
Agency.
Voices of Appalachia Health Start Project. (2001). Whitley County
Public Health Department. http://www.wcphd.com
Watkins, C. (2011). Blacks in Appalachia. Retrieved from http://www.
museum.appstate.edu/exhibits/blacks/pages/blacks.shtml
Wilson, C.M. (1989). Elizabethan America. In W.K. Neil (Ed.),
Appalachian images in folk and popular cultures (pp. 205–216).
London: UMI Press.
For reflective exercises, review questions, and additional
information, go to
http://davisplus.fadavis.com
158 Aggregate Data for Cultural-Specific Groups
2780_Ch08_137-158 16/07/12 11:43 AM Page 158

159
Chapter 9
People of Arab Heritage
Anahid Dervartanian Kulwicki and Suha Ballout
Overview
Overview, Inhabited Localities, and Topography
Arabs trace their ancestry and traditions to the no-
madic desert tribes of the Arabian Peninsula. They
share a common language, Arabic, and most are united
by Islam, a major world religion that originated in
7th-century Arabia. Despite these common bonds,
Arab residents of a single Arab country are often char-
acterized by diversity in thoughts, attitudes, and behav-
iors. Indeed, cultural variations may be significant
within and across countries and regions. For example,
a poor tradition-bound farmer from rural Yemen may
appear to have little in common with an educated pro-
fessional from cosmopolitan Beirut. Immigrant Arab
populations may exhibit great cultural differences
based on such additional factors as religion, country
of origin, refugee status, time since arrival, ethnic iden-
tity, education, economic status, employment status,
social support, and English language skills.
Since the September 11, 2001, terrorist attack on
the United States, there has been an observable in-
crease in hostility toward Arabs and Arab Americans.
Health-care providers need to understand that few
Arab Americans support the terrorist attacks and that
individuals must not be stereotyped by their cultural
background. A study conducted by Kulwicki and col-
leagues (2008) on the effects of 9/11 on Arab American
nurses in Detroit revealed that Muslims and Arabs
were discriminated against by being called names, in-
timidation, and verbal attacks about their appearance
and religion. They were also subject to suspicious
questioning, and the media supported this.
The diversity among Arabs makes presenting a rep-
resentative account of Arab Americans a formidable
task because of the variant cultural characteristics (see
Chapter 1) and the limited research literature on
Arabs in the Americas. The earliest Arab immigrants
arrived as part of the great wave of immigrants at the
end of the 19th century and the beginning of the 20th
century. They were predominantly Christians from the
region that is present-day Lebanon and Syria and, like
most newcomers of the period, they valued assimila-
tion and were rather easily absorbed into mainstream
U.S. society. Arab Americans tend to disappear in na-
tional studies because they are counted as white in
census data rather than as a separate ethnic group.
Therefore, to portray Arab Americans as fully as pos-
sible, including the large numbers of new arrivals since
1965, literature that describes Arabs in their home
countries is used to supplement research completed by
groups studying Arab Americans residing in Michigan,
Illinois, New York, Ohio, and the San Francisco Bay
area of California. An underlying assumption is that
the attitudes and behaviors of first-generation immi-
grants are similar in some aspects to those of their
counterparts in the Arab world.
Islamic doctrines and practices are included be-
cause most post-1965 Arab American immigrants are
Muslims. Religion, whether Islam, Christianity, or
minority faiths, is an integral part of everyday Arab
life. In addition, Islam is the official religion in most
Arab countries, Lebanon being a notable exception,
and Islamic law is identified as the source of national
laws and regulations. Consequently, knowledge of re-
ligion is critical to understanding the Arab American
patient’s cultural frame of reference and for providing
care that considers specific religious beliefs.
Heritage and Residence
Arab Americans are defined as immigrants from the
22 Arab countries of North Africa and Southwest
Asia: Algeria, Bahrain, Comoros, Djibouti, Egypt,
Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania,
Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia,
Sudan, Syria, Tunisia, United Arab Emirates, and
Yemen. Some Arabs may originate from neighboring
states such as Chad and Iran. The Arab American In-
stitute (2010) estimates that 3.5 million Arab Americans
live in the United States, with approximately 94 percent
living in metropolitan areas. The largest concentrations
are in Los Angeles County, California; Wayne County,
Michigan; and Kings County, New York. However,
2780_Ch09_159-177 16/07/12 11:44 AM Page 159

Zogby International (2011) estimates the number of
Arab Americans as three times greater than estimates
from the Arab American Institute.
Reasons for Migration and Associated
Economic Factors
First-wave immigrants came to the United States be-
tween 1887 and 1913 seeking economic opportunity
and perhaps the financial means to return home and
buy land or set up a shop in their ancestral villages.
Most first-wave Arab Americans worked in unskilled
jobs, were male and illiterate (44 percent), and were
from mountain or rural areas (Naff, 1980). Today,
32 percent of Arab Americans are from Lebanon,
and 11 percent come from Egypt (Arab American
Institute, 2010).
Second-wave immigrants entered the United States
after World War II; the numbers increased dramati-
cally after the Palestinian-Israeli conflict erupted and
the passage of the Immigration Act of 1965 (Naff,
1980). Unlike the more economically motivated
Lebanese-Syrian Christians, most second-wave immi-
grants are refugees from nations beset by war and
political instability—chiefly, occupied Palestine, Jordan,
Iraq, Yemen, Lebanon, and Syria. Included in
this group are a large number of professionals and
individuals seeking educational degrees who have
subsequently remained in the United States. Of the
current Arab American population, 57 percent are
male, 25 percent are age 18 years or younger, and
9 percent are age 65 years or older; their median
age is 33 years (Arab American Institute, 2010).
Educational Status and Occupations
Because Arabs favor professional occupations, edu-
cation, as a prerequisite to white-collar work, is val-
ued. Not surprisingly, both U.S. and foreign-born
Arab Americans are more educated than the average
American. Over 89 percent of Arab Americans have
a high school education, compared with all Americans
at 81 percent, and 46 percent have a college educa-
tion, compared with 28 percent of the total popula-
tion (U.S. Census Bureau, 2005).
In comparison with European Americans, Arab
Americans are more likely to be self-employed and
much more likely to be in managerial and profes-
sional specialty occupations (U.S. Census Bureau,
2005). Nearly 44 percent are employed in managerial
and professional positions, 29 percent in sales, and
11.7 percent in retail trade. Few Arab Americans are
employed in farming, forestry, fishing, precision pro-
duction, crafts, or work as operators and fabricators
(U.S. Census Bureau, 2005). Arab American house-
holds in the United States have a mean annual in-
come of $59,012, compared with $52,029 for all
households (Arab American Institute, 2010).
Communication
Dominant Language and Dialects
Arabic is the official language of the Arab world.
Modern or classical Arabic is a universal form of
Arabic used for all writing and formal situations rang-
ing from radio newscasts to lectures. Dialectal or col-
loquial Arabic, of which each community has a
variety, is used for everyday spoken communication.
Arabs often mix Modern Standard Arabic and collo-
quial Arabic according to the complexity of the
subject and the formality of the occasion. The pres-
ence of numerous dialects with differences in accent,
inflection, and vocabulary may create difficulties in
communication between Arab immigrants from Syria
and Lebanon and, for example, Arab immigrants from
Iraq and Yemen.
An Arab person’s speech is likely to be character-
ized by repetition and gesturing, particularly when in-
volved in serious discussions. Arabs may be loud and
expressive when involved in serious discussions to
stress their commitment and their sincerity in the sub-
ject matter. Observers witnessing such impassioned
communication may assume that Arabs are argumen-
tative, confrontational, or aggressive.
English is a common second language in Egypt,
Jordan, Lebanon, Yemen, Iraq, and Kuwait; French is
a common second language in Algeria and Morocco.
In contrast, literacy rates among adults in the Arab
world vary from 70 percent for men and 30 percent for
women (CIA World Factbook, 2011a, b, c) in Yemen;
93 percent for men and 82 percent for women in
Lebanon; and 95 percent for men and 85 percent for
women in Jordan. More than half speak a language
other than English at home, although many have a good
command of the English language (Arab American
Institute, 2010). Despite this, ample evidence indicates
that language and communication pose formidable
problems in American health-care settings. For exam-
ple, Kulwicki and Miller (1999) reported that 66 per-
cent of respondents using a community-based health
clinic spoke Arabic at home, and only 30.2 percent
spoke both English and Arabic. Even English-speaking
Arab Americans report difficulty in expressing their
needs and understanding health-care providers.
Health-care providers have cited numerous inter-
personal and communication problems including er-
roneous assessments of patient complaints, delayed
or failed appointments, reluctance to disclose per-
sonal and family health information, and in some
cases adherence to medical treatments (Kulwicki,
1996; Kulwicki, Miller, & Schim, 2000), as well as a
tendency to exaggerate when describing complaints
(Sullivan, 1993). This has been shown to create a
barrier to access (Kulwicki, Aswad, Carmona, &
Ballout, 2010).
160 Aggregate Data for Cultural-Specific Groups
2780_Ch09_159-177 16/07/12 11:44 AM Page 160

Cultural Communication Patterns
Arab communication has been described as highly
nuanced, with more communication contained in the
context of the situation than in the actual words spo-
ken. Arabs value privacy and resist disclosure of per-
sonal information to strangers, especially when it
relates to familial disease conditions. Conversely,
among friends and relatives, Arabs express feelings
freely. These patterns of communication become more
comprehensible when interpreted within the Arab cul-
tural frame of reference. Many personal needs may be
anticipated without the individual having to verbalize
them because of close family relationships. The family
may rely more on unspoken expectations and nonver-
bal cues than overt verbal exchange.
Arabs need to develop personal relationships with
health-care providers before sharing personal infor-
mation. Because meaning may be attached to both
compliments and indifference, manner and tone are
as important as what is said. Arabs are sensitive to
the courtesy and respect they are accorded, and good
manners are important in evaluating a person’s char-
acter. Therefore, greetings, inquiries about well-
being, pleasantries, and a cup of tea or coffee
precede business. Conversants stand close to one an-
other, maintain steady eye contact, and touch (only
between members of the same sex) the other’s hand
or shoulder. Sitting and standing properly is critical,
because doing otherwise is taken as a lack of respect.
Within the context of personal relationships, verbal
agreements are considered more important than
written contracts. Keeping promises is considered a
matter of honor.
Substantial efforts are directed at maintaining
pleasant relationships and preserving dignity and
honor. Hostility in response to perceived wrongdoing
is warded off by an attitude of maalesh: “Never
mind; it doesn’t matter.” Individuals are protected
from bad news for as long as possible and are then
informed as gently as possible. For example, they
may be protected from being informed about a can-
cer diagnosis. When disputes arise, Arabs hint at
their disagreement or simply fail to follow through.
Alternatively, an intermediary, someone with influ-
ence, may be used to intervene in disputes or present
requests to the person in charge. Mediation saves
face if a conflict is not settled in one’s favor and re-
assures the petitioner that maximum influence has
been employed (Nydell, 1987).
Guidelines for communicating with Arab Americans
include the following:
1. Health-care providers should employ an approach
that combines expertise with warmth. They
should minimize status differences, because Arab
Americans report feeling uncomfortable and
self-conscious in the presence of authority figures.
Also, health-care providers should pay special at-
tention to the person’s feelings. Arab Americans
perceive themselves as sensitive, with the potential
for being easily hurt, belittled, and slighted
(Reizian & Meleis, 1987).
2. Nurses and other health-care providers should
take time to get acquainted before delving into
business. If sincere interest in the person’s home
country and adjustment to American life is ex-
pressed, he or she is likely to enjoy relating such
information, much of which is essential to assess-
ing risk for traumatic immigration experience (see
Barriers to Health Care, later in this chapter) and
understanding the person’s cultural frame of ref-
erence. Sharing a cup of tea does much to give an
initial visit a positive beginning (Kulwicki, 1996).
3. Nurses may need to clarify role responsibilities re-
garding history taking, performing physical exam-
inations, and providing health information for
newer immigrants. Although some recent Arab
American immigrants may now recognize the
higher status of nurses in the United States, they
are still accustomed to nurses functioning as
medical assistants and housekeepers (see Status
of Health-Care Providers, later in this chapter).
4. Nurses will need to perform a comprehensive
assessment and explain the relationship of the
information needed for physical complaints.
5. Health-care providers should interpret family
members’ communication patterns within a cul-
tural context. Care providers should recognize
that a spokesperson may answer questions di-
rected to the patient and that the family members
may edit some information that they feel is inap-
propriate (Kulwicki, 1996). Family members can
also be expected to act as the patient’s advocates;
they may attempt to resolve problems by taking
appeals “to the top” or by seeking the help of an
influential intermediary.
6. Health-care providers need to convey hope and
optimism. The concept of “false hope” is not
meaningful to Arabs because they regard God’s
power to cure as infinite. The amount and type of
information given should be carefully considered.
7. It is important to be mindful of the patient’s mod-
esty and dignity. Islamic teachings forbid unneces-
sary touch (including shaking hands) between
unrelated adults of opposite sexes (al-Shahri, 2002).
Observation of this teaching is expressed most com-
monly by female patients with male health-care
providers and may cause the patient to be shy or
hesitant in allowing the health-care provider to do
physical assessments. Health-care providers must
make concerted efforts to understand the patient’s
feelings and to take them into consideration.
People of Arab Heritage 161
2780_Ch09_159-177 16/07/12 11:44 AM Page 161

Temporal Relationships
First-generation Arab immigrants may believe in
predestination—that is, God has predetermined the
events of one’s life. Accordingly, individuals are ex-
pected to make the best of life while acknowledging
that God has ultimate control over all that happens.
Consequently, plans and intentions are qualified with
the phrase inshallah—”if God wills”—and blessings
and misfortunes are attributed to God rather than to
the actions of individuals.
Throughout the Arab world, there is nonchalance
about punctuality except in cases of business or profes-
sional meetings; otherwise, the pace of life is more
leisurely than in the West. Social events and appoint-
ments tend not to have a fixed beginning or end.
Although certain individuals may arrive on time for
appointments, the tendency is to be somewhat late.
However, for most Arab Americans who belong to pro-
fessional occupations or who are in the business field,
punctuality and respecting deadlines and appointments
are considered important (Kulwicki, 2001).
Format for Names
Etiquette requires shaking hands on arrival and depar-
ture. However, when an Arab man is introduced to an
Arab woman, the man waits for the woman to extend
her hand. Traditional Muslims may not shake hands
with the opposite sex. Women and men put their hand
on their chest as a gesture to replace shaking hands.
Titles are important and are used in combination
with the person’s first name (e.g., Mr. Khalil or
Dr. Ali). Some may prefer to be addressed as mother
(Um) or father (Abu) of the eldest son (e.g., Abu
Khalil, “father of Khalil”). Married women usually
retain their maiden names.
Family Roles and Organization
Head of Household and Gender Roles
Arab Muslim families are characterized by a strong
patrilineal tradition (Aswad, 1999). Women are sub-
ordinate to men, and young people are subordinate
to older people. Consequently, within his immediate
family, the man is the head of the family and his in-
fluence is overt. In public, a wife’s interactions with
her husband are formal and respectful. However,
behind the scenes, she typically wields tremendous
influence, particularly in matters pertaining to the
home and children. A wife may sometimes be re-
quired to hide her power from her husband and
children to preserve the husband’s view of himself
as head of the family.
Within the larger extended family, the older male
figure assumes the role of decision maker. Women at-
tain power and status in advancing years, particularly
when they have adult children. The bond between
mothers and sons is typically strong, and most men
make every effort to obey their mother’s wishes, and
even her whims (Nydell, 1987).
Gender roles are clearly defined and regarded as a
complementary division of labor. Men are breadwin-
ners, protectors, and decision makers, whereas women
are responsible for the care and education of children
and for maintenance of a successful marriage by tend-
ing to their husbands’ needs. Although women in
more urbanized Arab countries such as Lebanon,
Syria, Jordan, and Egypt often have professional
careers, with some women advocating for women’s lib-
eration, the family and marriage remain primary com-
mitments for the majority. Most educated women still
consider caring for their children as their primary role
after marriage. The authority structure and division
of labor within Arab families are often interpreted in
the West as creating a subservient role for women,
fueling common stereotypes of the overly dominant
Arab male and the passive and oppressed Arab female.
Thus, by extension, conservative Arab Americans per-
ceive the stereotypical understanding of the subordi-
nate role of women as a criticism of Arab culture and
family values (Kulwicki, 2000).
Arabs value modesty among both men and
women and typically will cover the extremities and
avoid revealing garb. Many Muslim women view the
hijab—”covering the body except for one’s face and
hands”—as offering them protection in situations in
which the sexes mix, because it is a recognized sym-
bol of Muslim identity and good moral character.
Ironically, many Americans associate the hijab with
oppression rather than protection. The hijab is not
universal, and one may find women within the same
family choosing to wear or not wear it as a matter of
personal choice. Even if Muslim women don’t wear
the hijab during the day, they wear it during prayer
and while reading the Quran.
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
In the traditional Arab family, the roles of the father
and mother as they relate to the children are quite
distinct. Typically, the father is the disciplinarian,
whereas the mother is an ally and mediator, an unfail-
ing source of love and kindness. Although some
fathers feel that it is advantageous to maintain a degree
of fear, family relationships are usually characterized
by affection and sentimentality. Children are dearly
loved, indulged, and included in all family activities.
Among Arabs, raising children so they reflect well
on the family is an extremely important responsibility.
A child’s character and successes (or failures) in life
are attributed to upbringing and parental influence.
Because of the emphasis on collective familism rather
than individualism within the Arab culture, conform-
ity to adult rules is favored. Correspondingly, child-
rearing methods are oriented toward accommodation
162 Aggregate Data for Cultural-Specific Groups
2780_Ch09_159-177 16/07/12 11:44 AM Page 162

and cooperation. Family reputation is important; chil-
dren are expected to behave in an honorable manner
and not bring shame to the family. Child-rearing pat-
terns also include great respect toward parents and
elders. Children are raised to not question elders and
to be obedient to older brothers and sisters (Kulwicki,
1996). Methods of discipline include physical punish-
ment and shaming. Children are made to feel ashamed
because others have seen them misbehave, rather than
to experience guilt arising from self-criticism and
inward regret.
Whereas adolescence in the West is centered on ac-
quiring a personal identity and completing the sepa-
ration process from family, Arab adolescents are
expected to remain enmeshed in the family system.
Family interests and opinions often influence career
and marriage decisions. Arab adolescents are pressed
to succeed academically, in part because of the con-
nections between professional careers and social sta-
tus. Conversely, behaviors that would bring family
dishonor, such as academic failure, sexual activity,
illicit drug use, and juvenile delinquency, are avoided.
For girls in particular, chastity and decency are re-
quired. Adolescence in North America may provide
more opportunities for academic success and more free-
dom in making career choices than can be accessed by
their counterparts in the Arab countries. Cultural con-
flicts between American values and Arab values often
cause significant conflicts for Arab American families.
Arab American parents cite a variety of concerns re-
lated to conflicting values regarding dating, after-school
activities, drinking, and drug use (Zogby, 2002).
Family Goals and Priorities
The family is the central socioeconomic unit in Arab
society. Family members cooperate to secure livelihood,
rear children, and maintain standing and influence
within the community. Family members live nearby,
sometimes intermarry (first cousins), and expect a great
deal from one another regardless of practicality or abil-
ity to help. Loyalty to one’s family takes precedence
over personal needs. Maintenance of family honor is
paramount.
Within the hierarchical family structure, older family
members are accorded great respect. Children, sons in
particular, are held responsible for supporting elderly
parents. Therefore, regardless of the sacrifices involved,
the elderly parents are almost always cared for within
the home, typically until death.
Responsibility for family members rests with the
older men of the family. In the absence of the father,
brothers are responsible for unmarried sisters. In the
event of a husband’s death, his family provides for his
widow and children. In general, family leaders are ex-
pected to use influence and render special services and
favors to kinsmen.
Although educational accomplishments (doctoral
degrees), certain occupations (medicine, engineering,
law), and acquired wealth contribute to social status,
family origin is the primary determinant. Certain
character traits such as piety, generosity, hospitality,
and good manners may also enhance social standing.
Alternative Lifestyles
Most adults marry. Although the Islamic right to
marry up to four wives is sometimes exercised, partic-
ularly if the first wife is chronically ill or infertile, most
marriages are monogamous and for life. Recent stud-
ies have reported that 2 to 5 percent of Arab Muslim
marriages are polygamous (Kulwicki, 2000). Whereas
homosexuality occurs in all cultures to some extent, it
is stigmatized among Arab cultures. In Michigan,
46 percent of the Arab HIV/AIDS cases were men
having sex with men (Michigan Department of Com-
munity Health, 2010). In some Arab countries, it is
considered a crime. Fearing family disgrace and os-
tracism, gays and lesbians remain closeted (Global
Gayz, 2006). However, in recent years, Arab American
gays and lesbians have been active in gay and lesbian
organizations, and some have been outspoken and
publicly active in raising community awareness about
People of Arab Heritage 163
R E F L E C T I V E E X E R C I S E 9 . 1
Mr. and Mrs. AbulMuna presented to the clinic with Samah,
their 17-year-old daughter, who is not married. Samah was
complaining of nausea and a metallic aftertaste. Mrs. AbulMuna
also told the nurse that she noticed Samah was pale and
seemed weak during that period. Samah also told the nurse
that she was having breast tenderness for the past 2 weeks but
did not get her menstrual period yet. Mr. and Mrs. AbulMuna
were worried because they did not want Samah to be sick for
her final exams. During the assessment, the nurse asked Samah
if she was sexually active and if she could be pregnant. Mr. and
Mrs. AbulMuna were angry and thought the nurse’s questions
were inappropriate. They argued that because Samah was
unmarried, it was inappropriate for the nurse to ask her about
sexual activity and pregnancy. After he left the room, the nurse
could hear Mr. and Mrs. AbulMuna furiously asking Samah why
the nurse would ask her such a question. Samah insisted that
she believes her symptoms were related to something she ate
and that she cannot possibly be pregnant. Mr. AbulMuna told
the nurse they were going to take their daughter to another
facility.
1. How should the nurse deal with this situation?
2. Identify culturally appropriate strategies that may be effec-
tive in addressing the needs of the AbulMuna family.
3. How might the nurse ensure that the best care is pro-
vided to Samah?
4. Should the nurse ask Samah if she might be pregnant
while her parents are out of the room?
2780_Ch09_159-177 16/07/12 11:44 AM Page 163

gay and lesbian rights in Arab American communities.
Recently, some Arab countries like Lebanon have gay
organizations that support the rights of this popula-
tion and are working toward decreasing or removing
the legal and cultural barriers to homosexuality. In the
United States, several gay and lesbian Arab organiza-
tions are actively involved in educating the Arab com-
munities on the rights of gay and lesbian populations,
aiming at removing cultural stereotypes and stigma
associated with being gay or lesbian.
Workforce Issues
Culture in the Workplace
Cultural differences that may have an impact on work
life include beliefs regarding family, gender roles, one’s
ability to control life events, maintaining pleasant per-
sonal relationships, guarding dignity and honor, and
the importance placed on maintaining one’s reputa-
tion. Arabs and Americans may also differ in attitudes
toward time, instructional methods, patterns of think-
ing, and the amount of emphasis placed on objectivity.
However, because many second-wave professionals
were educated in the United States, and thereby so-
cialized to some extent, differences are probably more
characteristic of less-educated, first-generation Arab
Americans.
Stress is a common denominator in recent studies of
first-generation immigrants. Sources of stress include
separation from family members, difficulty adjusting to
American life, marital tension, and intergenerational
conflict, specifically coping with adolescents socialized
in American values through school activities (Seikaly,
1999). Issues related to discrimination have been reported
as a major source of stress among Arab Americans in
their work environment. In a recent study exploring
the perceptions and experiences of Arab American
nurses in the aftermath of 9/11, the majority of nurses
did not experience major episodes of discrimination
at work such as termination and physical assaults.
However, some did experience other types of discrim-
ination such as intimidation, being treated suspi-
ciously, negative comments about their religious
practices, and refusal by some patients to be treated
by them (Kulwicki & Khalifa, 2008). Arab Americans
are keenly aware of the misperceptions Americans
hold about Arabs, such as notions that Arabs are infe-
rior, backward, sinister, and violent. In addition, the
American public’s ignorance of mainstream Islam and
the stereotyping of Muslims as fanatics, extremist, and
confrontational burden Muslim Arab Americans. Mus-
lim Arab Americans face a variety of challenges as
they practice their faith in a secular American society.
For example, Islamic and American civil law differ on
matters such as marriage, divorce, banking, and inher-
itance. Individuals who wish to attend Friday prayer
services and observe religious holidays frequently
encounter job-related conflicts. Children are often
torn between fulfilling Islamic obligations regarding
prayer, dietary restrictions, and dress and hiding
their religious identity in order to fit into the American
public school culture.
Issues Related to Autonomy
Whereas American workplaces tend to be domi-
nated by deadlines, profit margins, and maintaining
one’s competitive edge, a more relaxed, cordial, and
relationship-oriented atmosphere prevails in the
Arab world. Friendship and business are mixed over
cups of sweet tea to the extent that it is unclear
where socializing ends and work begins. Managers
promote optimal performance by using personal in-
fluence and persuasion, and performance evalua-
tions are based on personality and social behavior
as well as job skills.
Significant differences also exist in workplace norms.
In the United States, position is usually earned, laws are
applied equally, work takes precedence over family,
honesty is an absolute value, facts and logic prevail, and
direct and critical appraisal is regarded as valuable feed-
back. In the Arab world, position is often attained
through one’s family and connections, rules are bent,
family obligations take precedence over the demands
of the job, subjective perceptions often dictate actions,
and criticism is often taken personally as an affront to
dignity and family honor (Nydell, 1987). In Arab
offices, supervisors and managers are expected to praise
their employees to assure them that their work is
noticed and appreciated. Whereas such direct praise
may be somewhat embarrassing for Americans, Arabs
expect and want praise when they feel they have earned
it (Nydell, 1987).
Biocultural Ecology
Skin Color and Other Biological Variations
Although Arabs are uniformly perceived as swarthy,
and whereas many do, in fact, have dark or olive skin,
they may also have blonde or auburn hair, blue eyes,
and fair complexions. Arabs from North Africa, such
as Egypt, Morocco, and Tunis, may be black and have
African features. Because color changes are more dif-
ficult to assess in dark-skinned people, pallor and
cyanosis are best detected by examination of the oral
mucosa and conjunctiva.
Diseases and Health Conditions
The major public health concerns in the Arab world
include trauma related to motor vehicle accidents,
maternal-child health, and control of communicable
diseases. The incidence of infectious diseases such as
tuberculosis, malaria, trachoma, typhus, hepatitis,
164 Aggregate Data for Cultural-Specific Groups
2780_Ch09_159-177 16/07/12 11:44 AM Page 164

typhoid fever, dysentery, and parasitic infestations
varies between urban and rural areas and from coun-
try to country. For example, disease risks are relatively
low in modern urban centers of the Arab world, but
are quite high in the countryside, where animals such
as goats and sheep virtually share living quarters, open
toilets are commonplace, and running water is not
available. Schistosomiasis (also called bilharzia), with
which about one-fifth of Egyptians are infected, has
been called Egypt’s number-one health problem. Its
prevalence is related to an entrenched social habit of
using the Nile River for washing, drinking, and uri-
nating. Similarly, outbreaks of cholera and meningitis
are continuous concerns in Saudi Arabia during the
Muslim pilgrimage season. In Jordan, where contagious
diseases have declined sharply, emphasis has shifted to
preventing accidental death and controlling noncom-
municable diseases such as cancer and heart disease.
Correspondingly, seat belt use, smoking habits, and pes-
ticide residues in locally grown produce are major issues.
Campaigns directed at improving children’s and young
adults’ health include smoking prevention, hepatitis B
vaccinations, and dental health programs.
Glucose-6-phosphate dehydrogenase (G-6-PD) de-
ficiency, sickle cell anemia, and the thalassemias are
extremely common in the eastern Mediterranean
region, probably because carriers enjoy an increased
resistance to malaria (Hamamy & Alwan, 1994). High
consanguinity rates—roughly 30 percent of marriages
in Iraq, Jordan, Kuwait, and Saudi Arabia are be-
tween first cousins—and the trend of bearing children
up to menopause also contribute to the prevalence of
genetically determined disorders in Arab countries
(Hamamy & Alwan, 1994).
With modernization and increased life expectancy,
multifactorial disorders—hypertension, diabetes, and
coronary heart disease—have also emerged as major
problems in eastern Mediterranean countries (Kulwicki,
2001). In many countries, cardiovascular disease is a
major cause of death. In Lebanon, the increased fre-
quency of familial hypercholesterolemia is a contribut-
ing factor. Individuals of Arabic ancestry are also more
likely to inherit familial Mediterranean fever, a disorder
characterized by recurrent episodes of fever, peritonitis,
or pleurisies, either alone or in some combination.
The extent to which these conditions affect the
health of Arab Americans is little understood, most
notably because epidemiological studies have prima-
rily originated from southeast Michigan, home of the
highest concentration of Arab Americans in the
United States. A Wayne County Health Department
(1994) project, which conducted telephone surveys
with Arabs residing in the Detroit, Michigan, area,
identified cardiovascular disease as one of two specific
risks, based on the high prevalence of cigarette smok-
ing, high-cholesterol diets, obesity, and sedentary
lifestyles. Although the prevalence of hypertension
was lower in the Arab community than in the rest of
Wayne County, Arab respondents were less likely to
report having their blood pressure checked. In fact,
lower rates for appropriate testing and screening, such
as cholesterol testing, colorectal cancer screening, and
uterine cancer screening, were considered a major risk
for this group of Arab Americans. In recent years, the
rate of mammography has increased dramatically. The
Institute of Medicine’s report Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health
Care (2002) indicated that death rates for Arab
females, compared with those of other white groups,
was higher from heart disease and cancer but lower
from strokes. However, the death rate for Arab males
from coronary heart disease is higher when compared
with that of white males. Metabolic syndrome is also
highly prevalent and increased with age in both male
and female Arab Americans (Jaber, Brown, Hammad,
Zhu, & Herman, 2004). Lung and colorectal cancer
are the two leading causes of death among Arab
Americans. For Arab American men, lung cancer is
the leading cause of death; breast cancer is the leading
cause of death in Arab American women (Schwartz,
Darwish-Yassine, & Wing, 2005).
The rate of infant mortality in the Arab world is
very high, ranging from 24 per 1000 births in Syria to
108 per 1000 births in Iraq. In Bahrain, the infant
mortality is low: 8.5 per 1000 births (World Health
Organization [WHO], 2006). Although overall infant
mortality rates for Arab Americans are the same as
for white infants, figures for Michigan show a lower
infant mortality rate for Arab Americans (6.2 per
1000 births) than for white infants (7.8 per 1000 births).
Variations in Drug Metabolism
Information describing drug disposition and sensitivity
in Arabs is limited. Between 1 and 1.4 percent of Arabs
are known to have difficulty metabolizing debrisoquine
and substances that are metabolized similarly, such as
antiarrhythmics, antidepressants, beta-blockers, neu-
roleptics, and opioid agents. Consequently, a small num-
ber of Arab Americans may experience elevated blood
levels and adverse effects when customary dosages
of antidepressants are prescribed. Conversely, typical
codeine dosages may prove inadequate because some in-
dividuals cannot metabolize codeine to morphine to
promote an optimal analgesic effect (Levy, 1993).
High-Risk Behaviors
Despite Islamic beliefs discouraging tobacco use,
smoking remains deeply ingrained in Arab culture.
For many Arabs, offering cigarettes is a sign of hos-
pitality. Consistent with their cultural heritage, Arab
Americans are characterized by higher smoking rates
and lower quitting rates than European Americans
People of Arab Heritage 165
2780_Ch09_159-177 16/07/12 11:44 AM Page 165

(Darwish-Yassine & Wang, 2005; Rice & Kulwicki,
1992). Besides smoking cigarettes, smoking tobacco
through a water pipe, commonly known as a hookah,
shisha, or narghile, is a common practice among both
adults and youths.
According to the 2001–2002 Special Cancer Behav-
ioral Risk Factor Survey, Arab Americans who are
50 years and older have the highest smoking rates
compared with other populations in Michigan. Smok-
ing rates for Arab women in the same age group are
considerably lower (39.9 versus 10.9 percent) (Michigan
Department of Community Health and Michigan
Department of Public Health Institute, 2003). Prelim-
inary research results related to tobacco use among
Arab Americans suggest that the rates of tobacco
smoking among Arab American youth are consider-
ably lower than those among non-Arab youth in
Michigan, with only 16 percent of Arab youths smok-
ing versus 34 percent of non-Arabs (Templin, Rice,
Gadelrab, Weglicki, Hammad, & Kulwicki, 2003).
Most recently, level of acculturation was found to in-
fluence nicotine dependence, with less-assimilated
Arab Americans smoking more than other Arab
Americans who primarily socialized with Americans
or behaved like them (Al-Omari & Scheibmeir, 2010).
Limited information is available on alcohol use
among Arab Americans. However, Islamic prohibi-
tions do appear to influence patterns of alcohol con-
sumption and attitudes toward drug use. In a study
of publicly funded treatment centers in Michigan,
Arfken, Kubiak, and Koch (2007) indicated that the
number of Arab Americans admitted for substance
abuse treatment centers was lower for Arab Americans
than others and that most abusers were concentrated
in the metropolitan Detroit area. Most common
drugs used were alcohol (34.8 percent), marijuana
(17.9 percent), heroin (17.4 percent), and crack cocaine
(15.6 percent). The majority of patients admitted to
treatment centers were male (76.3 percent), mostly
unemployed (62.1 percent), and more than half were
involved in the criminal justice system (58 percent).
Ninety percent of the Arab respondents in the survey
reported that they abstain from drinking alcohol.
None reported heavy drinking, with a limited number
reporting binge drinking (2.2 percent) and driving
under the influence of alcohol (1.4 percent). All
respondents believed that occasional use of cocaine
entails “great” risk, with most saying the same about
occasional use of marijuana.
The actual risk for, and incidence of, HIV infec-
tion and AIDS in Arab countries and among Arab
Americans is low. However, an increase in the rate of
infection has been noticed among many Arab coun-
tries and among Arab Americans (Centers for Disease
Control and Prevention [CDC], 2006). The reported
number of individuals having AIDS in the Arab coun-
tries varies and may not be an accurate reflection of
the real incidence owing to restrictions placed on
HIV/AIDS research by some Arab countries. The
largest number of AIDS cases is seen in Djibouti
(214); the lowest numbers of individuals reported as
having AIDS are found in Palestine (1), Kuwait (11),
Syria (18), Lebanon (24), Yemen (45), and Egypt (63)
(WHO, 2004).
Despite the reported low rate of HIV/AIDS among
Arab Americans, 4 percent of the Arab American re-
spondents surveyed by Kulwicki and Cass in 1994
reported that they were at high risk for AIDS. In ad-
dition, the sample demonstrated less knowledge of
primary routes of transmission and more misconcep-
tions regarding unlikely modes of transmission than
other populations surveyed. In 2010, the Michigan
Department of Community Health [MDCH] stated
that only 110 Arab Americans have ever been diag-
nosed with HIV and reported in Michigan. Of these,
83 are living, and 54 percent have progressed to AIDS
(MDCH, 2010).
Cultural norms of modesty for Arab women are
also a significant risk related to reproductive health
among Arab Americans. For example, the rate
of breast cancer screening among Arab women was
50.8 percent, compared with 71.2 percent for other
women in Michigan. The rate of cervical Pap smears
was 59.9 percent, and the rate of mammogram
screenings was 51.2 percent (Kulwicki, 2000). Arab
American women, especially new immigrants, may
be at a higher risk for domestic violence because of
the higher rates of stress, poverty, poor spiritual and
social support, and isolation from family members
owing to immigration (Kulwicki et al., 2010).
A systematic review of the health status of Arabs liv-
ing in the United States reports the following: (1) little
consensus on the rates of cardiovascular disease among
Arab Americans; (2) the prevalence of hypertension is
comparable to non-Hispanic whites at 13 to 30 percent;
(3) the prevalence of smoking among adults is compa-
rable to other Americans, but Arab American youths
have higher smoking rates; and (4) the prevalence of di-
abetes mellitus is similar to other Americans (El Sayed
& Galea, 2009).
Many Arab Americans are refugees fleeing war and
political and religious conflicts, placing them at
greater risk for psychological distress, depression, and
other psychiatric illnesses (Hikmet, Hakim-Larson,
Farrag, & Jamil, 2002; Kinzie, Boehnlein, Riley, &
Sparr, 2002; Kira, Smith, Lewandoski, Templin,
2010). Psychological distress was also documented
among immigrants who themselves were not victims
of war and conflict but who worried over family mem-
bers that were in areas of conflict. Studies conducted
with Iraqi refugees and victims of torture in the
United States identified higher prevalence of post-
traumatic stress disorder and depression (Kinzie et al.,
2002; Kulwicki, 2010). However, Kira and colleagues
166 Aggregate Data for Cultural-Specific Groups
2780_Ch09_159-177 16/07/12 11:44 AM Page 166

(2006) found that although tortured Arab immigrants
have multilateral trauma experiences and, thus, a sig-
nificantly higher trauma dose, they have more post-
traumatic growth, they are more resilient, and they
practice their religion more.
Health-Care Practices
According to the Wayne County Health Department
(1994), Arab Americans’ risk in terms of safety is
mixed. Factors enhancing safety include low rates of
gun ownership and high recognition of the risks asso-
ciated with having guns in the house. Conversely,
lower rates of fire escape planning and seat belt usage
for adults and older children (car seats are generally
used for younger children), as well as higher rates of
physical assaults, threaten their safety.
In most health areas surveyed in Michigan, edu-
cation and income were important determinants of
risk for people of Arab descent. Socioeconomic sta-
tus was also a strong indicator in accessing health-
care services. The Wayne County Health Department
(1994) indicated that 20.5 percent of the adult Arab
respondents were not covered by health insurance
and 18.8 percent were on Medicaid. Use of health-
care services for prenatal care was, however, higher
among Arab American females than other ethnic
groups in Michigan (Michigan Department of Com-
munity Health, 2009). Physical or mental disability
among Arab Americans in Michigan was almost
equal to that of white Americans.
Nutrition
Meaning of Food
Sharing meals with family and friends is a favorite pas-
time. Offering food is also a way of expressing love and
friendship, hospitality, and generosity. For the tradi-
tional Arab woman, whose primary role is caring for
her husband and children, the preparation and presen-
tation of an elaborate midday meal is taken as an indi-
cation of her love and caring. Similarly, in entertaining
friends, the types and quantity of food served, often
several entrees, are indicators of the level of hospitality
and esteem for one’s guests. Honor and reputation are
based on the manner in which guests are received. In
return, family members and guests express appreciation
by eating heartily.
Common Foods and Food Rituals
Although cooking and national dishes vary from
country to country, and seasoning from family to fam-
ily, Arabic cooking shares many general characteris-
tics. Familiar spices and herbs such as cinnamon,
allspice, cloves, ginger, cumin, mint, parsley, bay
leaves, garlic, and onions are used frequently along
with nutmeg, cardamom, marjoram, thyme, and rose-
mary. Skewer cooking and slow simmering are typical
modes of preparation. Yogurt is used in cooking or
served plain. All countries have rice and wheat dishes,
stuffed vegetables, nut-filled pastries, and fritters
soaked in syrup. Dishes are garnished with raisins,
pine nuts, pistachios, and almonds. It is also popular
to prepare hot drinks from several herbs such as
chamomile.
Favorite fruits and vegetables include dates, figs,
apricots, guavas, mangos, melons, apples, papayas,
bananas, citrus fruits, carrots, tomatoes, cucumbers,
parsley, mint, spinach, and grape leaves. Grains are
also an important part of the diet such as fava beans,
chickpeas, peas, corn, lentils, kidney beans, and white
beans. Lamb and chicken are the most popular
meats. Muslims are prohibited from eating pork and
pork products (e.g., lard). Arab Christians may eat
pork, but few of them do. Similarly, because the con-
sumption of blood is forbidden, Muslims are re-
quired to cook meats and poultry until well done.
Bread accompanies every meal and is viewed as a gift
from God. In many respects, the traditional Arab
diet is representative of the U.S. Department of
Agriculture’s food pyramid. Bread is a mainstay,
grains and legumes are often substituted for meats,
fresh fruit and juices are especially popular, and olive
oil is widely used. In addition, because foods are pre-
pared “from scratch,” consumption of preservatives
and additives is limited.
Lunch is the main meal in Arab households. How-
ever, this practice is changing in the United States,
where the main meal is becoming more common for
dinner. Encouraging guests to eat is the host’s duty.
Guests often begin with a ritual refusal and then suc-
cumb to the host’s insistence. Food is eaten with the
right hand because it is regarded as clean. Beverages
may not be served until after the meal because some
Arabs consider it unhealthy to eat and drink at the
same time. Similar concerns may exist regarding mix-
ing hot and cold foods.
Health-care providers should also understand
Ramadan, the Muslim month of fasting. The fast,
which is meant to remind Muslims of their depend-
ence on God and the poor who experience involuntary
fasting, involves abstinence from eating, drinking (in-
cluding water), smoking, and marital intercourse dur-
ing daylight hours. Although the sick are not required
to fast, many pious Muslims insist on fasting while
hospitalized, necessitating adjustments in meal
times and medications, including medications given
by nonoral routes. In outpatient settings, health-care
providers need to be alert to potential nonadherence
to treatment. Patients may omit or adjust the timing
of medications. Of particular concern are medica-
tions requiring constant blood levels, adequate
hydration, or both (e.g., antibiotics that may crys-
tallize in the kidneys). Health-care providers may
need to provide appointment times after sunset
People of Arab Heritage 167
2780_Ch09_159-177 16/07/12 11:44 AM Page 167

during Ramadan for individuals requiring injections
(e.g., allergy shots).
Dietary Practices for Health Promotion
Arabs associate good health with eating properly, con-
suming nutritious foods, and fasting to cure disease.
For some, concerns about amounts and balance
among food types (hot, cold, dry, moist) may be
traced to the prophet Mohammed, who taught that
“the stomach is the house of every disease, and absti-
nence is the head of every remedy” (Al-Akili, 1993, p. 7).
Within this framework, illness is related to excessive
eating, eating before a previously eaten meal is
digested, eating nutritionally deficient food, mixing
opposing types of foods, and consuming elaborately
prepared foods. Conversely, abstinence allows the
body to expel disease.
The condition of the alimentary tract has priority
over all other body systems in the Arab perception of
health (Meleis, 2005). Gastrointestinal complaints are
often the reason Arab Americans seek care (Meleis,
2005). Obesity is a problem for second-generation Arab
American women and children, most of whom report
eating American snacks that are high in fat and calories.
Most women try to lose weight by reducing caloric
intake (Wayne County Health Department, 1994).
Nutritional Deficiencies and Food Limitations
In Arab countries, diet is influenced by income, gov-
ernment subsidies for certain foods (e.g., bread, sugar,
oil), and seasonal availability. Arab Americans most
at risk for nutritional deficiencies include newly ar-
rived immigrants from Yemen and Iraq (Ahmad,
2004) and Arab American households below the
poverty level. Lactose intolerance sometimes occurs
in this population. However, the practice of eating
yogurt and cheese, rather than drinking milk, probably
limits symptoms in sensitive people.
Many of the most common foods are available in
American markets. Some Muslims may refuse to
eat meat that is not halal—”slaughtered in an
Islamic manner.” Halal meat can be obtained in
Arabic grocery stores and through Islamic centers
or mosques.
Islamic prohibitions against the consumption of al-
cohol and pork have implications for American health-
care providers. Conscientious Muslims are often wary
of eating outside the home and may ask many ques-
tions about ingredients used in meal preparation: Are
the beans vegetarian? Was wine used in the meat sauce
or lard in the pastry crust? Muslims are equally con-
cerned about the ingredients and origins of mouth-
washes, toothpastes, and medicines (e.g., alcohol-based
syrups and elixirs), as well as insulin and capsules
(gelatin coating) derived from pigs. However, if no sub-
stitutes are available, Muslims are permitted to use
these preparations.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Fertility rates in the countries from which most Arab
Americans emigrate range from 1.8 in Tunisia and
Lebanon, to 2.4 in Morocco, to 5.2 in Yemen
(UNICEF, 2008). Fertility practices of Arabs are in-
fluenced by traditional Bedouin values supporting
tribal dominance, popular beliefs that “God decides
family size,” and “God provides,” and Islamic rulings
regarding birth control, treatment of infertility, and
abortion.
High fertility rates are favored. Procreation is re-
garded as the purpose of marriage and the means of en-
hancing family strength. Accordingly, Islamic jurists
have ruled that the use of “reversible” forms of birth
control is “undesirable but not forbidden.” These should
be employed only in certain situations, listed in decreas-
ing order of legitimacy, such as threat to the mother’s
life, too frequent childbearing, risk of transmitting ge-
netic disease, and financial hardship. Moreover, irre-
versible forms of birth control such as vasectomy
and tubal ligation are haram—”absolutely unlawful.”
Muslims regard abortion as haram except when the
mother’s health is compromised by pregnancy-induced
disease or her life is threatened (Ebrahim, 1989). There-
fore, unwanted pregnancies are dealt with by hoping one
miscarries “by an act of God” or by covertly arranging
168 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 9 . 2
Rida is a 42-year-old man diagnosed with pancreatic cancer
who is receiving chemotherapy. As a side effect of his cyto-
toxic medications, Rida is constantly nauseated with decreased
appetite. Some days, Rida would not touch any of the food on
his tray. The nurse realizes that Rida is not eating his food and
requests that the dietician visit him and follow up with his di-
etary preferences. Rida tells the dietician that he is not eating
his soup and most of the food because it had meat in it, and
he was not sure if the meat was halal. The nurse tries to ex-
plain that the food was brought based on his agreement with
the dietician. Rida is uncomfortable that the nurse cannot re-
assure him that the meat is halal. Rida also doesnot believe
that the food is nutritious because it does not have vegetables
and salads. The nurse tries to explain that having raw vegeta-
bles is not appropriate for his neutropenia. Rida continues to
express his discomfort with his dietary management.
1. Based on your readings about the Arab culture, what
measures should the nurse have taken?
2. How can the nurse and the dietician enhance Rida’s food
intake?
3. How can the nurse prevent similar instances from taking
place?
2780_Ch09_159-177 16/07/12 11:44 AM Page 168

for an abortion. Recently, great decline in fertility
rates has occurred in Arab countries and among Arab
Americans. According to Michigan’s birth registration
data, fertility rates among Arab Americans are highest
when compared with those of the total population
(Office of Minority Health, 2001).
Among Jordanian husbands, religion and the fatal-
istic belief that “God decides family size” were most
often given as reasons why contraceptives were not
used. Contraceptives were used by 27 percent of the
husbands, typically urbanites of high socioeconomic
status. Although the intrauterine device (IUD) and the
pill were most widely favored, 4.9 percent of females
used sterilization despite religious prohibitions
(Hashemite Kingdom of Jordan, 1985). A survey of
a random sample of 295 Arab American women in
Michigan indicated that 29.1 percent of the surveyed
women did not use any birth control methods because
of their desire to have children, 4.3 percent did not use
any form of contraceptives because of their husband’s
disapproval, and 6 percent did not use contraceptive
methods because of religious reasons. The use of
birth control pills was the highest (33.2 percent)
among the users of contraceptive methods, followed
by tubal ligation (12.9 percent) and IUD (10.7 percent)
(Kulwicki, 2000).
Indeed, among Arab women in particular, fertility
may be more of a concern than contraception be-
cause sterility in a woman could lead to rejection and
divorce. Islam condones treatment for infertility, as
Allah provides progeny as well as a cure for every dis-
ease. However, approved methods for treating infer-
tility are mostly limited to artificial insemination
using the husband’s sperm and in vitro fertilization
involving the fertilization of the wife’s ovum by the
husband’s sperm.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Because of the emphasis on fertility and the bearing
of sons, pregnancy traditionally occurs at a younger
age, and the fertility rate among women in the Arab
world was higher than among Arab American women.
However, as educational and economic conditions for
Arab women have improved both in the Arab world
and in the United States, fertility has fallen.
The pregnant woman is indulged and her cravings
satisfied, lest she develop a birthmark in the shape of
the particular food she craves. Because of the prefer-
ence for male offspring, the sex of the child can be a
stressor for mothers without sons. Friends and family
often note how the mother is “carrying” the baby as
an indicator of the baby’s sex (i.e., high for a girl and
low for a boy). Although pregnant women are excused
from fasting during Ramadan, some Muslim women
may be determined to fast and thus suffer potential
consequences for glucose metabolism and hydration.
Labor and delivery are women’s affairs. In Arab
countries, home delivery, with the assistance of dayahs
(“midwives”) or neighbors was common because of
limited access to hospitals, “shyness,” and financial
constraints. However, recently, the practice of home
delivery has decreased dramatically in Arab countries,
and hospital deliveries have become common. During
labor, women openly express pain through facial
expressions, verbalizations, and body movements.
Nurses and medical staff may mistakenly diagnose
Arab women as needing medical intervention and
administer pain medications more liberally to alleviate
the pain.
Care for the infant includes wrapping the stomach
at birth, or as soon thereafter as possible, to prevent
cold or wind from entering the baby’s body (Luna,
1994). The call to prayer is recited in the Muslim new-
born’s ear. Male circumcision is almost a universal
practice, and for Muslims, it is a religious requirement.
Female circumcision is practiced in some Arab coun-
tries like Egypt.
Folk beliefs influence bathing and breastfeeding.
Arab mothers may be reluctant to bathe postpartum
because of beliefs that air gets into the mother and
causes illness (Luna, 1994) and washing the breasts
“thins the milk” (Cline, Abuirmeileh, & Roberts, 1986).
Breastfeeding is often delayed until the second or
third day after birth because of beliefs that the mother
requires rest, that nursing at birth causes “colic” pain
for the mother, and that “colostrum makes the baby
dumb” (Cline et al., 1986). Postpartum care also
includes special foods such as lentil soup to increase
People of Arab Heritage 169
R E F L E C T I V E E X E R C I S E 9 . 3
Mrs. Khairallah is a 32-year-old pregnant woman who arrives
at the delivery suite with contractions. While the nurses are
getting Mrs. Khairallah to her bed, her husband calls the nurse
and tells her that he demands that no man be allowed to
enter his wife’s room. He insists that all nurses, doctors, and
other staff be female. He also does not want any male person
to enter the room during the night because his wife will
have her veil removed while she is sleeping. The nurse iscon-
flicted because the doctor in the delivery suite is a male, and
Mrs. Khairallah is fully dilated and ready to deliver at any time.
The nurse puts a note next to the Khairallah family’s room
saying that males are not allowed in the room based on
patient preference.
1. Based on your nursing training, evaluate the response of
this nurse.
2. Explain the cultural connotations of Mr. Khairallah’s
behavior.
3. What can the nurse do in this situation?
2780_Ch09_159-177 16/07/12 11:44 AM Page 169

milk production and tea to flush and cleanse the body.
The 40 days after delivery are valued for women to
rest. Mothers, in-laws, and other female members of
the extended family may step in to help. The newly
delivered woman expects to receive guests to congrat-
ulate her for the birth of the child from all family
and friends.
A Michigan study with 2755 Arab Americans re-
ported the experiences of Arab American mothers and
infants as fairly comparable with their white counter-
parts with regard to adequacy of prenatal care, maternal
complications, infant mortality, and birth complications.
In addition, fewer Arab American mothers smoke,
drink alcohol, or gain too little weight (Kulwicki,
Smiley, & Devine, 2007). Although these statewide
statistics are quite favorable, it is important to mention
that earlier studies revealed an alarming rate of infant
mortality among Arab American mothers in Dearborn,
Michigan, a particularly disadvantaged community of
new immigrants with high rates of unemployment.
Factors contributing to poor pregnancy outcomes
include poverty; lower levels of educational attainment;
inability to communicate in English; personal, family,
and cultural stressors; cigarette smoking; and early
or closely spaced pregnancies. Fear of being ridiculed
by American health-care providers and a limited num-
ber of bilingual providers limit access to health-care
information.
Death Rituals
Death Rituals and Expectations
Although Arabs insist on maintaining hope regardless
of prognosis, death is accepted as God’s will. Accord-
ing to Muslim beliefs, death is foreordained and
worldly life is but a preparation for eternal life. Hence,
from the Qur’an, Surrah III, v. 185:
Every soul will taste of death. And ye will be paid on
the Day of Resurrection only that which ye have fairly
earned. Whoso is removed from the Fire and is made to
enter Paradise, he indeed is triumphant. The life of this
world is but comfort of illusion. (Pickthall, 1977, p. 70)
Muslim death rituals include turning the patient’s
bed to face the holy city of Mecca and reading from
the Qur’an, particularly verses stressing hope and ac-
ceptance. After death, the deceased is washed three
times by a Muslim of the same sex. The body is then
wrapped, preferably in white material, and buried un-
derground as soon as possible, usually the day of or
the day after death, in a brick- or cement-lined grave
facing Mecca. Prayers for the deceased are recited at
home, at the mosque, or at the cemetery. Women dress
in black but do not ordinarily attend the burial unless
the deceased is a close relative or husband. Instead,
they gather at the deceased’s home and read the
Qur’an. Similar memorials are planned one week and
40 days after the death. Cremation is not practiced.
Family members do not generally approve of
autopsy because of respect for the dead and feelings
that the body should not be mutilated. Islam allows
forensic autopsy and autopsy for the sake of medical
research and instruction.
Death rituals for Arab Christians are similar to
Christian practices in the rest of the world. Arab
American Christians may have a Bible next to the
patient, expect a visit from the priest, and expect
medical means to prolong life if possible. Organ
donations and autopsies are acceptable. Wearing
black during the mourning period is also common.
Widows may wear black for the remainder of their
lives. For both Christians and Muslims, patients, es-
pecially children, are not told about terminal illness.
The family spokesperson is usually the person who
should be informed about the impending death. The
spokesperson will then communicate news to family
members.
Responses to Death and Grief
Mourning periods and practices may vary among
Muslims and Christians emigrating from different
Arab countries. Extended mourning periods may be
practiced if the deceased is a young man, a woman,
or a child. However, in some cases, Muslims may per-
ceive extended periods of mourning as defiance of the
will of God. Family members are asked to endure with
patience and good faith in Allah what befalls them,
including death. Whereas friends and relatives are to
restrict mourning to 3 days, a wife may mourn for
4 months, and in some special cases, mourning can ex-
tend to 1 year. Although weeping is allowed, beating
the cheeks or tearing garments is prohibited. For
women, wearing black is considered appropriate for
the entire period of mourning.
Spirituality
Religious Practices and Use of Prayer
Not all Arab Americans are Muslims. Prominent
Christian groups include the Copts in Egypt, the
Chaldeans in Iraq, and the Maronites in Lebanon
(Kulwicki & Kridli, 2001). Despite their distinctive
practices and liturgies, Christians and Muslims share
certain beliefs because of Islam’s origin in Judaism
and Christianity. Muslims and Christians believe in
the same God and many of the same prophets, the
Day of Judgment, Satan, heaven, hell, and an afterlife.
One major difference from Catholicism and Christian
Orthodoxy is that Islam has no priesthood. Islamic
scholars or religious sheikhs, the most learned individ-
uals in an Islamic community, assume the role of
imam, or “leader of the prayer.” The imam also per-
forms marriage ceremonies and funeral prayers and
acts as a spiritual counselor or reference on Islamic
teachings. Obtaining the opinion of the local imam
170 Aggregate Data for Cultural-Specific Groups
2780_Ch09_159-177 16/07/12 11:44 AM Page 170

may be a helpful intervention for Arab American
Muslims struggling with health-care decisions.
As with any religion, observance of religious prac-
tices varies among Muslims. Some nominally practice
their religion, whereas others are devout. However,
because Islam is the state religion of most Arab coun-
tries and, in Islam, there is no separation of church
and state, a certain degree of religious participation is
obligatory.
To illustrate, consider a few examples of Islam’s
impact on Jordanian life. Because of Islamic law,
abortion is investigated as a crime, and foster par-
enting is encouraged, whereas adoption is forbidden.
The infertility treatments available are those ap-
proved by Islamic jurists. Islamic law courts rule on
family matters such as marriage, divorce, guardian-
ship, and inheritance employing shariah, or Islamic
law. Public schools have classes on Islam and prayer
rooms. School and work schedules revolve around
Islamic holidays and the weekly prayer. During
Ramadan, restaurants remain closed during daylight
hours and workdays are shortened to facilitate fast-
ing. Because Muslims gather for communal prayer
on Friday afternoons, the workweek runs from Sat-
urday through Thursday. Finally, because of Islamic
tradition that adherents of other monotheistic reli-
gions be accorded tolerance and protection, Jordan’s
Christians have separate religious courts and schools,
and non-Muslims attending public schools are not
required to participate in religious activities. Similar
arrangements exist in other Arab countries. In Saudi
Arabia, the practice of other religions is officially
banned.
For Arab American Christians, church is an im-
portant part of everyday life. Most celebrate Catholic
and Orthodox Christian holidays with fasting and
ceremonial church services. They may display or wear
Christian symbols such as a cross or a picture of the
Virgin Mary. There are also schools that offer classes
on Christianity.
Meaning of Life and Individual Sources
of Strength
For Muslims, adherents of the world’s second largest
religion, Islam means “submission to Allah.” Life
centers on worshipping Allah and preparing for one’s
afterlife by fulfilling religious duties as described in
the Qur’an and the hadith, the putative sayings of the
Prophet Muhammad. The five major pillars, or
duties, of Islam are declaration of faith, prayer five
times daily, almsgiving, fasting during Ramadan, and
completion of a pilgrimage to Mecca.
Despite the dominance of familism in Arab life, re-
ligious faith is often regarded as more important.
Whether Muslim or Christian, Arabs identify strongly
with their respective religious groups, and religious
affiliation is as much a part of their identity as
family name. God and his power are acknowledged in
everyday life.
Spiritual Beliefs and Health-Care Practices
Many Muslims believe in combining spiritual medi-
cine, performance of daily prayers, and reading or lis-
tening to the Qur’an with conventional medical
treatment. The devout patient may request that her or
his chair or bed be turned to face Mecca and that a
basin of water be provided for ritual washing or ablu-
tion before praying. Providing for cleanliness is par-
ticularly important because the Muslim’s prayer is not
acceptable unless the body, clothing, and place of
prayer are clean.
Islamic teachings urge Muslims to eat wholesome
food; abstain from pork, alcohol, and illicit drugs;
practice moderation in all activities; be conscious of
hygiene; and face adversity with faith in Allah’s mercy
and compassion, hope, and acceptance. Muslims are
also advised to care for the needs of the community
by visiting and assisting the sick and providing for
needy Muslims.
Sometimes, illness is considered punishment for
one’s sins. Correspondingly, by providing cures, Allah
manifests mercy and compassion and supplies a vehi-
cle for repentance and gratitude (Al-Akili, 1993).
Some emphasize that sickness should not be viewed
as punishment, but as a trial or ordeal that brings
about expiation of sins and that may strengthen char-
acter (Ebrahim, 1989). Common responses to illness
include patience and endurance of suffering because
it has a purpose known only to Allah, unfailing hope
that even “irreversible” conditions might be cured “if
it be Allah’s will,” and acceptance of one’s fate. Suf-
fering by some devout Muslims may be viewed as a
means for greater reward in the afterlife (Lovering,
2006). Because of the belief in the sanctity of life, eu-
thanasia and assisted suicide are forbidden (Lawrence
& Rozmus, 2001).
Arab American Christians have spiritual beliefs
related to health care that are similar or the same as
Orthodox or Catholic Christians. Caring for the body
and burial practices are similar. A priest is always ex-
pected to visit the patient; if the patient is Catholic, a
priest administers the sacrament of the sick.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Good health is seen as the ability to fulfill one’s roles.
Diseases are attributed to a variety of factors such as
inadequate diet, hot and cold shifts, and exposure of
one’s stomach during sleep, emotional or spiritual dis-
tress, and envy or the evil eye. Arabs are expected
to express and acknowledge their ailments when ill.
Muslims often mention that the Prophet urged physi-
cians to perform research and the ill to seek treatment
People of Arab Heritage 171
2780_Ch09_159-177 16/07/12 11:44 AM Page 171

because “Allah has not created a disease without pro-
viding a cure for it” (Ebrahim, 1989, p. 5), except for
the problem of old age
Despite beliefs that one should care for health and
seek treatment when ill, some Arab women are often
reluctant to seek care. Because of the cultural empha-
sis placed on modesty, some women express shyness
about disrobing for examination. Similarly, some fam-
ilies object to female family members being examined
by male physicians. Because of the fear that a diag-
nosed illness, such as cancer or psychiatric illness, may
bring shame and influence the marriage ability of the
woman and her female relatives, delays in seeking
medical care may be common.
Evidence also suggests that the cultural preference
for male offspring influences the health care that low-
income parents provide for female children. In poor
communities in Jordan, boys were better nourished,
more likely to be immunized, and more apt to receive
prompt medical attention for illnesses (West, 1987).
Delay in seeking treatment was noted by a local health-
care provider who diagnosed “failure to thrive” in a
young Iraqi female infant when her refugee parents
sought medical attention for a feverish male sibling.
Whereas Arab Americans readily seek care for ac-
tual symptoms, preventive care is not generally sought
(Kulwicki, 1996; Kulwicki et al., 2000). Similarly, pe-
diatric clinics are used primarily for illness and injury
rather than for well-child visits (Lipson, Reizian, &
Meleis, 1987). Laffrey, Meleis, Lipson, Solomon, and
Omidian (1989) attributed these patterns to Arabs’
present orientation and reluctance to plan and to the
meaning that Arab Americans attach to preventive
care. Whereas American health-care providers focus on
screening and managing risks and complications, Arab
Americans value information that aids in coping with
stress, illness, or treatment protocols. Arab Americans’
failure to use preventive care services may be related
to other factors such as insurance coverage, the avail-
ability of female physicians who accept Medicaid pa-
tients, and the novelty of the concept of preventive
care for immigrants from developing countries.
Responsibility for Health Care
Dichotomous views regarding individual responsibility
and one’s control over life’s events often cause misun-
derstanding between Arab Americans and health-care
providers (Abu Gharbieh, 1993). For example, indi-
vidualism and an activist approach to life are the
underpinnings of the American health-care system.
Accordingly, practices such as informed consent,
self-care, advance directives, risk management, and
preventive care are valued. Patients are expected to
use information seeking and problem solving in pref-
erence to faith in God, patience, and acceptance
of one’s fate as primary coping mechanisms. Simi-
larly, American health-care providers expect that the
patient’s hope be “realistic” in accordance with
medical science.
However, in the Arab culture, quite different values,
familism, and reliance on God’s will influence health
care and responses to illness. For Arabs, the family is
the context within which health care is delivered
(Lipson et al., 1987). Rather than engage in self-care
and decision making, patients often allow family
members to oversee care. Family members indulge the
individual and assume the ill person’s responsibilities.
Although the patient may seem overly dependent and
the family overly protective by American standards,
family members’ vigilance and “demanding behavior”
should be interpreted as a measure of concern. For
Muslims, care is a religious obligation associated with
individual and collective meanings of honor (Luna,
1994). Individuals are seen as expressing care through
the performance of gender-specific role responsibili-
ties as delineated in the Qur’an.
Although most American health-care providers
consider full disclosure an ethical obligation, most
Arab physicians do not believe that it is necessary for
a patient to know a serious diagnosis or full details of
a surgical procedure. In fact, communicating a grave
diagnosis is often viewed as cruel and tactless because
it deprives patients of hope. Similarly, preoperative in-
structions are believed to cause needless anxiety,
hypochondriasis, and complications. In Lebanon, a
qualitative study revealed that communication with
the physician was a means of relieving stress among
cancer patients (Doumit & Abu-Saad, 2008). How-
ever, some patients still prefer the traditional nondis-
closure approach, and thus it is best to ask patients
what they want to know about their illness. Apart
from the educated, most patients are not interested
in actively participating in decision making (Abu
Gharbieh, 1993). Most Arabs expect physicians, be-
cause of their expertise, to select treatments. The pa-
tient’s role is to cooperate. The authority of physicians
is seldom challenged or questioned. When treatment
is successful, the physician’s skill is recognized; adverse
outcomes are attributed to God’s will unless there is
evidence of blatant malpractice (Sullivan, 1993).
Not all Arabs may be familiar with the American
concept of health insurance. Traditionally, the family
unit, through its communal resources, provides insur-
ance. Certain Arab countries, such as Saudi Arabia,
Syria, and Kuwait, provide free medical care, whereas
in other countries many citizens are government em-
ployees and are entitled to low-cost care in govern-
ment-sector facilities. Private physicians and hospitals
are preferred because of the belief that the private
sector offers the best care.
Because many medications requiring a prescription
in the United States are available over the counter in
Arab countries, Arabs are accustomed to seeking med-
ical advice from pharmacists. In comparison with
172 Aggregate Data for Cultural-Specific Groups
2780_Ch09_159-177 16/07/12 11:44 AM Page 172

other Americans in Wayne County, Arab Americans
were less likely to take prescription medications, but
when they did, they were more likely to use medications
as directed (Wayne County Health Department, 1994).
Folk Practices
Although Islam disapproves of superstition, witch-
craft, and magic, concerns about the powers of jealous
people, the evil eye, and certain supernatural agents
such as the devil and jinn are part of the folk beliefs.
Those who envy the wealth, success, or beauty of oth-
ers are believed to cause adversity by a gaze, which
brings misfortune to the victim. Beautiful women,
healthy-looking babies, and the rich are believed to be
particularly susceptible to the evil eye, and expressions
of congratulations may be interpreted as envy. Protec-
tion from the evil eye is afforded by wearing amulets,
such as blue beads or figures involving the number 5;
reciting the Qur’an; or invoking the name of Allah
(Kulwicki, 1996). Barren women, the poor, and the
unfortunate are usually suspects for casting the evil eye.
Mental or emotional illnesses may be attributed to pos-
session by evil jinn, or demons. Some believe that in-
sanity or jinaan (“possession by the jinn”) may also be
caused by the evil wishes of jealous individuals.
Traditional Islamic medicine is based on the the-
ory of four humors and the spiritual and physical
remedies prescribed by the Prophet. Because illness
is viewed as an imbalance between the humors—
black bile, blood, phlegm, and yellow bile—and the
primary attributes of dryness, heat, cold, and mois-
ture, therapy involves treating with the disease’s op-
posite: hot disease, cold remedy. Although methods
such as cupping, cautery, and phlebotomy (bloodlet-
ting) may be employed, treating with special prayers
or simple foods such as dates, honey, salt, and olive
oil is preferred (Al-Akili, 1993). Yemeni or Saudi
Arabian patients may apply heat (cupping, moxibus-
tion) or use cautery in combination with modern
medical technology.
Barriers to Health Care
Newly arrived and unskilled refugees from poorer
parts of the Arab world are at particular risk for both
increased exposure to ill health and inadequate access
to health care. Factors such as refugee status, recency
of arrival, differences in cultural values and norms, in-
ability to pay for health-care services, and inability to
speak English add to the stresses of immigration (Kul-
wicki, 2000; Kulwicki et al., 2010) and affect both
health status and responses to health problems. More-
over, these immigrants are less likely to receive ade-
quate health care because of cultural and language
barriers, lack of transportation, limited health insur-
ance, poverty, a lack of awareness of existing services,
and poor coordination of services (Kulwicki, 1996;
2000; 2010).
Although a lack of insurance coverage is a factor
for a significant number of Wayne County Health
Department respondents (Wayne County Health
Department, 1994), other studies suggest that Arab
Americans regard other barriers and services
as more significant. For instance, language and
communication remain serious barriers for recent
Arab American immigrants (Kulwicki, 2000; 2010).
Transportation to health-care facilities and cultur-
ally competent service providers also adds to the
problems of accessing health-care services.
Cultural Responses to Health and Illness
Arabs regard pain as unpleasant and something to be
controlled (Reizian & Meleis, 1986). Because of their
confidence in medical science, Arabs anticipate imme-
diate postoperative relief from their symptoms. This
expectation, in combination with a belief in conserv-
ing energy for recovery, often contributes to a reluc-
tance to comply with typical postoperative routines
such as frequent ambulation. Although expressive,
emotional, and vocal responses to pain are usually re-
served for the immediate family, under certain circum-
stances, such as childbirth and illnesses accompanied
by spasms, Arabs express pain more freely (Reizian &
Meleis, 1986). The tendency of Arabs to be more ex-
pressive with their family and more restrained in the
presence of health-care providers may lead to conflict-
ing perceptions regarding the adequacy of pain relief.
Whereas the nurse may assess pain relief as adequate,
family members may demand that their relative receive
additional analgesia.
The attitude that mental illness is a major social
stigma is particularly pervasive. Psychiatric symptoms
may be denied, attributed to “bad nerves” (Hattar-
Pollara, Meleis, & Nagib, 2001), or blamed on evil spir-
its (Kulwicki, 1996). Underrecognition of signs and
symptoms may occur because of the somatic orienta-
tion of Arab patients and physicians, patients’ toler-
ance of emotional suffering, and relatives’ tolerance of
behavioral disturbances (El-Islam, 1994). Indeed,
home management with standard but crucial adjust-
ments within the family may abort or control symp-
toms until remission occurs. For example, female
family members manage the mother’s postpartum de-
pression by assuming care of the newborn and/or by
telling the mother she needs more help or more rest.
Islamic legal prohibitions further confound attempts
to estimate the incidence of problems such as alco-
holism and suicide, resulting in underreporting of
these conditions because of potential for social stigma.
When individuals suffering from mental distress
seek medical care, they are likely to present with a va-
riety of vague complaints, such as abdominal pain,
lassitude, anorexia, and shortness of breath. Patients
often expect and may insist on somatic treatment, at
least “vitamins and tonics” (El-Islam, 1994). When
People of Arab Heritage 173
2780_Ch09_159-177 16/07/12 11:44 AM Page 173

mental illness is accepted as a diagnosis, treatment by
medications rather than by counseling is preferred. In
a sample of United Arab Emirates subjects, the main
treatment adopted for psychiatric illness was prayer,
herbal ingredients, or both, while counseling by a psy-
chiatrist was preferred the least due to stigma (Salem,
Saleh, Yousef, & Sabri, 2009). Hospitalization is resis-
ted because such placement is viewed as abandonment
(Budman, Lipson, & Meleis, 1992). Although Arab
Americans report family and marital stress as well as
various mental health symptoms, they often seek family
counseling or social services rather than a psychiatrist
(Aswad & Gray, 1996). A study in 2007 suggested that
immigrant Muslim women in the United States are at
an increased risk for experiencing anxiety and depres-
sive symptoms, as well as stressors such as acculturative
stress, discrimination, and trauma (Hassouneh &
Kulwicki, 2007).
Yousef (1993) described the Arab public’s attitude
toward the disabled as generally negative, with low ex-
pectations for education and rehabilitation. Yousef also
related misconceptions about mental retardation to the
dearth of Arab literature about disability and the
public’s lack of experience with the disabled. Because
of social stigma, the disabled are often kept from public
view. Similarly, although there is a trend toward edu-
cating some children with mild mental retardation in
regular schools, special education programs are generally
institutionally based.
Reiter, Mar’i, and Rosenberg (1986) found that par-
ents who were most intimately involved with the devel-
opmentally disabled held rather positive attitudes. More
tolerant views were expressed among Arab-Israeli par-
ents, Muslims, the less educated, and residents of
smaller villages than among Christians, the educated,
and residents of larger villages with mixed populations.
Reiter and colleagues (1986) linked the less positive
attitudes of the latter groups to the process of modern-
ization, which affects a drive toward status and a weak-
ening of family structures and traditions. Traditions
include regarding the handicapped as coming from
God, accepting the disabled person’s dependency, and
providing care within the home.
Dependency is accepted. Family members assume
the ill person’s responsibilities. The ill person is cared
for and indulged. From an American frame of refer-
ence, the patient may seem overly dependent and the
family overly protective.
Blood Transfusions and Organ Donation
Although blood transfusions and organ transplants
are widely accepted, organ donation is a controversial
issue among Arabs and Arab Americans. Practices of
organ donation may vary among Arab Muslims and
non-Muslims based on their religious beliefs about
death and dying, reincarnation, or their personal feel-
ings about helping others by donating their organs to
others or for scientific purposes (Kulwicki, 2001).
Health-care providers should be sensitive to personal,
family, or religious practices toward organ donation
among Arab Americans and should not make any
assumptions about organ donation unless family
members are asked.
Health-Care Providers
Traditional Versus Biomedical Providers
Although Arab Americans combine traditional and
biomedical care practices, they are very cognizant of
the effective medical treatments in the West and con-
sider themselves privileged to be able to use the Amer-
ican health-care system (Kulwicki, 1996). Because of
their profound respect for medicine, Arab Americans
seek treatments for physical disorders or ailments.
Medical treatments that require surgery, removal of
causative agents, or eradicating by intravenous treat-
ments are valued more than therapies aimed at health
promotion or disease prevention. Although most
Arab Americans have high regard for medicine related
to physical disorders, many do not have the same re-
spect or trust for mental or psychological/psychiatric
treatment. A pervasive feeling among many Arab
Americans is that psychiatric services or therapies re-
lated to mental disorders are not effective and are re-
quired only for individuals who have severe mental
disorders or who are considered “crazy.” Psychiatric
services are, therefore, underutilized among Arab
Americans despite greater need for such services
among distressed immigrant populations.
Gender and, to a lesser extent, age are considera-
tions in matching Arab patients and health-care
providers. In Arab societies, unrelated males and
females are not accustomed to interacting. Shyness in
women is appreciated, and Muslim men may ignore
women out of politeness. Health-care settings, patient
units, and sometimes waiting rooms are segregated by
sex. Male nurses never care for female patients.
Given this background, many Arab Americans may
find interacting with a health-care provider of the op-
posite sex quite embarrassing and stressful. Discom-
fort may be expressed by refusal to discuss personal
information and a reluctance to disrobe for physical
assessments and hygiene. Arab American women may
refuse to be seen by male American health-care
providers, excluding or denying men the opportunity
to interact or appropriately diagnose health condi-
tions for high-risk Arab American females.
Status of Health-Care Providers
Arab Americans have great respect for science and
medicine. Most Arab Americans are aware of the his-
torical contributions of Arabs in the field of medicine
and are proud of their accomplishments. Knowledge
held by a doctor is believed to convey authority and
174 Aggregate Data for Cultural-Specific Groups
2780_Ch09_159-177 16/07/12 11:44 AM Page 174

power. When ill, most Arab American patients who
lack English communication skills prefer to see
Arabic-speaking doctors because of their feelings of
cultural and linguistic affinity toward Arab American
doctors. Many Arabic-speaking patients also feel that
Arab American doctors understand them better, and
they feel more at ease speaking with someone from
their own culture. However, patients who are able to
communicate in English do not usually show prefer-
ences for seeing Arab doctors over American doctors.
In some cases, these patients prefer to be seen by
American doctors because they view American
doctors as more professional and more respectful to
patients than their Arab American counterparts.
Although medicine is perhaps the most respected
prestigious profession in Arab society, nursing is
viewed as a menial profession that conflicts with soci-
etal norms proscribing certain female behavior. In this
conservative culture, in which contact between unre-
lated males and females is often discouraged, nursing
is considered particularly undesirable as an occupa-
tion because it requires close contact between the
sexes and work during evening and night hours (Abu
Gharbieh, 1993). American nurses are regarded more
favorably because of their education, expertise, and
performance of roles ascribed solely to Arab physi-
cians (e.g., performing physical examinations). How-
ever, younger immigrants, and especially immigrants
who come from Lebanon, Iraq, and Jordan, have
more favorable perceptions about nursing as a profes-
sion than the older generation of Arab American
immigrants (Kulwicki & Kridli, 2001).
Perhaps because Arab physicians tend to be older
males and Arab nurses are typically young females,
the status and roles of physicians and nurses mirror
the hierarchical family structure of Arab society.
Physicians require that nurses “know their place” and
leave the interpretation of data, decision making, and
disclosure of information to them. Nurses conform to
the role expectations of physicians and the public, and
they function as medical assistants and housekeepers
rather than as critical thinkers and health educators.
Recently, nursing has established professional organ-
izations in many Arab countries that resemble the
American Nurses Association.
R E F E R E N C E S
Abu Gharbieh, P. (1993). Culture shock. Cultural norms influencing
nursing in Jordan. Nursing and Health Care, 14(10), 534–540.
Ahmad, N.M. (2004). Arab-American culture and health care.
Retrieved from http://www.case.edu/med/epidbio/mphp439/
Arab-Americans.html
Al-Akili, M. (1993). Natural healing with the medicine of the
prophet. Philadelphia, PA: Pearl Publishing House.
Al-Omari, H., & Scheibmeir, M. (2010). Arab Americans’ accul-
turation and tobacco smoking. Journal of Transcultural Nurs-
ing, 20(2), 227–233.
Al-Shahri, M.Z. (2002). Culturally sensitive caring for Saudi
patients, Journal of Transcultural Nursing, 13(2), 133–138.
Arab American Institute. (2010). Demographics. Retrieved from
http://www.aaiusa.org/arab-americans/22/demographics
Arab human development report. (2000). Retrieved from http://www.
UNESCO.org/education
Arfken, C.L., Kubiak, S.P., & Koch, A.L. (2007). Health issues in
the Arab American community. Arab Americans in publicly fi-
nanced substance abuse treatment. Ethnicity Disease, 17(2
Suppl 3), S3-72–S3-76.
Aswad, B. (1999). Arabs in America: Building a new future. In
M.W. Suleiman (Ed.), Attitudes of Arab immigrants toward wel-
fare (pp. 177–191). Philadelphia: Temple University Press.
Aswad, B.C., & Gray, N. (1996). Challenges to the Arab-American
family and ACCESS (Arab Community Center for Economic
and Social Services). In B.C. Aswad & B. Bilgé (Eds.), Family
and gender among American Muslims: Issues facing Middle
Eastern immigrants and their descendants (pp. 223–240).
Philadelphia: Temple University Press.
Budman, C., Lipson, J., & Meleis, A. (1992). The cultural consult-
ant in mental health care: The case of an Arab adolescent.
American Journal of Orthopsychiatry, 62(3), 359–370.
Centers for Disease Control and Prevention (CDC). (2012). Com-
plete HIV/AIDS resource. Retrieved from www.cdc.gov/hiv/
CIA World Factbook. (2011a). Jordan. Retrieved from https://
www.cia.gov/library/publications/the-world-factbook/
geos/jo.html
CIA World Factbook. (2011b). Lebanon. Retrieved from https://
www.cia.gov/library/publications/the-world-factbook/
geos/le.html
CIA World Factbook. (2011c). Yemen. Retrieved from https://www.
cia.gov/library/publications/the-world-factbook/geos/ym.html
Cline, S., Abuirmeileh, N., & Roberts, A. (1986).Woman’s life cycle.
Fundamentals of health education (pp. 48–77). Yarmouk,
Jordan: Yarmouk University.
Darwish-Yassine, M., & Wang, D. (2005). Cancer epidemiology
in Arab Americans and Arabs outside the Middle East.
Ethnicity and Disease, 15, S1–S8.
Doumit, M.A., & Abu-Saad, H.H. (2008). Lebanese cancer pa-
tients: Communication and truth-telling preferences. Contem-
porary Nurse, 28, 74–82
Ebrahim, A. (1989). Abortion, birth control and surrogate parent-
ing. An Islamic perspective. Indianapolis, IN: American Trust
Publications.
El-Islam, M. (1994). Cultural aspects of morbid fears in
Qatari women. Social Psychiatry Psychiatric Epidemiology,
29, 137–140.
El Sayed, A.M., & Galea, S. (2009). Health of Arab Americans
living in the United States: A systematic review of the litera-
ture. BMC Public Health, 9. Retrieved from http://www.
biomedcentral.com/
Global Gayz: Muslims. (2006). Retrieved from http://www.global-
gayz.com/art-index.html#middleeast
Hamamy, H., & Alwan, A. (1994). Hereditary disorders in the
Eastern Mediterranean region. Bulletin of the World Health
Organization, 72(1), 145–154.
Hashemite Kingdom of Jordan, Department of Statistics. (1985).
Jordan’s husbands’ fertility survey. Amman, Jordan: Author, in
collaboration with Division of Reproductive Health, Centers
for Disease Control and Prevention, Atlanta, GA.
Hassouneh, D.M., & Kulwicki, A. (2007). Mental health, dis-
crimination, and trauma in Arab Muslim women living in the
U.S.: A pilot study. Mental Health, Religion & Culture, 10(3),
257–262.
People of Arab Heritage 175
2780_Ch09_159-177 16/07/12 11:44 AM Page 175

Hattar-Pollara, M., Meleis, A.I., & Nagib, H. (2001). A study of
spousal role of Egyptian women in clerical jobs. Health Care
for Women International, 21(4), 305–517.
Hikmet, J., Hakim-Larson, J., Farrag, M., & Jamil, L. (2002). A
retrospective study of Arab American mental health clients:
Trauma and the Iraqi refugees. American Journal of Orthopsy-
chiatry, 72, 355–361.
Institute of Medicine (2002).Unequal treatment: Confronting racial
and ethnic disparities in health care. Retrieved from
http://www.iom.edu/?id=4475
Jaber, L.A., Brown, M.B., Hammad, A., Nowak, S.N., Zhu, Q.,
Ghafoor, A., & Herman, W.H. (2003). Epidemiology of dia-
betes among Arab Americans. Diabetes Care, 26(2), 308–313.
Jaber, L.A., Brown, M.B., Hammad, A., Zhu, Q., & Herman,
W.H. (2004). The prevalence of the metabolic syndrome among
Arab Americans. Diabetes Care, 27, 234–238.
Kinzie, J., Boehnlein J.K., Riley, C., & Sparr, L. (2002). The effects
of September 11 on traumatized refugees: Reactivation of
posttraumatic stress disorder. Journal of Nervous and Mental
Disease, 190, 437–441.
Kira, I., Smith, I, Lewandoski, L., & Templin, T. (2010). The ef-
fects of gender discrimination on refugee torture survivors: A
cross-cultural traumatology perspective. Journal of American
Psychiatric Nurses Association, 16, 299–306.
Kira, I., Templin, T., Lewandoski, L., Clifford, D., Wieneck, P.,
Hammad, A., et al. (2006). The effects of torture: Two com-
munity studies. Peace and Conflict: Journal of Peace Psychol-
ogy, 12(3), 205–228.
Kulwicki, A. (1996). Health issues among Arab Muslim families.
In B.C. Aswad & B. Bilgé (Eds.), Family and gender among
American Muslims: Issues facing Middle Eastern immigrants
and their descendants (pp. 187–207). Philadelphia: Temple Uni-
versity Press.
Kulwicki, A. (2000). Arab women. In M. Julia (Ed.), Constructing
gender: Multicultural perspectives in working with women
(pp. 89–98). Nelson, BC, Canada: Brooks/Cole.
Kulwicki, A. (Ed.). (2001). Ethnic resource guide. Dearborn, MI:
Henry Ford Hospital.
Kulwicki, A., Aswad, B., Carmona, T., & Ballout, S. (2010). Bar-
riers in the utilization of domestic violence services among
Arab immigrant women: Perceptions of professionals, service
providers & community leaders. Journal of Family Violence,
25(8), 727–735.
Kulwicki, A., & Cass, P. (1994). An assessment of Arab-American
knowledge, attitudes, and beliefs about AIDS.IMAGE: Journal
of Nursing Scholarship, 26(1), 13–17.
Kulwicki, A., & Khalifa, R. (2008). The impact of September 11,
2001, on Arab American nurses in Michigan. Journal of
Transcultural Nursing, 19(2), 134–139.
Kulwicki, A., & Kridli, S. (2001). Health-care perceptions and
experiences of Chaldean, Arab Muslim, Arab Christian, and Ar-
menian women in the metropolitan area of Detroit. Unpublished
manuscript.
Kulwicki, A., & Miller, J. (1999). Domestic violence in the Arab
American population: Transforming environmental conditions
through community education. Issues in Mental Health Nursing,
20(3) 199–215.
Kulwicki, A., Miller, J., & Schim, S. (2000). Collaborative part-
nership for culture care: Enhancing health services for the Arab
community. Journal of Transcultural Nursing, 11(1), 31–39.
Kulwicki, A., Smiley, K., & Devine, S. (2007). Smoking behavior in
pregnant Arab Americans. The American Journal of Maternal/
Child Nursing, 32(6), 363–367.
Laffrey, S., Meleis, A., Lipson, J., Solomon, M., & Omidian, P.
(1989). Assessing Arab-American health care needs. Social
Science and Medicine, 29(7), 877–883.
Lawrence, P., & Rozmus, C. (2001). Culturally sensitive care of the
Muslim patient. Journal of Transcultural Nursing, 12, 228–233.
Levy, R. (1993). Ethnic and racial differences in response to med-
icines: Preserving individualized therapy in managed pharma-
ceutical programmes. Pharmaceutical Medicine, 7, 139–165.
Lipson, J., Reizian, A., & Meleis, A. (1987). Arab-American pa-
tients: A medical record review. Social Science and Medicine,
24(2), 101–107.
Lovering, S. (2006). Cultural attitudes and beliefs about pain.
Journal of Transcultural Nursing, 17(4), 389–395.
Luna, L. (1994). Care and cultural context of Lebanese Muslim
immigrants: Using Leininger’s theory. Journal of Transcultural
Nursing, 5(2), 12–20.
Meleis, A. (2005). Arabs. In J. Lipson & S. Dibble (Eds.), Culture
and clinical care (pp. 42–57). San Francisco, CA: The Regents,
University of California.
Michigan Department of Community Health. (2009). National
Trends and Deterrent Strategies for Prescription and OTC
Drug Abuse. Retrieved from www.deadiversion.usdoj.gov/
pubs/presentations/stermidcpgov09
Michigan Department of Community Health. (2010). 2010 Profile
of HIV/AIDS in Michigan—Special populations: Arab-Americans.
Retrieved from http://www.michigan.gov/documents/mdch/21
arab_335588_7
Michigan Department of Community Health. (2010). Michigan
Department of Community Health 2009 health disparities re-
port. Lansing, MI: Author.
Michigan Department of Public Health. (1994). Health profiles of
Michigan populations. Lansing, MI: Author.
Michigan Department of Community Health and Michigan Pub-
lic Health Institute. (2003). 2001–2002 special cancer behavioral
risk factor survey. Lansing, MI: Author.
Naff, A. (1980). Arabs in America: A historical overview (pp. 128–136).
Boston: Harvard Encyclopedia of American Ethnic Groups.
Nydell, M. (1987). Understanding Arabs. A guide for Westerners.
Yarmouth, ME: Intercultural Press.
Office of Minority Health (OMH). (2001). Health facts. Retrieved
from http://www.mdch.state.mi.us/pha/omh/aram-ch.htm
Pickthall, M. (1977). The meaning of the glorious Qur’an. Mecca,
Saudi Arabia: Muslim World League.
Reiter, S., Mar’i, S., & Rosenberg, Y. (1986). Parental attitudes to-
ward the developmentally disabled among Arab communities
in Israel: A cross-cultural study. International Journal of Reha-
bilitation Research, 9(4), 335–362.
Reizian, A., & Meleis, A. (1986). Arab-Americans’ perceptions of
and responses to pain. Critical Care Nurse, 6(6), 30–37.
Reizian, A., & Meleis, A. (1987). Symptoms reported by
Arab-American patients on the Cornell Medical Index (CMI).
Western Journal of Nursing Research, 9(3), 368–384.
Rice, V., & Kulwicki, A. (1992). Cigarette use among Arab Americans
in the Detroit metropolitan area. Public Health Reports, 107(5),
589–594.
Salem, M.O., Saleh, B., Yousef, S., & Sabri, S. (2009). Help-seeking
behavior of patients attending the psychiatric service in a sample
of United Arab Emirates population. International Journal of
Social Psychiatry, 55(2), 141–148.
Schwartz, S., Darwish-Yassine, M., & Wing, D. (2005). Cancer di-
agnosis in Arab Americans and Arabs outside the United
States. Ethnicity and Disease, 15, 1–8.
176 Aggregate Data for Cultural-Specific Groups
2780_Ch09_159-177 16/07/12 11:44 AM Page 176

Seikaly, M. (1999). Arabs in America: Building a new future. In
M.W. Suleiman (Ed.), Attachment and identity: The Palestinian
community of Detroit (pp. 25–38). Philadelphia: Temple
University Press.
Sullivan, S. (1993). The patient behind the veil: Medical culture
shock in Saudi Arabia. Canadian Medical Association Journal,
148(3), 444–446.
Templin, T., Rice, H., Gadelrab, H., Weglicki, L., Hammad, A.,
& Kulwicki, A. (2003). Michigan Trends in tobacco use among
Arab/Arab American adolescents: Preliminary findings. Eth-
nicity and Disease, 15(1), S-65–S-69.
UNICEF. (2008). United Nations Population Division. Retrieved
from http://www.unicef.org/infobycountry/index.html
U.S. Census Bureau. (2005). Special Report. We the People of
Arab Ancestry in the United States. Retrieved from http://
www.census.gov/prod/2005pubs/censr-21
Wayne County Health Department. (1994). Arab community in
Wayne County, Michigan: Behavior risk factor survey (BRFS).
East Lansing, MI: Michigan State University, Institute for
Public Policy and Social Research.
West, M. (1987, April 29). Surveys indicate girls face discrimina-
tion in provision of nutrition and health care. Jordan Times.
World Health Organization (WHO). (2004). Regional database on
HIV/AIDS, WHO Regional Office for the Eastern Mediter-
ranean. Retrieved from http://www.emro.who.int/asd/
World Health Organization (WHO). (2006). Country and selection
for infant deaths. Retrieved from www.who.int/whosis/data-
base/mort/table2.cfm
Yousef, J. (1993). Education of children with mental retardation
in Arab countries. Mental Retardation, 31(2), 117–121.
Zogby, J. (2002). What Arabs think: Values, beliefs and concerns.
Retrieved from http://www.zogby.com/News/ReadNews.dbm?
ID=629
Zogby International. (2011). Retrieved from www.ibopezogby.com/
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
People of Arab Heritage 177
2780_Ch09_159-177 16/07/12 11:44 AM Page 177

178
Chapter 10
People of Chinese Heritage
Hsiu-Min Tsai
Overview, Inhabited Localities,
and Topography
Overview
Although some Western health-care providers, including
some research, categorize all Asians into aggregate data
as if they were one group, each nationality is very
different. Cultural values differ even among Chinese ac-
cording to their geographic location within China—
north, south, east, west; rural versus urban; interior
versus port city—as well as other variant cultural
characteristics (see Chapter 1). Chinese immigrants
to Western countries are even more diverse, with
a mixture of traditional and Western values and
beliefs. These differences must be acknowledged and
appreciated.
Han Chinese are the principal ethnic group of
China, constituting about 91.5 percent of the popu-
lation of mainland China, especially as distin-
guished from Manchus, Mongols, Huis, and other
minority nationalities. The remaining 8.5 percent are
a mixture of 56 different nationalities, religions, and
ethnic groups (CIA World Factbook, 2011). Substan-
tial genetic, linguistic, cultural, and social differ-
ences exist among these subgroups. Because of the
complexity of their values, it is critical to consider
social and cultural contexts to develop appropriate
interventions and provide culturally competent care
for multiethnic Chinese patients. The information
included in this chapter is only a beginning point for
understanding the Chinese people; it is not meant to
be a definitive profile.
Children born to Chinese parents in Western coun-
tries tend to adopt the Western culture easily, whereas
their parents and grandparents tend to maintain their
traditional Chinese culture in varying degrees. Chinese
who live in the “Chinatowns” of North America and
other places outside of China maintain many of their
cultural and social beliefs and values and insist that
health-care providers respect these values and beliefs
with their prescribed interventions.
Heritage and Residence
The Chinese culture is one of the oldest in recorded
human history, beginning with the Xia dynasty, dat-
ing from 2200 B.C., to the present-day People’s Re-
public of China (PRC). The Chinese name for their
country is Zhong guo, which means “middle king-
dom” or “center of the earth.” Many of the current
values and beliefs of the Chinese remain grounded in
their history; many believe that the Chinese culture is
superior to other Asian cultures. Ideals based on the
teachings of Confucius (551–479 B.C.) continue to
play an important part in the values and beliefs of the
Chinese. These ideals emphasize the importance of
accountability to family and neighbors and reinforce
the idea that all relationships embody power and rule.
Although industrialization, urbanization, and inter-
action with Western society have affected some
Chinese, the ideas and behavioral patterns related to
Confucianism are still deep-seated.
During early Communist rule, an attempt was made
to break down the values grounded in Confucianism
and substitute values consistent with equal social re-
sponsibility. This was initially achieved, and rank in
society was no longer seen as important. During the
People’s Revolution, feudal rank frequently meant loss
of social importance, physical punishment, imprison-
ment, and even death. Later, during the Cultural Rev-
olution, the young were held responsible for the deaths
of many previously esteemed older adults and edu-
cated Chinese. Today, many of the Confucian values
have reasserted themselves. Families, older adults, and
highly educated individuals are again considered im-
portant. Research completed by the Chinese Culture
Connection, a group of Chinese sociologists, lists 40
important values in modern China, including filial
piety, industry, patriotism, paying deference to those
in hierarchical status positions, tolerance of others,
loyalty to superiors, respect for rites and social rituals,
knowledge, benevolent authority, thrift, patience, cour-
tesy, and respect for tradition (Hu & Grove, 1991).
2780_Ch10_178-196 16/07/12 11:44 AM Page 178

Since China’s economic reforms social development in
the late 1990s, the Chinese society has been on the
stage of full transformation. According to Chinese
sociologists, the main social values consist of richness,
democracy, harmony, and innovation (Chen, 2009).
The population of China is 1.37 billion people, with
7.1 million in Hong Kong, over 550,000 in Macau,
and over 23.1 million in Taiwan (National Bureau of
Statistics of China, 2011). According to 2010 National
statistics, 50.32 percent live in rural communities, a
decrease of approximate 133.2 million persons since
the 2000 census. In other words, urban residents
increased by 13.46 percentage points compared with
the 2000 population census (Wang, 2011a). The higher
level of urbanization is a result of economic and social
development.
China is over 9.6 million square kilometers (3.7 million
square miles), with 23 provinces; 5 regions, including
Tibet, Hong Kong, and Taiwan; and 4 municipalities.
Each province, region, and municipality functions inde-
pendently and in many different ways. The Chinese con-
sider each region as part of greater China and predict
that the day will come when all of China is reunited.
Tibet has already been reassimilated, Hong Kong re-
turned to Chinese control in 1997, and Macau in 1999
(CIA World Factbook, 2011).
The largest communities of Chinese Americans are
in California, New York, Florida, and Texas. Chinese
Americans compose the largest subgroup among
Asians/Pacific Islanders (APIs), exceeding 3.6 million
people (U.S. Census Bureau, 2006).
Reasons for Migration and Associated
Economic Factors
Chinese immigrated to the United States in three dif-
ferent waves: in the 1800s, in the 1950s, and in the
past several years. Chinese immigration was initially
fueled by economic needs. Over 100,000 male peas-
ants from Guangdong and Fujian came to the
United States without their families in the early
1830s to make their fortune on the transcontinental
railroad. This immigration continued through the
Gold Rush of 1849. Many believed that they could
make money in the United States to help their fami-
lies and later return to China. Unfortunately, most
found that opportunities were limited to hard labor and
other vocations not desired by European Americans.
Their culture and physical features made them read-
ily identifiable in the predominantly white American
society. They could not simply change their names
and blend in with other, primarily European immi-
grant populations. The Chinese had few rights
and were barred from becoming U.S. citizens. Racial
violence and prejudice against them were common,
and the courts did not punish the violators. Com-
pared with other ethnic groups, their immigration
numbers were small until 1952, when the McCarran-
Walters Bill relaxed immigration laws and permitted
more Chinese to enter the country (U.S. Citizenship
and Immigration Services, 2011).
The most recent immigrants from Taiwan, Hong
Kong, and mainland China are strikingly different from
earlier Chinese immigrants in that they are more di-
verse. In addition, whereas many emigrated to reunite
with their families, students, scholars, and professionals
flocked to the United States to pursue higher education
or research. For their safety and the maintenance of
their cultural values, most Chinese settled in closed
communities.
Educational Status and Occupations
Influenced by the Confucian principles, the Chinese
people believe that “to be a scholar is to be at the top
of society” (Ho & Lee, 2010). In Chinese society, aca-
demic achievement is highly valued for increasing
one’s own career benefits and enhancing a family’s
reputation and position. Chinese parents are much
more willing to provide their children with the best
possible education and invest huge sums of money in
supplementary education.
Education is compulsory in China, and most chil-
dren receive the equivalent of a ninth-grade education.
Middle school students must complete a state exami-
nation to determine their eligibility to enter a general
high school, to go to a preparatory high school before
entering technical school or college, or to begin their
lives as employees. Those who complete either the gen-
eral or the preparatory high school experience compete
academically to continue their education at college and
university levels. The Chinese educational system is
complex and is not presented here in its entirety; fur-
ther study is encouraged.
A university education is highly valued; however,
few have the opportunity to achieve this life goal be-
cause enrollments in better educational institutions
are limited. Because competition for top universities
is keen, many families select less valued universities to
ensure that their child is accepted into a university
rather than slated for a technical school education.
After their undergraduate or graduate programs,
many young adults come to Western countries to at-
tend universities to seek more advanced education or
research. A foreign education is considered prestigious
in Chinese society.
In the West, initially the Chinese tend to be either
highly or poorly educated. This dichotomy may result
in health-care providers categorizing patients in a
similar manner. Many people believe that Chinese
occupations are limited to restaurant work, service
employment, and the garment industry. However, this
phenomenon has changed since the 1980s. A signifi-
cant number of Chinese students and scholars from
People of Chinese Heritage 179
2780_Ch10_178-196 16/07/12 11:44 AM Page 179

the PRC and Taiwan come to the United States to
study every year. Because of the competitive educa-
tional system in mainland China and Taiwan, where
only the brightest students go to a university, Chinese
immigrants with a college education are often very
well educated. Student immigrants are expected to re-
turn to China or Taiwan when their education and re-
search are completed. However, many do not return
but elect to remain in Western countries, having ob-
tained graduate degrees in the United States, and
many find employment in high-technology companies
or educational and research institutes.
Another group of Chinese immigrants are profes-
sionals from Hong Kong who moved to North America
and other Western countries to avoid repatriation in
1997. These immigrants usually have family connec-
tions or close friends who are highly educated and
skilled in Western countries. A third group of immi-
grants consists of uneducated individuals with diverse
manual labor skills. Finding employment opportunities
for this group may be more difficult. They often settle
with family members who are not skilled or highly ed-
ucated. This arrangement drains family resources for
many years until they obtain financial security, learn
the language, and become acculturated in other ways.
Communication
The Chinese speak a variety of different languages
and dialects. The official language of China is Mandarin
(pu tong hua), which means “common speech” (Cheung,
Nelson, Advincula, Young, & Canham, 2005) spoken
by about 70 percent of the population, primarily in
northern China, but there are 10 major, distinct dialects,
including Cantonese, Fujianese, Shanghainese, Toishanese,
and Hunanese. For example, pu tong hua is spoken
in Beijing, the capital of China in the north, and
Shanghainese is spoken in Shanghai. The two cities are
only 1462 kilometers (about 665 miles) apart, but be-
cause the dialects are so different, the two groups cannot
understand one another verbally. Even though people
from one part of China cannot understand those
from other regions, the written language is the same
throughout the country and consists of over 50,000
characters (about 5000 common ones); thus, most
children are at least 10 to 12 years old before they can
read the newspaper.
Most Chinese people tend to be more passive and
less sharing when explaining or discussing something,
whereas Americans appreciate more direct and clear
explanations. Many Americans might not understand
these communication practices and become upset be-
cause they consider Chinese communication to be in-
direct and offensive. In addition, the Chinese are less
likely to tell the other party things that may upset him
or her (O’Keefe & O’Keefe, 1997). Because of this
communication style, the Chinese might avoid sharing
a health concern such as a mental illness, a chronic
disease, or cancer when consulting with unfamiliar
health-care providers about a specific health issue.
To prevent misunderstanding, American health-care
providers have to be aware of these differences.
Although many times the Chinese sound loud when
talking with other Chinese, they generally speak in a
moderate to low voice. Americans are considered loud
to most Chinese, and health-care providers must be
cautious about their voice volume when interacting
with Chinese patients in English so intentions are not
misinterpreted.
When possible, health-care providers should use the
Chinese language to communicate (Table 10-1 lists
some common phrases), being careful to avoid jargon
and to use the simplest terms. Many times, verbs can
be omitted because the Chinese language has only a
limited number of verbs. The Chinese appreciate
any attempt to use their language. They do not mind
mistakes and will correct speakers when they believe
it will not cause embarrassment. When asked whether
they understand what was just said, the Chinese
invariably answer yes, even when they do not under-
stand because admitting it is embarrassing to them.
Thus, it is better to have Chinese patients repeat the
instructions they have been given or ask them to give
a demonstration.
Negative queries are difficult for the Chinese to
understand. For example, do not say, “You know how
to do that, don’t you?” Instead say, “Do you know
how to do that?” Also, it is easier for them to under-
stand instructions placed in a specific order, such as
the following:
1. At 9 o’clock every morning, get the medicine
bottle.
2. Take two tablets out of the bottle.
3. Get your hot water.
4. Swallow the pills with the water.
Do not use complex sentences with ands and buts.
The Chinese have difficulty deciding what to respond
to first when the speaker uses compound or complex
sentences.
Cultural Communication Patterns
There is a very obvious difference between traditional
Chinese communication patterns and American com-
munication patterns. The Chinese have a reputation
for not openly displaying emotion. They tend not to
discuss their concerns with health-care providers,
while most Americans are willing to openly give and
accept comments with others. The Chinese often con-
sider their concerns to be personal and to be shared
only with the family, friends, and relatives. They might
share information freely with health-care providers
once a trusting relationship has developed. This is not
always easy, because Western health-care providers
may not have the patience or time to develop such
180 Aggregate Data for Cultural-Specific Groups
2780_Ch10_178-196 16/07/12 11:44 AM Page 180

People of Chinese Heritage 181
❙❙◗ Table 10-1 Frequently Used Words and Phrases
English Word Chinese Phonetic
or Phrase Pinyin Pronunciation
Hello Ňi hǎo Nee how (note tones
to be used*)
Good-bye Zài jiàn Dzai jee en
How are you? Ňi hǎo mā Nee how mah
Please Qing Ching
Thank you X ı̄e xie Shee eh shee eh
I don’t understand W̆o bù dŏng Wah boo doong
Yes Sh̀i d̀e Shur da or doee
or d̀ui (no real yes or no
comparable saying—
this means I agree or
okay)
No Bú s h̀i d̀e Boo shur or boo how
or b̀u hǎo
My name is W̆o jiào Wah djeeow
Very good H̆en hǎo Hun hao
Hurt Téng Tung
I, you, he/she/it Wo, n̆i, tā Wah, nee, tah
Hot Rè Ruh
Cold Len̆g Lung
Happy Gāo xi ǹgu Gow shing
Where Ňa li Na lee
Not have ḾeiY̆ou May yo
Doctor Ȳi shēng Yee shung
Nurse Hù s̀ hi Who shur
*Each pu tong hua Chinese word is pronounced with five different tones:
First tone is high and even across the word (–); Second tone starts low
and goes high (–`); Third tone starts neutral, goes low, and then goes high
(ˇ); Fourth tone is curt and goes low (·`); Fifth tone is neutral and pro-
nounced very slowly.
relationships. In situations in which Chinese people
perceive that health-care providers or other people of
authority may lose face or be embarrassed, they
may choose not to be totally truthful. As a result, they
may always give a “no” response when unfamiliar
health-care providers ask them questions.
Touching between health-care providers and
Chinese patients should be kept to a minimum. Most
Chinese maintain a formal distance with one an-
other, which is a form of respect. Some are uncom-
fortable with face-to-face communications, especially
when there is direct eye contact. Because they prefer
to sit next to others, the health-care providers may
need to rearrange seating to promote positive com-
munication. When touching is necessary, the health-
care provider should provide explanations to Chinese
patients.
Facial expressions are used extensively among fam-
ily and friends. The Chinese love to joke and laugh.
They use and appreciate smiles when talking with oth-
ers. However, if the situation is formal, smiles may be
limited. In most greeting and communication situa-
tions, shaking hands is common; hugs are limited. The
health-care provider should watch for cues from their
Chinese patients.
Format for Names
Among the Chinese, introductions, either by name
card or verbally, are different from those in Western
countries. For example, the family name is stated first
and then the given name. Calling individuals by any
name except their family name is impolite unless they
are close friends or relatives. If a person’s family name
is Li and the given name is Ruiming, then the proper
form of address is Li Ruiming. Men are addressed by
their family name, such as Ma, and a title such as Ma
xian sheng (“Mister Ma”), lao Ma (“respected older
Ma”), or xiao Ma (“young Ma”). Titles are important
to the Chinese people, so, when possible, identify the
person’s title and use it.
Women in China do not use their husband’s last
name after they get married and retain their own fam-
ily last name. Therefore, unless the woman is from
Hong Kong or Taiwan, or has lived in a Western
country for a long time, do not assume that her last
name is the same as her husband’s. Her family name
comes first, followed by her given names, and finally
by her title. Many Chinese living in Western coun-
tries take an English name as an additional given
name because their name is difficult for Westerners
to pronounce. Their English name can be used in
many settings. Addressing them as “Miss Millie” or
“Mr. Jonathan” rather than simply by their English
name is better. Even though they have adopted an
English name, some Chinese may give permission
to use only the English name. In addition, some
Chinese switch the order of their names to be the
same as Westerners, with their family name last.
R E F L E C T I V E E X E R C I S E 1 0 . 1
Mr. Wang is a 75-year-old first-generation Chinese American
and lives with his 70-year-old Chinese wife. Mr. Wang speaks
very limited English, while his wife speaks only Chinese.
Mr. Wang visited a clinic, where he was told by his physician
that he had lung cancer. The physician wanted Mr. Wang to
be hospitalized for further treatment and chemotherapy.
Mr. Wang gave no response.
1. What barriers might exist for Mr. Wang in deciding to
accept hospitalization and seek treatment?
2. What concerns might the nurse have regarding a support
system for Mr. Wang if he decides to have his lung cancer
treated?
3. With the limited English-language ability of Mr. Wang
and his wife, how can a health-care professional ensure
effective communication?
4. If Mr. Wang prefers traditional Chinese medical treatment,
how might the nurse respond?
2780_Ch10_178-196 16/07/12 11:44 AM Page 181

This practice can be confusing; therefore, health-care
providers should address Chinese patients by their
whole name or by their family name and title, and
then ask them how they wish to be addressed.
Family Roles and Organization
Head of Household and Gender Roles
Kinship traditionally has been organized around the
male lineage. Fathers, sons, and uncles are the impor-
tant, recognized relationships between and among
families in politics and in business. Each family main-
tains a recognized head who has great authority and
assumes all major responsibilities for the family. A
common and desirable domestic traditional structure
is to have four generations under one roof. However,
with the improvement in the standards of living and
other changes, families have gradually gotten smaller.
The first generation of one-child families appeared in
the 1970s when China introduced a policy of family
planning. This phenomenon led to the nuclear family
of three (parents and one child) gradually becoming
the mainstream family structure in cities. In 2010, of
401.52 million family households in China, the aver-
age number of people in each household was 3.10, or
0.34 persons fewer as compared with the 3.44 persons
in the 2000 population census (Wang, 2011a). The
shrinking household size might be caused by the
decline of fertility, the increase of migration, and
the independent living arrangement of young couples
after marriage (Wang, 2011a).
Family life takes on various faces and follows new
trends. Because young people face greater and greater
pressure from work and want a higher standard of
living and spiritual life, the traditional concept of rais-
ing children has faded, and more couples are choosing
the “double income, no kids” (DINK) way of life.
Because increasing numbers of young people leave
home to work in other parts of the country or to study
abroad, the number of households consisting of older
couples is also rising. Improvements in housing con-
ditions make it possible for the younger generations
to move out of the house and live apart from senior
members of the family. Longer life spans have resulted
in more seniors living alone and those who have lost
their spouse living by themselves in one-person house-
holds. “Empty nests” will become the norm for seniors
as parents of the first generation of single-child fam-
ilies get older. That, in turn, means a switch from an
old system in which children looked after their parents
to one in which seniors are cared for by society in gen-
eral through benefits.
Another traditional practice in many rural Chinese
families is the submissive role of the daughter-in-law
to the mother-in-law. Often the mother-in-law is de-
manding and hostile to the daughter-in-law and may
treat her worse than the servants. This relationship has
changed significantly since modern culture was intro-
duced to Chinese society. However, such relationships
may continue to influence some Chinese families today
to some extent, or mothers-in-law and daughters-in-law
may simply not get along with each other. Overseas,
Chinese are quite different. The involvement of parents,
especially the husband’s parents, in the new family’s life
may have a great impact on families.
A Confucian cosmology of gender roles permeates
Chinese society. A woman is characterized as a yin
union, while a man is a yang union (Shim, 2001). As
yang, man is superior, and as yin, woman is inferior
(Li, 2000). Thus, a woman is expected to be obedient
and dependent on a man (Shrestha & Weber, 1994).
Because of stereotypical roles of men and women,
men are largely in control of the country. However,
since the founding of the PRC, this has been changing
somewhat. In 1949, the Communist Party stated that
“women hold up half the sky” and are legally equal
to men.
Almost half of the workforce in China are
women. Favored professions are education, culture
and arts, broadcasting, television and film, finance
and insurance, public health, welfare, sports, and social
services. In trades requiring higher technical skills and
knowledge such as computer science, telecommunica-
tions, environmental protection, aviation, engineering
design, real estate development, finance and insurance,
and the law are preferred. To promote Chinese women’s
employment, the Chinese government declared “The
Program for the Development of Chinese Women” in
2001 (Huangjuan, 2009). Since then, the number of
women employed increased from 291 million in 1990 to
337 million in 2003. In 2006, there were 41.56 million
employed women in China urban areas, accounting for
38 percent of the total employees in urban sites
(Women of China, 2006a).
In patriarchal Confucianism, the roles of Chinese
women are referred to as nei (the internal), while the
roles of Chinese men are referred to as wai (the exter-
nal) (Li, 2000). In other words, women are socialized
to assume domestic roles and are expected to be re-
sponsible for household tasks (Chang, 2004; Chen,
2009). The traditional gender roles of women are
changing, but a sense remains that a woman’s respon-
sibility is to maintain a happy and efficient home life,
especially in rural China. Recently, some Chinese men
have begun to include housework, cooking, and clean-
ing as their responsibilities when their spouses work.
Most Chinese believe that the family is most impor-
tant, and thus each family member assumes changes
in roles to achieve this harmony.
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Children are highly valued among the Chinese. China’s
one-child rule is still in effect (Center for Reproductive
182 Aggregate Data for Cultural-Specific Groups
2780_Ch10_178-196 16/07/12 11:44 AM Page 182

Rights, 2002; Zhuhong, 2006). Because of overpopu-
lation in China, the government has mandated that
each married couple may have only one child; however,
in some specific situations, family plans for a second
child may be allowed. For instance, in rural areas, if
the firstborn child is female or if the only child of a
couple is disabled or killed in an accident, the couple
might be permitted to have a second child (Zhuhong,
2006). Families often wait many years, until they
are financially secure, to have a child. After the child
is born, many family resources are lavished on the
child. Families may be able to afford only to live
with relatives in a two-room apartment, but if the
family believes that the child will benefit by having
a piano, then the resources will be found to provide
a piano. Children are well dressed and kept clean
and well fed.
In China, the child is protected from birth, and inde-
pendence is not fostered. The entire family makes deci-
sions for the child, even into young adulthood. Children
usually depend on the family for everything. Few teens
earn money because they are expected to study hard and
to help the family with daily chores rather than to seek
employment. Children are pressured to succeed and im-
prove the future of the family and the country. Their
common goal is to score well on the national examina-
tions when they reach age 18. Most Chinese children
and adolescents value studying over playing and peer
relationships. They recognize that they are constantly
evaluated on having healthy bodies and minds and
achieving excellent marks in school.
With the traditional structure of a patriarchal family,
girls are valued less than boys in Chinese society. In
rural communities, male children are more valued
than female children because they continue the family
lineage and provide labor. In urban areas, however,
female children are valued as highly as male children.
Children in China are taught to curb their expression
of feelings because individuals who do not stand out
are successful. However, this is changing. The young
in China today frequently think that their parents are
too cautious. The children are becoming even more
outspoken as they read more and watch more televi-
sion and movies.
From elementary school to university, students take
courses in Marxist politics and learn not to question
the doctrine of the country. If they do, they may be
interrogated and ridiculed for their radical thoughts.
Nationalism is important to Chinese children, and
they want to help their country continue to be the cen-
ter of the world. Children are also expected to help
their parents in the home. Many times in the cities
when children get home from school before their par-
ents, they are expected to do their homework imme-
diately and then do their household chores. They
exhibit their independence not so much by expressing
their individual views but by performing chores on
their own. However, because of China’s one-child rule
and high competition for enrollment to colleges, parents
and grandparents spoil most children. The children are
expected to earn good grades, and household chores
are not encouraged; this is exhibited in overseas
Chinese families as well. Lin and Fu (1990) studied
138 children—44 Chinese, 46 Chinese Americans, and
48 white Americans—in kindergarten through second
grade and found that both Chinese and Chinese
American parents expected increased achievement
and parental control over their children. One surpris-
ing finding was the high expectation for independence
in Chinese and Chinese American children.
Boys and girls play together when they are young,
but as they get older, they do not because their roles
and the corresponding expectations are predetermined
by Chinese society. Girls and boys both study hard.
Boys are more active and take pride in physical fitness.
Girls are not nearly as interested in fitness as boys,
preferring reading, art, and music.
Adolescents are expected to determine who they are
and what they want to do with their lives. Adolescents
maintain their respect for older people even when
they disagree with them. Although they may argue
with their parents and teachers, they have learned
that it seldom does any good. Teens value a strong
and happy family life and seldom do things that jeop-
ardize that unanimity. Adolescents question affairs of
life and make great efforts to see at least two sides of
every issue. They enjoy exploring different views with
their peers, and they try to explore them with their
parents as well.
Teenage pregnancy is becoming a common issue
among the Chinese. According to a government survey,
more than 70 percent of 5000 students from 10 univer-
sities in Beijing have participated in a one-night stand
(Huangjuan, 2009). More female teens are willing to
have sex to show their affection for their boyfriends, and
most of them do not use any contraception, which
leads to a high rate of pregnancy among teenage
females (Zhuhong, 2009a). Young men and women
enter the workforce immediately after high school if
they are unable to continue their education. Many con-
tinue to live with their parents and contribute to the
family, even after marriage, into their 20s and, if they
have a child, into their 30s.
Family Goals and Priorities
The Chinese perception of family is through the con-
cept of relationships. In Confucian principles, hierar-
chical relationships exist between father and son, ruler
and ruled, husband and wife, elder brother and younger
brother, and friend and friend (Cheung et al., 2005).
Each person identifies himself or herself in relation to
others in the family. The individual is not lost, just de-
fined differently from individuals in Western cultures.
Personal independence is not valued; rather, Confucian
People of Chinese Heritage 183
2780_Ch10_178-196 16/07/12 11:44 AM Page 183

teachings state that true value is in the relationships a
person has with others, especially the family.
Older children who experienced the Cultural Rev-
olution may feel some discomfort with their tradi-
tional parents. During the Cultural Revolution, the
young were encouraged to inform on older people and
peers who did not espouse the doctrine of the time.
Most of those who were reported were sent to “reed-
ucation camps,” where they did hard labor and were
“taught the correct way to think.” As a result, many
families have been permanently separated.
Extended families are important to the Chinese and
function by providing ways to get ahead. Often, chil-
dren live with their grandparents or aunts and uncles
so individual family members can obtain a better
education or reduce financial burdens. Relatives are
expected to help one another through connections,
called guanxi, which the Chinese society uses in a
manner similar to the way other cultures use money.
Such connections are perceived as obligations and are
placed in a mental bank with deposits and with-
drawals. These commitments may remain in the
“bank” for years or generations until they are used to
get jobs, housing, business contacts, gifts, medical
care, or anything that demands a payback.
Filial loyalty to the family is extended to other
Chinese. When Chinese immigrants need additional as-
sistance, health-care providers may be able to call on
local Chinese organizations to obtain help for patients.
Older people in China are venerated just as they
were in earlier years. Chinese government leaders are
often older and remain in power until they are in their
70s, 80s, and older. Traditional Chinese people view
older people as very wise, a view that communism has
not changed. Chinese children are expected to care for
their parents, and in China, this is mandated by law.
Younger Chinese who adopt Western ideas and
values may find that the expectations of older
people are too demanding. Even though younger
Chinese Americans do not live with their older rela-
tives, they maintain respect and visit them fre-
quently. Older Chinese mothers are viewed as
central to family feelings, and older fathers retain
their roles as leaders. As generations live in areas
removed from China and families become more
Westernized, family relationships need to be as-
sessed on an individual basis. An extended-family pat-
tern is common and has existed for over 2000 years.
The traditional marriage still remains nuclear. His-
torically in China, marriage was used to strengthen
positions of families in society.
Kinship relationships are based on the concept
of loyalty, and the young experience pressure to
improve the family’s standing. Many parents give
up items of daily living to provide more for their
children, thereby increasing opportunities for them
to get ahead.
Maintaining reputation is very important to the
Chinese and is accomplished by adhering to the
rules of society. Because power and control are
important to Chinese society, rank is very impor-
tant. True equality does not exist in the Chinese
mind; their history has demonstrated that equality
cannot exist. If more than one person is in power,
then consensus is important. If the person in power
is not present at decision-making meetings, barriers
are raised, and any decisions made are negated un-
less the person in power agrees. Even after negotia-
tions have been concluded and contracts signed, the
Chinese continue to negotiate.
The Chinese concept of privacy is even more im-
portant than recognized social status, corresponding
values, and beliefs. The Chinese word for “privacy”
has a negative connotation and means something un-
derhanded, secret, and furtive. People grow up in
crowded conditions, they live and work in small areas,
and their value of group support does not place a high
value on privacy. The Chinese may ask many personal
questions about salary, life at home, age, and children.
Refusal to answer personal questions is accepted as
long as it is done with care and feeling. The one sub-
ject that is taboo is sex and anything related to sex.
This may create a barrier for a Western health-care
provider who is trying to assess a Chinese patient with
sexual concerns. The patient may feel uncomfortable
discussing or answering questions about sex with hon-
esty. Privacy is also limited by territorial boundaries.
Some Chinese may enter rooms without knocking or
invade privacy by not allowing a person to be alone.
The need to be alone is viewed as “not good” to some
Chinese, and they may not understand when a
Westerner wants to be alone. A mutual understanding
of these beliefs is necessary for harmonious working
relationships.
Alternative Lifestyles
In Chinese society, people have very little acceptance
of gays and lesbians. In many provinces, homosexu-
ality is illegal and punishable by death. Divorce is legal
but is not encouraged; Although it is evident that di-
vorce is a growing trend in China (Women of China,
2006b)—approaching 30 percent in 2006 Alexander
& Marget, 2006)—the reasons are multifaceted. First,
society is going through a transitional period, which
is greatly affecting the stability of marriages. Second,
as living standards improve, people have higher expec-
tations toward marriage and love. Third, the simplifi-
cation of marriage and divorce procedures has made
getting a divorce much easier (Women of China,
2006b).
Tradition, consideration for children’s feelings, and
difficulty in remarrying are some of the reasons many
Chinese families would rather stay in an unhealthy
marriage than divorce. Remarriage is encouraged, but
184 Aggregate Data for Cultural-Specific Groups
2780_Ch10_178-196 16/07/12 11:44 AM Page 184

some difficult relationships may occur in the blended
family, especially remarriage with children from
previous marriages.
Workforce Issues
Culture in the Workplace
China is becoming more Westernized with high tech-
nology and increased knowledge. The Communist
Party is responsible for establishing the dan wei—
local Chinese work units—that are responsible for
jobs, homes, health, enforcement of governmental reg-
ulations, and problem solving for families. Although
recent immigrants know that the culture in the work-
place is different in the United States, they adapt to
it quickly. The Chinese acculturate by learning as
much as possible about their new culture in the work-
place. They observe people from the culture and listen
closely for nuances in language and interpersonal
connections. They frequently call on other Chinese
people to teach them and to discuss how to fit into
the new culture more quickly. Chinese Americans
support one another in new settings and help one an-
other find resources and learn to live effectively and
efficiently in the new culture. They also watch televi-
sion, listen to music, and go to movies to learn about
Western ways of life. They read about the new culture
in magazines, books, newspapers, and on the Internet.
They love to travel, and when an opportunity arises
to see different aspects of the new culture, they do not
hesitate to do so.
The Chinese are accustomed to giving coworkers
small gifts of appreciation for helping them accul-
turate and adapt to the American workforce. Often,
Americans seek opportunities to reciprocate with a
gift, such as at a birthday party, farewell party, or
other occasion. Whereas a wide variety of gifts is ap-
propriate, some gifts are not. For example, giving an
umbrella means that one wishes to have the recipient’s
family dispersed; giving a gift that is white in color or
wrapped in white could be interpreted as meaning
the giver wants the recipient to die; and giving a
clock could be interpreted as never wanting to see the
person again or wishing the person’s life to end
(Smith, 2002).
On the surface, Chinese Americans form classic ex-
ternal networks, including groupings by family sur-
name, locality of origin in China, dialect or subdialect
spoken, craft practiced, and trust from prior experience
or recommendation. Therefore, Chinese Americans ap-
proximate external networks with some characteristic
of internal networks (Haley, Tan, & Haley, 1998).
Guanxi is a Mandarin term with no exact English
translation. This term includes the concept of trust
and presenting uprightness to build close relationships
and connections. It definitely helps to build networks.
This Guanxi network can be used in the work-related,
decision-making process and is also used with family,
friends, and community-related issues in the Chinese
American community.
Issues Related to Autonomy
Historically, the Chinese have been autonomous. They
had to exhibit this characteristic to survive through
difficult times. However, their autonomy is limited and
is based on functioning for the good of the group.
When a new situation arises that requires independent
decision making, many times the Chinese know what
should be done but do not take action until the leader
or superior gives permission. Because of deferring to
authority, Chinese people tend to avoid conflict and
will not challenge anyone whom they regard as a
leader or expert. For example, if a doctor prescribes
an incorrect medication, Chinese people might accept
the doctor’s prescription without saying anything.
However, the Western workforce expects independ-
ence, and some Chinese may need to be taught that
true autonomy is necessary to advance. Health-care
providers should be aware, however, that the training
might not be successful because it is foreign to Chinese
cultural values. A demonstration is the best alterna-
tive, leaving it up to the individuals to determine
whether assertiveness can be a part of their lives. After
acculturation takes place, Chinese Americans do not
differ significantly in assertiveness.
Language may be a barrier for Chinese immigrants
seeking assimilation into the Western workforce.
Western languages and Chinese have many differ-
ences, among them sentence structure and the use of
intonation. The Chinese language does not have verbs
that denote tense, as in Western languages. Whereas
the ordering of the words in a sentence is basically
the same, with the subject first and then the verb, the
Chinese language places descriptive adjectives in
different orders. Intonation in Chinese is in the words
themselves rather than in the sentence. Chinese people
who have taken English lessons can usually read and
write English competently, but they may have diffi-
culty understanding and speaking it. Research has re-
ported that the ability to speak English is a significant
factor among Chinese people in accessing health care
(Cheung et al., 2005).
Biocultural Ecology
Skin Color and Other Biological Variations
The skin color of Chinese is varied. Many have skin
color similar to that of Westerners, with pink under-
tones. Some have a yellow tone, whereas others
are very dark. Mongolian spots, dark bluish spots
over the lower back and buttocks, are present in about
80 percent of infants. Bilirubin levels are usually
higher in Chinese newborns, with the highest levels
occurring on the 5th or 6th day after birth.
People of Chinese Heritage 185
2780_Ch10_178-196 16/07/12 11:44 AM Page 185

Although Chinese are distinctly Mongolian, their
Asian characteristics have many variations. China is
very large and includes people from many different
backgrounds, including Mongols and Tibetans. Gen-
erally, men and women are shorter than Westerners,
but some Chinese are over 6 feet tall. Differences in
bone structure are evidenced in the ulna, which is
longer than the radius. Hip measurements are signifi-
cantly smaller: Females are 4.14 cm shorter, and males
7.6 cm shorter than Westerners (Seidel, Ball, Dains, &
Benedict, 1994). Not only is overall bone length
shorter, but bone density is also less. Chinese have a
high hard palate, which may cause them problems
with Western dentures. Their hair is generally black
and straight, but some have naturally curly hair. Most
Chinese men do not have much facial or chest hair.
The Rh-negative blood group is rare, and twins are
not common in Chinese families, but they are greatly
valued, especially since the emergence of China’s
one-child law.
Diseases and Health Conditions
Many Chinese who come to the United States settle
in large cities like San Francisco and New York, so
they are at risk for the same problems and diseases ex-
perienced by other inner-city populations. For exam-
ple, crowding in large cities often results in poor
sanitation and increases the incidence of infectious
diseases, air pollution, and violence.
Noninfectious chronic diseases have become the
major threat to Chinese people, claiming 85 percent
of deaths in China (Zhang, 2011). The Chinese
Ministry of Health (2009) reports that cerebrovascular
disease, cancer, respiratory disease, and heart disease
are the four principal causes of death in China.
In 1949, the average life expectancy was only 35 years
(People’s Daily, 2002). According to the CIA World Fact-
book (2011), in 2011, the overall Chinese average life
expectancy was 74.68 years—72.68 years for men and
76.94 years for women. The life expectancy in China has
dramatically increased due to the improvement of living
conditions and medical facilities, as well as a nationwide
fitness campaign. Disease incidence has decreased as
well, but major problems still exist in rural China, where
perinatal deaths and deaths from infectious diseases re-
main high. Tobacco use is a major problem and results
in an increased incidence of lung disease. Health-care
providers must screen newer immigrants from China for
these health-related conditions and provide interven-
tions in a culturally congruent manner.
Many Chinese immigrants have an increased inci-
dence of hepatitis B and tuberculosis. Poor living con-
ditions and overcrowding in some areas of China
enhance the development of these diseases, which persist
after immigrants settle in other countries.
According to the Office of Minority Health (2007),
Chinese American women have a 20 percent higher
rate of pancreatic cancer and higher rates of suicide
after the age of 45 years, and all Chinese have higher
death rates owing to diabetes. The incidence of differ-
ent types of cancer, including cervical, liver, lung,
stomach, multiple myeloma, esophageal, pancreatic,
and nasopharyngeal cancers, is higher among Chinese
Americans (Office of Minority Health, 2007). Overall,
the incidence of disease in this population has not
been studied sufficiently, and continuing research is
desperately needed.
Variations in Drug Metabolism
Studies outlining problems with drug metabolism and
sensitivity have been conducted among the Chinese.
Results suggest a poor metabolism of mephenytoin
(e.g., diazepam) in 15 to 20 percent of Chinese; sensi-
tivity to beta-blockers, such as propranolol, as evi-
denced by a decrease in the overall blood levels
accompanied by a seemingly more profound response;
atropine sensitivity, as evidenced by an increased heart
rate; and increased responses to antidepressants and
neuroleptics given at lower doses. Analgesics have
been found to cause increased gastrointestinal side ef-
fects, despite a decreased sensitivity to them. In addi-
tion, the Chinese have an increased sensitivity to the
effects of alcohol (Levy, 1993).
Delineating specific variations in drug metabolism
among the Chinese is difficult because various studies
tend to group them in aggregate as Asians. Much
more research needs to be completed to determine
variations between Westerners and Asians, as well as
among Asians. The same thing is true of Hispanics/
Latinos
High-Risk Behaviors
High-risk behaviors are difficult to determine with
accuracy among the Chinese in the United States be-
cause most of the data on the Chinese are included
in the aggregate called Asian Americans. Smoking
is a high-risk behavior for many Chinese men
and teenagers. Smoking-related diseases kill roughly
1.2 million Chinese people every year, and the death
rate is expected to keep climbing in the coming
decades (Yang, 2011).
Yu, Edwin, Chen, Kim, and Sawsan (2002) reported
that the male prevalence of smoking in Chicago is
higher than that reported in California and exceeds the
rate for African Americans aged 18 years and older.
Most Chinese women do not smoke, but recently, the
numbers for women are increasing, especially after im-
migration to the United States. Travelers in China see
more cigarette street vendors than any other type. The
decrease in smoking in the United States made cigarette
manufacturers target China as a good market in which
to sell their product.
Alcohol consumption has increased significantly in
China. In two random samples of 2327 and 2613 people,
186 Aggregate Data for Cultural-Specific Groups
2780_Ch10_178-196 16/07/12 11:44 AM Page 186

it was found that 90 percent of men and 55 percent of
women drank alcohol in 2005 (Zhang, Casswell, &
Cai, 2008). The greatest increase in alcohol consump-
tion occurred in 18- and 19-year-olds and among
older women (Zhang et al., 2008).
Nutrition
Meaning of Food
Food habits are important to the Chinese, who offer
food to their guests at any time of the day or night.
Most celebrations with family and business events
focus on food. Foods served at Chinese meals have a
specific order, with the focus on a balance for a healthy
body. The importance of food is demonstrated daily
in its use to promote good health and to combat dis-
ease and injury. Traditional Chinese medicine fre-
quently uses food and food derivatives to prevent and
cure diseases and illnesses and to increase the strength
of weak and older people.
Common Foods and Food Rituals
The typical Chinese diet is difficult to describe be-
cause each region in China has its own traditional
foods. Peanuts and soybeans are popular. Common
grains include wheat, sorghum, and maize. Rice is
usually steamed but can be fried with eggs, vegetables,
and meats. Many Chinese eat beans or noodles in-
stead of rice. The Chinese eat steamed and fried rice
noodles, which are usually prepared with a broth base
and include vegetables and meats. Meat choices in-
clude pork (the most common), chicken, beef, duck,
shrimp, fish, scallops, and mussels. Tofu, an excellent
source of protein, is a staple of the Chinese diet and
can be fried or boiled or eaten cold like ice cream.
Bean products are another source of protein, and
many of the desserts or sweets in Chinese diets are
prepared with red beans.
At celebrations, before-dinner toasts are usually
made to family and business colleagues. The toasts
may be interspersed with speeches, or the speeches
may be incorporated into the toasts. Cold appetizers
often include peanuts and seasonal fruits. Chopsticks,
a chopstick holder, a small plate, and a glass are part
of the table setting. If the foods are messy, like Beijing
duck, then a finger towel may be available. The Chinese
use ceramic or porcelain spoons for soup. Knives are
unnecessary because the food is usually served in bite-
sized pieces. Eating with chopsticks may be difficult
for some at first, but the Chinese are good-natured
and are pleased by any attempt to use them. Chop-
sticks should never be stuck in the food upright be-
cause that is considered bad luck (Smith, 2002).
Westerners soon learn that slurping, burping, and
other noises are not considered offensive, but are ap-
preciated. The Chinese are very relaxed at meals and
commonly rest their elbows on the table.
Fruits and vegetables may be peeled or eaten raw.
Some vegetables commonly eaten raw by Westerners
are usually cooked by the Chinese. Unpeeled raw
fruits and vegetables are sources of contamination
owing to unsanitary conditions in China. The Chinese
enjoy their vegetables lightly stir-fried in oil with salt
and spices. Salt, oil, and oil products are important
parts of the Chinese diet.
Drinks with dinner include tea, soft drinks, juice,
and beer. Foreign-born Chinese and older Chinese
may not like ice in their drinks. They may just not like
anything cold while eating or may believe it is damag-
ing to their body and shocks the body systems out of
balance. Conversely, hot drinks are enjoyed and be-
lieved to be safe for the body. This “goodness” of hot
drinks may stem from tradition in which the only safe
drinks were made from boiled water. All food is put
in the center of the table, arriving all at one time,
but usually multiple courses are served. The host
either serves the most important guests first or signals
everyone to start.
Dietary Practices for Health Promotion
For the Chinese, food is important in maintaining their
health. Foods that are considered yin and yang prevent
sudden imbalances and indigestion. A balanced diet is
considered essential for physical and emotional har-
mony. Health-care providers need to provide special
instructions regarding risk factors associated with diets
that are high in fats and salt. For example, the Chinese
may need education regarding the use of salty fish and
condiments, which increase the risk for nasopharyn-
geal, esophageal, and stomach cancers.
Nutritional Deficiencies and Food Limitations
Little information is available about dietary deficien-
cies in the Chinese diet. The life span of the Chinese
is long enough to suggest that severe dietary deficien-
cies are not common as long as food is available. Peri-
odically, some deficiencies, such as rickets and goiters,
have occurred. The Chinese government added iodine
to water supplies, and fish, which is rich in iron, is en-
couraged to enhance the diets of people with goiters.
Native Chinese generally do not drink milk or eat milk
products because of a genetic tendency for lactose in-
tolerance. Their healthy selection of green vegetables
limits the incidence of calcium deficiencies. Health-
care providers may need to screen newer Chinese im-
migrants for these deficiencies and assist them in
planning an adequate diet.
Most Chinese do not eat desserts with a high sugar
content. Their desserts are usually peeled or sliced
fruits or desserts made of bean and bean curd. The
higher death rate from diabetes in Western countries
mentioned earlier in this chapter may be due to a
change from the typical Chinese diet with few sweets
to a Western diet with many sweets.
People of Chinese Heritage 187
2780_Ch10_178-196 16/07/12 11:44 AM Page 187

Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
China continues to make efforts to slow the rate of
population growth by enforcing a one-child law. The
most popular form of birth control is the intrauterine
device. Sterilization is common even though oral con-
traception is available. Contraception is free in China.
Abortion is fairly common, with 13 million abortions
performed in China every year (Zhuhong, 2009b).
Health-care providers working in women’s health need
to be aware of the abortion issues among newly
arrived Chinese immigrants, as well as among Chinese
Americans who may still adhere to premigration prac-
tices. It is critical for women’s health to reduce the
abortion issue among Chinese women.
Most Chinese families see pregnancy as positive
and important in the immediate and extended family.
Many couples wait a long time to have their first and
only child. If a woman does become pregnant before
the couple is ready to start a family, she may have an
abortion. When the pregnancy is desired, the nuclear
and extended families rejoice in the new family mem-
ber. Overall, pregnancy is seen as a woman’s business,
although the Chinese men are beginning to demon-
strate an active interest in pregnancy and the welfare
of the mother and baby.
China has 80 million one-child families. The gender
imbalance has become a serious issue in recent years
because many families, especially those in rural areas,
prefer boys to girls. China has 119 boys born for every
100 girls, whereas the global ratio is 103 to 107 boys
for every 100 girls. In China, the “Care for Girls” pro-
gram was initiated in 2003 to promote the social status
of women, and attempts are being made to decrease
gender identification abortions without a medical pur-
pose and the abandonment of newborn girls. Political
action is through professional organizations but it is
mostly sub rosa (XinHua News Agency, 2006). As a
result, the sex ratio declined from 106.74 in 2000 to
105.20 in 2010 (National Bureau of Statistics of
China, 2011). However, as of 2011, the reported male
to female ratio was 1.133 (CIA World Factbook, 2011).
Of the population enumerated in the 2010 census,
males accounted for 51.27 percent, while females
accounted for 48.73 percent (Wang, 2011c).
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Because Chinese women are very modest, many
women insist on a female midwife or obstetrician.
Some agree to use a male physician only when an
emergency arises. Pregnant women usually add more
meat to their diets because their blood needs to be
stronger for the fetus. Many women increase the
amount of organ meat in their diet, and even during
times of severe food shortages, the Chinese govern-
ment has tried to ensure that pregnant women receive
adequate nutrition. These traditions are also reflected
in Chinese families living in the West.
Other dietary restrictions and prescriptions may be
practiced by pregnant women, such as avoiding shell-
fish during the first trimester because it causes aller-
gies. Some mothers may be unwilling to take iron
because they believe that it makes the delivery more
difficult.
The Chinese government is proud of the fact that
since the People’s Revolution in 1949, infant mortality
has been significantly reduced. In 2001, the mortality
rates for infants and children under age 5 were reduced
to 30 per 1000 from 35.9 per 1000 (Women of China,
2006d). This has been accomplished by providing a
three-level system of care for pregnant women in rural
and urban populations. Over 90 percent of childbirths
take place under sterile conditions by qualified
personnel. The infant mortality rate dropped from
20.3 per thousand in 2005 to 14.1 per thousand in
2009 (Wang, 2011c). Therefore, most Chinese who
have immigrated to Western countries are familiar
with modern sterile deliveries.
In China, a woman stays in the hospital for a
few days after delivery to recover her strength and
body balance. Traditional postpartum care includes
1 month of recovery, with the mother eating cooked
and warm foods that decrease the yin (cold) energy.
The Chinese government supports this 1-month recu-
peration period through labor laws that entitle the
mother from 56 days to 6 months of maternity leave
with full pay (Ministry of Public Health, 1992).
Women who return to work are allowed time off for
breastfeeding, and in many cases, factories provide a
special lounge for the women to breastfeed. Families
who come to Western societies expect the same impor-
tance to be placed on motherhood and may be
surprised to find that many Western countries do not
provide similar benefits.
Traditional prescriptive and restrictive practices
continue among many Chinese women during the
postpartum period. Drinking and touching cold water
are taboo for women in the postpartum period. Raw
fruits and vegetables are avoided because they are con-
sidered “cold” foods. They must be cooked and be
warm. Mothers eat five to six meals a day with high
nutritional ingredients, including rice, soups, and
seven to eight eggs. Brown sugar is commonly used be-
cause it helps rebuild blood loss. Drinking rice wine is
encouraged to increase the mother’s breast milk pro-
duction, but mothers need to be cautioned that it may
also prolong the bleeding time. Many mothers do not
expose themselves to the cold air and do not go out-
side or bathe for the first month postpartum because
the cold air can enter the body and cause health prob-
lems, especially for older women. Some women wear
188 Aggregate Data for Cultural-Specific Groups
2780_Ch10_178-196 16/07/12 11:44 AM Page 188

many layers of clothes and are covered from head to
toe, even in the summer, to keep the air away from
their bodies. However, this practice has changed
among some young women who live in Western
cultures for a long period of time and when there
are no older Chinese parents around during the
postpartum period.
Adopted Chinese children display a similar pattern
of growth and developmental delays and medical
problems as seen in other groups of internationally
adopted children. An exception is the increased
incidence of elevated lead levels (overall 14 percent).
Although serious medical and developmental issues
were found among Chinese children, overall their
health was better than expected based on recent pub-
licity about conditions in the Chinese orphanages.
The long-term outcome of these children remains
unknown (Miller, 2000). Many children adopted
from China have antibody titers that do not correlate
with those expected from their medical records.
These children, unlike children adopted from other
countries, have documented evidence of adequate
vaccinations. However, they should be tested for an-
tibody concentrations and reimmunized as necessary
(Schulpen, 2001).
Death Rituals
Death Rituals and Expectations
Chinese death and bereavement traditions are cen-
tered on ancestor worship. Ancestor worship is fre-
quently misunderstood; it is not a religion, but
rather a form of paying respect. Many Chinese
believe that their spirits can never rest unless living
descendants provide care for the grave and worship
the memory of the deceased. These practices were
so important to early Chinese that Chinese pioneers
to the West had statements written into their work
contract that their ashes or bones be returned to
China (Halporn, 1992).
The belief that the Chinese greet death with sto-
icism and fatalism is a myth. In fact, most Chinese
fear death, avoid references to it, and teach their
children this avoidance. The number 4 is considered
unlucky by many Chinese because it is pronounced
like the Chinese word for death; this is similar to the
bad luck associated with the number 13 in many
Western societies. Huang (1992) wrote:
At a very young age, a child is taught to be very careful
with words that are remotely associated with the
“misfortune” of death. The word “death” and its
synonyms are strictly forbidden on happy occasions, es-
pecially during holidays. People’s uneasiness about
death often is reflected in their emphasis on longevity
and everlasting life. . . . In daily life, the character
“Long Life” appears on almost everything: jewelry,
clothing, furniture, and so forth. It would be a terrible
mistake to give a clock as a gift, simply because the pro-
nunciation of the word “clock” is the same as that
of the word “ending.” Recently, many people in
Taiwan decided to avoid using the number “four”
because the number has a similar pronunciation to
the word “death.” (p. 1)
Many Chinese are hesitant to purchase life insur-
ance because of their fear that it is inviting death. The
color white is associated with death and is considered
bad luck. Black is also a bad luck color.
Many Chinese believe in ghosts, and the fear of
death is extended to the fear of ghosts. Some ghosts
are good and some are bad, but all have great power.
Communism discourages this thinking and sees it as
a hindrance to future growth and development of the
society, but the ever-pragmatic Chinese believe it is
better not to invite trouble with ghosts just in case they
might exist.
The dead may be viewed in the hospital or in the
family home. Extended family members and friends
come together to mourn. The dead are honored by
placing objects around the coffin that signify the life
of the dead: food, money designated for the dead per-
son’s spirit, and other articles made of paper. In
China, cremation is preferred by the state because of
a lack of wood for coffins and a limited space for
People of Chinese Heritage 189
R E F L E C T I V E E X E R C I S E 1 0 . 2
Mrs. Huang, a 32-year-old woman from China, lives with her
husband and his parents. She delivered a healthy baby girl
yesterday. This morning, Mrs. Huang says she is constipated.
The physician told Mrs. Huang that constipation was a com-
mon problem after delivery. The nurse suggested that she eat
more fresh fruits and vegetables to facilitate a bowel move-
ment. However, Mrs. Huang rejected fruits and vegetables
and stated that a woman was characterized as a yin union and
eating too much cold food was not good for a postpartum
woman. Later in the day, Mrs. Huang told the nurse that she
did not think she wanted to experience childbirth again. When
the nurse approached Mrs. Huang about possible contracep-
tion, she said that her parents-in-law wanted her be become
pregnant very soon in the hopes of having a male child.
1. According to Chinese perspectives, foods are divided into
yin and yang categories. What information does the nurse
need before discussing Mrs. Huang’s concerns about
constipation?
2. What other culturally congruent dietary instructions might
the nurse recommend to resolve Mrs. Huang’s concerns
with constipation?
3. As a daughter-in-law in a traditional Chinese family,
Mrs. Huang’s autonomy to make decisions seems to
be limited. What concerns might the nurse have when
discussing contraception?
4. Describe some traditional postpartum Chinese practices.
2780_Ch10_178-196 16/07/12 11:44 AM Page 189

burial. The ashes are placed in an urn and then in a
vault. As cities grow, even the space for vaults is lim-
ited. In rural areas, many families prefer traditional
burial and have family burial plots. It is preferable to
burying an intact body in a coffin.
Responses to Death and Grief
The Chinese react to death in various ways. Death is
viewed as a part of the natural cycle of life, and some
believe that something good happens to them
after they die. These beliefs foster the impression that
Chinese are stoic. In fact, they feel similar emotions
to Westerners but do not overtly express those emo-
tions to strangers. During bereavement, a person does
not have to go to work, but instead can use this
mourning time for remembering the dead and plan-
ning for the future. Bereavement time in the larger
cities is 1 day to 1 week, depending on the policy of
the government agency and the relationship of family
members to the deceased. Mourners are recognized by
black armbands on their left arm and white strips of
cloth tied around their heads.
Spirituality
Dominant Religion and Use of Prayer
In mainland China, the practice of formal religious
services is minimal. The ideals and values of the dif-
ferent religions are practiced alone rather than with
people coming together to participate in a formal re-
ligious service. In recent years, in some parts of China,
religion is becoming more popular. The main formal
religions in China are Taoism, Buddhism, Christianity
(3 to 4 percent), and Islam (1 to 2 percent) (CIA World
Factbook, 2011).
As immigration from China increases, Chinese
people who practice Christian religions have become
more visible on the American landscape. Chinese
immigrants from the People’s Republic of China may
express perspectives on religious beliefs different from
those of the Chinese from other countries, or from
Hong Kong and Taiwan, where they have been per-
mitted to practice Christianity. At first, they may go
to a church attended by other Chinese people; even-
tually some are baptized, and others continue to at-
tend Bible studies. In cities in the United States,
churches are playing a very important role in the
local Chinese community in terms of providing
support and services to Chinese immigrants, stu-
dents, scholars, and their families. An understanding
of this concept is essential when the health-care
provider attempts to obtain religious counseling
services for Chinese patients.
Prayer is generally a source of comfort. Some
Chinese do not acknowledge a religion such as
Buddhism, but if they go to a shrine, they burn
incense and offer prayers.
Meaning of Life and Individual Sources
of Strength
The Chinese view life in terms of cycles and interrela-
tionships, believing that life gets meaning from the
context in which it is lived. Life cannot be broken into
simple parts and examined because the parts are in-
terrelated. When the Chinese attempt to explain life
and what it means, they speak about what happened
to them, what happened to others, and the importance
and interrelatedness of those events. They speak not
only of the importance of the current phenomena but
also about the importance of what occurred many
years, maybe even centuries, before their lives. They
live and believe in a true systems framework.
“Life forces” are sources of strength to the Chinese.
These forces come from within the individual, the en-
vironment, the past and future of the individual, and
society. Chinese use these forces when they need
strength. If one usual source of strength is unsuccess-
ful, they try another. The individual may use many
different techniques such as meditation, exercise, mas-
sage, and prayer. Drugs, herbs, food, good air, and
artistic expression may also be used. Good luck
charms are cherished, and traditional and nontradi-
tional medicines are used.
The family is usually one source of strength. Indi-
viduals draw on family resources and are expected to
return resources to strengthen the family. Resources
may be financial, emotional, physical, mental, or spir-
itual. Calling on ancestors to provide strength as a re-
source requires giving back to the ancestors when
necessary. The interconnectedness of life provides a
source of strength for individuals from before birth to
death and beyond.
Health-care providers need to understand this
multidimensional manner of thinking and believing.
Assessments, goal setting, interventions, and evalua-
tions may be different for Chinese patients than for
American patients. The context of client problems is
the emphasis, and the physical, mental, and spiritual
aspects of the person’s life are the focal points.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Health care in China is provided for most citizens.
Every work unit and neighborhood has its own clinic
and hospital. Traditional Chinese medicine shops
abound (Fig. 10-1). Even department stores and su-
permarkets have Western medicines and traditional
Chinese medicines and herbs.
The focus of health has not changed over the cen-
turies, and it includes having a healthy body, a healthy
mind, and a healthy spirit. Preventive health-care
practices are a major focus in China today. An addi-
tional focus is placed on infectious diseases such as
schistosomiasis, tuberculosis, childhood diseases, and
190 Aggregate Data for Cultural-Specific Groups
2780_Ch10_178-196 16/07/12 11:44 AM Page 190

malaria; cancer; heart diseases; and maternal–infant
care. Chinese Ministry of Health statistics indicate
that China had 840,000 HIV-infected people in 2004
(Chinese Ministry of Health, 2004; CIA World Fact-
book, 2011). That means that China had the 14th
highest number of HIV-infected people in the world
and the second highest in Asia. Between 2000 and
2005, the percentage of people infected with HIV rose
from 19.4 percent to 28.1 percent (Women of China,
2006c). The CIA World Factbook gives similar figures
for 2011. China claimed that the country had no
HIV cases, but in 2004, it was revealed that a huge
number of Chinese contracted HIV from blood trans-
fusions. China now faces a critical period in the fight
to curb the spread, and ultimately the cure, of HIV
and AIDS. The World Health Organization (WHO)
has predicted that if China fails to control the disease’s
spread, there will be 10 million people with AIDS by
2010 (Gu, 2006).
A regulation on AIDS prevention and control
(effective January 1, 2007) spells out the plan to
administer the free test in areas of the province where
the AIDS situation is “grave.” HIV carriers and AIDS
patients will be asked to inform their spouses or sex
partners of the results, or the local disease prevention
authorities will do so (Women of China, 2006c).
Whereas many Chinese have made the transition to
Western medicine, others maintain their roots in tra-
ditional Chinese medicine, and still others practice
both types. The Chinese are similar to other national-
ities in seeking the most effective cure available.
Younger Chinese people usually do not hesitate to
seek health-care providers when necessary. They
generally practice Western medicine unless they feel
that it does not work for them; then they use tradi-
tional Chinese medicine. Conversely, older people may
try traditional Chinese medicine first and only seek
Western medicine when traditional medicine does not
seem to work.
Among Chinese Americans, these health-seeking
beliefs, practices, and patterns remain the same as the
ones in China. This results in sicker older people
seeking care from Western health-care providers.
Even after seeking Western medical care, many older
Chinese continue to practice traditional Chinese med-
icine in some form. However, some Chinese patients
may not tell health-care providers about other forms
of treatment they have been using because they are
conscious of saving face. Health-care providers need
to understand this practice and include it in their care.
Members of the health-care team need to develop a
trusting relationship with Chinese patients so all infor-
mation can be disclosed. Health-care providers must
impress upon patients the importance of disclosing all
treatments because some may have antagonistic effects.
Responsibility for Health Care
Chinese people often self-medicate when they think
they know what is wrong or if they have been success-
fully treated by their traditional medicine or herbs in
the past. They share their knowledge about treatments
and their medicines with friends and family members.
This often happens among Chinese Americans as well
because of the belief that occasional illness can be
ameliorated through the use of nonprescription drugs.
Many consider seeing Western health-care providers
as a waste of time and money. Health-care providers
need to recognize that self-medication and sharing
medications are accepted practices among the Chinese.
Thus, health-care providers should inquire about this
practice when making assessments, setting goals, and
evaluating the results of treatments. A trusting rela-
tionship between members of the health-care team
and the patient and family is necessary to enhance the
disclosure of all treatments.
Traditional Chinese Medicine Practices
Traditional Chinese medicine is practiced widely, with
concrete reasons for the preparation of medications,
taking medicine, and the expected outcomes. Western
medicine needs to be explained to Chinese patients in
equally concrete terms.
Traditional Chinese medicine has many facets, in-
cluding the five basic substances (qi, energy; xue, blood;
jing, essence; shen, spirit; and jing ye, body fluids); the
pulses and vessels for the flow of energetic forces (mai);
the energy pathways (jing); the channels and collaterals,
including the 14 meridians for acupuncture, moxibus-
tion, and massage (jing luo); the organ systems (zang fu);
and the tissues of the bones, tendons, flesh, blood ves-
sels, and skin. The scope of traditional Chinese medicine
is vast and should be studied carefully by professionals
who provide health care to Chinese patients.
Acupuncture and moxibustion are used in many of
the treatments. Acupuncture is the insertion of needles
into precise points along the channel system of flow
People of Chinese Heritage 191
Figure 10-1 A traditional Chinese medicine shop. Many
Chinese practice traditional Chinese medicine, either alone
or in conjunction with Western medicine.
2780_Ch10_178-196 16/07/12 11:45 AM Page 191

of the qi called the 14 meridians. The system has over
400 points. Many of the same points can be used in
applying pressure and massage to achieve relief from
imbalances in the system. The same systems approach
is used to produce localized anesthesia.
Moxibustion is the application of heat from differ-
ent sources to various points. For example, one source,
such as garlic, is placed on the distal end of the needle
after it is inserted through the skin, and the garlic is
set on fire. Sometimes, the substance is burned directly
over the point without a needle insertion. Localized
erythema occurs with the heat from the burning sub-
stance, and the medicine is absorbed through the skin.
Cupping is another common practice. A heated cup
or glass jar is put on the skin, creating a vacuum,
which causes the skin to be drawn into the cup. The
heat generated is used to treat joint pain.
The Chinese believe that health and a happy life can
be maintained if the two forces, the yang and the yin,
are balanced. This balance is called the dao. Heaven
is yang, and Earth is yin; man is yang, and woman is
yin; the sun is yang, and the moon is yin; the hollow
organs (bladder, intestines, stomach, gallbladder),
head, face, back, and lateral parts of the body are
yang, and the solid viscera (heart, lung, liver, spleen,
kidney, and pericardium), abdomen, chest, and the
inner parts of the body are yin. The yang is hot, and
the yin is cold. Health-care providers need to be aware
that the functions of life and the interplay of these
functions, rather than the structures, are important to
the Chinese people.
Central to traditional medicine is the concept of the
qi. It is considered the vital force of life; includes air,
breath, or wind; and is present in all living organisms.
Some of the qi is inherited, and other parts come from
the environment, such as in food. The qi circulates
through the 14 meridians and organs of the body to
give the body nourishment. The channels of flow are
also responsible for eliminating the bad qi. All chan-
nels, the meridians and organs, are interconnected.
The results resemble a system in which a change in one
part of the system results in a change in other parts,
and one part of the system can assist other parts in
their total functioning.
Diagnosis is made through close inspection of the
outward appearance of the body, the vitality of
the person, the color of the person, the appearance of
the tongue, and the person’s senses. The health-care
provider uses listening, smelling, and questioning
techniques in the assessment. Palpation is used by feel-
ing the 12 pulses and different parts of the body. Treat-
ments are based on the imbalances that occur. Many
are directly related to the obvious problem, but many
more are related through the interconnectedness of
the body systems. Many of the treatments not only
“cure” the problem but are also used to “strengthen”
the entire human being. Traditional Chinese medicine
cannot be learned quickly because of the interplay of
symptoms and diagnoses. Health-care providers take
many years to become adept in all phases of diagnosis
and treatment.
T’ai chi, practiced by many Chinese, has its roots in
the 12th century. This type of exercise is suitable for all
age groups, even the very old. T’ai chi involves different
forms of exercise, some of which can be used for self-
defense. The major focus of the movements is mind and
body control. The concepts of yin and yang are included
in the movements, with a yin movement following a yang
movement. Total concentration and controlled breath-
ing are necessary to enable the smoothness and rhythmic
quality of movement. The movements resemble a slow-
motion battle, with the participant both attacking and
retreating. Movements are practiced at least twice a
day to bring the internal body, the external body, and
the environment into balance (Mayo Clinic, 2010).
Yoga is also a fashionable exercise among women.
Yoga incorporates meditation, relaxation, imagery,
controlled breathing, stretching, and other physical
movements. Yoga has become increasingly popular in
Western cultures as a means of exercise and fitness
training. Yoga needs to be better recognized by the
health-care community as a complement to conven-
tional medical care.
Herbal therapy is integral to traditional Chinese
medicine and is even more difficult to learn than
acupuncture and moxibustion. Herbs fall into four
categories of energy (cold, hot, warm, and cool), five
categories of taste (sour, bitter, sweet, pungent, and
salty), and a neutral category. Different methods are
used to administer the herbs, including drinking and
eating, applying topically, and wearing on the body.
Each treatment is specific to the underlying problem
or a desire to increase strength and resistance.
Barriers to Health Care
In China, the government is primarily responsible for
providing basic health care within a multilevel system.
Native Chinese are accustomed to the neighborhood
work units called dan wei, where they get answers to
their questions and health-care services are provided.
After transition to the United States, Chinese patients
face many of the same barriers to health care faced by
Westerners, yet they have other special concerns and
difficulties that prevent them from accessing health-
care services. Ma (2000) summarized these barriers as
the following:
• Language barriers: This is one of the major reasons
that Chinese Americans do not want to see West-
ern health-care providers. They feel uncomfortable
and frustrated with not being able to communicate
with them freely and not being able to adequately
express their pains, concerns, or health problems.
Even highly educated Chinese Americans, who
192 Aggregate Data for Cultural-Specific Groups
2780_Ch10_178-196 16/07/12 11:45 AM Page 192

have limited knowledge in the medical field and
are unfamiliar with medical terminology, have
difficulty complying with recommended procedures
and health prescriptions.
• Cultural barriers: Lack of culturally appropriate and
competent health-care services is another key obsta-
cle to health-care service utilization. Many Chinese
Americans have different cultural responses to
health and illness. Although they respect and accept
the Western health-care provider’s prescription
drugs, they tend to alternate between Western and
traditional Chinese physicians.
• Socioeconomic barriers: Being unable to afford
medical expenses is another barrier to accessing
health-care services for some Chinese Americans.
However, having health insurance does not always
ensure the utilization of the health-care system or
the benefits of health insurance. There may be a
sense of distrust between patients and health-care
providers or between patients and insurance com-
panies. In addition, many do not know the cost of
the service when they enter a clinic or hospital.
They are frustrated with being caught in the battle
between health insurance companies and the clinic
or hospital.
• Systemic barriers: Not understanding the Western
health-care system and feeling inconvenienced by
managed-care regulations deter many from seeking
Western health-care providers unless they are seri-
ously ill. The complexity of the rules and regula-
tions of public agencies and medical assistance
programs such as Medicaid and Medicare blocks
their effective use.
Tan (1992), in a different perspective, summarized
barriers for Chinese immigrants seeking health care:
• Many Chinese Americans have great difficulty fac-
ing a diagnosis of cancer because families are the
main source of support for patients, and many
family members are still in China.
• Because many Chinese Americans do not have
medical insurance, any serious illness will lead to
heavy financial burdens on the family.
• Once the patient responds to initial treatment, the
family tends to stop treatment and the patient does
not receive follow-up care or becomes nonadherent.
Chinese American families may be reluctant to allow
autopsies because of their fear of being “cut up.”
• The most difficult barrier is frequently the reluc-
tance to disclose the diagnosis to the patient or
the family.
In recent years, clinics of Chinese medicine and
health-care providers who are originally from China
have been significantly visible in the United States,
especially in the larger cities. These provide oppor-
tunities or options for those Chinese Americans
who prefer to seek traditional Chinese treatment for
certain illness.
Cultural Responses to Health and Illness
Chinese people express their pain in ways similar to
those of Americans, but their description of pain dif-
fers. A study by Moore (1990) included not only the
expression of pain but also common treatments used
by the Chinese. The Chinese tend to describe their
pain in terms of more diverse body symptoms,
whereas Westerners tend to describe pain locally. The
Western description includes words like “stabbing”
and “localized,” whereas the Chinese describe pain as
“dull” and more “diffuse.” They tend to use explana-
tions of pain from the traditional Chinese influence of
imbalances in the yang and yin combined with location
and cause. The study determined that the Chinese cope
with pain by using externally applied methods, such as
oils and massage. They also use warmth, sleeping on
the area of pain, relaxation, and aspirin.
The balance between yin and yang is used to explain
mental as well as physical health. This belief, coupled
with the influence of Russian theorists such as Pavlov,
influence the Chinese view of mental illness. Mental
illness results more from metabolic imbalances and or-
ganic problems. The effect of social situations, such as
stress and crises, on a person’s mental well-being is
considered inconsequential, but physical imbalances
from genetics are the important factors. Because a
stigma is associated with having a family member who
is mentally ill, many families initially seek the help of
a folk healer. Many use a combination of traditional
and Western medicine. Many mentally ill clients are
treated as outpatients and remain in the home.
Although the Chinese do not readily seek assis-
tance for emotional and nervous disorders, a study of
143 Chinese Americans found that younger, lower
socioeconomic, and married Chinese with better
language ability seek help more frequently (Ying &
Miller, 1992). The researchers recommended that
new immigrants be taught that help is available
when needed for mental disorders within the mental
health-care system.
Chinese people in larger cities are becoming more
supportive of people with disabilities, but for the most
part, support services are popular. Because the focus has
been on improving the overall economic growth of the
country, the needs of the disabled have not had priority.
The son of Deng Xiaoping was crippled in the Cultural
Revolution and has been active in making the country
more aware of the needs of the disabled. The Beijing
Paralympic Games were held on September 6–17, 2008,
and opened 12 days after the 29th Olympic Games.
A successful Paralympics in Beijing promoted the
cause of disabled persons in Beijing as well as
throughout China. The Games urged the whole of
society to pay more attention to this special segment
People of Chinese Heritage 193
2780_Ch10_178-196 16/07/12 11:45 AM Page 193

of our population and reinforced the importance of
building accessible facilities for the disabled and thus
enhance efforts to construct a harmonious society in
China (Nan, 2006). Overall, the Chinese still view
mental and physical disabilities as a part of life that
should be hidden.
The expression of the sick role depends on the level
of education of the patient. Educated Chinese people
who have been exposed to Western ideas and culture
are more likely to assume a sick role similar to that of
Westerners. However, the highly educated and accul-
turated may exhibit some of the traditional roles as-
sociated with illness. Each patient needs to be assessed
individually for responses to illness and for expecta-
tions of care. Traditionally, the Chinese ill person is
viewed to be passive and accepting of illness. To the
Chinese, illness is expected as a part of the life cycle.
However, they do try to avoid danger and to live as
healthy a life as possible. To the Chinese, all of life is
interconnected; therefore, they seek explanations and
connections for illness and injury in all aspects of life.
Their explanations to health-care providers may not
make sense, but the health-care provider should try to
determine those connections so they can be incorpo-
rated into treatment regimens. The Chinese believe
that because the illness or injury is caused from an im-
balance, there should be a medicine or treatment that
can restore the balance. If the medicine or treatment
does not seem to do this, they may refuse to use it.
Native Chinese and Chinese Americans like treat-
ments that are comfortable and do not hurt. Treat-
ments that hurt are physically stressful and drain their
energy. Health-care providers who have been ill them-
selves can appreciate this way of thinking, because
sometimes the cure seems worse than the illness. Treat-
ments will be more successful if they are explained in
ways that are consistent with the Chinese way of
thinking. The Chinese depend on their families and
sometimes on their friends to help them while they are
sick. These people provide much of the direct care;
health-care providers are expected to manage the care.
The family may seem to take over the life of the
sick person, and the sick person is very passive in
allowing them the control. One or two primary people
assume this responsibility, usually a spouse. Health-
care providers need to include the family members in
the plan of care and, in many instances, in the actual
delivery of care.
Blood Transfusions and Organ Donation
Modern-day Chinese accept blood transfusions, organ
donations, and organ transplants when absolutely es-
sential, as long as they are safe and effective. Chinese
Americans have the same concerns as Americans about
blood transfusion because of the perceived high inci-
dence of HIV and hepatitis B. No overall ethnic or reli-
gious practices prohibit the use of blood transfusions,
organ donations, or organ transplants. Of course, some
individuals may have religious or personal reasons for
denying their use.
Health Care Providers
Traditional Versus Biomedical Providers
China uses two health-care systems. One is grounded
in Western medical care, and the other is anchored in
traditional Chinese medicine. The educational prepa-
ration of physicians, nurses, and pharmacists is similar
to Western health-care education. Ancillary workers
have responsibility in the health-care system, and
the practice of midwifery is widely accepted by the
Chinese. Physicians in Chinese medicine are trained
in universities, and traditional Chinese pharmacies
remain an integral part of health care.
Status of Health-Care Providers
Traditional Chinese medicine providers are shown
great respect by the Chinese. In many instances, they
are shown equal, if not more, respect than Western
health-care providers. The Chinese may distrust
Western health-care providers because of the pain and
invasiveness of their treatments. The hierarchy among
Chinese health-care providers is similar to that of
Chinese society. Older health-care providers receive
respect from the younger providers. Men usually re-
ceive more respect than women, but that is beginning
to change. Physicians receive the highest respect, fol-
lowed closely by nurses with a university education.
Other nurses with limited education are next in the
hierarchy, followed by ancillary personnel.
Health-care providers are usually given the same re-
spect as older people in the family. Chinese children
194 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 0 . 3
Mrs. Cheng brought her 4-year-old son, Justin, to the emer-
gency department early one morning. She stated that her son
has had a high fever for 4 days. Her mother-in-law used tradi-
tional herbal medicine, but it was ineffective. The advanced
practice nurse diagnosed a pulmonary infection and prescribed
liquid antibiotics.
1. From a traditional Chinese medical perspective, how
might the nurse incorporate Western medical prescrip-
tions while respecting Mrs. Cheng’s family, who wishes to
continue Chinese herbal treatments?
2. What additional cultural and socioeconomic barriers
should the nurse assess to provide culturally competent
health-care and nursing services to Justin?
3. Identify and describe traditional, nonherbal Chinese med-
ical practices that are used to treat pulmonary disorders?
4. Describe from the traditional Chinese individual the ideal
health-care provider.
2780_Ch10_178-196 16/07/12 11:45 AM Page 194

recognize them as authority figures. Physicians and
nurses are viewed as individuals who can be trusted
with the health of a family member. Nurses are gen-
erally perceived as caring individuals who perform
treatments and procedures as ordered by the physi-
cian. Nursing assistants provide basic care to patients.
Adult Chinese respond to health-care providers with
respect, but if they disagree with the health-care
provider, they may not follow instructions. They may
not verbally confront the health-care provider because
they fear that either they or the provider will suffer a
loss of face.
The Chinese respect their bodies and are very mod-
est when it comes to touch. Most Chinese women feel
uncomfortable being touched by male health-care
providers, and most seek female health-care providers.
R E F E R E N C E S
Alexander, R.M., & Marg, A.M. (2006). Chinese women local
leaders exchange realities with WEI. Women and Environments,
74, 17–19.
Center for Reproductive Rights. (2002). China turns one child pol-
icy into law. Retrieved from http://www.crlp.org/ww_asia_
1child.html
Chang, J.S. (2004). Refashioning womanhood in 1990s Taiwan:
An analysis of Taiwanese edition of cosmopolitan magazine.
Modern China, 30, 361–397.
Chen, S.E. (2009). Mother of the culture: Founding a Taiwanese
feminist theology. Feminist Theology, 27, 81–88.
Cheung, R., Nelson, W., Advincula, L., Young, C.V., & Canham,
D.L. (2005). Understanding the culture of Chinese children
and families. The Journal of School Nursing, 21(1), 3–9.
Chinese Ministry of Health. (2004). An about face on AIDS pre-
vention. Retrieved from http://www.highbeam.com/doc/
pi-103213525.htm
Chinese Ministry of Health. (2009). Chinese factfile. Retrieved
from http://english.gov.cn/about.htm
CIA World Factbook. (2011). China. Retrieved from https://www.
cia.gov/library/publications/the-world-factbook/geos/ch.html
Gu, W. (2006). Women of China: The human face of HIV/AIDS.
Retrieved from http://www.womenofchina.cn
Haley, G., Tan, C., & Haley, U. (1998). New Asian emperors: The
overseas Chinese, their strategies and competitive advantages.
Woburn, MA: Butterworth-Heinemann.
Halporn, R. (1992). Introduction. In C.L. Chen, W.C. Lowe,
D. Ryan, A.H. Kutscher, R. Halporn, & H. Wang (Eds.), Chinese
Americans in loss and separation (pp. v–xii). New York: Founda-
tion of Thanatology.
Ho, H.F., & Lee, H.L. (2010). Great expectations: Family educa-
tional expenditure in Taiwan vs China. European Journal of
Social Sciences, 17(4), 628–637.
Hu, W., & Grove, C.L. (1991). Encountering the Chinese.
Yarmouth, MA: Intercultural Press.
Huang, W. (1992). Attitudes toward death: Chinese perspectives
from the past. In C.L. Chen, W.C. Lowe, D. Ryan, A.H.
Kutscher, R. Halporn, & H. Wang (Eds.), Chinese Americans
in loss and separation (pp. 1–5). New York: Foundation of
Thanatology.
Huangjuan. (2009). One-night stands accepted, few practice. Retrieved
from http://www.womenofchina.cn/html/node/104673-1.htm
Levy, R.A. (1993). Ethnic and racial differences in response to
medicines: Preserving individualized therapy in managed phar-
maceutical programmes. Pharmaceutical Medicine, 7, 139–165.
Li, C. (2000). Confucianism and feminist concerns: Overcoming
the Confucian “Gender complex”. Journal of Chinese Philosophy,
27, 187–199.
Lin, C.C., & Fu, V.R. (1990). A comparison of child-rearing prac-
tices among Chinese, immigrant Chinese, and Caucasian-
American parents. Child Development, 61, 429–433.
Ma, G.X. (2000). Barriers to the use of health services by Chinese
Americans. Journal of Allied Health, 29(2), 64–70.
Mayo Clinic. (2010). Tai chi: Discover the many possible health ben-
efits. Retrieved from http://www.mayoclinic.com/health/tai-chi/
SA00087
Miller, L.C. (2000). Health of children adopted from China.
Pediatrics, 105(6), 76.
Ministry of Health of the People’s Republic of China. (2011).
Center for statistics information Ministry of Health, P. R. China.
Retrieved from http://www.moh.gov.cn/publicfiles/business/
htmlfiles/mohwsbwstjxxzx/s7967/201104/51512.htm
Ministry of Public Health. (1992). A brief introduction to China’s
medical and health services. Beijing, People’s Republic of
China: Author.
Moore, R. (1990). Ethnographic assessment of pain coping per-
ceptions. Psychosomatic Medicine, 52, 171–181.
Nan, C. (2006). Beijing gears up for 2008 Paralympic Games. Re-
trieved from http://www.btmbeijing.com
National Bureau of Statistics of China. (2011). The sixth national
population census. Retrieved from http://www.stats.gov.cn/zgrkpc/
dlc/yw/index.htm
Office of Minority Health. (2007). Asian American profiles. Re-
trieved from http://www.omhrc.gov/templates/browse.aspx?
lvl=2&lvlID=32
O’Keefe, H., & O’Keefe, W. (1997). Chinese and Western behav-
ioral differences: Understanding the gaps. International Journal
of Social Economics, 24, 190–197.
People’s Daily. (2002). China’s life expectancy averaged 71.8 year.
Retrieved from http://english.peopledaily.com.cn
Schulpen, T. (2001). Immunization status of children adopted
from China. The Lancet, 358, 2131–2132.
Seidel, H., Ball, J., Dains, J., & Benedict, W. (1994). Quick reference
to cultural assessment. St. Louis, MO: Mosby.
Shim, Y.H. (2001). Feminism and the discourse of sexuality in
Korea: Continuities and changes. Human Study, 24, 133–148.
Shrestha, M., & Weber, K.E. (1994). Reflection of Confucianism,
Hinduism, and Buddhism on gender relations and gender spe-
cific occupation in Thai society. Journal of Population and So-
cial Studies, 5(1–2), 31–54.
Smith, C.S. (2002, April 30). Beware of cross-cultural faux pas in
China. New York Times.
Tan, C.M. (1992). Treating life-threatening illness in children. In
C.L. Chen, W.C. Lowe, D. Ryan, A.H. Kutscher, R. Halporn,
& H. Wang (Eds.), Chinese Americans in loss and separation
(pp. 26–33). New York: Foundation of Thanatology.
USAID. (2010). HIV/AIDS health profile. Retrieved from http://
www.usaid.gov/our work/global health/aids/countries/asia/china_
05
U.S. Census Bureau. (2006). Selected population profile in the
United States. Retrieved from http://factfinder.census.gov/
U.S. Citizenship and Immigration Services. (2011). Immigration
and Nationality Act. Retrieved from http://www.uscis.gov/
Wang, Y. (2011a). Press release on major figures of the 2010 National
Population Census. Retrieved from http://www.womenofchina.cn
People of Chinese Heritage 195
2780_Ch10_178-196 16/07/12 11:45 AM Page 195

Wang, Y. (2011b). AIDS deaths hit “peak” as 7,700 die. Retrieved
from http://www.womenofchina.cn
Wang, Y. (2011c). Maternal, infant death rates drop in China’s re-
mote count. Retrieved from http://www.womenofchina.cn/
html/report/124973-1.htm
Women of China. (2006a). Employment status of women.
Retrieved from http://www.womenofchina.cn
Women of China. (2006b). Survey of divorce rates in different coun-
tries. Retrieved from http://www.womenofchina.cn
Women of China. (2006c). HIV test mandatory. Retrieved from
http://www.womenofchina.cn
Women of China. (2006d). Women and children’s health care serv-
ices. Retrieved from http://www.womenofchina.cn
XinHua News Agency. (2006). Official calls for more efforts to curb
gender imbalance. Retrieved from http://english.peopledaily.
com.cn
Yang, Z. (2011). Chinese smokers not prepared to face hasty smok-
ing ban. Retrieved from http://www.womenofchina.cn/html/
node/129421-1.htm
Ying, Y., & Miller, L.S. (1992). Help-seeking behavior and attitude
of Chinese Americans regarding psychological problems.
American Journal of Community Psychology 20(4), 549–556.
Yu, E.S., Edwin, H., Chen, K., Kim, K., & Sawsan, A. (2002).
Smoking among Chinese Americans: Behavior, knowledge, and
beliefs. American Journal of Public Health, 92(6), 1007–1013.
Zhang, J., Casswell, S., & Cai, H. (2008). Increased drinking in a
metropolitan city in China: A study of alcohol consumption
patterns and changes. Addiction, 103(3), 416–423.
Zhang, S. (2011). Non-infectious chronic diseases become major
health threat, claiming 85% of deaths in China. Retrieved from
http://www.womenofchina.cn/html/report/130433-1.htm
Zhuhong, A. (2006). Population and family planning law of the People’s
Republic of China. Retrieved from http://www.womenofchina.cn
Zhuhong, A. (2009a). Survey shows more teens have sexual expe-
rience. Retrieved from http://www.womenofchina.cn/html/
node/102669-1.htm
Zhuhong, A. (2009b). Abortion issue causes for concern. Retrieved
from http://www.womenofchina.cn/html/node/102775-1.htm
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
196 Aggregate Data for Cultural-Specific Groups
2780_Ch10_178-196 16/07/12 11:45 AM Page 196

197
Chapter 11
People of Cuban Heritage
Larry D. Purnell and Jorge Gil
Overview, Inhabited Localities,
and Topography
Overview
The Republic of Cuba, with a population of over
11 million people, is located 90 miles south of Key West,
Florida (CIA World Factbook, 2011). Approximately
the size of Pennsylvania, it is the largest island in the
West Indies. The capital, Havana, is the largest city.
Fidel Castro was president of this communist country
from 1959 until 2008, at which time he resigned due to
health problems. Major agricultural products and in-
dustries include sugar, petroleum, tobacco, textiles,
nickel, copper, cement, and fertilizer. Cuba is a multira-
cial society, with a population of primarily Spanish and
African origins; other significant ethnic groups include
Chinese, Haitians, and Eastern Europeans (CIA World
Factbook, 2011).
Over 1.6 million Cuban Americans live in the
United States, representing the third largest Hispanic
group, after Mexican Americans and Puerto Ricans
(U.S. Census Bureau, 2009). Cubans in Miami-Dade
County, Florida—the dominant center of Cuban
settlement—are credited with the area’s socioeco-
nomic transformation (Boswell, 2002). In this ethnic
enclave, Cubans have created businesses and rejuve-
nated the economy, leading some to speak of the
“great Cuban miracle.” The distinctive Cuban culture
is evidenced by their music, dance, and art. Cubans
have made a number of dances popular, including
the rumba, the cha-cha, the guaracha, the bolero, and
the conga. The classical ballerina, Alicia Alonso,
was a Cuban dancer famous for, among other things,
her portrayal in the ballet Carmen. The film Fresa y
Chocolate (Strawberries and Chocolate) won the Silver
Bear Award at the Berlin Film Festival in February
1995 (Cultural Orientation Resource Center, 2002).
The experience of Cubans in their homeland and
in the United States is distinct from that of other His-
panic groups. The history and culture of Cuba and
the Cuban people have been heavily influenced by
Spain, the United States, the Soviet Union, and,
through the slave trade in Cuba’s sugar industry, West
African groups such as the Yoruba.
Cuba was under Spanish control from 1511 until
1898, making it one of Spain’s last colonies in the New
World. Control of the sugar industry by Spanish penin-
sulares (individuals born in Spain) was challenged by
the growing class of criollo landowners (individuals of
Spanish ancestry born in Cuba) and the independen-
tista movement. This absentee ownership created po-
litical turmoil and social imbalances that gave rise to
the Cuban national character. The mistrust of govern-
ment reinforced a strong personalistic tradition, a sense
of national identity evolving from family and interper-
sonal relationships (Szapocznik & Hernandez, 1988).
Unlike most other immigrant groups, under the
Cuban Adjustment Act of 1966, Cubans were wel-
comed by the U.S. government and were provided
with support from the Cuban Refugee Program begun
by the Kennedy administration. Cubans engaged in a
wide range of entrepreneurial activity, in both sales
and services, within the shelter of the Cuban commu-
nity. Consequently, newer Cuban immigrants found
networks of support and were somewhat protected
from the difficulties associated with a competitive
labor market. There is a common feeling of thankful-
ness and appreciation among newer Cuban genera-
tions in the United States and also from the first
cohort of Cuban immigrants who arrived in the early
1960s. Cubans in the United States are a strong pres-
ence, not only economically but also politically.
An exile ideology, a preoccupation with events in
Cuba, and militant opposition to the regime of Fidel
Castro characterize their predominant political stance.
Overwhelmingly, Cuban Americans tend to be conser-
vative, Republican, and anti-Communist. They have
demonstrated high voter turnout and tend to vote in
blocs during local and national elections (National
Council of la Raza, 2011).
Cubans have managed to adjust to mainstream
American culture while remaining close to their
Cuban roots. However, young adults and adolescents
who were educated in Cuba with strict Communist
2780_Ch11_197-213 16/07/12 11:45 AM Page 197

ideation and who emigrated with their parents may
find the clash in values between Cuba and their new
country confusing and negative. The bicultural Cuban
American population can help in their adjustment.
Many Cubans outside Cuba possess a strong ethnic
identity, speak Spanish, and adhere to traditional
Cuban values and practices at home while working in
the dominant culture of their new homeland.
Cuban Economy
From the late 1800s to mid-1900s, Cuba was consid-
ered one of the most prosperous countries in Latin
America. The economy was based on treaties mainly
with United States, France, and Spain. Taxes were col-
lected from people at a high rates compared with those
of countries from the “first world.” At the same time,
construction of new buildings and roads increased.
Since the 1959 Communist Revolution of Castro, the
island has based its economy on subsidies from com-
munist countries such as the former Soviet Union and
China. With perestroika (literally translated, “restruc-
turing”) in 1988 by ex-president Mikhail Gorbachev,
Cuba tried without success to implement changes in
the economy.
Cuban economy today is primarily based on
tourism and gastronomy. Recently, the government
established taxes for so-called “private businesses,” but
because Cuba has no experience with a capitalist
economy, its government does not know how to im-
plement the taxation system. The general population
cannot pay these excessively high taxes and continue
to depend on their families en el extranjero: those who
reside outside Cuba.
Heritage and Residence
Ethnically, Cubans are 61.1 percent white, 24.8 percent
mulatto or mestizo, and 10.1 percent black (CIA
World Factbook, 2011). The native Arawak Indian
population that inhabited the island when Columbus
landed in 1492 died from diseases brought by Spanish
settlers. Cubans have a rich historical heritage. Spain
launched its conquest of Mexico from Cuba in 1519.
During the Spanish colonial period (1511–1898),
Spanish boats stopped in Havana on their way to
Mexico and Central America. In the 19th century, the
Monroe Doctrine led to a special relationship between
Cuba and the United States. The U.S. military con-
trolled the island from 1898 to 1902. In 1902, Cuba
was a politically independent capitalist state. In 1959,
Fidel Castro led a revolution to free Cuba of the
U.S.-backed dictator Fulgencio Batista and subse-
quently established a totalitarian Communist govern-
ment, which still controls the country through the sole
party, the Cuban Communist Party (PCC).
Most Cuban Americans reside in four states:
Florida, New Jersey, California, and New York.
The largest proportion live in Florida, especially in
Miami-Dade County. The Cuban American popula-
tion is aging, with a median age of 43.6 years and
more than 20 percent over 65 years old. By compari-
son, Mexicans, Puerto Ricans, and Central and South
Americans living in the United States have median
ages between 11 to 16 years younger than the average
for Cuban Americans. The higher median age is ex-
plained by lower fertility rates of Cuban American
women and the older age of those who immigrate
from Cuba (Boswell, 2002; Martinez, 2002).
About two-thirds of Cuban Americans residing in
the United States were born in Cuba, making this group
a largely immigrant population as compared with other
Hispanic groups. To illustrate, only 32 percent of Cuban
Americans were born in the United States, compared
with 64 percent for Mexican Americans and 60 percent
for Puerto Ricans (Boswell, 2002).
Based on the 2010 U.S. Census, the total estimated
Cuban population in the United States is almost
1.6 million, which is the third largest Hispanic popu-
lation in this country (U.S. Census Bureau, 2010). The
largest is the Mexican population with a total of al-
most 30 million people, followed by Puerto Ricans
with over 4 million. The major concentration of
Cubans is located in Miami-Dade County, Florida,
with 778,389 (U.S. Census Bureau, 2010)—almost half
of the total estimated number of Cuban Americans.
The second concentration of Cubans is located in
New York City with a total of 42,414, followed by
Texas with 36,945. (U.S. Census Bureau, 2010). Places
like South Dakota and Alaska have smaller Cuban
populations with 134 and 740, respectively (U.S. Census
Bureau, 2010).
Reasons for Migration and Associated
Economic Factors
Approximately 1 million Cubans immigrated to the
United States between 1959 and 1980; fewer than
200,000 arrived between 1990 and 2000. In the first
2 decades of the earlier period, most arrived on the
U.S. mainland after the 1959 revolution that brought
Fidel Castro to power and changed the social, eco-
nomic, and political landscape of Cuba. Although the
American government has defined the exodus as a
political rather than an economic migration, a com-
bination of these factors provided the motivation for
migration. The desire for personal freedom, the hope
of refuge and political exile, and the promise of
economic opportunities have been the main reasons
for Cuban immigration.
Portes and Bach (1985) identified six stages of
Cuban immigration to the United States:
1. First stage: Departures from January 1959 to
October 1962. When Fidel Castro overthrew the
government of Fulgencio Batista in January 1959,
approximately 250,000 landowners, industrialists,
198 Aggregate Data for Cultural-Specific Groups
2780_Ch11_197-213 16/07/12 11:45 AM Page 198

professionals, and merchants left on commercial
flights from Havana for the United States.
Operation Pedro Pan. In the early 1960s, some
14,000 Cuban children and teens were flown to the
United States without their parents through Operation
Pedro Pan. Triggered by fears that their children would
be made wards of the state and forced to participate
in counterrevolutionary activities, Cuban parents sent
their children to the United States. The Pedro Pan chil-
dren were placed with foster families and relocated to
different parts of the country; some never saw their
parents again (Conde, 1999). Although a number of
children were eventually reunited with their parents,
many suffered years of isolation and estrangement
from their families.
2. Second stage: Departures from November 1962 to
September 1965. The confrontation between
Cuba and the United States over Russian missiles
in Cuba ended all direct flights from Cuba to the
United States. At this time, about 56,000 people
left on small boats and rafts because no direct
transportation was available.
3. Third stage: Departures from October 1965 to
April 1973. Cuba and the United States reached
an understanding in which an airlift was allowed
from Varadero Beach, Cuba, to Miami. These
“freedom flights” or “family reunification
flights” provided the opportunity for about
297,000 people to immigrate.
4. Fourth stage: Departures from May 1973 to
September 1978. The Cuban government unilater-
ally ended the airlift. Travel to Spain, Mexico,
and Jamaica became the only means of leaving
Cuba. About 39,000 people arrived in the
United States on commercial flights by way
of these countries.
5. Fifth stage: Departures from October 1978 to
March 1980. Fidel Castro allowed political pris-
oners from Cuban jails to leave with their families.
About 10,000 people arrived in this manner on
airplane flights, boats, and rafts.
6. Sixth stage: Departures from April to September
1980. The Cuban government again allowed a
massive boatlift from the Mariel Harbor in Cuba
to Key West, Florida. Approximately 125,000
people arrived (known as the Marielitos), includ-
ing people with criminal records, homosexuals,
deaf-mutes, lepers, and patients from mental
institutions. About 5000, or 4 percent, of these
were hard-core criminals, causing an increase in
the levels of violent crime in the metropolitan
Miami and New York areas.
In the decade from 1990 to 2000, a total of 191,506
Cuban immigrants entered the United States (U.S. Im-
migration and Naturalization Service, 2000). Skaine
(2004) characterized two significant groups in this
period:
Balseros: The term balseros was derived from balsa
(raft), denoting the arrival of Cubans in the 1990s
using homemade rafts. This wave of migration
was preceded by deteriorating living conditions in
Cuba, with long electric power outages and
chronic shortages of food and basic necessities.
Of 35,000 balseros who were allowed by the Cas-
tro government to leave in 1994, only 30,000 were
estimated to have arrived in the United States.
Many did not survive the crossing because of
dehydration or boats that capsized. The most-
celebrated case was that of 5-year-old Elian
Gonzalez, who was rescued floating on an inner
tube after his mother and others perished when
their boat capsized (Skaine, 2004).
Immigrating through other countries: From 2001 until
the present, increasing numbers of Cubans have
been immigrating by land through Mexico,
Canada, Spain, or other countries (Skaine, 2004).
Two immigration accords signed by the United States
and Cuba set a limit of 20,000 visas annually for Cuban
immigrants and stipulated that any illegal immigrants
will be repatriated. At present, U.S. law enforces the
wet-foot/dry-foot policy with Cuban refugees. This
means that if a Cuban refugee reaches dry land in the
United States, that individual will be awarded legal im-
migrant status. This policy has generated some resent-
ment from other immigrant groups such as Mexicans
and Haitians, who are not awarded similar status even
if they manage to arrive on dry land in the United States
(Skaine, 2004).
In the 3 decades of Cuban immigration, significant
change has been observed in the waves of immigrants,
from the elite classes of the first stage, called the golden
exiles, to the Marielitos of the sixth stage and the
balseros of the 1990s. Each wave is distinct: The earli-
est waves of immigrants represented higher educa-
tional and economic status in Cuba than subsequent
waves; the later groups were more representative of
the Cuban population. The motivation for immigra-
tion also changed from the desire to escape political
and religious persecution in the earlier waves to the
hope for economic improvement in the later waves
(Skaine, 2004).
Educational Status and Occupations
The level of educational attainment of Cuban Americans
is higher than that of other Hispanic groups. About
22 percent of Cuban Americans are college graduates,
compared with 7 percent for Mexican Americans,
12 percent for Puerto Ricans, and 16 percent for Central
and South Americans. The educational preparation of
Cuban Americans is reflected in their median income,
People of Cuban Heritage 199
2780_Ch11_197-213 16/07/12 11:45 AM Page 199

which is also higher than that of other Hispanic groups.
The median household income for Cubans is $38,000,
higher than for other Hispanics ($36,000) but lower than
for non-Hispanic whites ($48,000). Native-born Cubans
have a higher median income than non-Hispanic whites
($50,000 vs. $48,000). Among foreign-born Cubans,
those who arrived before 1980 have the highest median
income ($38,000). However, those who arrived between
1980 and 1990 have a lower median income compared
with those who arrived in 1990 or later ($30,000 vs.
$33,000). Cubans living outside Florida have a higher
median income than those living in Florida ($44,000 vs.
$36,000) (Pew Hispanic Center, 2006). Relatively high
proportions of Cubans work in wholesale and retail
trade, banking and credit agencies, insurance, real estate,
and finance. A larger proportion of Cuban Americans
are found in higher-paying managerial and professional
jobs (24 percent), compared with Mexican Americans
(12 percent), Puerto Ricans (17 percent), and Central
and South Americans (15 percent). Conversely, in lower-
paying jobs as operators, fabricators, handlers, and
farmers, Cuban Americans have a smaller proportion
(18 percent) than that of Mexican Americans (18 percent),
Puerto Ricans (21 percent), and Central and South
Americans (24 percent) (Boswell, 2002).
Communication
Dominant Language and Dialects
Language is often used as an index of assimilation of
an immigrant group into the dominant culture. Virtu-
ally all first-generation Cubans in the United States
speak Spanish as their first language, although Cuban
Spanish varies somewhat in choice of words and pro-
nunciation from the Spanish spoken in Spain and
Central and South America.
Some Cuban Americans consider English to be
their dominant language, others consider Spanish to
be their dominant language, and yet others are com-
pletely bilingual. Because many Cubans live and
transact business in Spanish-speaking ethnic enclaves,
they have little need or motivation to learn English
and are less likely to acculturate. Many, like one of the
authors, speak Spanglish, a mixture of Spanish and
English with phrases such as Have a buen dia; Hola,
donde va today? (Have a good day; Hello, where are
you going?). The large number and variety of Spanish-
language media, including newspapers, magazines,
and radio programs, also reflect some Cuban immi-
grants’ preference for Spanish over English. A stroll
through Little Havana in Miami or Little Havana
North along New Jersey’s Union City–west New York
corridor, as well as other places in the United States,
reveals that Spanish is reflected in billboard and poster
advertisements. Signs announcing joyeria (jewelry
store), carniceria (butcher shop), muebleria (furniture
store), farmacia (drugstore), or zapateria (shoe store)
are quite commonplace. In addition, Cubans in
the United States have incorporated into their every-
day Spanish many English words, such as futbol, ros-
bif, coctel, sueter, frigidaire, and bridge. For Cuban
Americans, Spanglish becomes a reflection of both
their Cuban and their American heritages.
Cultural Communication Patterns
Like other Hispanic groups, Cubans value simpatia and
personalismo in their interactions with others. Simpatia
refers to the need for smooth interpersonal relation-
ships and is characterized by courtesy, respect, and the
absence of harsh criticism or confrontation. Personal-
ismo emphasizes intimate interpersonal relationships
over impersonal bureaucratic relationships. Choteo, a
lighthearted attitude with teasing, bantering, and exag-
gerating, may often be observed in the way Cubans
communicate with one another (Bernal, 1994).
Conversations among Cubans are characterized by
animated facial expressions, direct eye contact, hand
gestures, and gesticulations. Voices tend to be loud
and the rate of speech faster than may be observed
with non-Cuban groups. Linguistically, the use of the
second-person form usted to address older people and
authority figures has fallen into disuse, replaced by the
familiar form tu, although some older people prefer
the formal use of language, especially in hierarchal re-
altionships such as with health professionals. The use
of tu in interpersonal situations serves to reduce dis-
tance and promotes personalismo. Touching, in the
form of handshakes or hugs, is acceptable among
family, friends, and acquaintances. In the health-care
setting, patients and family members may hug or
kiss the health-care provider to express gratitude and
appreciation.
Cubans feel a sense of “specialness” about them-
selves and their culture that may be conveyed in com-
munication with others. This sense of specialness
arises from pride in their unique culture, a fusion of
European and African; the geopolitical importance
of Cuba in relation to powerful countries in history;
and the exceptional success they have achieved in
adapting to their new environment. This sense of spe-
cialness, combined with the fast rate and loud volume
of speech, may sometimes be interpreted as arrogance
or grandiosity in a non-Cuban cultural context
(Bernal, 1994).
Temporal Relationships
Cubans tend to be present oriented compared with
future-oriented European Americans. A greater em-
phasis is paid to current issues and problems than
on projections into the future. In the clinical setting,
health-care providers must realize that Cuban pa-
tients tend to be motivated to seek help in response
to crisis situations. Hence, visits to health-care
providers for resolution of a crisis must be used
200 Aggregate Data for Cultural-Specific Groups
2780_Ch11_197-213 16/07/12 11:45 AM Page 200

as opportunities for teaching and promotion of
personal growth.
Hora cubana (Cuban time) refers to a flexible time
period that stretches from 1 to 2 hours beyond the des-
ignated clock time. A Cuban understands that when
a party starts at 8 p.m., the socially acceptable time to
arrive is between 9 and 10 p.m. However, families who
have acculturated to American values may adhere to
a more rigid clock time. When setting up appoint-
ments for clinic visits, the health-care provider must
determine the patient’s level of acculturation with re-
spect to time and make arrangements for flexible
scheduling, if necessary.
Format for Names
Modeled after Spanish and other Latin American
societies, Cubans use two surnames, representing the
mother’s and the father’s sides of the family. For ex-
ample, a woman may use the name Regina Morales
Colon, indicating that her patrilineal surname is
Morales and her matrilineal surname is Colon. When a
Cuban woman marries, she adds de and her husband’s
name after her father’s surname and drops her
mother’s surname. In the previous example, if Regina
marries Mr. Ordonez, her name will be Regina
Morales de Ordonez (Skaine, 2004). When addressing
Cuban patients, especially the elderly, the health-
care provider should use the formal rather than the
familiar form, unless told otherwise. In the previous
example, the appropriate appellation would be Señora
Morales, or Mrs. Morales, instead of Regina.
Cubans translate English, Russian, or any other
language in their own “Cuban way,” and this is true
for names as well. Some examples of common terms
that have been adapted from other languages are
Naivy (like U.S. Navy), Yusimi (You see me), and
Yeneisy (Yeah, nein—German for “no” and “see”).
Family Roles and Organization
Head Of Household And Gender Roles
As among most Hispanic/Latino populations, family is
the most important social unit among Cubans and
Cuban Americans. The traditional Cuban family struc-
ture is patriarchal, characterized by a dominant and ag-
gressive male and a passive, dependent female, although
the more acculturated families in the United States have
become more egalitarian. La casa, the house, is consid-
ered the province of the woman, and la calle, the street,
the domain of the man. La calle includes everything
outside the home, which is considered a proper testing
ground for masculinity but dangerous and inappropriate
for women. Traditionally, Cuban wives are expected to
stay at home, manage the household, and care for the
children. Husbands are expected to work, provide, and
make major decisions for the family. However, with ac-
culturation and more women working outside the home,
egalitarian decision making prevails in the United States.
Cultural values acquired through 4 centuries of
Spanish domination influence the behavior of Cuban
men and women toward one another. The concept of
honor is described as personal goodness or virtue,
which can be lost or diminished by an immoral or un-
worthy act. Honor is maintained mainly by fulfilling
family obligations and by treating others with respeto
(respect). Verguenza, a consciousness of public opin-
ion and the judgment of the entire community, is
considered more important for women than men.
Machismo dictates that men display physical strength,
bravery, and virility.
In Cuba, the transition from an agricultural to an
industrial economy, the rising educational attainment
of women, the increased participation of women in
the workforce, and the passage of the Family Code of
1975 resulted in more gender equality and parity
beween men and women with respect to marriage,
divorce, property relations, and sharing of household
responsibilities (Skaine, 2004).
Since the massive migration from Cuba to the
United States in 1959, the traditional Cuban family
has undergone a transition to a less male-dominated,
less segregated, and more egalitarian structure. Cuban
women who arrived in the United States were
frequently the first in the family to find jobs and
contribute to the survival of the family. According to
People of Cuban Heritage 201
R E F L E C T I V E E X E R C I S E 1 1 . 1
Pedro is a 12-year-old child who arrived from Cuba 6 months
ago. He flew from the island with his parents and a 4-year-old
sister. He lives now with his paternal grandparents in the Coral
Gables area of Miami. He started school one week after he
came from Cuba in a local public school. “Pedrito,” as he is
called by his family and close friends, used to do very well in
school. He had received several accommodations from his
teachers, always had good grades, was very friendly and active
socially, was always a team player, and had several awards in
different sports.
For the past 4 or 5 months, he appears to be lonely and
quiet. His mother approached him once and asked him what
changed his attitude. Pedrito told her that he does not under-
stand English, the teachers talk too fast, and when he asks
questions, several children in the classroom laugh at him. He
told his mother that he wants to go back to Cuba, hates his
new country, and will no longer go to school.
1. Do you think Pedrito’s behavior is a common pattern in all
immigrant kids during the process of acculturation? Explain
your answer.
2. What is the best action for the parents to take?
3. Describe three consequences of Pedrito’s behavior for his
future professional and personal development if his par-
ents do not take early measures to try to help him.
2780_Ch11_197-213 16/07/12 11:45 AM Page 201

Gallagher (1980), Cuban immigrant women were
more receptive to life in the United States, more
flexible, and more readily hired for jobs than men.
Eventually, as their contributions to the family’s eco-
nomic well-being increased, the women’s power to make
decisions was enhanced. Cuban American women have
the highest rate of labor participation when compared
with all other groups of women in the United States
(Suarez, 1993). Thus, contemporary Cuban families
from the 1980s to the present may demonstrate greater
gender equality in decision making for the family.
Prescriptive, Restrictive, and
Taboo Practices for Children
and Adolescents
Cuban parents tend to pamper and overprotect their
children, showering them with love and attention.
Among Cubans, the expectation is that children study
and respect their parents and older people. Children
are encouraged to acquire knowledge and learning
porque eso no te lo puede quitar nadie (because no one
can take that away from you) (Bernal, 1994).
When a Cuban daughter reaches the age of 15 years,
a quince, or 15th birthday party, is typically held to cel-
ebrate this rite of passage. Socially, the quince is indica-
tive of the young woman’s readiness for courting by a
novio (boyfriend). In Cuba, as among many families in
the United States, the quince is celebrated with food,
music, and dancing among family and friends. In
Miami’s Cuban enclave, as well as in other cities, the
quince is a major social event. Parents may save up for
years to prepare for a daughter’s quince, which has
today evolved into a large, extravagant party.
Many Cuban adolescents may undergo an identity
crisis, not knowing whether they are fully Cuban or
American. During this time, they may reject traditional
cultural values, and parents may feel threatened when
their authority is being challenged. The opposing values
and demands of their Cuban heritage and American so-
ciety create a potential for tension and conflict between
Cuban adolescents and their parents. Some examples
are the Cuban practice of chaperoning unmarried cou-
ples when they date. Unmarried daughters are expected
to live at home with the family until they marry.
Family Goals and Priorities
Cubans have tightly knit nuclear families that allow
for inclusion of relatives and padrinos (godparents).
La familia (the family) is the most important source
of emotional and physical support for its members.
Extended, multigenerational households are common,
with grandparents often being part of the nuclear
family. Compared with other Hispanic ethnic or cul-
tural groups, Cubans have the lowest proportion of
families with children. Cubans also have the highest
proportion of people aged 65 and older who live with
their relatives. The high proportion of older people
living with family members has led to the typical
three-generation Cuban family (Perez, 2002).
A system of personal relationships known as com-
padrazgo is also typical. A set of godparents, or com-
padres, is selected for each child who is baptized and
confirmed. Compadres tend to be close friends or rela-
tives of the child’s natural parents and may be counted
on for moral or financial assistance. Compadres are usu-
ally considered part of the Cuban family, whether or not
a true blood relationship exists.
In recent years, as Cubans have become more accul-
turated to American society, and as the children of
Cuban immigrants have become more Americanized
and more economically successful than their parents,
family dynamics, expectations, and behaviors are chang-
ing. Multigenerational living arrangements are markedly
declining, with increased numbers of older adults be-
coming more independent and living alone. Despite
these trends, the need and desire for frequent family con-
tact through daily telephone calls and frequent visits are
still predominant. Although more likely now to be living
alone, older Cuban adults have close interactions
not only with their children but also with grandchildren,
siblings, cousins, and other relatives (Martinez, 2002).
Alternative Lifestyles
There is a high proportion of divorced women among
Cuban Americans compared with other Hispanic and
non-Hispanic groups in the United States. In spite of
this, Cubans have the highest percentage of children
under 18 years living with both parents, a low percent-
age of families headed by women with no husbands
present, and the lowest rate of mothers and children
living within a larger family unit. One explanation for
these patterns may be that divorced Cuban women re-
turn to their parents’ home, but because they typically
have fewer children, they do not tend to be accompa-
nied by children (Perez, 2002).
In dealing with some Cuban Americans, health-
care providers may hear the term Marielito used in a
derogatory manner to refer to the estimated 4 percent
of the 125,000 Cubans who arrived during the Mariel
boatlift. Because some of the Marielitos were hard-
core criminals released from Cuban jails, the increased
levels of crime in metropolitan Miami and New York
have been attributed in part to their arrival. Although
very few of them were criminals, unfortunately, the
negative attitudes toward them have been extended to
Cuban Americans as a group. The Marielitos were
predominantly single, black, working-class Cuban
males, in contrast to the professional and managerial
workers of earlier waves of migration.
Little or no data are available on the occurrence of
homosexuality among Cuban Americans, although the
gay lifestyle would be contradictory to the prevailing
machismo orientation of Cuban culture. Same-sex
202 Aggregate Data for Cultural-Specific Groups
2780_Ch11_197-213 16/07/12 11:45 AM Page 202

couples living together may be alienated from their fam-
ilies, especially among first-generation Cubans who ad-
here closely to traditional gender roles and family values.
Undoubtedly, gay and lesbian films such as Gay Cuba,
Strawberry and Chocolate, and La Carne de Rey and the
Miami Gay and Lesbian Film Festival are attempts at
making alternative lifestyles more acceptable. Given the
stigma associated with homosexuality in this culture, a
matter-of-fact, nonjudgmental approach must be used
by health-care providers when questioning Cuban
patients regarding sexual orientation or sexual practices.
Workforce Issues
Culture in the Workplace
Cubans have enjoyed enormous economic success in the
United States. Twenty percent of first-generation Cuban
Americans and 43 percent of second-generation Cuban
Americans are college graduates. The high educational
achievement is reflected in the large proportions—
53 percent for first-generation Cuban Americans and
75 percent for second-generation Cuban Americans—
who are employed in managerial and technical jobs, the
two highest-paying occupational categories (Boswell,
2002). Cuban families also have proportionately more
people participating in the labor force and earning a
higher median income than Mexican, Puerto Rican, or
Central and South American families (Boswell, 2002).
Their strong entrepreneurial abilities tend to be concen-
trated in construction, transportation, textiles, whole-
sale, and retail trades. The existence of several Cuban
ethnic enclaves with a familiar language and culture has
created numerous employment opportunities for recent
Cuban immigrants.
A frequent source of tension in the workplace is the
tendency of Cubans to speak Spanish with other
Cuban or Hispanic coworkers. Speaking the same lan-
guage allows them to form a common bond, relieve
anxieties at work, and feel comfortable with one an-
other. In Blank and Slipp’s (1994) study, one Cuban
supervisor asserted, “Others should know that we tend
to go back and forth in language—Spanish when we’re
talking personally and English when it’s professional.”
Issues Related to Autonomy
Traditional Cubans tend to be hierarchical in their rela-
tionships, recognizing supervisors or superiors as au-
thority figures and treating them with respect and
deference. In mainstream American culture, collegial re-
lationships, in which workers can exercise initiative,
question the supervisor, and participate in decision mak-
ing, may make Cubans uncomfortable. Cubans value a
structure characterized by personalismo—that is, one that
is oriented around people rather than around concepts
or ideas. For Cubans, personal relationships at work are
considered an extension of family relationships. Cuban
workers may function best in a working environment
that is warm and friendly and fosters personalismo. Be-
cause of the emphasis on the job or task in the American
workplace, many Cubans view this workplace as being
too individualistic, business-like, and detached. In the
past, the language barrier may have insulated Cuban
Americans from the dominant culture, retarded accul-
turation, and fostered some interethnic tensions; as the
ability to speak English and acculturation increases,
Cuban Americans have fewer interethnic tensions.
Biocultural Ecology
Skin Color and Other Biological Variations
Most Cuban Americans are white. Because of their pre-
dominantly European ancestry, Cuban Americans have
skin, hair, and eye colors that vary from light to dark.
A minority, who are of African Cuban extraction, are
dark-skinned and may have physical features similar to
those of African Americans.
People of Cuban Heritage 203
R E F L E C T I V E E X E R C I S E 1 1 . 2
Alberto Gonzaga is a 43-year-old Cuban American male.
He migrated 18 years ago with his wife and 3-year-old son,
Alberto. Before he emigrated to the United States, Mr. Gonzaga
was imprisoned in Cuba for political reasons. He did not com-
plete the 20-year sentence imposed by the Castro regime
and was released from jail after 12 years for good behavior.
He was immediately granted a U.S. visa for himself and his
family. Since his arrival, he has been an active member of the
Republican Party and has participated in the local Miami area
in the anticommunist movement. His son is now 21, and he
still lives with his parents, helping them financially. He works
full-time and pursues a law degree in a local college. There
have been several confrontations between Mr. Gonzaga and
his son. The new, more liberal “open” era has brought Cuban
musicians from the island to perform in public concerts in
Miami. Mr. Gonzaga is totally opposed to this. He claims that
“these Communist musicians will take our money and our
taxes and give it to Castro” and prohibits his son from going to
the concerts. Alberto states that music has nothing to do with
politics and that many of these musicians are opposed to the
regime, but this is a way to travel outside Cuba and earn some
money. He confronts his father, telling him that he is an adult
and he will go to the concerts, despite his father’s opposition.
1. How different is the Cuban population that migrated
20 years ago compared with those who arrived 5 or
6 years ago?
2. Are the children of the Cubans who arrived in the 1980s
maintaining their traditions? Is their way of thinking the
same as their parents’?
3. What could be the consequences of the confrontations
between Mr. Gonzaga and his son?
4. Is the Castro government still separating the family even
outside Cuba, or is this situation just a matter of character?
2780_Ch11_197-213 16/07/12 11:46 AM Page 203

Diseases and Health Conditions
Nath’s (2005) analysis of data from the Hispanic
Health and Nutrition Examination Survey (HHANES)
reported that, among Cuban Americans, major health
conditions are a high prevalence of coronary heart
disease, hypertension, overweight or obesity, type 2
diabetes mellitus, and depression. Twenty-nine percent
of Cuban American men and 34 percent of Cuban
American women are overweight, compared with
25 percent and 37 percent of Puerto Rican males and
females, respectively, and 30 percent and 39 percent of
Mexican American males and females, respectively. The
same study found that 16 percent of Cuban Americans
aged 45 to 74 had diabetes mellitus, compared with
26 percent of Puerto Ricans and 24 percent of Mexican
Americans.
In a comparison of hypertension-related mortality
among Hispanic groups, Cuban Americans were
found to have the lowest death rate and Puerto
Ricans had the highest death rate. In addition,
age-standardized hypertension-related mortality rates
in Cuban Americans were 39 percent lower than
those for non-Hispanic whites (Centers for Disease
Control and Prevention, 2006).
Variations in Drug Metabolism
Although some studies have reported differences in
drug metabolism among Hispanics, little or no data
specific to Cuban Americans are available.
High-Risk Behaviors
Devieux and colleagues (2005) at Florida Interna-
tional University conducted an assessment of HIV
risk behaviors of adolescents participating in an HIV
risk-reduction intervention. Of the 137 participants in
the interview assessment, 81 were African American
teens and 57 were Cuban American teens. Cuban
American teens reported more unprotected sex acts
and more anal sex acts in the 6 months prior to the in-
terview than did African American teens. The groups
were similar on the total number of sexual partners and
sex acts reported. Regarding drug use, a greater propor-
tion of Cuban American teens reported using drugs in
the 6 months prior than did African American teens,
and more Cuban American teens reported engaging in
unprotected sex while using drugs than did African
American teens. The authors speculate that higher ac-
culturation of Cuban American teens, and accompa-
nying family conflict, may account for the relatively
more risky behaviors among Cuban American teens.
More research is needed to clarify the processes leading
teens of different backgrounds to initiate and maintain
risky behaviors and to identify the most effective ways
to intervene to reduce risk (Devieux et al., 2005).
The HHANES findings also revealed that drinking
alcohol was significantly more common among
Cuban males than females and among younger versus
older Cuban groups, a pattern that was similar to that
in Mexicans and Puerto Ricans. Among middle-aged
and older Cuban males, who tend to be relatively well
educated and have higher incomes compared with the
younger, more recent Cuban immigrants, control of
intoxication is important. Among Cuban women, the
proportion of lifelong abstainers increased signifi-
cantly from the younger to the older groups (Black &
Markides, 1994).
Smoking is responsible for 87 percent of the lung
cancer deaths in the United States. Overall, lung can-
cer is the leading cause of cancer deaths among His-
panics. Lung cancer deaths are about three times
higher for Hispanic men (23.1 per 100,000) than for
Hispanic women (7.7 per 100,000). The rates of lung
cancer deaths per 100,000 were higher among Cuban
American men (33.7) than among Puerto Rican (28.3)
and Mexican American (21.9) men (Centers for Dis-
ease Control and Prevention, 2011).
Health-Care Practices
An obstacle to good nutritional practices is the Cuban
cultural perspective of the “healthy body.” A healthy
and beautiful Cuban infant is fat. Even among adults,
a little heaviness is considered attractive. Que gordo
204 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 1 . 3
Pablo Perez is a 42-year-old Cuban immigrant. He arrived in the
United States 2 years ago with his wife and a 10-year-old daugh-
ter. He was a successful physician in Cuba and was selected to
travel outside the island in 1991 to Spain to assist in an interna-
tional congress. He also was chosen to provide medical services
in Senegal in 2002. Both times, he returned to Cuba—the first
time because his mother was in bad health (she died a short
time later), and the second time because he had a wife and
daughter waiting for him. In 2006, he and his wife were selected
to go to Venezuela. After 2 years there, where he demonstrated
an excellent professional and communist attitude, the consulate
allowed their daughter to join them.
This was the chance Dr. Perez was waiting for. He and his
family immediately headed north, crossed the Mexican border
into the United States, and settled in Las Vegas. Both Dr. and
Mrs. Perez each have two full-time jobs. They have had problems
learning the language. Dr. Perez has taken the medical boards
twice, but he failed both times. He has told his wife that if they
moved to Miami, it will be better for them because there are
more Hispanic people there, the weather is better, and the
support system is greater. Do you think that Dr. and Mrs. Perez’s
behavior in Venezuela is a common pattern among Cuban
professionals who are trying to get into the United States?
1. How different is the Cuban health system compared to
that of the United States?
2. Explain the options that Dr. and Mrs. Perez have for joining
the health-care field again in the United States?
3. Do you think that moving to Miami will solve Dr. and
Mrs. Perez’s problems?
2780_Ch11_197-213 16/07/12 11:46 AM Page 204

estas! (How fat you are!) is considered a compliment.
The traditional Cuban diet—high in calories, starches,
and saturated fats—predisposes individuals to the de-
velopment of obesity. In Cuba, health care is viewed
as a basic human right and occupies a prominent
place in the Cuban government’s domestic and foreign
policies. Polyclinics in communities are the basic unit
of health care. Physician–nurse teams attend patients
in these polyclinics, as well as in the home, school,
day-care center, and workplace.
In the United States, Cubans exhibit high levels of
preventive health behaviors, as evidenced by routine
physical examinations within the last 2 years. The uti-
lization of preventive services was usually associated
with accessibility, which, in turn, was significantly in-
fluenced by education, annual income, and age (Solis,
Marks, Garcia, & Shelton, 1990).
Lopez and Masse (1993) found that unmarried
Cuban American women who had little recreational ac-
tivity tended to have a higher mean weight. In addition,
in contrast to Mexican American and Puerto Rican
women, body fatness in Cuban American women was
not significantly associated with income (Lopez &
Masse, 1993).
Nutrition
Meaning of Food
Besides satisfying hunger, food has a powerful social
meaning among Cuban Americans, allowing families
to reaffirm kinship ties, promote a sense of commu-
nity, and perpetuate their customs and heritage. To
grasp this fully, one needs only to observe multigen-
erational families assembled for dinner on a Saturday
or Sunday evening in a Cuban restaurant in Miami’s
Little Havana or Cuban friends sharing a cup of cafe
cubano and pastelitos at a stand-up sidewalk counter.
In Miami alone, the demand for Cuban food and
food products has resulted in the establishment of
about 400 Latin restaurants, mostly Cuban, and some
700 bodegas, or grocery stores. Other Cuban enclaves
paint a similar picture.
Common Foods and Food Rituals
Cuban foods reflect the environmental influences of
Cuba’s tropical climate and agriculture, the historical
influences of Spanish colonial rule, the African slave
trade, and the Arawak Indians’ cultivation methods.
Typical staple foods are root crops like yams, yucca,
malanga, and boniato; plantains; and grains. Tradi-
tional Spanish dishes like arroz con pollo and paella
are frequently served. Many dishes are prepared with
olive oil, garlic, tomato sauce, vinegar, wine, lime juice
(called sofrito), and spices. Meat is usually marinated
in lemon, lime, sour orange, or grapefruit juice before
cooking (Kittler & Sucher, 2008).
The main course in Cuban meals is meat, usually
pork or chicken. Some popular entrees are roast pork
(lechon), fried pork chunks (masas de puerco), sirloin
steak (palomilla), shredded beef (ropa vieja), pot roast
(boliche), and roasted chicken (pollo asado). A roasted
suckling pig is traditionally served on Christmas Eve,
New Year’s Day, and other festive celebrations. Black
beans are prepared with a sauce containing fat, pork,
and spices. Ripe plantains (platanos maduros) or green
plantains (platanos verdes) are served fried. Fried green
plantains (tostones or mariquita) may also be smashed
between a brown paper bag and the fist (un cartucho y
el puno), giving them the familiar name platanos a pune-
tazo. Desserts are rich and very sweet, such as custard
(flan), egg pudding (natilla), rice pudding (arroz con
leche), coconut pudding (pudin de coco), or bread
pudding (pudin de pan) (Kittler & Sucher, 2008).
Beverages may include sugar cane juice (guarapo),
iced coconut milk (coco frio), milkshakes (batidos),
Cuban soft drinks such as Iron Beer or Materva,
sangria, or beer. The strong and bittersweet coffee
called cafe cubano is a standard drink after meals and
throughout the day, whether at home, in restaurants,
or in other social situations. In the United States,
Cubans may drink the cafe cubano as cortadito or with
a dash of milk to cut the strength and bittersweet
taste. A traditional Cuban meal includes a generous
helping of white rice with black beans or black bean
soup, fried plantains, roasted pork or fried chicken, a
tuber such as malanga or yucca, followed by dessert
and espresso. Thus, the typical diet is high in calories,
starches, and saturated fats. As in Spain and other
Hispanic countries, a leisurely noon meal (almuerzo)
and a late evening dinner (comida), sometimes as late
as 10 or 11 p.m., are customary.
Nutritional Deficiencies and Food Limitations
As seen in Figure 11-1, the major food groups are well
represented in the Cuban diet; however, leafy green
vegetables may be lacking in the average Cuban meal.
Therefore, when assessing the nutritional adequacy of
a Cuban patient’s diet, the health-care provider must
ensure sufficient fiber content.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
The low fertility rate of Cuban women, which is con-
sistent in every maternal age group, has been attrib-
uted to three factors (Perez, 2002):
1. Cuban American women have a high rate of labor
force participation.
2. Before the revolution, Cuba had the lowest birth
rate in Latin America.
3. Cuba’s current reproductive rate is among the
lowest in the developing world.
In an analysis of HHANES data, Stroup-Benham
and Trevino (1991) found that only 9 percent of Cuban
People of Cuban Heritage 205
2780_Ch11_197-213 16/07/12 11:46 AM Page 205

American women took oral contraceptives, compared
with 11 percent among Puerto Ricans and 20 percent
among Mexican Americans. In the same study, hys-
terectomies, oophorectomies, and tubal ligations were
found to be less common among Cuban American
women than among either Mexican American or
Puerto Rican women. Based on these data, Cuban
American women appear to be at greatest risk for un-
intended pregnancies. Paradoxically, they have the low-
est birth rate among the three groups of Hispanic
women (Stroup-Benham & Trevino, 1991). A possible
explanation for this inconsistency may be the high di-
vorce rate and the high labor force participation rate
among Cuban American women. No more recent data
on Cuban American women could be found.
Many Cuban folk beliefs and practices surround
pregnancy. For example, some Cuban women believe
that they have to eat for two during the pregnancy and
end up gaining excessive weight. Some believe that
morning sickness is cured by eating coffee grounds,
that eating a lot of fruit ensures that the baby will be
born with a smooth complexion, and that wearing
necklaces during pregnancy causes the umbilical cord
to be wrapped around the baby’s neck.
Among Cuban Americans, childbirth is a time for
celebration. Family members and friends congregate in
the hospital, awaiting the delivery of the baby. Although
traditionally it was not acceptable for Cuban men to at-
tend the birth of their children, the younger and more
acculturated Cuban fathers tend to be present to sup-
port their wives during labor and delivery. In the post-
partum period, it is believed that ambulation, exposure
to cold, and going barefoot place the mother at risk for
infection. Because of this, family members and relatives
often care for the mother and baby for about 4 weeks
postpartum.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Cuban Americans participate in prenatal care if it is
affordable. Rest is encouraged, and abstaining from
strenuous activities and loud noises is recommended.
Fresh fruits are encouraged for the health of the
mother and the fetus. More acculturated fathers par-
ticipate in prenatal classes and support the mother in
the delivery room. Breastfeeding among Cuban
American women is becoming more popular than
in the past. Most do a combination of breast- and
bottle-feeding (Varela, 2005).
Thomas and DeSantis (1995) related the early intro-
duction of solid foods and prolonged bottle-feeding of
Cuban children to the traditional Cuban beliefs that
“a fat child is a healthy child” and that breastfeeding
may contribute to a deformity or asymmetry of the
breasts. In the same study, 97 percent of Cuban mothers
indicated that they administer vitamin preparations to
promote the healthy development of their children.
Cuban mothers also used advice about child health
given by their spouses, mothers, mothers-in-law, and
clerks and pharmacists who sold them over-the-
counter drugs (Thomas & DeSantis, 1995).
Traditionally, postpartum mothers and their infants
are not supposed to leave the house for 41 days. This
initial postpartum period is a time for mothers to rest
and devote their energies to caring for the baby. The
new mother’s immediate family—mother and sisters—
help care for the new mother and baby. The mother is
sheltered from bad news and any stress that could
harm her or her baby. She is also encouraged to eat
more to foster milk production (Varela, 2005).
Death Rituals
Death Rituals And Expectations
In death, as in life, the support of the extended family
network is important. Whether in the hospital or at
home, the dying person is typically surrounded by a
large gathering of relatives and friends. In Catholic
families, individual and group prayers are offered for
the dying to provide a peaceful passage to the here-
after. Religious artifacts such as rosary beads, cruci-
fixes, and estampitas (little statues of saints) are placed
in the dying person’s room.
Depending on the dying person’s religious beliefs,
a Catholic priest, a Protestant minister, a rabbi, or a
santero may be summoned to the deathbed to perform
appropriate death rites. For adherents of Santería,
death rites may include animal sacrifice, chants, and
ceremonial gestures. Health-care providers need to be
open-minded and responsive to both the physical and
the psychosocial needs of the dying and the bereaved
and, regardless of religious beliefs, accord them the
utmost respect and privacy.
After a person’s death, candles are lighted to illumi-
nate the path of the spirit to the afterlife. A wake, or
velorio, is usually held at a funeral parlor, where friends
and relatives gather to support the bereaved family.
The wake lasts for 2 to 3 days until the funeral. Burial
in a cemetery is the common practice for Cuban
Catholics, although some may choose cremation.
Responses to Death and Grief
Bereavement is expressed openly among Cuban Amer-
icans, with loud crying and other physical manifesta-
tions of grief considered socially acceptable. Death is
an occasion for relatives living far away to visit and
commiserate with the bereaved family. Women from
the immediate family usually dress in black during the
period of mourning. Visitors make offerings of can-
dles and floral wreaths (coronas), provide assistance
with household chores, and attend to visitors or
funeral arrangements. Cuban Americans customarily
remember and honor the deceased on their birthdays
or death anniversaries by lighting candles, offering
206 Aggregate Data for Cultural-Specific Groups
2780_Ch11_197-213 16/07/12 11:46 AM Page 206

prayers or masses, bringing flowers to the grave, or
gathering with family members at the grave site.
Spirituality
Dominant Religion and Use of Prayer
Approximately 85 percent of Cuban Americans are
Roman Catholics, with the remaining 15 percent being
Protestants, Jews, and believers in the African Cuban
practice of Santería. The original habitants in Cuba
were the Guanatayabes Indians, located mainly in the
center-west area of the island, and the Taino Indians,
mainly in the east side. When Spaniards arrived, they
not only abused and killed the Indians, but they also
imposed their Catholic religion. This religion continued
in Cuba for many years and was combined with some
Christian practices during the colonization period.
The Roman Catholic Church has been an impor-
tant source of support, especially for first-generation
Cuban immigrants. A number of predominantly
Cuban parishes with Cuban clergy are located in
Florida and New Jersey, where large Cuban popula-
tions reside. The Roman Catholic Church has exerted
an important influence on Cuban families by provid-
ing educational opportunities in Catholic schools.
Many Cuban parents, especially the upper middle
class, prefer to have their children educated in private
Catholic schools.
Roman Catholicism as practiced by Cubans is per-
sonal rather than institutional in nature. The religious
practice of Cuban Catholics is characterized by devo-
tion and intimate, confiding relationships with the
Virgin Mary, Jesus, and the saints.
Some families may have shrines dedicated to La
Caridad del Cobre (the patron saint of Cuba) or other
saints at the entrance to their homes, in their yards, or
in commercial establishments. The three favorite saints
that are enshrined are Santa Barbara, San Lazaro, and
La Caridad del Cobre. Inside the home, crucifixes and
pictures or statues depicting images of saints may be
found. When someone is ill, small pictures of saints,
called estampitas, may be placed under the pillow or
at the sick person’s bedside.
Significant religious holidays for Cuban families in-
clude Christmas, Los Tres Reyes Magos (Three Kings’
Day), and the festivals of the La Caridad del Cobre and
Santa Barbara. The Cuban community usually cele-
brates the feast of La Caridad del Cobre (September 8)
by transporting the statue of the patron saint on a boat
to a specific location, where a mass is held in her honor.
Cuban families also celebrate Christmas Eve (Noche
Buena) with a traditional Cuban meal. Typically, a
pig is cooked all day in a wooden box lined in metal
(una caja china) and set in the backyard. The pig is
placed at the bottom of the box and is covered with
charcoal. The meat is served with black beans and
rice, yucca, and turones (Spanish dessert). The evening
concludes with the family attending Midnight Mass
(Misa de Gallo).
With the arrival of slaves from Africa in the late
1700s and early 1800s, a new type of religious practice
emerged in Cuba. One group from the Bantu tribe in
the Congo were called palos (sticks) by the Spaniards
because they used sticks for their religious practices.
Today, the paleros (plural for people who practice the
religion with sticks and who perform black magic) are
viewed in a negative way, representing a “bad” type of
African Cuban religion. Another group of slaves came
from the Carabali tribe from South Nigeria (also
known as the Abakua tribe). They still exist today, but
they do not have a negative reputation like the paleros.
In addition, other groups of slaves mixed with the
criollos (native Cubans born from Spaniards and In-
dians), Spaniards, French, and other ethnicities who
were already residing in Cuba in the mid-1800s. Be-
cause of this extensive mixture of races and ethnicities,
Cubans say that en Cuba el que no tiene de Congo tiene
de Carabali (in Cuba if you don’t have it from Congo,
you will have it from Carabali), denoting that wonderful
combination of cultures.
Another African Cuban religion is the Yoruba/
Lucumi. Yoruba is an African dialect also known as
Lucumi. The minister is known as “Olorisha” or owner
of Orisa or Orisha, the saints. The different types of
Orishas are Eleggua, Ogun, Oshun, Babalu-Aye,
Chango, Oya, Obatala, Yemaya, and Orula. When this
priest initiates other priests, they are known as
babalorishas (the father of Orishas) or Iyalorishas
(the mother of Orishas). The Supreme Priest is
known as Ifa, the Father who knows the secret. Ifas
are commonly known among the general population
as Babalaos or, correctly said, Babalawo. They are
the most widely seen santeros in Cuba and the ones
from whom people seek help with their health or a
better economy.
Santeria, or Regla de Ocha, is a 300-year-old
African Cuban religious system that combines ele-
ments of Roman Catholicism with ancient Yoruba
tribal beliefs and practices. Santeria originated among
the Yoruba people of Nigeria, who brought their
beliefs with them when they arrived in the New
World as slaves. As a condition of their entry into the
West Indies, slaves were required to be baptized as
Roman Catholics (Perez y Pena, 1998). In the process
of adapting to their new non-African environment,
the slaves altered their beliefs to incorporate those
of their predominantly Catholic masters. Santeria
evolved from two main cultural antecedents: the wor-
ship of the orishas among the Yoruba tribe of Nigeria
and the cult of saints from the Roman Catholicism of
Spain. Through their exposure to the Catholic reli-
gion, the slaves came to associate their African gods,
called orishas, with the Roman Catholic saints, or
santos. The worship of the orishas and the associated
People of Cuban Heritage 207
2780_Ch11_197-213 16/07/12 11:46 AM Page 207

beliefs, rituals, incantations, magic, and spirit posses-
sion are central to Santeria.
Table 11-1 displays the seven African powers, or
main orishas (Martinez & Wetli, 1982). The Yoruba
deity of fire and thunder, called Chango, became iden-
tified with Santa Barbara, the patron saint of the
Spanish artillery, who appeared in Catholic litho-
graphs in red, the color of the orisha (Sandoval, 1979).
Chango, the most popular god in Santeria, controls
thunder, violent storms, lightning, and fire. The six
other orishas, the Catholic saints with whom they are
identified, and their corresponding functions and
powers are also shown in Table 11-1.
When people decide to practice Santeria, their or-
ishas become known to them and must be worshipped
throughout their lives. Followers of Santeria believe
in the magical and medicinal properties of flowers,
herbs, weeds, twigs, and leaves. Sweet herbs such as
manzanilla, verbena, and mejorana are used for attract-
ing good luck, love, money, and prosperity. Bitter
herbs such as apasote, zarzaparilla, and yerba bruja
are used to banish evil and negative energies.
Adherents of Santeria also believe in the power of
consecrated objects such as stones (otanes) in which
the orishas reside. Necklaces, bracelets, and charms
may be given by santeros to their patients to protect
them from evil and strengthen their well-being.
Sacrifice, or ebo (pronounced “egbo” or “igbo”), is
a central ritual in Santeria. The main purpose of ebo
is to establish communication between the spirits and
human beings. The initiation of a santero involves the
sacrifice of a four-legged animal and a series of rites
lasting 7 days. Transition through major life events
such as birth, death, and marriage requires ritual sac-
rifices to appease the gods and solicit their support.
Sacrificial objects in Santeria include plants, foods,
and animals. Plants and foods include plantains,
malanga, yam, okra, flour, gourds, and ground black-
eyed peas wrapped in plantain leaves. Animals used
for sacrifice, such as hens, birds, lambs, or goats, are
killed by wringing the head or severing the carotid ar-
teries with a knife. The animal’s blood is offered as a
type of communion with the deities. In 1993, the
Supreme Court struck down anti–animal sacrifice
laws in Hialeah, Florida, and recognized the right of
a Santeria sanctuary, the Church of Chango Eyife, to
offer an animal sacrifice as a religious sacrament
(Gonzalez, 1995).
Santeria, viewed as a link to the past, is used among
Cubans and other Hispanic groups to cope with phys-
ical and emotional problems. When someone is sick,
that person’s physical complaints may be diagnosed
and treated by a physician, but the santero may be
summoned to assist in balancing and neutralizing the
208 Aggregate Data for Cultural-Specific Groups
❙❙◗ Table 11-1 Seven African Powers or Main Orishas
Orisha Christian Saint Function/Power Punishment Propitiation
Eleggua Holy Child of Atocha Guardian of entrances, Blindness, paralysis, and Blood of goats; black rooster ;
roads, and paths; Trickster birth deformities smoked fish; smoked junia; yams;
sugar cane
Obatala Our Lady of Mercy Father of all human Death, suicide by fire White pigeons; white canaries;
beings; gives advice; is female goat; plums; yam puree
source of energy,
wisdom, purity, and
peace
Chango Saint Barbara Warrior deity; controls Abdominal distress, Roosters; goats; lambs; apples;
thunder and violent social and domestic bananas
storms, lightning, and fire strife
Oshun Our Lady of Charity Deity that controls Respiratory distress Female goat; white chickens;
money and love, makes sheep; honey
marriages, protects
genitals
Yemaya Our Lady of Regla Primary mother of the Leprosy, gangrene, skin Ducks; lambs; female goats;
santos, protects diseases watermelons; black-eyed peas
womanhood, owns seas
Babaluaye Saint Lazarus Patron of the sick, Violent death (such Spotted rooster ; snakes; cigars;
especially diseases of as an automobile pennies; glasses of water
the skin accident)
Ogun Saint Peter Warrior deity, owns all Blood and feathers; young bulls;
metals and weapons roosters; steel knife; railroad
tracks
Source: Adapted from Martinez, R., & Wetli, C. (1982). Santeria: A magicoreligious system of Afro-Cuban origin.
American Journal of Social Psychiatry, 2(3), 34, with permission.
2780_Ch11_197-213 16/07/12 11:46 AM Page 208

various aspects of the illness. Santeria is actively prac-
ticed in Miami, New York, New Jersey, and California
where Cubans and Haitians reside.
In eliciting a complete history from patients, health-
care providers must include information regarding the
type of religion being practiced, if any. Patients’ reli-
gious beliefs and practices must be viewed in an open,
sincere, and nonjudgmental manner. In the hospital
setting, maintenance of privacy is important if pa-
tients and families need to perform certain rituals or
prayers. A visit from a priest, rabbi, or santero may
provide a sense of psychological support and spiritual
well-being. At times, santeros have been known to
make sacrificial offerings at the patient’s hospital bed-
side. As long as standards of safety and sanitation
are maintained, families must be allowed space
and privacy to be able to engage in specific religious
ceremonies .
In Cuba today, 4 decades of Fidel Castro’s revolu-
tion have significantly affected religious beliefs and
practices. Only about 30 to 40 percent of Cubans are
Catholic, whereas Santeria has about 55 to 60 percent
adherents. The multiple groups that follow syncretic
Santeria practices include Abakua, Yoruba, Regla
Conga, Regla Ocha, Regla Arara, Regla Arada, and
Yebbe. Thus, compared with their peers from previous
migration waves, recent Cuban immigrants may be
less likely to be Catholic. Further, large numbers of
Cubans consider themselves adherents of Catholicism
and Santeria simultaneously (Ramos, 2002).
Meaning of Life and Individual Sources
of Strength
As in other Latin American communities, the family
is the most important source of strength, identity,
and emotional security. Cubans usually rely on a
network of family members and relatives for assis-
tance in times of need. The sense of specialness
Cubans feel, stemming from pride in their culture
and their remarkable success in adapting to their
new country, is, likewise, a source of self-esteem and
self-identity. For many Cubans, deeply held religious
beliefs have provided guidance and strength during
the long and difficult process of migration and
adaptation and continue to play an important role
in their day-to-day lives.
Spiritual Beliefs and Health-Care Practices
Many Cubans tend to be fatalistic, feeling that they
lack control over circumstances influencing their lives.
The belief in a higher power is evident in a variety of
practices—such as using magical herbs, special
prayers or chants, ritual cleansing, and sacrificial
offerings—that Cubans may engage in for the purpose
of maintaining health and well-being or curing illness.
When Cuban patients consult health-care providers,
in all likelihood they have already tried some folk
remedies advised by older women in their family or
obtained from a botanica. Most folk remedies are
harmless and do not interfere with biomedical treat-
ment. In most cases, patients may be encouraged to
continue using these remedies, such as herbal teas.
Encourage patients to report the use of specific teas
and herbs. For example, chamomile tea may increase
bleeding time, while jaborandi may decrease bleeding
time. Other teas and herbs may increase or decrease
glucose metabolism. Health-care providers should be
alert to the frequent practice of sharing prescription
medications in families and among relatives. A family
member who found an antibiotic effective in curing an
ailment may share the medication with another rela-
tive suffering from the same symptoms. The health
history must always include assessment of past or
present medication use, whether traditional, over-the-
counter, or prescription. Appropriate explanations
must be given regarding the actions and adverse
effects of drugs and the reasons why they cannot be
shared with other family members.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
As in other Latin American societies, Cubans rely on
the family as the primary source of health advice. Typ-
ically, the older women in the family are sought out
for information, such as traditional home remedies for
common ailments. Herbal teas or mixtures may be
prepared to relieve mild or moderate symptoms. Con-
currently or alternatively, a santero may be consulted,
or a trip to the botanica may be warranted to obtain
treatment.
Socialized into a strong health ideology and suc-
cessful primary-care system in Cuba, Cubans are able
to use biomedical services as primary or secondary
sources of care. Cuba has a regionalized, hierarchi-
cally organized, national health system that provides
universal coverage and standardization of services. An
innovative family practice program assigns physicians
and nurses to city blocks and remote communities to
promote physical fitness, detect risk factors for disease,
and cure disease. In the United States, many Cuban
clinics have evolved into health maintenance organi-
zations (HMOs).
Responsibility for Health Care
Most Cuban Americans access the health-care system
for preventive care and health screenings. Cubans
with a more recent history of immigration to the
United States are accustomed to preventive health ac-
tivities as part of the Cuban governmental services
under Castro. Practices for healthy living, including
avoiding stress and bad news and avoiding extremes
of hot and cold, are important for health mainte-
nance. Most take full advantage of vaccinations.
People of Cuban Heritage 209
2780_Ch11_197-213 16/07/12 11:46 AM Page 209

Folk and Traditional Practices
Cubans may use traditional medicinal plants in the
form of teas, potions, salves, or poultices. As noted
above, in Cuban communities like Little Havana in
Miami, stores called botanicas sell a variety of herbs,
ointments, oils, powders, incenses, and religious fig-
urines to relieve maladies, bring luck, drive away evil
spirits, or break curses. In addition, Santeria necklaces
and animals used for ritual sacrifice are available at
botanicas (Fig. 11-1).
Herbal teas that may be used to treat common ail-
ments include the following:
Cosimiento de anis (anise): to relieve stomachaches,
flatulence, and baby colic; also to calm nerves.
Cosimiento de limon con miel de abeja (lemon
and honey): to relieve cough and respiratory
congestion.
Cosimiento de apasote (pumpkin seed): to treat
gastrointestinal worms.
Cosimiento de canela (cinnamon): to relieve cough,
respiratory congestion, and menstrual cramps.
Cosimiento de manzanilla (chamomile): to relieve
stomachaches.
Cosimiento de naranja agria (sour orange): to relieve
cough and respiratory congestion.
Cosimiento de savila (aloe vera): to relieve
stomachaches.
Cosimiento de tilo (linden leaves): to calm nerves.
Cosimiento de yerba buena (spearmint leaves): to
relieve stomachaches and calm nerves.
Chamomile tea: to calm nerves and calm babies
with colic.
Fruits and vegetables, abundant in the natural
tropical environment of Cuba, may include the
following:
Chayote (vegetable): to calm nerves.
Zanaoria (carrots): to help problems with vision.
Toronja y ajo (grapefruit and garlic): to lower blood
pressure.
Papaya y toronja y pina (papaya, grapefruit,
and pineapple): to eliminate gastrointestinal
parasites.
Remolacha (beets): to treat influenza and anemia.
Cascara de mandarina (fruit): to relieve cough.
Other home remedies may include the following:
Agua con sal (salt water): to relieve sore throat.
Agua de coco (coconut water): to relieve kidney
problems and infections.
Agua raja (turpentine): to relieve pain in sore mus-
cles and joints.
Bicarbonato, limon, y agua (baking soda, lemon,
and water): to relieve stomach upset or
heartburn.
Cebo de carnero (fat of lamb): to treat contusions
and swelling; applied directly on the skin.
Mantequilla (butter): to soothe pain; applied directly
on burns.
Clara de huevos (egg white): to promote hair growth;
applied directly over scalp.
Cuban families may use an azabache, la manito de
coral, or ojitos de Santa Lucia for various protective
purposes. The azabache is a black stone placed on in-
fants and children as a bracelet or pin to protect them
from the evil eye. La manito de coral, symbolic of the
hand of God protecting a person, may also be worn
as a necklace or bracelet. Los ojitos de Santa Lucia, or
the eyes of Saint Lucy, may be hung on a bracelet or
necklace for prevention of blindness and protection
from the evil eye.
Barriers to Health Care
Poverty and lack of financial resources may be a bar-
rier to health care for Cuban families. Other barriers
include language, time lag, and transportation,
especially if they do not live in an urban environ-
ment. Others indicate that the red tape and paper-
work required by health-care facilities are deterrents
to accessing care, especially preventive care and
health wellness checkups. For some, overdependence
on family and folk practices may also be a barrier to
accessing care.
210 Aggregate Data for Cultural-Specific Groups
Figure 11-1 In Cuban communities, botanicas such as this
one sell herbs, ointments, oils, powders, incenses, and religious
figurines to relieve maladies, bring luck, or drive away evil
spirits.
2780_Ch11_197-213 16/07/12 11:46 AM Page 210

Cultural Responses to Health and Illness
Because of the many losses they experienced in leaving
their homeland and the difficulties associated with
adaptation to a new culture and environment, Cuban
immigrants may suffer from loneliness, depression,
anger, anxiety, insecurity, and health problems. In
evaluating Cuban families, Bernal (1994) suggested
that health-care providers assess the following:
1. Migration phase associated with the family. It is
important to know how long the family has lived
in the United States and the reasons for migration.
Information about political and social pressures
that prompted the move should be elicited. Because
family members acculturate at different rates, the
level of acculturation should also be determined.
2. Degree of connectedness to the culture of origin.
Conflicts in value orientations must be identified
when assessing Cuban families. For example, the
varying expectations between mainstream Ameri-
can and Cuban cultures with respect to depend-
ence and independence may give rise to tension
and conflict.
3. Differentiation between stresses of migration, dif-
ferences in cultural values, and family developmen-
tal conflicts. In a clinical situation, health-care
providers must be able to recognize whether the
patients’ responses are due to migration-related
problems, value orientation conflicts, or dysfunc-
tional family development.
Among Cuban Americans, dependency is a cultur-
ally acceptable sick role. Sick family members are
showered with attention and support. Frequently, a
hospitalized Cuban patient will have a room full of
flower arrangements and visitors. Favorite dishes may
be brought to the hospital from home. The extended
family network is relied on to temporarily assume the
household chores and other tasks usually performed
by the sick person. Family members are consulted and
typically participate in decision making relative to the
patient’s treatment.
Cuban Americans tend to seek help in response to
crisis situations. The experience of pain constitutes a
signal of a physical disturbance that warrants consul-
tation with a traditional or a biomedical healer. Sim-
ilar to other Hispanic patients, Cuban Americans tend
to express their pain and discomfort. Verbal com-
plaints, moaning, crying, and groaning are culturally
appropriate ways of dealing with pain. The expression
of pain itself may serve a pain-relieving function and
may not necessarily signify a need for administration
of pain medication.
African Cubans may seek biomedical care for or-
ganic diseases but consult a santero for spiritual or
emotional crises. Conditions such as decensos (faint-
ing spells) or barrenillos (obsessions) may be treated
solely by a santero or simultaneously with a physician.
The trance state achieved through Santeria enables the
patient to act out emotional problems in a manner
that is nonthreatening to the person’s self-esteem.
Blood Transfusions and Organ Donation
Receiving blood transfusions and organ donations is
usually acceptable for Cubans. This is probably due to
their experience with the sophisticated, high-technology
medical-care system in Cuba.
Health-Care Providers
Traditional Versus Biomedical Providers
As with many other cultural groups, Cubans use
both traditional and biomedical care. Initially, folk
remedies may be used at home to treat an ailment or
illness. If the condition persists, folk practitioners
such as santeros and biomedical practitioners may
be used either simultaneously or successively. When
seeing Cuban patients, health-care providers must
always ask about the use of folk remedies and con-
sultations with folk practitioners to prevent conflicting
therapeutic regimens.
Although Santeria was once associated with the
lower, uneducated classes in Cuba, it has emerged as
a viable and dynamic religious and health system
among middle-class Cubans in the United States. The
santero may prescribe treatment or perform the appro-
priate rituals or ceremonies to enable ill people to re-
cover. The santero may invoke various types of
supernatural deities to intervene in their lives and
make them well. Often, the santero is seen simultane-
ously with allopathic practitioners, sometimes without
the knowledge of the other one.
People of Cuban Heritage 211
R E F L E C T I V E E X E R C I S E 1 1 . 4
Consuegro Luna is a retired 72-year-old Cuban American. She
arrived in the United States in the early 1960s after Castro’s
Cuban Revolution. Her entire family lives in Miami, and she has
no family connections in Cuba. However, she has deep emo-
tional roots to her beloved island. Lately, she has become de-
pressed because she is afraid she will die without ever seeing
Cuba again. She sees her primary physician, but apparently is
not adherent to the therapy.
1. What would be her primary physician’s best approach
for Mrs. Luna?
2. Based on her Cuban cultural background, how would
you involve Mrs. Luna’s family in her treatment?
3. Besides her nutrition and prescribed/over-the-counter
medications, what other information could be relevant
for the treatment of Mrs. Luna?
2780_Ch11_197-213 16/07/12 11:46 AM Page 211

Many Cubans consult a family physician for primary
care. Before the revolution, Cuba had an organized,
government-supported health program that provided
medical care to most citizens. Since the 1959 revolution,
the Cuban government has articulated a fundamental
principle that health care is a right of all and a respon-
sibility of the state. Thus, a national health-care system
provides universal coverage, equitable geographic dis-
tribution of health-care facilities, and standardization
of health services.
Cuban families in Miami gained access to pri-
mary health-care services predominantly through
private health practitioners and private clinics,
whereas in Union City, the main sources of health
care were private health practitioners. An extensive
network of privately owned and operated health
clinics exist in Dade County, mainly located in
Miami’s Cuban ethnic enclaves: Little Havana and
Hialeah. The private health clinics are believed to be
popular among the Cubans because they provide
services that are culturally sensitive to Cuban needs,
such as emphasis on the family, use of the Spanish
language, focus on preventive health-care behaviors,
and low cost.
Status of Health-Care Providers
Although Hispanics, including Cubans, represent
13 percent of the U.S. population, they are seriously
underrepresented in the health occupations. In the
National Sample Survey of Registered Nurses (RNs)
(U.S. Department of Health and Human Services,
2008), of over 3 million registered nurses, only 3.6 per-
cent are Hispanic. Cubans generally have respect for all
health professionals, including nurses. Respect and trust
are increased if the nurse know some Spanish.
R E F E R E N C E S
Batista, C. (December 20, 2010) Cubans are skeptic from speech of
Castro. Retrieved from http://www.elnuevoherald.com/2010/
12/19/856593/cubanos-escepticos-ante-discurso.html
Bernal, G. (1994). Cuban families. In M. Uriarte-Gaston & J. Canas-
Martinez (Eds.). Cubans in the United States (pp. 135–156).
Boston: Center for the Study of the Cuban Community.
Black, S.A., & Markides, K.S. (1994). Aging and generational pat-
terns of alcohol consumption among Mexican Americans,
Cuban Americans and mainland Puerto Ricans. International
Aging and Human Development, 39(2), 97–103.
Blank, R., & Slipp, S. (1994). Voices of diversity (pp. 63–64).
New York: American Management Association.
Boswell, T.D. (2002). A demographic profile of Cuban Americans.
Miami, FL: Cuban American National Council.
Centers for Disease Control and Prevention. (2006). Hypertension-
related mortality among Hispanic subpoopulations—United States,
1995–2002. MMWR Morbidity and Mortality Weekly Report,
55(7), 177–180.
Centers for Disease Control and Prevention. (2011). Smoking and
tobacco use. Retrieved from http://www.cdc.gov/search.do?
queryText=smoking+cuban+hispanic&action=search&search-
Button.x=15&searchButton.y=4
CIA World FactBook. (2011). Retrieved from https://www.cia.gov/
library/publications/the-world-factbook/geos/cu.html
Conde, Y.M. (1999). Operation Pedro Pan: The untold exodus of
14,048 Cuban children. New York: Routledge.
Cultural Orientation Resource Center. (2002). The Cubans: Their his-
tory and culture. Retrieved from http://www.culturalorientation.
net.cubans/index.htm
Devieux, J.G., Malow, R.M., Ergon-Perez, E., Samuels, D., Rojas, P.,
Kushal, S.R., & Jean-Gilles, M. (2005). Research findings—
Research on behavioral and combined treatments for drug abuse.
Journal of Social Work Practices in Addiction, 2(1), 69–83.
Gallagher, P.L. (1980). The Cuban exile: A socio-political analysis.
New York: Arno Press.
Gonzalez, A.M. (1995, June 11). Santeria still shrouded in secrecy.
The Miami Herald, pp. 1B–5B.
Kittler, P., & Sucher, K. (2008). Food and culture in America
(3rd ed.). Belmont, CA: Wadsworth Publishing Co.
Lopez, L.M., & Masse, B.R. (1993). Income, body fatness, and fat
patterns in Hispanic women from the Hispanic Health and
Nutrition Examination Survey. Health Care for Women Inter-
national, 14, 117–128.
Martinez, I L. (2002). The elder in the Cuban family. Making
sense of the real and ideal. Journal of Comparative Family
Studies, 33(3), 359–375.
Martinez, R., & Wetli, C. (1982). Santeria: A magico-religious sys-
tem of Afro-Cuban origin. The American Journal of Social
Psychiatry, 2(3), 496–503.
Nath, S.D. (2005). Coronary heart disease risk factors among
Cuban Americans. Ethnicity and Disease, 15, 607–614.
National Council of la Raza. (2011) Retrieved from http://www.
nclr.org/
Perez, L. (2002). Cuban families in the United States. In R.L. Taylor
(Ed.), Minority families in the United States: A multicultural per-
spective (pp. 95–112). Englewood Cliffs, NJ: Prentice Hall.
Perez y Pena, A. (1998). Cuban Santeria, Haitian Vodun, Puerto
Rican spiritualism: A multiculturalist inquiry into syncretism.
Journal for the Scientific Study of Religion, 37(1), 15–27.
Pew Hispanic Center. (2006). Cubans in the United States.
Retrieved from http://pewhispanic.org/files/factsheets/23
Portes, A., & Bach, R.L. (1985). Latin journey: Cuban and Mexican
immigrants in the United States. Berkeley: University of
California Press.
Ramos, M.A. (2002). Religion and religiosity in Cuba: Past, pres-
ent, and future. Cuba Occasional Paper Series. Washington,
DC: Trinity College.
Sandoval, M. (1979). Santeria as a mental health care system: An
historical overview. Social Science and Medicine, 13, 137–151.
Skaine, R. (2004). The Cuban family. Custom and change in an
era of hardship. Jefferson, NC: McFarland & Co.
Solis, J.M., Marks, G., Garcia, M., & Shelton, D. (1990). Accultur-
ation, access to care, and use of preventive services by Hispanics:
Findings from HHANES 1982–84. American Journal of Public
Health, 80(Suppl.), 11–19.
Stroup-Benham, C.A., & Trevino, F.M. (1991). Reproductive char-
acteristics of Mexican-American, mainland Puerto Rican, and
Cuban-American women. Journal of the American Medical
Association, 265(2), 222–226.
Suarez, Z.E. (1993). Cuban Americans. From golden exiles to so-
cial undesirables. In H.P. McAdoo (Ed.), Family ethnicity:
Strength in diversity (pp. 164–176). Newbury Park, CA: Sage
Publications.
212 Aggregate Data for Cultural-Specific Groups
2780_Ch11_197-213 16/07/12 11:46 AM Page 212

Szapocznik, J., & Hernandez, R. (1988). The Cuban American
family. In C.H. Mindel, R.W. Habenstein, & R. Wright (Eds.),
Ethnic families in America (3rd ed., pp. 160–172). New York:
Elsevier.
Thomas, J.T., & DeSantis, L. (1995). Feeding and weaning prac-
tices of Cuban and Haitian immigrant mothers. Journal of
Transcultural Nursing, 6(2), 34–42.
U.S. Census Bureau. (2010). Hispanic or Latino origin by specific
origin. Retrieved from http://factfinder.census.gov/servlet/
DTTable?_bm=y&-geo_id=01000US&-ds_name=ACS_2009_
5YR_G00_&-mt_name=ACS_2009_5YR_G2000_B03001
U.S. Department of Health and Human Services. (2008). The reg-
istered nurse population: National sample survey of registered
nurses. Washington, DC: U.S. Government Printing Office.
U.S. Immigration and Naturalization Service. (2000). Immigrants,
fiscal year 2000. In Statistical yearbook of the INS (pp. 1–67).
Varela, L. (2005). Cubans. In J. Lipson & S.L. Dibble (Eds.), Culture
and clinical care (2nd ed., pp. 121–131).
For reflective exercises, review questions, and additional
information, go to
http://davisplus.fadavis.com
People of Cuban Heritage 213
2780_Ch11_197-213 16/07/12 11:46 AM Page 213

214
Chapter 12
People of European American
Heritage
Larry D. Purnell
This chapter presents the dominant European
American cultural values, practices, and beliefs. The
European American culture is a blended culture re-
sulting from early immigrants in the United States,
primarily Caucasians from Europe, who adapted to
and adopted one another’s cultures and, over time,
have formed their own distinct, new cultures. Many
other groups have assimilated and now self-identify
with the European American culture as well. Al-
though Canada and Mexico are part of North
America, American, as used in this chapter, refers to
the dominant middle-class values of citizens of
mainland United States, and the term European
American is shortened to American. Due to space
limitations, this chapter deals not with the objective
culture—arts, literature, humanities, and so on—but
rather with the subjective culture. Many Americans
are not aware of the subjective culture because they
identify differences as individual personality traits
and disregard political and social origins of culture.
Many view culture as something that belongs only
to foreigners or disadvantaged groups, although this
is not unique to Americans. When Americans travel
abroad, many times their host country inhabitants
stereotypically identify them as Americans because
of their values, beliefs, attitudes, behaviors, speech
patterns, and mannerisms. Some feel that Americans
are “fun lovers” and that, for some Americans, vio-
lence is a way of life. This may be due to the fact that
American media coverage may be better than other
countries, thereby giving the impression that the
United States is more violent than it actually is. Ac-
cordingly, these stereotypes are not always accurate.
However, “the right to bear arms” is guaranteed by
the Constitution. Most likely, the United States is
not any more violent than, or even as violent as,
many other societies.
Overview, Inhabited Localities,
and Topography
Overview
For most Americans, dominant cultural values and
beliefs include individualism, free speech, rights of
choice, independence and self-reliance, confidence,
“doing” rather than “being,” egalitarian relationships,
nonhierarchical status of individuals, achievement sta-
tus over ascribed status, “volunteerism,” friendliness,
openness, futuristic temporality, ability to control the
environment, and an emphasis on material things and
physical comfort.
Given the size, population density, and diversity of
the United States, one cannot generalize too much
about American culture. Every generalization in this
chapter is subject to exceptions, although most people
will agree with the descriptions to some degree and on
some level. Moreover, the descriptions about the dom-
inant American culture are aggregate data for white
middle-class European Americans who hold the ma-
jority of prestigious positions in the United States.
The degree to which people conform to or agree with
the European American culture depends on their vari-
ant cultural characteristics as discussed in Chapter 1,
as well as individual personality differences. Many for-
eigners believe that all Americans are rich, everyone
lives in fancy apartments or houses, crime is rampant,
everyone drives expensive gasoline-inefficient cars, and
there is little or no poverty. For the most part, these
misconceptions come from the media and Americans
who travel overseas.
Heritage and Residence
The United States comprises 3.5 million square miles
and a population of 308,745,538 people, making it the
world’s third most populous country (U.S. Census
2780_Ch12_214-227 16/07/12 11:46 AM Page 214

Bureau, 2010). The United States is mostly temperate
but tropical in Hawaii and Florida, arctic in Alaska,
semiarid in the Great Plains west of the Mississippi
River, and arid in the Great Basin of the southwest.
Low winter temperatures in the northwest are amelio-
rated in January and February by warm Chinook winds
from the eastern slopes of the Rocky Mountains. There
is a vast central plain; mountains in the west; hills and
low mountains in the east; rugged mountains and
broad river valleys in Alaska; and rugged, volcanic to-
pography in Hawaii (CIA World Factbook, 2011).
When Europeans began settling the United States in
the 16th century, approximately 2 million American In-
dians, who mostly lived in geographically isolated tribes,
populated the land. The first permanent European
settlement in the United States was St. Augustine,
Florida, which was settled by the Spanish in 1565. The
first English settlement was Jamestown, Virginia, in
1607 (Information Please Almanac, 2009). By 1610, the
nonnative population in the United States amounted
to 350 people. By 1700, the population increased
to 250,900; by 1800, to 5.3 million; and by 1900, to
75.9 million (Information Please Almanac: United States,
2009). From 1607 until 1890, most immigrants to the
United States came from Europe and essentially shared
a common European culture. Britain’s American
colonies broke with the mother country in 1776 and
were recognized as the new nation of the United States
of America following the Treaty of Paris in 1783.
During the 19th and 20th centuries, 37 new states
were added to the original 13 as the nation expanded
across the North American continent and acquired a
number of overseas possessions. The two most trau-
matic experiences in the nation’s history were the Civil
War (1861–1865), in which a northern Union of states
defeated a secessionist Confederacy of 11 southern slave
states, and the Great Depression of the 1930s, an eco-
nomic downturn during which about a quarter of the
labor force lost its jobs. Buoyed by victories in World
Wars I and II and the end of the Cold War in 1991, the
United States remains the world’s most powerful nation
state. Over a span of more than 5 decades, the economy
has achieved steady growth, low unemployment and in-
flation, and rapid advances in technology (CIA World
Factbook, 2011)
The Constitution of the United States was ratified
in 1789 and included seven articles, which laid the foun-
dation for an independent nation. The Bill of Rights,
the first 10 amendments to the Constitution, guarantees
freedom of religion, speech, and the press; the right to
petition; the right to bear arms; and the right to a
speedy trial. Only 17 additional amendments have been
made to the Constitution. The 13th Amendment in
1865 prohibited slavery; the 14th Amendment in 1868
defined citizenship and privileges of citizens; the 15th
Amendment in 1870 gave suffrage rights regardless of
race or color; and the 19th Amendment in 1920 gave
women the right to vote.
The United States is the world’s oldest constitutional
democracy with three branches of government: the ex-
ecutive branch, which includes the Office of the Presi-
dent and the administrative departments; the legislative
branch, Congress, which includes both the Senate and
the House of Representatives; and the judicial branch,
which includes the Supreme Court and the lesser federal
courts. The Supreme Court has nine members ap-
pointed by the president and approved by Congress. The
justices serve a life term if they so choose. The president
serves a 4-year term and can be reelected only one time.
The president is the commander in chief of the armed
forces and oversees the executive departments. The
members of the House of Representatives are divided
among the states based on the population of each state.
Members of the House of Representatives serve 2-year
terms. Each state has two senators, regardless of the
population of the state. Senators serve 6-year terms.
Each of the 50 states has its own constitution establish-
ing, for the most part, a parallel structure to the federal
government, with the executive branch headed by a gov-
ernor, a state congress with representatives and senators,
and a state court system.
No limitations were placed on immigrants from
Europe until the late 1800s. From 1892 to 1952, most
European immigrants to America came through Ellis
Island, New York, where they had to prove to officials
that they were financially independent. More severe
restrictions were placed on other immigrant groups,
particularly those from Asia. In the 1960s, immigra-
tion policy changed to allow immigrants from all parts
of the world without favoritism to or restrictions
on ethnicity. Today, the United States includes immi-
grants or descendants from immigrants from almost
every nation and culture of the world and is the world’s
premier international nation. The United States admit-
ted over 62,000 refugees during fiscal year 2004–2005,
including more than 10,000 from Somalia, over 8500
from Laos, over 6600 from Russia, 6500 from Cuba, and
3100 from Haiti (CIA World Factbook, 2011).
The United States has the largest and most techno-
logically powerful economy in the world, with a per
capita gross domestic product (GDP) of $41,061 (U.S.
Census Bureau, 2011). In this market-oriented econ-
omy, private individuals and business firms make most
of the decisions, and the federal and state govern-
ments buy needed goods and services predominantly
in the private marketplace. U.S. firms are at or near
the forefront in technological advances, especially in
computer technology and in medical, aerospace, and
military equipment; their advantage has narrowed
since the end of World War II. The on-rush of tech-
nology largely explains the gradual development of a
“two-tier labor market,” in which those at the bottom
People of European American Heritage 215
2780_Ch12_214-227 16/07/12 11:46 AM Page 215

lack the education and the professional/technical skills
of those at the top and, more and more, fail to get
comparable pay raises, health insurance coverage, and
other benefits. People have been attracted to the
United States because of its vast resources and eco-
nomic and personal freedoms, particularly the dogma
that “all men are created equal.” Immigrants and their
descendants achieved enormous material success,
which further encouraged immigration.
Reasons for Migration and Associated
Economic Factors
The United States has a very large middle-class pop-
ulation and a small, but growing, wealthy population.
Approximately 13.4 percent of the population lives in
poverty, with higher rates among children, older per-
sons, blacks, and nonwhite Hispanics (U.S. Census
Bureau, 2010).
The earlier settlers in the United States came for
better economic opportunities because of religious
and political oppression; environmental disasters,
such as earthquakes and hurricanes in their home
countries; and by forced relocation, such as with slaves
and indentured servants. Others have immigrated for
educational opportunities and personal ideologies or
a combination of factors. Most people immigrate in
the hope of a better life; however, the individual or
group personally defines this ideology.
Educational Status and Occupations
In the United States, preparation in elementary and sec-
ondary education varies widely. There is no national
curriculum that each school is expected to follow, al-
though there is standardized testing at a national level,
which is used in the selection process for admission to
institutions of higher education. Most states require
children to attend school until the age of 16, although
the child can drop out of school at a younger age with
parents’ signed permission. Overall, the United States
has the goal of producing a well-rounded individual
with a variety of courses and 100 percent literacy.
Theoretically, people have the freedom to choose a pro-
fession, regardless of gender and background. The
American educational system stresses application of
content over theory. The United States’ dominant sys-
tem places a high value on the student’s ability to cate-
gorize information using linear, sequential thought
processes, which is common in individualistic cultures.
Communication
Dominant Language and Dialects
Over 82 percent of the U.S. population speaks English
(CIA World Factbook, 2011), mostly American English,
which differs somewhat in its pronunciation, spelling,
and choice of words from English spoken in Great
Britain, Australia, and other English-speaking countries.
Within the United States, several dialects exist, but
generally the differences do not cause a major concern
with communications. Aside from people with foreign
accents, in certain areas of the United States, people
speak with a dialect; these include the South and
Northeast, in addition to local dialects such as
“Elizabethan English” and “western drawl.” In such
cases, dialects that vary widely may pose substantial
problems for health-care providers and interpreters in
performing health assessments and in obtaining accu-
rate health data, in turn increasing the difficulty of
making accurate diagnoses.
American English is a monochromic, low-contextual
language in which most of the message is in the verbal
mode, and verbal communication is frequently seen as
being more important than nonverbal communication.
Other common languages spoken in the United States
include Spanish (10 percent), other Indo-European lan-
guages (3.8 percent), Asian and Pacific Islander lan-
guages (2.7 percent), and other (0.7 percent) (CIA World
Factbook, 2011). In addition, the speed at which people
speak varies by region; for example, in parts of Ap-
palachia and the South, people speak more slowly than
do people in the northeastern part of the United States.
Americans may be perceived as being loud and boister-
ous because their volume carries to those nearby.
Cultural Communication Patterns
Many Americans are willing to disclose very personal
information about themselves, including information
about sex, drugs, and family problems. In fact, per-
sonal sharing is encouraged in a wide variety of topics,
but not religion. In the United States, having well-
developed verbal skills is seen as important.
For the most part, America is a low-touch society,
which has recently been reinforced by sexual harass-
ment guidelines and policies. For many, even casual
touching may be seen as a sexual overture and should
be avoided whenever possible until people get to know
each other. People of the same sex (especially men) or
opposite sex do not generally touch each other unless
they are close friends.
American conversants tend to place at least 18 inches
of space between themselves and the person with whom
they are talking. Clients may interpret American health-
care providers as being cold because they stand so far
away. An understanding of personal space and distanc-
ing characteristics can enhance the quality of commu-
nication among individuals.
Regardless of class or social standing of the con-
versants, Americans are expected to maintain direct
eye contact without staring. A person who does not
maintain eye contact may be perceived as not listen-
ing, not being trustworthy, not caring, or being less
than truthful.
216 Aggregate Data for Cultural-Specific Groups
2780_Ch12_214-227 16/07/12 11:46 AM Page 216

People of European American Heritage 217
Most Americans gesture moderately when conversing
and smile easily as a sign of pleasantness or happiness,
although one can smile as a sign of sarcasm. A lack of
gesturing can mean that the person is too stiff, too for-
mal, or too polite. However, when gesturing to make,
emphasize, or clarify a point, one should not raise one’s
elbows above the head unless saying hello or good-bye.
For American men and women in business, the prac-
tice is to extend the right hand with a firm handshake
when greeting someone for the first time. Confidence
and competence are associated with a relaxed posture.
Although many people consider it impolite or offensive
to point with one’s finger, many Americans do so, and
do not see it as impolite.
Temporal Relationships
The American culture is future oriented, and people
are encouraged to sacrifice for today and work to save
and invest in the future. The future is important in that
people can influence it. Americans generally see fatal-
ism, the belief that powers greater than humans are in
control, as negative; to many others, however, it is seen
as a fact of life not to be judged. However, for many,
temporality is balanced among past, present, and fu-
ture in the sense of respecting the past, valuing and
enjoying the present, and saving for the future.
Americans see time as a highly valued resource and
do not like to be delayed because it “wastes time.”
When visiting friends or meeting for strictly social en-
gagements, punctuality is less important, but one is still
expected to appear within a “reasonable” time frame.
In the health-care setting, if an appointment is made
for 8 a.m., the person is expected to be there at 7:45 a.m.
so she or he is ready for the appointment and does not
delay the health-care provider. Some organizations re-
fuse to see the patient if he or she is more than 15 to
30 minutes late for an appointment; a few charge a fee,
even though the patient was not seen, giving the impres-
sion that money is more important than the person.
Format for Names
The American name David Thomas Jones denotes a
man whose first name is David, middle name is
Thomas, and family surname is Jones. Friends
would call him by his first name, David. In the for-
mal setting, he would be called Mr. Jones. In addi-
tion, he could also have a nickname that would be
used by family and close friends—for example, Davy
from his first name or Tom or Tommy from his mid-
dle name. When women marry, they may drop their
maiden name and adopt their husband’s last name,
or they may keep both their maiden and husband’s
names. In this case, they may or may not hyphenate
it, as in Elizabeth Parker-Jones or Elizabeth Parker
Jones. Their children usually, but not always, take
the husband’s last name.
Family Roles and Organization
Head of Household and Gender Roles
Among Americans, it is acceptable for women to have
a career and for men to assist with child care, house-
hold domestic chores, and cooking responsibilities.
Both parents work in many families, necessitating
placing children in child-care facilities. In some fami-
lies, fathers are responsible for deciding when to seek
health care for family members, but mothers may have
significant influence on final decisions.
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
For most Americans, a child’s individual achievement
is valued over the family’s financial status. In many
middle- and upper-class American families, children
have their own room, television, and telephone, and
even their own computer. At younger ages, rather than
having group toys, each child has his or her own toys
and is taught to share them with others. Americans
encourage autonomy in children, and after completing
homework assignments (with which parents are ex-
pected to help), children are expected to contribute to
the family by doing chores, such as taking out the
garbage, washing dishes, cleaning their own room,
feeding and caring for pets, and helping with cooking.
They are not expected to help with heavy labor except
in rural farm communities.
Children are allowed and encouraged to make their
own choices, including managing their own allowance
money and deciding who their friends might be, al-
though parents may gently suggest one friend as a bet-
ter choice than another. American children and
teenagers are permitted and encouraged to have
friends of both the same and opposite genders. They
are expected to be well behaved, especially in public.
They are taught to stand in line—first come, first
served—and to wait their turn. As they reach the
teenage years, they are expected to refrain from pre-
marital sex, smoking, using recreational drugs, and
drinking alcohol until they leave the home. However,
this does not always occur, and teenage pregnancy and
use of recreational alcohol and drugs remain high.
When children become teenagers, most are expected
to get a job, such as babysitting, delivering newspa-
pers, or doing yard work to make their own spending
money, which they manage as a way of learning inde-
pendence. The teenage years are also seen as a time of
natural rebellion.
In American society, when young adults become
18 or complete their education, they usually move out
of their parents’ home (unless they are in college) and
live independently or share living arrangements with
nonfamily members. If the young adult chooses to
remain in the parents’ home, then she or he might be
2780_Ch12_214-227 16/07/12 11:46 AM Page 217

expected to pay room and board. However, young
adults are generally allowed to return home when they
are needed or for financial or other purposes. Individu-
als over the age of 18 are expected to be self-reliant and
independent, which are virtues in the American culture.
Adolescents have their own subculture, with its own
values, beliefs, and practices that may not be in
harmony with those of their parents’ wishes. Being in
harmony with peers and conforming to the prevalent
choice of music, clothing, hairstyles, and adornments
may be especially important to adolescents. Thus, role
conflicts can become considerable sources of family
strain in many more traditional families who may not
agree with the American values of individuality, inde-
pendence, self-assertion, and egalitarian relationships.
Many teens may experience a cultural dilemma with
exposure outside the home and family.
Family Goals and Priorities
American family goals and priorities are centered on
raising and educating children. During this stage in
the American culture, young adults make a personal
commitment to a spouse or significant other and seek
satisfaction through productivity in career, family, and
civic interests.
The median age at first marriage in the United States
has gradually increased over the last 10 years from
26.8 years to 27.7 years for men; for women, the me-
dian age of first marriage has gradually increased
from 25.1 years to 26 years (Information Please
Almanac, 2009). In 1900, the divorce rate was 0.7 per
year per 1000 marriages; this increased to 5.3 per year
by 1981 and has gradually declined since then to
3.6 per year per 1000 (Information Please Almanac,
2009). As for births, currently 39.7 percent of all births
are to unmarried women (Centers for Disease Control
and Prevention, 2007).
The United States has seen an explosion in its older
population during the 20th century, up from 3.1 million
in 1900 to over 39.5 million in 2009 being over the age
of 65 years (U.S. Census Bureau, 2009). The American
culture, which emphasizes youth, beauty, thinness, in-
dependence, and productivity, contributes to some so-
cietal views of the aged as less important members and
tends to minimize the problems of older people. A con-
trasting view among some emphasizes the importance
of older people in society.
Americans also place a high value on egalitarianism,
nonhierarchical relationships, and equal treatment
regardless of their race, color, religion, ethnicity, edu-
cational or economic status, sexual orientation, or
country of origin. However, these beliefs are theoretical
and not always seen in practice. For example, women
still have a lower status than men, especially when it
comes to prestigious positions and salaries. Most top-
level politicians and corporate executive officers
are white men. Subtle classism does exist, as evidenced
by comments referring to “working-class men and
women.” Despite the current inequities, Americans
value equal opportunities for all, and most would agree
that significant progress is being made.
Americans are known worldwide for their informality
and for treating everyone the same. They call people by
their first names very soon after meeting them, whether
in the workplace, in social situations, in classrooms, in
restaurants, or in places of business. Americans readily
talk with waitstaff and store clerks and call them by
their first names. Most Americans consider this respect-
ful behavior. Formality can be communicated by
using the person’s last (family) name and title such as
Mr., Mrs., Miss, Ms., or Dr. To this end, achieved status
is more important than ascribed status. What one has
accumulated in material possessions, where one went
to school, and one’s job position and title are more im-
portant than one’s family background and lineage.
However, in some families in the South and the North-
east, one’s ascribed status has equal importance to
achieved status. The United States does not have a caste
or class system, and theoretically, one can move readily
from one socioeconomic position to another. To many
Americans, if formality is maintained, it may be seen
as pompous or arrogant, and some even deride the per-
son who is very formal. However, formality is a sign of
respect and is valued by most older Americans.
Alternative Lifestyles
The American family is becoming a more varied com-
munity, including unmarried people, both women and
men, living alone; single people of the same or different
genders living together with or without children; single
parents with children; and blended families consisting
of two parents who have remarried, with children from
their previous marriages and additional children from
their current marriage.
The newest category of family, domestic partner-
ships, is sanctioned by many cities or counties in the
United States and grants some of the rights of tradi-
tional married couples to unmarried heterosexual,
homosexual, older people, and disabled couples who
share the traditional bond of the family. Some states
allow gay and lesbian couples to marry and to adopt
children. The last 10 years have seen many hotly de-
bated issues regarding same-sex marriages and civil
unions. Among more rural subcultures, same-sex cou-
ples living together may not be as accepted or recog-
nized in the community as they are in larger cities. As
gay parents have become more visible, lesbian and gay
parenting groups have started in many cities across the
United States to offer information, support, and guid-
ance, resulting in more lesbians and gay men consid-
ering parenthood through adoption and artificial
insemination. Some national groups that have links to
local and regional organizations are included on
DavisPlus.
218 Aggregate Data for Cultural-Specific Groups
2780_Ch12_214-227 16/07/12 11:46 AM Page 218

Workforce Issues
Culture in the Workplace
Americans are expected to be punctual on their jobs,
with formal meetings, and with appointments. If one
is more than a minute or two late, an apology is ex-
pected, and if one is late by more than 5 or 10 minutes,
a more elaborate apology is expected. When people
know they are going to be late for a meeting, the ex-
pectation is that they call or send a message indicating
that they will be late. The convener of the meeting or
teacher in a classroom is expected to start and stop on
time out of respect for the other people in attendance.
However, in social situations, a person can be 15 or
more minutes late, depending on the importance of
the gathering. In this instance, an apology is not really
necessary or expected; however, most Americans will
politely provide a reason for the tardiness.
The American workforce stresses efficiency (time is
money), operational procedures on how to get things
done, task accomplishment, and proactive problem
solving. Intuitive abilities and common sense are not
usually valued as much as technical abilities. The sci-
entific method is valued, and everything has to be
proven. Americans want to know why, not what, and
will search for a single factor that is the cause of the
problem and the reason why something is to be done
in a specific way. Many are obsessed with collecting
facts and figures before they make decisions. Pragma-
tism is valued. In the United States, everyone is ex-
pected to have a job description, meetings are to have
a predetermined agenda (although items can be added
at the beginning of the meeting), and the agenda is fol-
lowed throughout the meeting. Americans prefer to
vote on almost every item on an agenda, including ap-
proving the agenda itself. Everything is given a time
frame, and deadlines are expected to be respected. In
these situations, American values expect that the needs
of individuals are subservient to the needs of the
organization. However, with the postmodernist move-
ment, where there are no absolute truths and most
aspects of a person’s worldview are based on percep-
tions and social contexts, greater credibility and recog-
nition have been given to approaches other than the
scientific method.
Issues Related to Autonomy
Most Americans place a high value on “fairness” and
rely heavily on procedures and policies in the decision-
making process. However, Americans’ value for indi-
vidualism, in which the individual is seen as the most
important element in society, favors a person’s deci-
sion to further her or his own career over the needs or
wants of the employer. Therefore, individuals fre-
quently demonstrate little loyalty to the organization
and leave one position to take a position with another
company for a better opportunity or higher salary. In
organizations in which people generally conform be-
cause of the fear of failure, there is a hierarchical
order for decision making, and the person who suc-
ceeds is the one with strong verbal skills who conforms
to the hierarchy’s expectations. This person is well
liked and does not stand out too much from the crowd.
Frequently, others view as a threat the person with a
high level of competence and who stands out. Thus, to
be successful in the highly technical American work-
force, the individual must get the facts, control feelings,
have precise and technical communication skills, be in-
formal and direct, and clearly and explicitly state his
or her conclusions.
During workforce shortages, American health-care
facilities rely on emigrating nurses and physicians from
the Philippines, Canada, England, Ireland, India, and
other countries to supplement their numbers. Some
foreign nurses, such as British and Australian, cultur-
ally assimilate into the workforce more easily than oth-
ers but still have difficulty with defensive charting as is
required in the United States. In their socialized health-
care system, clients are not likely to initiate litigation
(Purnell & Galloway, 1995). Others may have difficulty
with the assertiveness expected from American nurses.
People of European American Heritage 219
R E F L E C T I V E E X E R C I S E 1 2 . 1
Bonnie Jackson, a European American Roman Catholic
age 42 years, was diagnosed with breast cancer 8 months
ago and had bilateral mastectomies. She underwent
chemotherapy and radiation therapy, but the cancer has
metastasized to her lungs, ribs, and brain. She has decided to
forgo additional allopathic medical treatments, but is open
to herbal therapies. Because of intense pain, she has been
admitted to a home hospice service. Bonnie has never been
married and currently lives with her life partner of 22 years,
Jeni Chambers, who has durable power of attorney for
health-care decision making.
On the intake home hospice assessment, the nurse asked
who was the next of kin and was told that it was Jeni. The
nurses then asked what blood relative would make decisions
about health care if she was unable to make decisions. Bonnie
again gave Jeni’s name and explained their relationship. The
nurse stated she was unsure if this was acceptable and would
ask her supervisor. Bonnie explained that both her parents
were deceased and that she was estranged from her two
older brothers and younger sister, at which point the nurse
responded, “I can understand why!”
1. What is the incidence of breast cancer among women in
the United States?
2. Is there a difference in breast cancer among different
racial and ethnic groups?
3. Is there a difference between breast cancer rates in
lesbians and heterosexual women?
Continued
2780_Ch12_214-227 16/07/12 11:46 AM Page 219

Biocultural Ecology
Skin Color and Other Biological Variations
The majority of European Americans are generally
fair-skinned, and thus prolonged exposure to the sun
places them at an increased risk for skin cancer. Oxy-
genation determination can easily be determined from
skin color as well as the nail beds.
Diseases and Health Conditions
In the United States, cardiovascular disease is the
leading killer of both men and women. Factors that
contribute to the development of cardiovascular dis-
ease include obesity, lack of physical activity, and
smoking. For white male Americans, the leading sites
for cancer include the prostate, lung, and colon. For
white female Americans, the most common sites in-
clude the breast, lung, and colon. Although these
same sites account for most cancers in other ethnic
and racial groups, the order of occurrence differs.
Almost 23.6 million Americans have been diagnosed
with diabetes mellitus (DM), and the disease is
undiagnosed in an additional 5.4 million people.
The prevalence of DM among whites is 7.8 percent
(Centers for Disease Control and Prevention, 2011).
The Centers for Disease Control and Prevention
(CDC) estimate that more than 1 million people
are living with HIV in the United States. One in five
(21 percent) of those people living with HIV is un-
aware of the infection. Despite increases in the total
number of people living with HIV in the United States
in recent years, the annual number of new HIV infec-
tions has remained relatively stable. However, the
level remains far too high, with an estimated 56,300
Americans becoming infected with HIV each year.
More than 18,000 people with AIDS still die each year
in the United States. Gay, bisexual, and other men
who have sex with men (MSM) are strongly affected
and represent the majority of persons who have died.
Through 2007, more than 576,000 people with AIDS
in the United States have died since the epidemic began
(Centers for Disease Control and Prevention, 2011).
Sexually transmitted infections (STIs) remain a
major public health challenge in the United States.
CDC’s surveillance report as of 2007, the latest data
available, includes data on the three STIs that physi-
cians are required to report to the agency—chlamydia,
gonorrhea, and syphilis—which represent only a
fraction of the true burden of STIs. Some common
STIs, such as human papillomavirus (HPV) and gen-
ital herpes, are not reported to CDC. In total, CDC
estimates that there are approximately 19 million new
STIs each year, which cost the U.S. health-care system
$16.4 billion annually and cost individuals even more
in terms of acute and long-term health consequences
(Centers for Disease Control and Prevention, 2011).
Despite the continued high burden of STIs, the lat-
est CDC data show some signs of progress:
1. The national gonorrhea rate is at the lowest level
ever recorded.
2. Continuing increases in chlamydia diagnoses
likely reflect expanded screening efforts and not
necessarily a true increase in disease burden.
3. For the first time in 5 years, reported syphilis
cases did not increase among women overall.
4. Likewise, cases of congenital syphilis (transmitted
from mother to infant) did not increase for the
first time in 4 years (Centers for Disease Control
and Prevention, 2011).
Illnesses and diseases with an increased incidence
in white ethnic groups in the United States include ap-
pendicitis, diverticular disease, cancer of the colon,
hemorrhoids, varicose veins, cystic fibrosis, rosacea,
osteoporosis and osteoarthritis, and phenylketonuria.
Since the late 1990s, every continent has had out-
breaks of new or reemerging diseases. North America
has had outbreaks of bubonic plague, campylobacte-
ria, cyclospora, salmonella, E. coli in spinach, and
Legionnaire’s disease. See the Appendix for illnesses
and diseases and their causes for specific ethnic and
cultural groups common in the United States.
Variations in Drug Metabolism
Information regarding drug metabolism among racial
and ethnic groups has important implications for
health-care practitioners when prescribing medica-
tions. Besides the effects of smoking, which accelerates
drug metabolism; malnutrition, which affects drug re-
sponse; a high-fat diet, which increases absorption of
antifungal medication, whereas a low-fat diet renders
the drug less effective; cultural attitudes and beliefs
220 Aggregate Data for Cultural-Specific Groups
4. What do you know about advance directives and
durable power of attorney in health-care decision
making? Can Jeni legally be the decision maker for
Bonnie?
5. What family support systems does Bonnie have?
6. Would you ask Jeni if her family is supportive of their
relationship?
7. What resources besides family might be available for
Bonnie and Jeni?
8. What is your response to Bonnie deciding to forgo
allopathic treatments but be willing to entertain herbal
therapies?
9. How do you feel about same-sex intimate partnerships?
What differences do you see between providing care to
patients with same-sex partnerships and to patients from
heterosexual partnerships?
10. If Bonnie and Jeni were to seek support from the
Catholic Church, how do you think church members
would respond? What is the Roman Catholic Church’s
view on same-sex intimate partner relationships?
2780_Ch12_214-227 16/07/12 11:46 AM Page 220

about taking medication; and stress, which affects cat-
echolamine and cortisol levels on drug metabolism,
studies have identified some specific alterations in drug
metabolism among diverse racial and ethnic groups
(Prows & Prows, 2004). The studies on drug metabo-
lism across ethnicity and race have used white ethnic
groups/race as the control. Thus, differences in drug
metabolism variations among whites are not reported.
Health-care providers need to investigate the literature
for ethnic-specific studies regarding variations in drug
metabolism, communicate these findings to other
colleagues, and educate their clients regarding these
side effects.
High-Risk Behaviors
The steady decline in smoking prevalence has been ob-
served nationally; however, in certain segments of the
population, incidence remains high, thus highlighting
the need for expanded interventions that can better
reach persons of low socioeconomic status and pop-
ulations living in poverty. In 2009, the latest figures
available, 20.6 percent of all adults (46.6 million
people) continue to smoke. In the United States, to-
bacco use is responsible for about one in five deaths
annually (i.e., about 443,000 deaths per year), and an
estimated 49,000 of these tobacco-related deaths are
the result of secondhand smoke exposure. On average,
smokers die 13 to 14 years earlier than nonsmokers;
the percentage varies by race and ethnicity, as
evidenced by the following statistics:
• 23.2 percent of American Indian/Alaska Native
adults
• 22.1 percent of white adults
• 21.3 percent of African American adults
• 14.5 percent of Hispanic adults
• 12 percent of Asian American adults (excluding
Native Hawaiians and other Pacific Islanders)
(Centers for Disease Control and Prevention, 2011)
Alcohol use is very common in the United States
and has immediate effects that can increase the risk of
many harmful health conditions. Excessive alcohol
use, either in the form of heavy drinking (drinking
more than two drinks per day on average for men or
more than one drink per day on average for women)
or binge drinking (drinking five or more drinks during
a single occasion for men or four or more drinks dur-
ing a single occasion for women), can lead to increased
risk of health problems, such as liver disease or unin-
tentional injuries.
According to the Behavioral Risk Factor Surveil-
lance System (BRFSS) survey, more than half of
the adult U.S. population drank alcohol in the past
30 days. Approximately 5 percent of the total popula-
tion drank heavily, whereas 15 percent of the popula-
tion binge drank. According to the Alcohol-Related
Disease Impact (ARDI) tool, from 2001 to 2005, there
were approximately 79,000 deaths annually attributable
to excessive alcohol use. In fact, excessive alcohol use
is the third leading lifestyle-related cause of death for
people in the United States each year (Centers for Dis-
ease Control and Prevention, 2011). The conclusion of
many studies suggests that alcohol-related violence is a
learned behavior, not an inevitable result of alcohol
consumption (Purnell & Foster, 2003a; 2003b).
Health-Care Practices
American society has become “obesogenic,” charac-
terized by environments that promote increased food
intake, nonhealthful foods, and physical inactivity.
Policy and environmental change initiatives that make
healthy choices in nutrition and physical activity avail-
able, affordable, and easy will likely prove most effec-
tive in combating obesity. The Division of Nutrition,
Physical Activity, and Obesity (DNPAO) is working
to reduce obesity and obesity-related conditions
through state programs, technical assistance and train-
ing, leadership, surveillance and research, intervention
development and evaluation, translation of practice-
based evidence and research findings, and partnership
development. Although the obesity rate appears to be
declining or (at least) leveling, obesity remains high
among adults and children (Centers for Disease Con-
trol and Prevention, 2011). Obesity is a complex issue
related to lifestyle, environment, and genes. Many un-
derlying factors have been linked to the increase in obe-
sity, such as increased portion sizes; eating out more
often; increased consumption of sugar-sweetened
drinks; increased television, computer, electronic gam-
ing time; changing labor markets; and fear of crime,
which prevents outdoor exercise. Health-care providers
can assist overweight clients in reducing calorie con-
sumption by identifying healthy choices among cul-
turally preferred foods, altering preparation practices,
and reducing portion size.
The practice of self-care using folk and magico-
religious practices before seeking professional care
may also have a negative impact on the health status
of some individuals. Overreliance on these practices
may mean that the health problem is in a more
advanced stage when a consultation is sought. Such
delays make treatment more difficult and prolonged.
People of European American Heritage 221
R E F L E C T I V E E X E R C I S E 1 2 . 2
Tammy Shorts, a 54-year-old patient care assistant, has worked
on the same acute-care teenage pediatric unit for 12 years.
She tells everyone that she loves her job and the teenagers.
The unit got a new male nurse manager, Mr. Galway, 2 years
ago. During that time, Mrs. Shorts has had six counseling
sessions for coming to work more than 10 minutes late and
leaving early. She insists that she still gets her work completed,
Continued
2780_Ch12_214-227 16/07/12 11:46 AM Page 221

Nutrition
Meaning of Food
When Americans invite a guest to dinner for the first
time, the guest frequently brings a gift, although this
is not required, and one of the choices is often food.
There are no specific rules as to what type of food to
bring, but wine, cheese baskets, and candy are usually
appropriate. Bread (unless it is a very special bread)
and soft drinks are not usually appropriate unless
specifically requested.
Common Foods and Food Rituals
American food and preparation practices reflect tra-
ditional food habits of early settlers who brought their
unique cuisines with them. Accordingly, the “typical
American diet” has been brought from elsewhere.
Americans vary their mealtimes and food choices
according to the region of the country, urban versus
rural residence, and weekdays versus weekends. In
addition, food choices vary by marital status, economic
status, climate changes, religion, ancestry, availability,
and personal preferences.
Many older people and people living alone do not
eat balanced meals, stating they do not take the time
to prepare a meal, even though most American homes
have labor-saving devices such as stoves, microwave
ovens, refrigerators, and dishwashers. For those
who are unable to prepare their own meals because
of disability or illness, most communities have a Meals
on Wheels program through which community and
church organizations deliver, usually once a day, a hot
meal along with a cold meal for later and food for the
following morning’s breakfast. Other community and
church agencies prepare meals for the homeless or col-
lect food, which is delivered to those who have none.
When people are ill, they generally prefer toast, tea,
juice, and other easily digested foods.
Given the size of the United States and its varied
terrain, food choices differ by region: beef in the Mid-
west, fish in coastal areas, and poultry in the South
and along the Eastern Seaboard. Vegetables vary by
season, climate, and altitude, although larger grocery
stores have a wide variety of all types of American
and international meats, fruits, and vegetables. Many
television stations and major newspapers have large
sections devoted to foods and preparation practices, a
testament to the value that Americans place on food
and diversity in food preparation.
Special occasions and holidays are frequently asso-
ciated with specific foods and may vary according to
the ethnicity of the family. For example, hot dogs are
consumed at sports events, and turkey is served at
Thanksgiving.
Dietary Practices for Health Promotion
Overall, the typical American diet is high in fats and
cholesterol and low in fiber, according to the U.S.
Department of Agriculture (USDA) (www.mypyramid.
gov). The USDA recommends MyPyramid for
Americans, which was originally adopted in 1950, re-
vised in 1992, and revised again in 2005. This food
pyramid is commonly taught in elementary and sec-
ondary education and is used as a guide for teaching
healthy eating to the public. Daily recommendations
include 6 to 11 servings of bread, cereal, rice, or pasta;
3 to 5 servings of vegetables; 2 to 4 servings of fruit; 2
to 3 servings of milk, yogurt, or cheese; 2 to 3 servings
of meat, poultry, fish, dry beans, eggs, and nuts; and
limited use of fats, oils, and sweets.
Nutritional Deficiencies and Food Limitations
Socioeconomic status may dictate food selections—for
example, hamburger instead of steak; canned or frozen
vegetables and fruit rather than fresh produce; and fish
instead of shrimp or lobster. Most grocery stores have
an adequate supply of frozen and canned fruits and
vegetables, although they may be high in sodium
and sugars. Given the size of the United States and
proximity of farms to urban areas, there are few overall
limitations for food choices for most Americans.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Commonly used methods of birth control among
Americans include natural ovulation methods, birth
222 Aggregate Data for Cultural-Specific Groups
despite coming in late and leaving early. Besides, what is the
big deal about 10 or 15 minutes? The nurse manager has in-
formed her that if she is late or leaves early one more time,
she will be suspended without pay. Mrs. Shorts believes she is
being treated unfairly and, unknown to Mr. Galway, has gone to
his supervisor and complained that he has touched her on the
shoulder unnecessarily and that he is singling her out because
she is female and he is male. In addition, he calls her “Tammy”
instead of “Mrs. Shorts.”
1. Is the expectation of punctuality on reporting on time
consistent with the European American culture?
2. In the American workforce, when employees have a
complaint or concern about their supervisor, who is the
first person they should speak to about it?
3. What should Mrs. Shorts’s first response be to being
touched unnecessarily?
4. What should Mrs. Shorts’s first response be if she is
offended by Mr. Galway calling her by her first name? Is
this common with the European American culture?
5. What is the first thing you would do to resolve this
situation?
6. If your first action does not resolve the situation, what is
your second action?
2780_Ch12_214-227 16/07/12 11:46 AM Page 222

control pills, foams, Norplant, the morning-after pill,
intrauterine devices, sterilization, vasectomy, prophy-
lactics, and abortion. Although not all of these meth-
ods are acceptable to all people, many women use a
combination of fertility control methods. The most
extreme examples of fertility control are sterilization
and abortion. Sterilization in the United States is
strictly voluntary. Abortion remains a controversial
issue in the United States, as it is in other countries.
The “morning-after pill” also continues to be contro-
versial to some. Anyone, male or female, over the age
of 18 years can purchase the drug without a prescrip-
tion. Those under the age of 18 years must have a pre-
scription. Although some men have vasectomies, the
literature is also scarce on the number of families who
use vasectomy as a method of birth control.
Fertility practices and sexual activity, sensitive
topics for many, are two areas where “outside”
health-care providers may be more effective than
health-care providers known to the client because of
the concern about providing intimate information to
someone they know.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
A prescriptive belief among Americans is that women
are expected to seek preventive care, eat a well-balanced
diet, and get adequate rest to have a healthy pregnancy
and baby. The American health-care system encourages
women to breastfeed, and many places of employment
have made arrangements so women can breastfeed
while at work.
A restrictive belief among Americans is that preg-
nant women should refrain from being around loud
noises for prolonged periods of time. Taboo behaviors
during pregnancy among Americans include smoking,
drinking alcohol, drinking large amounts of caffeine,
and taking recreational drugs—practices that are sure
to cause harm to the mother or baby.
In the American culture, in which the father is often
encouraged to take prenatal classes with the expectant
mother and provide a supportive role in the delivery
process, fathers with opposing beliefs may feel guilty
if they do not comply. The woman’s female relatives
may provide assistance to the new mother until she is
able to care for herself and the baby.
Additional cultural beliefs carried over from cultural
migration and shared among other cultures as well as
the European American culture include the following:
• A pregnant woman should not reach over her head
because the baby may be born with the umbilical
cord around its neck.
• If you wear an opal ring during pregnancy, it will
harm the baby.
• Birthmarks are caused by eating strawberries or
seeing a snake and being frightened.
• Congenital anomalies can occur if the mother sees
or experiences a tragedy during her pregnancy.
• Nursing mothers should eat a bland diet to avoid
upsetting the baby.
• The infant should wear a band around the abdomen
to prevent the umbilicus from protruding and
becoming herniated.
• A coin, key, or other metal object should be put on
the umbilicus to flatten it.
• Cutting a baby’s hair before baptism can cause
blindness.
• Moving heavy items can cause your “insides” to
fall out.
• If the baby is physically or mentally abnormal,
God is punishing the parents.
In the past, the postpartum woman was prescribed
a prolonged period of recuperation in the hospital or
at home, something that is no longer as feasible the
shortened length of confinement in the hospital after
delivery.
The health-care provider must respect cultural be-
liefs associated with pregnancy and the birthing
process when making decisions related to the health
care of pregnant women, especially those practices
that do not cause harm to the mother or the baby.
Most cultural practices can be integrated into preven-
tive teaching in a manner that promotes compliance.
People of European American Heritage 223
R E F L E C T I V E E X E R C I S E 1 2 . 3
Robert Northrop, a white 64-year-old manager in a large shoe
store, presented at a neighborhood clinic with a chief com-
plaint of difficulty urinating, especially in the morning. He has
been divorced for over 20 years, lives alone, and has no
children. He admits to weekend-only binge drinking when he
is out with friends. During the week, he works 10-hour days
and does not have time to go out with friends in the evening.
His diet consists of frozen TV dinners, prepared fast foods,
sandwiches made from deli meats and cheese, and snacks that
include potato chips, pretzels, cheese twists, soft drinks, and
energy drinks. Mr. Northrop’s past medical history includes
skin cancer, hemorrhoids, varicose vein surgery, and hyperten-
sion and hypercholesterolemia, for which he is on medication.
1. Name one occupation-related condition for which
Mr. Northrop is at risk.
2. What lifestyle changes would you recommend to
Mr. Northrop?
3. Do you think giving him the USDA MyPlate will help him
change his dietary habits?
4. Can you suggest an alternative for Mr. Northrop for his
weekend binge drinking?
5. Would you use low- or high-contexted communication
with Mr. Northrop?
6. What health conditions does Mr. Northrop have that are
consistent with European American Caucasians?
2780_Ch12_214-227 16/07/12 11:46 AM Page 223

Death Rituals
Death Rituals and Expectations
For many American health-care providers educated in
a culture of mastery over the environment, death is seen
as one more disease to conquer, and when this does not
happen, death becomes a personal failure. Thus, for
many, death does not take a natural course because it is
“managed” or “prolonged,” making it difficult for some
to die with dignity. Moreover, death and responses to
death are not easy topics for many Americans to verbal-
ize. Instead, many euphemisms are used rather than
verbalizing that the person died: “passed away,” “no
longer with us,” and “went to heaven.”
The American cultural belief in self-determination
and autonomy extends to people making their own
decisions about end-of-life care. Mentally competent
adults have the right to refuse or decide what medical
treatment and interventions they wish to extend life,
such as artificial life support and artificial feeding and
hydration.
Most Americans believe that a dying person should
not be left alone, and accommodations are usually made
for a family member to be with the dying person at all
times. Health-care providers are expected to care for the
family as much as for the patient during this time.
Most people are buried or cremated within 3 days
of the death, but extenuating circumstances may
lengthen this period to accommodate family and
friends who must travel a long distance to attend a
funeral or memorial service. The family can decide
whether to have an open or closed casket at the
viewing (or wake). Significant variations in burial
practices occur with other ethnocultural groups in
the United States.
Responses to Death and Grief
American society has been launching major initiatives
to help patients die as comfortably as possible without
pain; one such initiative is Toolkit for Nurturing
Excellence at End-of-Life Transition (TNEEL, 2003).
As a result, more people are choosing to remain at
home or to enter a hospice for end-of-life care where
their comfort needs are better met.
One of the requirements for entering a hospice in
the United States is that the patient must sign docu-
ments indicating that he or she does not want exten-
sive life-saving measures performed. Bereavement
support strategies include being physically present,
encouraging a reality orientation, openly acknowl-
edging the family’s right to grieve, accepting varied
behavioral responses to grief, acknowledging the pa-
tient’s pain, assisting them to express their feelings,
encouraging interpersonal relationships, promoting
interest in a new life, and making referrals to other
resources such as a priest, minister, rabbi, or pas-
toral care.
Spirituality
Dominant Religion and Use of Prayer
In the United States, major religious groups include
Protestant (51.3 percent), Roman Catholic (23.9 per-
cent), Mormon (1.7 percent), other Christian (1.6 per-
cent), Jewish (1.7 percent), Muslim (0.6 percent), other
or unspecified (2.5 percent), unaffiliated (12.1 per-
cent), and none (4 percent) (CIA World Factbook,
2011). Many groups settled in America for religious
freedom. Furthermore, specific religious groups are
concentrated regionally in the United States, with
Baptists in the South, Lutherans in the North and
Midwest, and Catholics in the Northeast, East, and
Southwest. Within this context, there is a separation
of church and state, and the U.S. government cannot
support a particular religion or prevent people from
practicing their chosen religion. However, this does
not include cults or extremist groups, which usually
devote themselves to esoteric ideals and fads.
Even though there is a separation of church and
state in the United States, many public events and cer-
emonies open with a prayer, and phrases such as “one
224 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 2 . 4
Margaret Schultz, age 15 years, is 3 months pregnant and mak-
ing her first visit to the maternal child nurse practitioner. She is
accompanied by her 17-year-old boyfriend, Billy, who is the
father. Billy declines to give his last name but says he will take
care of Margaret and the baby. Margaret and Billy currently live
with Margaret’s mother and three younger siblings. Margaret
says she has no health problems and wants to keep the baby.
She has made this appointment because she just wants to
have a healthy baby. She is particularly concerned because her
classmates tell her that she cannot lift heavy packages or carry
her book bag because she might have a miscarriage. Her
mother told her she could eat anything she wants, but Mar-
garet is afraid that if she does, she will gain lots of weight like
her mother, her boyfriend will leave her, and the baby might be
born with a birthmark.
1. What is your overall first impression of this case?
2. Why might Billy not be willing to provide his last name?
3. What kind of support does Margaret have? Do you think
this support will continue after the baby is born?
4. What is your response to Margaret’s concern about lifting
heavy objects?
5. What is your response to Margaret’s concern about eating
whatever she wants?
6. What is your response to Margaret’s concern that the
baby might be born with a birthmark?
7. What overall advice do you have for Margaret at this time?
Do you think you should call Margaret’s mother and
discuss the pregnancy?
2780_Ch12_214-227 16/07/12 11:46 AM Page 224

nation under God” are often included. American
money still has the phrase “in God we trust” printed
on it. Most people see these religious symbols as
harmless rituals. Instead of speaking to “religious val-
ues,” politicians speak to “family values” as a way of
getting around religious principles. However, these is-
sues are subject to debate from time to time. Unlike
many countries that support a specific church or
religion and in which people discuss their religion fre-
quently and openly, religion is not an everyday topic
of conversation for most Americans.
The health-care provider who is aware of the
client’s religious practices and spiritual needs is in a
better position to promote culturally competent
health care. The practitioner must demonstrate an ap-
preciation of and respect for the dignity and spiritual
beliefs of clients by avoiding negative comments about
religious beliefs and practices. Clients may find con-
siderable comfort in speaking with religious leaders in
times of crisis and serious illness.
Meaning of Life and Individual Sources
of Strength
When Americans are asked what gives their lives mean-
ing and where they find strength, a variety of answers
are offered. Formal religion is one, but other common
responses include family, work, self-improvement,
friends, music, dance, hobbies, sports events, and med-
itation. For some, sources and meaning of life come
from having a pet, such as a dog or cat.
Spiritual Beliefs and Health-Care Practices
Spiritual wellness brings fulfillment from a lifestyle of
purposeful and pleasurable living that embraces free
choices, meaning in life, satisfaction in life, and self-
esteem. Practices that interfere with a person’s spiri-
tual life can hinder physical recovery and promote
physical illness.
Health-care providers should inquire whether the
person wants to see a member of the clergy even if she
or he has not been active in church. Religious em-
blems should not be removed because they provide
solace to the person and removing them may increase
or cause anxiety. A thorough assessment of spiritual
life is essential for the identification of solutions and
resources that can support other treatments.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Currently, the United States is undergoing a paradigm
shift from one that places high value on curative and
restorative medical practices with sophisticated tech-
nological care to one of health promotion and well-
ness; illness, disease, and injury prevention; health
maintenance and restoration; and increased personal
responsibility. Most believe that the individual, the
family, and the community have the ability to influ-
ence their health. For a few, good health may be seen
as a divine gift from God, with individuals having little
control over health and illness.
The primacy of patient autonomy is generally
accepted as an enlightened perspective in American so-
ciety. To this end, advance directives such as “durable
power of attorney” or a “living will” are an important
part of medical care. Accordingly, patients can specify
their wishes concerning life and death decisions before
entering an inpatient facility. The durable power of at-
torney for health care allows the patient to name a
family member or significant other to speak for the
patient and make decisions when or if the patient is
unable to do so. The patient can also have a living
will that outlines the person’s wishes in terms of
life-sustaining procedures in the event of a terminal
illness. Each inpatient facility has these forms avail-
able and will ask the patient what his or her wishes
are. Patients may sign these forms at the hospital or
elect to bring their own forms, many of which are on
the Internet.
Guidelines for immunizations were developed
largely as a result of the influence of the World Health
Organization (WHO). Specific immunization sched-
ules and the ages at which they are prescribed vary
widely among countries and can be obtained from the
WHO Web site (http://www.who.int). Recently, con-
troversy has arisen when some facilities have made the
requirement that all employees must be immunized
against the flu. Most employees comply, but a few see
it as an infringement of their individual rights. In
addition, some religious groups, such as Christian
Scientists, do not believe in immunizations. Beliefs like
this, which restrict optimal child health, have resulted
in court battles with various outcomes.
Responsibility for Health Care
The United States is moving to a paradigm in which
people take increased responsibility for their own
health. In a society in which individualism is valued,
people are expected to be self-reliant. In fact, people
are expected to exercise some control over disease, in-
cluding controlling the amount of stress in their lives.
If someone does not maintain a healthy lifestyle and
then gets sick, some believe it is the person’s own fault.
Unless someone is very ill, she or he should not
neglect social and work obligations.
At the time of this writing, the Patient Protection
and Affordable Care Act (PPACA) of 2010—aimed
to provide health insurance for all Americans—is
being instituted. The PPACA continues to be hotly de-
bated, with some states declaring it unconstitutional.
The next few years will determine the success of the
PPACA. In the United States, everyone, regardless of
socioeconomic or immigration status, can receive
acute-care services. However, they will be charged a
People of European American Heritage 225
2780_Ch12_214-227 16/07/12 11:46 AM Page 225

fee for the service, and they may not be able to get
nonacute follow-up care unless they can prove they
are able to pay for the service. Even if they are covered
by health insurance, an insurance company represen-
tative may need to approve the visit and then have a
list of procedures, medicines, and treatments for which
it will pay.
Health-care providers should not assume that
clients who do not have health insurance or practice
health prevention do not care about their health.
Many are included in the working poor where they
make minimum wage, which is less than the cost of a
family insurance policy.
Self-medicating behavior in itself may not be harm-
ful, but when combined with or used to the exclusion
of prescription medications, it may be detrimental to
the person’s health. A common practice with prescrip-
tion medications is for people to take medicine until
the symptoms disappear and then discontinue the
medicine prematurely. This practice commonly occurs
with antihypertensive medications and antibiotics. No
culture is immune to self-medicating practices; almost
everyone engages in it to some extent.
One cannot ignore the ample supply of over-the-
counter medications in American pharmacies, the nu-
merous television advertisements for self-medication,
and media campaigns for new medications, encourag-
ing viewers to ask their doctor or health-care provider
about a particular medication for cholesterol, erectile
dysfunction, and a host of other conditions.
Folk and Traditional Practices
Some Americans favor traditional, folk, or magico-
religious health-care practices over biomedical practices
and use some or all of them simultaneously. For many,
what are considered alternative or complementary
health-care practices may be mainstream medicine for
another person. In the United States, interest has in-
creased in alternative and complementary health prac-
tices. The U.S. government has an Office of Alternative
Medicine at the National Institutes of Health that has
awarded millions of dollars in grants to bridge the gap
between traditional and nontraditional therapies.
As an adjunct to biomedical treatments, many peo-
ple use acupuncture, acupressure, acumassage, herbal
therapies, and other traditional treatments. Examples
of folk medicines include covering a boil with axle
grease, wearing copper bracelets for arthritis pain,
mixing wild turnip root and honey for a sore throat,
and drinking herbal teas. Most Americans practice
folk medicine in some form; they may use family reme-
dies passed down from previous generations.
An awareness of combined practices when treating
or providing health education helps ensure that ther-
apies do not contradict each other, intensify the treat-
ment regimen, or cause an overdose. At other times,
they may be harmful, conflict with, or potentiate the
effects of prescription medications. Many times, these
traditional, folk, and magico-religious practices are
and should be incorporated into the plans of care for
clients. Inquiring about the full range of therapies
being used, such as food items, teas, herbal remedies,
nonfood substances, over-the-counter medications,
and medications prescribed or loaned by others, is es-
sential so that conflicting treatment modalities are not
used. If clients perceive that the health-care provider
does not accept their beliefs, they may be less compli-
ant with prescriptive treatment and less likely to reveal
their use of these practices.
Barriers to Health Care
Barriers to health care for European Americans are
essentially the same for any culture and include avail-
ability, accessibility, affordability, appropriateness,
accountability, adaptability, acceptability, awareness,
attitudes, approachability, alternative and comple-
mentary practices and providers, and health literacy
(see Chapter 2). In order for people to receive ade-
quate health care, a number of considerations need
to be addressed. Several studies have identified that
a lack of fluency in language is the primary barrier
to receiving adequate health care in the United States
(see Chapter 1).
Health-care providers can help reduce some of
these barriers by calling an area ethnic agency or
church for assistance, establishing an advocacy role,
involving professionals and laypeople from the same
ethnic group as the client, using cultural brokers, and
organizationally providing culturally congruent and
linguistically appropriate services. If all of these ele-
ments are in place and used appropriately, they have
the potential of generating culturally responsive care.
Cultural Responses to Health and Illness
Significant research has been conducted on patients’
responses to pain, which has been called the “fifth vital
sign.” Most Americans believe that patients should be
made comfortable and not have to tolerate high levels
of pain. Accrediting bodies, such as the Joint Commis-
sion, survey organizations to ensure that patients’ pain
levels are assessed and that appropriate interventions
are instituted. Cultural backgrounds, worldviews, and
the variant cultural characteristics profoundly influ-
ence the pain experience.
Additional resources for pain are the American
Pain Foundation, the American Pain Society, the
Boston Cancer Pain Education Center (in 11 lan-
guages), and the OUCHER Pain scale (OUCHER!,
n.d,) for children, all of which are available on the
Internet. The health-care provider may need to offer
and encourage pain medication and explain that it
will help the healing to progress. Research needs to
be conducted in the areas of ethnic pain experiences
and management of pain.
For some Americans, mental illness may be seen
as being as important as physical illness. For some,
226 Aggregate Data for Cultural-Specific Groups
2780_Ch12_214-227 16/07/12 11:46 AM Page 226

mental illness and severe physical handicaps are con-
sidered a disgrace or cause a stigma. As a result, the
family is likely to keep the mentally ill or handicapped
person at home as long as they can. This practice may
be reinforced by the belief that all individuals are ex-
pected to contribute to the household for the common
good of the family, and when a person is unable to
contribute, further disgrace occurs.
In previous decades, physically handicapped individ-
uals in the United States were seen as less desirable than
those who did not have a handicap. If the handicap was
severe, the person was sometimes hidden from the pub-
lic’s view. In 1992, the Americans with Disabilities Act
went into effect, protecting handicapped individuals
from discrimination.
In the United States, rehabilitation and occupa-
tional health services focus on returning individuals
with handicaps to productive lifestyles in society
as soon as possible. The goal of the American
health-care system is to rehabilitate everyone: con-
victed criminals, people with alcohol and drug prob-
lems, as well as those with physical conditions.
Rehabilitation seems to now be well established in
the United States.
Blood Transfusions and Organ Donation
Most Americans and most, but not all, religions favor
organ donation and transplantation and transfusion of
blood or blood products. Jehovah’s Witnesses do not
believe in blood transfusions. Health-care providers
may need to assist clients in obtaining a religious leader
to support them in making decisions regarding organ
donation or transplantation.
Health-Care Providers
Traditional Versus Biomedical Providers
Most Americans combine the use of biomedical
health-care practitioners with traditional practices,
folk healers, and magico-religious healers. The health-
care system abounds with individual and family folk
practices for curing or treating specific illnesses. A sig-
nificant percentage of all care is delivered outside the
perimeter of the formal health-care arena. Many times
folk and traditional therapies are handed down from
family members and may have their roots in religious
beliefs. Traditional and folk practices often contain
elements of historically rooted beliefs.
The American practice is to assign staff to pa-
tients regardless of gender differences, although
often an attempt is made to provide a same-gender
health-care provider when intimate care is involved,
especially when the patient and caregiver are of the
same age. However, health-care providers should
recognize and respect differences in gender relation-
ships when providing culturally competent care
because not all people accept care from someone of
the opposite gender.
Status of Health-Care Providers
Individual perceptions concerning competence and
acceptability of providers may be closely associated
with previous contact and experiences with health-
care providers. In general, health-care providers, es-
pecially physicians, are viewed with great respect,
although recent studies show that this is declining
among some groups. Although many nurses in the
United States do not believe they have respect, public
opinion polls usually place patients’ respect of nurses
higher than that of physicians. The advanced prac-
tice role of registered nurses is gaining respect as
more of them have successful careers and the public
sees them as equal or preferable to physicians in
many cases. Evidence suggests that respect for pro-
fessionals is correlated with their educational level,
including baccalaureate-, master’s-, and doctoral-level
programs of study, and the impact of nursing interven-
tions on health-care outcomes. In the United States,
approximately 10 percent of nurses are men, with
very active campaigns in some areas of the country
to recruit men and other underrepresented groups
into nursing (Purnell, 2007).
R E F E R E N C E S
Centers for Disease Control and Prevention. (2007). Unmarried
childbearing. Retrieved from http://www.cdc.gov/nchs/fastats/
unmarry.htm
Centers for Disease Control and Prevention. (2011). Retrieved
from www.cdc.gov
CIA World Factbook. (2011). United States. Retrieved from https://
www.cia.gov/library/publications/the-world-factbook/geos/
us.html
Information Please Almanac. (2009). United States. Retrieved from
http://www.gale.cengage.com/reference/peter/200901/info_
almanac.htm
Munoz, C., & Hilgenberg, C. (2005). Ethnopharmacology. American
Journal of Nursing, 105(8), 40–49.
OUCHER! (n.d.). Retrieved from http://www.oucher.org/
Prows, C.A., & Prows, D.R. (2004). Tailoring drug therapy with
pharmacogenetics. American Journal of Nursing, 104(5), 60–71.
Purnell, L. (2007). Men in nursing: An international perspective. In
C. O’Lynn & R. Tranbarger (Eds.), Men in nursing (pp. 219–235).
New York: Springer Publishing.
Purnell, L., & Foster, J. (2003a). Cultural aspects of alcohol use:
Part I. The Drug and Alcohol Professional, 3(3), 17–23.
Purnell, L., & Foster, J. (2003b). Cultural aspects of alcohol use:
Part II. The Drug and Alcohol Professional, 2(3), 3–8.
Purnell, L., & Galloway, W. (1995). What to do if called upon to
testify. Accident and Emergency Nursing, 17(4), 246–249.
Toolkit for Nurturing Excellence at End-of-Life Transition
(TNEEL, 2003). Retrieved from http://www.tneel.uic.edu/
tneel-ss/introduction.asp
U.S. Census Bureau. (2010). Retrieved from http://factfinder2.cen-
sus.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=
ACS_10_5YR_S1701&prodType=table
For reflective exercises, review questions, and additional
information, go to
http://davisplus.fadavis.com
People of European American Heritage 227
2780_Ch12_214-227 16/07/12 11:46 AM Page 227

228
Chapter 13
People of Filipino Heritage
Corazon C. Munoz
*The author would like to thank Dula Pacquiao for her work on this chapter in previous editions.
Overview, Inhabited Localities,
and Topography
Overview
The Philippines is located in Southeast Asia in the
Western Pacific ocean. To its north lies Taiwan, and
to its west is Vietnam. The tropical climate makes the
Philippines prone to earthquakes and typhoons but
has also endowed the country with natural resources
and made it one of the richest areas of biodiversity in
the world. The Philippines is an archipelago consisting
of 7107 islands, with three main geographical divi-
sions: Luzon, Visayas, and Mindanao (CIA World
Factbook, 2011). With a landmass of 300,000 square
kilometers (115,830 square miles), it is slightly larger
than the state of Arizona. The terrain is mostly moun-
tainous with narrow-to-extensive coastal lowlands.
The tropical climate consists of dry and rainy seasons
suitable for year-round agriculture and fishing, but it
is affected by the seasonal northeastern and south-
western monsoons. With an estimated population of
about 104 million, the population has decreased since
2005 (CIA World Factbook, 2012). Although the coun-
try is rich in natural resources and has a mixed econ-
omy of agriculture, light industry, and support
services, almost 33 percent of the population lives
below the poverty level (CIA World Factbook, 2011).
The Spaniards colonized the country for over
3 centuries from 1565 to 1898. Following the Spanish-
American War, the islands were ceded to the
United States and given the anglicized name “the
Philippines.” Filipinas (Pilipinas) and Philippines are
used interchangeably today. Native speakers refer
to the country as Filipinas or Pilipinas and use
Philippines when speaking to outsiders or writing in
English. In 1946, when the Philippines gained its in-
dependence from the United States, it adopted the
Tagalog-based Pilipino as its national language. In
1959, Pilipino was officially declared the national
language. In 1986, however, the national assembly
declared the national language as Filipino, based on
existing Philippine and other languages. Generally,
Filipino is used interchangeably with Filipino American.
The term Pilipino is generally used to distinguish in-
digenous identity and nationalistic empowerment.
Filipino Americans are a diverse group because
of regional variations in the Philippines, which in-
fluence the dialect spoken, food preferences, reli-
gion, and traditions. Generational differences within
families are associated with age and time of migra-
tion from the Philippines. Other factors influencing
diversity include pre- and postmigration level of ed-
ucation, occupation, and intermarriage, as well as
other variant cultural characteristics (see Chapter 1).
This chapter discusses the major characteristics of
mainstream Filipino culture, offering some insights
into some differences among groups. The reader
should avoid using this information as a universal
template for every Filipino.
Heritage and Residence
The Filipino way of life is a tapestry of multicultural
influences superimposed on indigenous tribal origins
(Fig. 13-1). The people are predominantly of Malayan
ancestry, with overlays of Chinese, Japanese, East
Indian, Indonesian, Malaysian, and Islamic cultures
(CIA World Factbook, 2012). The Philippine culture
is distinct from its Asian neighbors largely because of
the major influences from the Spanish and American
colonization.
The Filipino sense of morality and justice evolved
from tribal times. Close-knit, kin-based groups known
as barangays emerged to protect communities from
outside atrocities. Communal values of collective wel-
fare and solidarity fostered security of its members in
an unstable environment. Outsiders to the culture rec-
ognize these values in the Filipino traits of collective
loyalty, generosity, hospitality, and humility. These
basic values are strong components of childhood
socialization in the family. Filipinos inculcate a strong
2780_Ch13_228-249 16/07/12 11:47 AM Page 228

sense of family loyalty beyond the nuclear family.
Family obligations extend to cousins, in-laws, and oth-
ers who are intimately linked with the family by cere-
monies such as serving as sponsors of marriage or
baptisms (Bautista, 2002).
Most Filipinos in North America were born in
the Philippines. The majority of Filipino Americans
reside in the states of California, Hawaii, Illinois,
New Jersey, New York, Washington, and Texas.
Filipinos make up the second largest foreign-born
population after Mexicans in the United States
(Reeves & Bennett, 2004).
Reasons for Migration and Associated
Economic Factors
Many Filipinos migrate to America and elsewhere pri-
marily for economic prosperity. The economic chal-
lenges in the Philippines are exaggerated by its
unemployment rate, foreign debt, population growth,
and social inequities. These factors contribute to the
migration of Filipinos to the United States, including
physicians, nurses, engineers, information technology
experts, and other laborers. American corporations,
trade companies, and financial institutions partnering
with Philippine companies have invested in promoting
economic development and exchanges with the coun-
try. These larger political and economic influences,
along with social and cultural exchanges, have helped
create transnational community networks and estab-
lished multiple migration streams over time.
These early migrants were ineligible for citizenship
and were denied privileges such as employment requir-
ing citizenship, union membership, the right to own
land, and the right to marry in states with antimisce-
genation laws (laws prohibiting cohabitation, sexual
relations, or marriage between people of different races).
The Great Depression heightened racial animosity
toward Filipino workers, and passage of the Tydings-
McDuffie Act (Philippines Independence Act) in 1934
virtually ended immigration (Ceniza-Choy, 2003).
In 1946, immigration restrictions for Filipinos were
eased and they were granted naturalization rights. Be-
tween 1946 and 1965, 33,000 immigrants entered the
United States and contributed to a 44 percent increase
in the Filipino population in America. The Immigra-
tion Act of 1965 initiated a period of renewed mass
immigration by promoting family reunification and re-
cruitment of occupational immigrants. Since the pas-
sage of the 1965 Act, the Philippines has become the
largest source of immigrants from Asia. A search for
better economic and educational opportunities and re-
unification with family members in the United States
continue to be the primary motivating factors for
emigration. Working adult children sponsor their older
relatives to come to the United States to care for their
young children. In turn, older people facilitate the
subsequent immigration of other children.
Because the Philippine economy has been unable
to provide jobs for college graduates, an estimated
6 million Filipino professionals work overseas, and as
many as 300,000 Filipinos emigrated in 2006. Export
of professional and skilled labor is one of the biggest
industries in the Philippines. Remittances sent home
by Filipinos overseas contribute as much as 10 percent
to the country’s gross domestic product, estimated at
between 11 and 13 billion pesos (approximately US$278
million) in 2006 (IBON Foundation, 2007).
Educational Status and Occupations
Around 1900, Americans introduced public education
in the Philippines. Early training of schoolteachers was
provided by the Thomasites, forerunners of the U.S.
Peace Corps. The development of educational pro-
grams in the Philippines was highly influenced and pat-
terned after those in the United States, as in the case of
nursing and medicine. Early missionaries and philan-
thropic organizations such as the Daughters of the
American Revolution, the Catholic Scholarship Fund,
and the Rockefeller Foundation were instrumental in
the Westernization of health-care education and prac-
tice in the Philippines. American nursing educators
went to the Philippines, and Filipino nurses were sent
to the United States for training. They subsequently
People of Filipino Heritage 229
Figure 13-1 Traditional Filipino costumes.
2780_Ch13_228-249 16/07/12 11:47 AM Page 229

returned to the Philippines and assumed leadership
positions in nursing schools and hospitals. Since 1970,
all nursing curricula have converted to a 4-year degree
program leading toward a BSN (Pacquiao, 2004).
The Philippines has one of the highest literacy rates
in Asia at 96 percent. Schools are either publicly or
privately funded. Formal education starts at the age
of 7 years, with 6 years of primary education. Nursery
school and kindergarten are offered in most private
schools. Students get 4 years of secondary education
in either a vocational-technical or an academic school.
A high school graduate is 2 years younger than those
graduating from U.S. high schools because of the
omission of middle school years.
Filipinos view educational achievement as a path-
way to economic success, status, and prestige for both
the individual and the family. A person’s profession is
always identified when introducing, addressing, or
writing about the person (e.g., Doctor, Magpantay, or
Engineer, Paredes). A family’s status in the community
is enhanced by the educational achievement of the
child, and a child’s education is considered an invest-
ment for the whole family. Both male and female chil-
dren are expected to do well in school, and parents do
their best to provide for their children’s full-time edu-
cation. Adolescents who closely identify with their
families are found to be concerned with the potential
effect of their scholastic achievement on their families’
reputation (Salazar, Schuldermann, Schuldermann, &
Hunyh, 2000). Family members and other relatives
commonly contribute toward the education of their
kin. Among lower- and middle-class families, siblings
take turns going to college in order to maximize re-
sources for one member to finish school, who can then
contribute to the education of her or his siblings. One’s
choice of profession is generally a family decision and
is based on potential economic return to the group.
Hence, increased demand for nurses abroad attracts
higher enrollment in nursing, as families view this
occupation as a pathway to economic improvement.
Filipinos appear to be assimilated and successful
and tend to blend into American society, which gives
them a reputation as a “model minority.” In reality,
high educational attainment of American-born and
immigrant Filipinos does not guarantee their entry
into well-paying or high-status jobs. Significant
discrimination confronts native-born and immigrant
Filipinos in the American labor market linked with
factors such as ethnicity, gender, region of residence,
and level of education (Yamane, 2002). As is the
experience of many foreign graduates, Filipinos’ edu-
cation and experience are rarely matched with a suit-
able job because of the restricted labor market,
resulting in many individuals competing for low-level
jobs for which many are overqualified. Only those who
are educated in health-care fields tend to find jobs
consistent with their education.
Whereas American nursing education stresses criti-
cal thinking, in the Philippines, mastery of facts and
rote learning are emphasized. A defined hierarchy ex-
ists in schools, with the teacher as the expert authority.
This hierarchy is congruent with the social organiza-
tion in the broader society, in which age and position
are markers of status and power. The younger genera-
tions are rewarded for accepting the ideas and counsel
of older people and teachers. Challenging authority
and asserting one’s creative ideas are unnatural predis-
positions, especially for the young. Nursing faculty
have identified the tendency of Filipino students to
take things at face value, avoid conflict, communicate
nonassertively, and learn by rote memorization.
Students’ traditional values at home were in conflict with
values in school and teacher expectations (Pacquiao,
1996). Facilitating understanding of the dominant cul-
tural values and norms in school, in addition to teach-
ing the subject matter, is essential to facilitate these
students’ academic success.
Communication
Dominant Language and Dialects
Filipinos were influenced by American language and
culture beyond the period when the United States
recognized its independence in 1946. Tagalog is the
primary language spoken in the Philippines. The two
other official languages are English and Spanish. Within
the Philippines there are approximately 75 ethnolinguis-
tic groups who speak more than 100 dialects. For the
sake of simplicity, the Philippine government has
given all of these languages the collective name of
Pilipino (Munoz & Luckmann, 2005).
English is the official language used for business
and legal transactions, as well as taught in secondary
schools and universities. This has an impact on how
Filipinos adjust in the United States, making it easier
and faster to navigate the systems in the United States
as compared with other Asian immigrant groups.
Business and social interactions commonly use a
hybrid of both Tagalog and English (Tag-Lish) in the
same sentence. Tag-Lish is often used in health edu-
cation. Most Filipinos speak the national language,
Filipino, which is based on Tagalog (Tatak Pilipino,
2003). This has created some regional tensions be-
cause the other dialects are not well represented in
Tagalog as the national language, making it difficult
for those in the Central and Southern regions of the
country to learn and speak Tagalog.
Many Spanish words are found in the Filipino lan-
guage such as sopa (soup), calle (street), hija/hijo
(daughter/son), and respeto (respect). The influence of
indigenous Filipino and Spanish languages produces
distinct characteristics when Filipinos speak English.
There is absence of certain sounds in the Filipino
language such as short i, long a, and long o. Hence,
230 Aggregate Data for Cultural-Specific Groups
2780_Ch13_228-249 16/07/12 11:47 AM Page 230

People of Filipino Heritage 231
liver may be enunciated as lever, make as mik, and flow
as flaw. Many Filipinos are unable to differentiate s
from sh (physiology as fishiology), u from short o or
short a sounds (cut as cot or cat; church as charts).
They have a tendency to place emphasis on the second
syllable of a multisyllabic word (in ter´fe rence, pen
ni´cill in, Ro bi´tus sin(™)).
Filipino social hierarchy is evident in the language.
Specific nouns rather than pronouns are used to denote
a person’s age, gender, and position in the social hier-
archy. For instance, Manang and Manong are used to
refer to or address an older woman and man, respec-
tively. These nouns are used to address the person or
when speaking about her or him. There is absence of
the “she/he” in the Filipino language. Rather, generic
and gender-neutral pronouns siya (singular “she/he”)
and sila (plural “they/them”) are used. Hence, many
Filipinos may unconsciously use “she” and “he” inter-
changeably in reference to the same individual.
Although many Filipinos speak English, their ethnic
language or dialect, knowledge and use of the English
language, and age of migration to the United States
often influence enunciation, pronunciation, and accen-
tuation. Older Filipinos who originated from non–
Tagalog-speaking regions may understand and speak
better English than other Filipinos. In multigenera-
tional Filipino American families, different languages
may be used to communicate with family members
and friends. Although many Filipinos speak and write
fluently in English, they may have difficulty under-
standing American idiomatic expressions. For exam-
ple, to a new immigrant, “How are you?” may be
interpreted as a question about the person’s well-being,
requiring an elaboration of one’s situation, rather than
a mere greeting. Filipinos may have difficulty commu-
nicating their lack of understanding to others and may
use ritualistic language and euphemistic behavior that
appear to be the opposite of how they actually perceive
the situation. Saving face, or concealment (Pasco,
Morse, & Olson, 2004), is a characteristic pattern of
behavior employed to protect the integrity of both par-
ties, which is a consequence of the cultural value on
maintaining smooth interpersonal relations. Desirous
of group approval, the individual becomes sensitive to
the feelings of others and, in turn, develops a high
sense of sensitivity to personal insults.
Traditional Filipino communication is highly con-
textual. It is basically formal, addressing individuals
by their academic titles such as Dr. or Mr. and Mrs.
The communication pattern is also rooted in the past
and is hierarchical, which is consistent with respect for
older adults or those with known accomplishment and
achievement (Munoz & Luckmann, 2005).
The individual is enculturated to attend to the con-
text of the interaction and to adopt appropriate
behaviors. Many Filipinos are keenly observant, dis-
playing an intuitive feeling about the other person and
the contextual environment during interactions. Con-
textual variables include the presence of ibang tao
(outsiders) versus hindi ibang tao (insiders) and the
age, social position, and gender of the other individ-
ual. In the company of insiders, such as one’s family,
each member develops an intuitive knowledge of the
other so that words are unnecessary to convey a mes-
sage and meanings are embedded in nonverbal com-
munication. In the presence of outsiders, a child’s
emotional outburst may be met with adults’ stern
silence, indifference, or euphemistic grins. These
behaviors imply to insiders that emotional outbursts
are inappropriate in front of outsiders. One may not
disagree, talk loudly, or look directly at a person who
is older and who occupies a higher position in the
social hierarchy. Honorific terms of address denoting
an individual’s status within the hierarchy exist in all
dialects. In Tagalog, when communicating to an older
person or a person of status, he or she is addressed
using gender and age-specific honorific nouns such as
Lolo/Lola (Grandpa/Grandma), and ate/kuya (older
sister/older brother).
Filipino interpersonal and social life operates to
maintain smooth interpersonal relationships; commu-
nication tends to be indirect and ambiguous to prevent
the risk of offending others. Filipinos may sacrifice clear
communication to avoid stressful interpersonal conflicts
and confrontations. As saying no to a superior is con-
sidered disrespectful, it predisposes an individual to
make an ambiguous positive response. Filipinos are
often puzzled, and sometimes offended, by the precision
and exactness of American communication. Newly re-
cruited Filipino nurses are stunned by their American
coworkers’ abrasiveness and open expressions of anger
toward one another and their subsequent behavior of
sitting down at coffee “as if nothing happened.”
To many traditional Filipinos, actions speak louder
than words. They value respect and might find questions
like “Do you understand?” or “Do you follow?” disre-
spectful. It is preferable for the speaker to say, “Please
let me know if I understood you correctly.” When speak-
ers occupy different positions in the social hierarchy, an
informal and familiar manner of speaking by the sub-
ordinate may be perceived as impolite and disrespectful.
Allowing time for a Filipino to respond not only com-
municates respect but also gives time for translating the
dialect into English. Speaking clearly and slowly facili-
tates appreciation of varying pronunciation and accen-
tuation of the English language across cultures.
Cultural Communication Patterns
Relational orientation has been suggested as the
essence of Asian social psychology. Enriquez (1994)
posited that the Filipino core values of shame (hiya),
yielding to the leader or majority (pakikisama), grati-
tude (utang na loob), and sensitivity to personal
affront (amor propio) emphasize a strong sense of
2780_Ch13_228-249 16/07/12 11:47 AM Page 231

human relatedness. These values originate from the
central concept of kapwa, which arises from the aware-
ness of shared identity with others. Kapwa embraces
the insider-outsider categories of human relations and
prescribes different levels of interrelatedness or in-
volvement with others. Pakakikipagkapwa, being one
with others, implies accepting and dealing with the
other individual as a fellow human being. Kapwa is
grounded in the fundamental value of shared inner
perception or feeling for another, from which all other
attributes for human relations are made possible.
Eight levels of social interactions were identified by
Enriquez within the core concept of kapwa. These levels
demonstrate a hierarchy of human relatedness within
the Filipino language and context of meanings. The
contextual axis of interactions is conceptualized within
a continuum of how the “other” is categorized—
whether as an insider or outsider. The degree of sharing
and involvement with outsiders may progress from levels
1 to 5, whereas interactions at levels 6 to 8 are observed
with insiders. The eight levels are pakikitungo (civility,
level 1), pakikisalimuha (interacting, level 2), pakikihalok
(participating, level 3), pakikibagay (conforming, level
4), pakikisama (adjusting, level 5), pakikipagpalagayang
loob (understanding and accepting, level 6), pakik-
isangkot (getting involved, level 7), and pakikiisa (being
one with, level 8).
Developing working relationships with Filipinos
requires an understanding of where one is situated
within the insider-outsider continuum. Outsiders can
move toward higher levels of interactions by observ-
ing cultural norms of communication, using trusted
gatekeepers to mediate conflicts, seeking validation of
perceptions of behaviors from more acculturated
members of the group, and allowing face-saving op-
portunities to prevent embarrassment and personal
denigration. When confronting a Filipino coworker,
provide privacy, and point out positive attributes as
well as the problem. Observing nonverbal behaviors
and interpreting them within the Filipino cultural con-
text help promote culturally congruent interactions.
Accommodating differential sharing and involvement
between insiders and with outsiders shows cultural un-
derstanding that enhances development of intercul-
tural relationships. For example, a Filipino speaking
Tagalog with another reinforces the value of being one
with others. Learning and using some Filipino greetings
and honorific terms of address facilitate movement of
the relationship to higher levels of involvement. Defin-
ing work situations in which Filipino dialects may be
spoken demonstrates cultural sensitivity and accommo-
dation. The insider and outsider delineations may be
less important to some Filipinos who are highly edu-
cated and take pride in their global outlook. Unlike
other immigrants who settle in ethnic enclaves, more
recent Filipino immigrants acculturate and relate well
with people from various cultures.
Smiling and giggling are often observed, especially
among young Filipino women. The meanings of these
spontaneous and highly unconscious behaviors are
embedded in the context of the situation and may
range from glee, genuine interest, and agreement, to
discomfort, politeness, or indifference. It is helpful to
point out how the behavior can be misinterpreted by
patients and others, if inappropriate to the situation.
Behavior change can be expected if correction is done
in a timely, respectful, and sincere manner.
Having a heightened sensitivity to personal insults,
Filipinos have a remarkable ability to maintain a proper
front to protect their self-esteem when threatened.
Conflict-avoidance behaviors to conceal discomfort or
distress are evident in euphemistic denial of anger, min-
imization of pain, and silence. However, pent-up
emotions and accumulated resentment may result in ex-
plosive anger, depression, and somatization. Health-care
providers should be sensitive to these behaviors and ex-
plore the underlying causes by establishing trust and
maintaining respectful relationships. Offering pain med-
ications and attending to nonverbal behaviors, rather
than waiting for the patient to verbalize his or her needs,
are culturally congruent approaches.
First-generation Filipinos in North America have
high regard for health-care providers (Abe-Kim,
Gong, & Takeuchi, 2004) and present themselves in
therapy sessions as polite, cooperative, verbal, and en-
gaging. However, agreement with health-care providers
does not ensure that patients will follow through with
the recommendations. Health-care providers should be
comfortable with patients’ deferential attitudes without
resorting to authoritarian approaches, which may be
perceived as oppressive and may encourage euphemistic
complaint behaviors. Once trust is developed, expres-
sion of authentic feelings is possible. Filipinos who are
accustomed to indirect communication may perceive
focusing on action-oriented strategies and outcomes as
intrusive and coercive.
Direct eye contact varies among Filipinos de-
pending on the degree of acculturation, length of
time in America, age, and education. Some individ-
uals may avoid prolonged eye contact with authority
figures and older people as a form of respect. Older
men may refrain from maintaining eye contact with
young women because it may be interpreted as flir-
tation or a sexual advance. Filipinos are comfortable
with silence and may allow the other person to ini-
tiate verbal interaction as a sign of respect. During
a teaching session, a Filipino patient’s nod may have
several meanings that can range from “Yes, I hear
you,” “Yes, we are interacting,” “Yes, I can see the
instructions,” or some other message that may be
difficult for the patient to disclose. Validating a pa-
tient’s response in a sensitive and respectful manner,
as well as observing her or his behaviors, can prevent
miscommunication.
232 Aggregate Data for Cultural-Specific Groups
2780_Ch13_228-249 16/07/12 11:47 AM Page 232

Touch is used freely, especially with insiders.
Greater distance is observed when interacting with
outsiders and people in positions of authority. Same-
gender closeness and touching, which may be per-
ceived as homosexual adult behavior in America, are
considered normal. Young adults of the same gender
may hold hands, put one arm over another’s shoulder,
or walk arm-in-arm. As they become more accultur-
ated, many Filipinos become aware of the differences
and adapt to the new culture.
The implicit rules of the social hierarchy are ob-
served when conflicts arise. A subordinate does not
confront his or her superiors. Rather, a mediator who
is likely to be a trusted individual at the same level of
hierarchy as the superior may be employed to mediate
and approach the superior on behalf of the subordi-
nate. This behavior may be interpreted as dishonest by
those who value direct and assertive communication.
Temporal Relationships
Filipinos have a relaxed temporal outlook. They have
a healthy respect for the past, an ability to enjoy the
present, and hope for the future. Past orientation is
evident in their respect for older people and dead an-
cestors (galang), and a sense of gratitude and obliga-
tion to kin (utang na loob). Future orientation is
manifested in the family’s commitment to provide for
the education of the young, parental participation in
the care of their children and grandchildren, and a
strong work ethic. A strong present orientation is as-
sociated with the cultural emphasis on maintaining
positive relationships with others. Permanent social
bonds with kin and significant others outside of kin
are nurtured. Filipinos enjoy their families, fiestas, and
life. They spend generously to make family events
memorable and enjoyable. Although most Filipinos
have adapted to American punctuality in the business
sphere, promptness for social events is situationally
determined. “Filipino time” means arriving much
later than the scheduled appointment, which can be
from 1 to several hours. The focus is on the gathering
rather than on the schedule. A Filipino host may invite
American guests at least 1 hour later than the Filipino
guests in the hope that both will arrive at the same time.
Format for Names
The Filipino family is bilineally extended to several gen-
erations. Kinship and family affinity can be legally and
spiritually claimed equally from both sets of families,
giving the child the identity of the extended family. This
bilineal kinship is reflected in their names. Children
carry the surnames of both parents. For example, Jose
Romagos Lopez and Leticia Romagos Lopez are the
children of Maria Romagos and Eduardo Lopez. The
middle name or initial (R) is the mother’s maiden name,
Romagos. After marriage, Jose keeps the same name,
whereas his sister’s name becomes Leticia L. Lukban
(her husband being Ernesto Lukban). Leticia’s maiden
name, Lopez, is abbreviated as her middle initial.
Many Filipino names are of Spanish origin. Sym-
bolic of Filipinos’ Catholic faith, saint names are often
used with first names. Filipino females may have a Ma.
(for Maria) before their given names—for example, Ma.
Luisa stands for Maria Luisa. Although the name
Maria is often given to girls, some males may use Maria
as a first or second name—hence, Ma. Jose Romagos
Lopez and Jose Ma. Paredes Castro. The saint name is
an integral part of the first name, so an individual will
use both first names: Maria Luisa or Jose Maria. Few
Filipino American women keep their own surname
after marriage, although this may increase among
second- and third-generation Filipinos.
Adults use first names to address young children.
Nicknames symbolizing affectionate regard for the
person (Nini, Baby, Bongbong) are commonly used
instead of the first name. These nicknames may in-
dicate special meanings, positions, and/or outstand-
ing characteristics of the child. First names are
avoided when addressing older adults and those oc-
cupying higher positions in the hierarchy. In formal
business transactions, prefixes such as Mr., Mrs.,
Miss, or Ms. or the person’s professional degree are
used before the person’s last names (Dr. Abaya or
Attorney Abaya).
People of Filipino Heritage 233
R E F L E C T I V E E X E R C I S E 1 3 . 1
Marianita de la Fuente, a 95-year-old female, was admitted to a
general medical unit for chest pain, generalized weakness, and
dizziness. She has diabetes mellitus and hypertension for which
she is on medication. With 8 children and 23 grandchildren,
she proudly tells all the health-care providers that all her
children finished college and her grandchildren are doing
very well in school. The patient had several diagnostic tests
in the first 2 days of her hospitalization.
On the third day of her hospitalization, her condition wors-
ened. Because she is a devout Catholic, the family requested a
Catholic priest to provide the sacrament for the sick. With a
large and extended family, Mrs. de la Fuente’s room is always
crowded with visitors. The staff are complaining about the
number of visitors and how there is not adequate room when
providing care for the patient.
1. What cultural value regarding family does the staff need to
consider in this situation?
2. What are some culturally sensitive strategies that nurses
can do to provide care to this patient and address the
number of visitors in the patient’s room?
3. Describe the Filipino family kinship system and the roles of
older parents and adult children.
4. How does Mrs. de la Fuente express her value of
education?
2780_Ch13_228-249 16/07/12 11:47 AM Page 233

Family Roles and Organization
Head of Household and Gender Roles
Since the pre-Spanish era, Filipino women have been
held in high regard, having rights equal to those of
men (Agoncillo & Guerrero, 1987). In contemporary
Filipino families, although the father is the acknowl-
edged head of the household, authority in the family
is considered egalitarian. The mother plays an equal,
and often major, role in decisions regarding health,
children, and finances (Fig. 13-2).
Traditional female roles include caring for the sick
and children, maintaining kinship ties, and managing
the home. Parents and older siblings are involved in
the care and discipline of younger children. In ex-
tended family households, older relatives and grand-
parents share much authority and responsibility for
the care and discipline of younger members. Tradi-
tional Filipino families may not expect female children
to engage in activities that are considered appropriate
for men, such as driving, bicycling, and other func-
tions requiring mechanical or technical skills. Blurring
of roles between men and women occurs with in-
creased education, urbanization, and emigration to a
new culture, as in the United States and elsewhere.
In the United States, Filipino families predomi-
nantly consist of married couples with both spouses
working. Filipino womanhood has evolved from
the Spanish construct of modesty, demureness, and
femininity to a contemporary image of a woman who
is educated, working, and adept at balancing tradi-
tional roles and career demands. Traditional Filipino
parents expect their male and female children to
pursue college education and economically productive
careers and also to have a family. Family members and
Filipino friends or acquaintances are the preferred
caregivers of young children when parents are work-
ing. Older adults, especially grandmothers, emigrate
in time for the birth of their grandchildren and are
expected to take care of them on behalf of their work-
ing adult children (Pacquiao, 1993).
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Like other cultural groups, Filipinos highly value their
children. They are seen as gifts from God and therefore
are considered special blessings to the family. The
strong in-group consciousness of Filipinos is rooted in
the centrality of family and kin, to the exclusion of oth-
ers, in the socialization of individuals. As the strongest
unit of society, the family demands the deepest loyalties
and significantly influences an individual’s social inter-
actions. Ascriptive and particularistic personal ties with
kin are significant in the allocation of rank, authority,
and power to individuals. Generational position condi-
tions the status as well as the role performance of indi-
viduals. The family and one’s familial role define
and order authority, rights, obligations, and modes of
interaction. Younger generations are taught to be re-
spectful and heed the authority of older siblings and
relatives, parents, and grandparents. Respect is mani-
fested in both speech and actions by using honorific
terms of address, avoiding confrontation and offensive
language, keeping a low tone of voice, greeting older
people by kissing their forehead or back of their hand,
avoiding direct eye contact when being admonished, of-
fering food, touching, and so forth. Husbands and wives
address each other using the honorific terms that they
wish to model for their children. In front of the children,
a husband will address his wife as Inay (Mother) and
the wife correspondingly refers to her husband as Itay
(Father). Under no circumstance are children permitted
to call their parents by their first names. Friends of
Filipino children are expected to show respect to adult
members of the family when they visit.
Reciprocal obligations among kin are embodied in
the value of utang na loob, a personal sense of indebt-
edness and loyalty to kin, which carries an obligation
to repay or perform services for one another. Filial re-
spect and obligation for caring for one’s parents is the
ultimate confluence of generational respect and recip-
rocal obligation. Childhood socialization to the mech-
anism of shame (hiya) reinforces the value of utang na
loob and generational respect. Failure to perform or
recognize reciprocal obligations, as well as disrespect
of older people or people of authority, results in the
loss of one’s self-esteem and status, as well as incurs
shame to one’s family.
Conditions such as mental illness, divorce, terminal
illness, criminal offenses, unwanted pregnancy, homo-
sexuality, and HIV/AIDS are not readily shared with
outsiders until trust is established. The extent to which
a Filipino patient may disclose personal information
is contextualized. Family presence may act as a barrier
to full disclosure of conditions that may be perceived
as putting the family at risk for shame.
234 Aggregate Data for Cultural-Specific Groups
Figure 13-2 Members of a Filipino family that is bilaterally
extended to three generations. (Photograph by Rowena Legaspi.)
2780_Ch13_228-249 16/07/12 11:47 AM Page 234

Dating at an early age is discouraged for young
daughters who are advised that a short courtship pe-
riod may suggest that they are “easy to get.” Young
men with sincere intent must strive to get on the good
side of the family and have patience with a long
courtship. Open demonstrations of affection with sex-
ual undertones are to be avoided by the young couple.
Ideally, the groom’s parents formally ask for the
bride’s parents’ consent for the marriage of their chil-
dren. Traditional families desire that their daughters
remain chaste before marriage. Pregnancy out of wed-
lock brings shame to the whole family. Modernization
and urbanization have changed the social mores in the
Philippines; yet, many Filipino American families are
still perceived by younger family members as having
an overly protective attitude toward children in mat-
ters of “hanging out” with friends, dating, and
courtship. Girls are subjected to greater limitations
than boys, which contributes to higher reports of con-
templating suicide by Filipino girls. Studies of second-
generation Filipino students in high schools revealed
greater parental control over daughters, with more lat-
itude allowed for sons. For many Filipinas, high
school achievement was met by parental control over
their choice of colleges and pressure to remain close
to home and family supervision (Wolf, 1997).
Family Goals and Priorities
In addition to blood relatives, fictive kinship is estab-
lished through the compadrazgo system in which
friends and associates are invited to become godpar-
ents or surrogate parents in religious ceremonies, such
as baptism and marriage. Fictive kinship is a signifi-
cant support system for Filipino Americans who left
families or relatives in the home country. In times of
illness, the extended family provides support and as-
sistance. Sometimes, a family visit to the hospital takes
on the semblance of a family reunion.
The family is the basic social and economic unit of
Filipino kinship. Family relations strongly influence
individual decisions and actions. Relatives and family
constitute the reference group for individuals, deter-
mining their behavior as well as that of their relatives
in any social exchange. Family loyalties and obliga-
tions supersede individual interests and residential
migration. This is evident in migration patterns of
adult children and aged parents, which are planned
to maximize the economic welfare and support for
group members.
Family emphasis on communal values and genera-
tional respect is highly institutionalized. Community
activities generally center on the family. Fiestas, wed-
dings, baptisms, illnesses, and funerals are occasions
for reinvigorating relations with kin and rekindling
local connections, in which the presence and, more im-
portantly, the absence of relatives are viewed as highly
significant. Early child-rearing practices are permissive,
with emphasis on providing an emotionally secure
environment for the child. Priority is placed on pro-
moting the child’s well-being and social acceptance.
The child is introduced early into various mechanisms
designed to impose compliance with family values.
A family’s prestige is measured by the upbringing of
their children, judged by their adherence to traditional
cultural values.
The family emphasis on faithfulness to religious ob-
ligations is tied with the cultural values of genera-
tional respect and reciprocal obligation. Child-rearing
practices stress entire family participation in the reli-
gious education and adherence to rituals by young
members. Older generations share the responsibility
for reinforcing these values. Religious sacraments,
such as marriage, are embedded in the age-grading
activities of the extended family (Fig. 13-3).
As the basic economic unit of society, the family
defines the economic obligations of kin to one an-
other. Children are looked upon as economic assets
and as sources of support for parents in old age. Thus,
educating young members becomes a family priority.
The socioeconomic status of the aged is closely linked
with the family’s wealth; if resources are limited, older
people rely on children and relatives. Older parents
and grandparents are integrated within the family,
thus lessening the impact of advancing age. Tradi-
tional Filipinos consider institutionalization of aged
parents tantamount to abandonment of filial obliga-
tion and respect for older people. Many older people
aspire to return to the Philippines to spend their
remaining years with loving kin.
The development of pakiramdam and kapwa is the
defining goal of the family. Group cohesiveness, loy-
alty, and faithfulness to shared obligation are expecta-
tions that transcend distant migration, marriage, and
adulthood. Students who feel obligated to maintain
People of Filipino Heritage 235
Figure 13-3 The Spanish influence in the Philippines is
depicted in this Roman Catholic wedding featuring godparents
as an important part of fictive kinship development for the
couple and their families. (Photograph by Rowena Legaspi.)
2780_Ch13_228-249 16/07/12 11:47 AM Page 235

their family’s reputations believe that effort and inter-
est, rather than ability, can result in school success
(Salazar et al., 2000).
Filipino American older people have reported ex-
periencing conflict between the maintenance of family
obligations, such as babysitting for their grandchil-
dren, and their desire to be more independent from
their adult children. Family obligations may result in
their inability to meet medical appointments, obtain
needed medications, and make meaningful social con-
nections because of lack of independent transporta-
tion. Depression has been associated with loneliness,
feelings of isolation, and financial difficulty (McBride
& Parreno, 1996). Older Filipino Americans identified
integration in the family of their adult children, par-
ticipation in community activities with family and
close friends, and maintaining religious functions as
highly important (Pacquiao, 1993).
Diversity exists in the degree to which Filipino
Americans adhere to the traditional cultural values.
Some middle-aged immigrant Filipino parents do not
expect to live with their children in old age. Diversity
in family member roles and priorities exists as a result
of the financial resources of the family. Reciprocal ob-
ligations with kin are expressed differentially based on
the capacity of older people and adult children to
meet them and include economic, physical, emotional,
and social support dimensions.
Alternative Lifestyles
Traditional Filipino parents seldom provide sex edu-
cation, and sex is not discussed openly at home. Ho-
mosexuality may be recognized and considered an
aberrant behavior, but it is not openly practiced in
order to save face and prevent shame for the family.
In recent years, younger gay, lesbian, bisexual, and
transgender Filipinos in the Philippines and in North
America are taking a more active role in being recog-
nized and expressing their rights.
Although the tenets of the Catholic Church have a
direct bearing on sexual mores for older generations of
Filipinos, they have less influence on younger genera-
tions, as is seen in the high incidence of HIV/AIDS
among Filipinos compared with that of other Asian/
Pacific Islanders (APIs). The family may not be the pri-
mary source of support for individuals, who may be
isolated to prevent stigma to the family. The nuclear
family may protect the affected member from outsiders
and intentionally remove them from a network of
friends and extended family. Providing an atmosphere
that fosters the much-needed sense of belonging should
be the goal of culturally congruent services.
Divorce can carry a stigma for older and more tra-
ditional Filipinos, especially those who are devout
Catholics. The stigma may be worse for Filipinos in
the Philippines for whom divorces are not allowed and
are considered a religious taboo. Divorces among
Filipino Americans generally result from failed mari-
tal duties, lack of mutual support between partners,
and marital infidelity.
Workforce Issues
Culture in the Workforce
Experience with racism is a continuing theme voiced
by Filipino nurses working with white American
nurses (Spangler, 1992). Among Filipino American fe-
male nurses and nurse’s aides, longer residence in the
United States is associated with increased stress, evi-
denced by higher levels of serum norepinephrine, and
higher diastolic pressure and lower dips in blood pres-
sure readings during sleep (Brown & James, 2000).
The requirement by the American Nurses Association
for equal pay for the same job transformed foreign
nurse recruitment into a competitive enterprise, in
which employers and existing staff expected recruited
nurses to be functionally competent on the job as soon
as they received their American RN license because
they will receive pay comparable with that of other
RNs. In reality, providing transitional support for for-
eign nurses requires a significant commitment of time
and financial investment and a prolonged accultura-
tion process (Pacquiao, 2004).
Filipino nurses have been recruited in large num-
bers to staff mostly evening and night shifts in which
acute shortages of American trained nurses exist. This
has reinforced the cultural tendency toward collective
solidarity by defining the context of interactions
within the insider-outsider continuum. American
nurses and administrators of health organizations
with large contingents of Filipino nurses are becoming
aware of the need for special knowledge and skills in
understanding and managing a diverse workforce and
in developing culturally specific staff development
programs.
Cultural conflicts in the workplace stem from dif-
ferent communication patterns: the dominant norm
of assertiveness versus the highly contextual Filipino
communication. The cultural concept of shared iden-
tity with other Filipinos creates a propensity among
Filipino nurses to speak in their own dialect with one
another to the exclusion of non-Filipino coworkers
and patients. A lack of fluency in speaking and in
enunciating English words results in anxiety when in-
teracting with outsiders. Assertive communication is
difficult for Filipinos, who have been enculturated to
avoid conflict. Filipino nurses may consider it impolite
and disrespectful to confront or challenge the author-
ity of a superior. When a problem with a manager oc-
curs, a Filipino nurse may communicate through a
mediator, usually another Filipino nurse, who is in
the same level within the hierarchy as the manager.
Communicating disagreement with a physician is dif-
ficult for many Filipino nurses. Conversely, Filipino
236 Aggregate Data for Cultural-Specific Groups
2780_Ch13_228-249 16/07/12 11:47 AM Page 236

registered nurses expect their subordinates to be
deferential toward them.
Conflict can result from different cultural values
about caring. Coming from a highly collective orien-
tation, Filipinos define caring in terms of active caring
for others. This perspective differs from the American
value of self-care. Filipino nurses feel comfortable per-
forming what they perceive as caring tasks for patients
that American nurses expect patients to do for them-
selves. Initially, they may not be inclined to teach and
demonstrate procedures to patients because of their
traditional belief in doing the caring tasks for patients.
Outsiders may misconstrue Filipino nurses’ preoccu-
pation with caring tasks as disorganization or lack of
assertiveness.
Different views about a valued coworker may be an-
other source of conflict. The Filipino values of shared
perception and being one with others create a coop-
erative, rather than a competitive, outlook. A valued
individual produces for the group and puts the group
above her or his own personal gain. Humility, hard
work, loyalty, and generosity are admired. The busi-
nesslike and competitive perspectives of Americans,
in which behavior is internally motivated by individual
gain, may be interpreted as selfish and uncaring. Self-
proclamations of accomplishments are viewed as
cocky and offensive. Instead, it is up to the group to
recognize a member’s achievement, which is assessed
in terms of how the action benefited the group.
Health-care organizations are cultural entities de-
fined by norms that reflect the dominant values of the
host society. Professional schools mirror these domi-
nant societal norms, which are congruent with those
of health-care organizations. Among outsiders to the
dominant American culture, the experience in nursing
schools and health-care organizations is dissonant
with previous life experiences, which require an under-
standing of both cultural and occupational role dif-
ferences. Bicultural development of Filipino and
non-Filipino staff should be the goal of occupational
orientation and training. Biculturalism requires
awareness of self and others and the ability to adapt
behaviors that build positive relationships with others
who may be different from oneself (Pacquiao, 2003).
Understanding cultural differences and similarities al-
lows for the development of intercultural understand-
ing and skills that promote teamwork. Bicultural
mentors who can teach cultural norms of the organi-
zation and work with diverse patients and staff will
foster the individual’s ability to adapt behaviors. Staff
development requires training in frame switching—
using different frameworks to understand behaviors
of others and commitment to the belief that other per-
spectives are equally sound in explaining our experi-
ences. Impression management is a bicultural skill that
is grounded in the ability to interpret behaviors of
others within their own cultural context and manifest
behaviors that promote relationship and intercultural
understanding (Pacquiao, 2001).
Issues Related to Autonomy
A core Filipino cultural concept is bahala na, which
consists of the belief and predisposition to trust the
divine providence and social hierarchy to resolve prob-
lems. Filipinos may avoid taking an active role in man-
aging problems because of their fatalistic belief that a
“greater power” will prevail. Outsiders may interpret
this behavior as a lack of initiative or responsibility.
Many Filipino nurses are hesitant to assume leader-
ship roles and assert their points of view, especially
with outsiders. After an initial effort, further attempts
to resolve the problem are generally left to the leader
or hierarchy. Providing support and acting as a role
model help these nurses assert themselves and feel
confident in problem solving and conflict resolution.
Filipinos are proud people who place importance on
maintaining self-esteem and dignity by saving face and
avoiding shame. Their sensitivity and attention to
other people’s feelings are often exhibited as indeci-
siveness, which many Americans interpret as lack of
assertiveness.
The Filipino hierarchy and emphasis on collectivity
bring a consequent group-oriented sense of responsi-
bility and accountability. The leader is respected,
followed, and expected to make decisions on behalf
of members. The leader is trusted to act in the best
interests of the group. The concept of individual
accountability and responsibility in a highly litigious
society, such as the United States, may initially be dif-
ficult for Filipino nurses to understand. Supportive
role modeling in assuming individual accountability
is important for Filipino-educated nurses.
Biocultural Ecology
Skin Color and Other Biological Variations
Variations in anthropomorphic physical and biophys-
iological characteristics of Filipinos exist as a result
of ethnic and racial intermingling. The people of one
of the Filipino aboriginal tribes, the Aeta, are negroid
and petite in stature. They are believed to have mi-
grated from Africa through land bridges during the
Ice Age. However, like other tribal groups in the
Philippines, they are now a minority. The typical
native-born or immigrant Filipino may be of Malay
stock (brown complexion) with a multiracial genetic
background.
The youthful features of Filipinos make it difficult
for some to assess their age. Common Filipino physi-
cal features may include jet black to brunette or light
brown hair, dark to light brown pupils with eyes set in
almond-shaped eyelids, deep brown to very light tan
skin tones, and mildly flared nostrils and slightly low
to flat nose bridges. The eye structure may challenge
People of Filipino Heritage 237
2780_Ch13_228-249 16/07/12 11:47 AM Page 237

health-care providers in assessments such as observing
pupillary reactions for increased intracranial pressure,
measuring ocular tension, and evaluating peripheral
vision. The flat nose bridge may be overlooked by
opticians when fitting and dispensing eyeglasses.
The high-melanin content of the skin and mucosa
may pose problems when assessing signs of jaundice,
cyanosis, and pallor. This feature also poses difficulty
in diagnosing retinal, gum-related, and oral tissue ab-
normalities. When performing skin assessments, prac-
titioners should consider the complexion and skin tone
of the Filipino patient. The usual manifestations of
anemia (pallor and jaundice) should be assessed in the
conjunctiva. Newborns may have Mongolian spots—
bluish-green discolorations on the buttocks—that are
physiological and eventually disappear.
Filipinos range in height from under 5 feet to the
height of average Americans. Body weight varies ac-
cording to nativity and other factors such as nutrition,
physical activity, and heredity. Filipinos commonly
gain weight when they come to the United States.
There are no definitive studies relating nutrition with
standard height and weight measures for this popula-
tion; therefore, it is essential to assess for weight
changes on an individual basis.
Filipinos have a small thoracic capacity. Approxi-
mately 40 percent have blood type B and a low inci-
dence of the Rh-negative factor (Anderson, 1983). As
more interracial families emerge in Filipino communi-
ties, changes in their serologic profile will likely occur.
Diseases and Health Conditions
Filipino men and women have the highest prevalence
of hypertension compared with whites (Ryan, Shaw,
& Pilam, 2000) and compared with other Asians char-
acterized by sodium sensitivity (Garde, Spangler, &
Miranda, 1994). Despite the high prevalence of hyper-
tension among Filipino Americans, the rate of con-
trolled hypertension is lower than the rates for whites
and other Asians.
Filipinos also had the highest rate and risk of type
2 diabetes at 32.1 percent, compared with 5.8 percent
in whites and 12.1 percent in African American women.
Filipino women were found to have higher visceral adi-
pose tissues compared with non-Hispanic whites and
African American women. Filipino Americans have a
disproportionately high prevalence of diabetes in a
nonobese population (Bateman, Abesamis-Mendoza,
& Ho-Asjoe, 2009).
High incidence of hyperuricemia is attributed to a
shift from a Filipino to an American diet (McBride,
Mariola, & Yeo, 1995). Liver cancer tends to be diag-
nosed in the late stages of the disease and appears to
be associated with the presence of the hepatitis B
virus. Silent carriers of the virus are common among
Asians, and its presence is detected only when other
problems are being evaluated. Health-care providers
should routinely screen for hepatitis B virus, especially
among recent immigrants. A high incidence of glucose-
6-phosphate dehydrogenase (G-6-PD), thalassemias,
and lactose intolerance and malabsorption exist
among the Filipino population (Anderson, 1983).
Compared with other APIs and white males,
Filipinos are more likely to be diagnosed with
advanced-stage colorectal and prostatic cancers. They
have the worst survival rates from these cancers (Lim,
Clarke, Prehn, Glaser, West, & O’Malley, 2002). Like
other APIs, Filipinos underuse cancer screening tests
(Kagawa-Singer & Pourat, 2000). Filipino Americans
are at increased risk for type 2 diabetes and have
higher visceral adipose tissue (VAT) than whites and
African Americans (Araneta & Barrett-Connor,
2005). The three leading causes of mortality among
Filipino Americans are cardiovascular disorders
followed by stroke and cancer.
Lack of insurance, low income, and limited access to
care were found to have a significant impact on APIs’
use of health services (Coughlan & Uhler, 2000; Yu,
Huang, & Singh, 2004). A Canadian study using the
2001 Community Health Survey revealed that minori-
ties, including Filipinos, were less likely to be admitted
in the hospital, tested for prostate-specific antigen
(PSA), or given a mammogram or Pap test, despite the
fact that they had more contact with a general practi-
tioner than white Canadians (Quan et al., 2006). Among
older Filipinas, length of residence in the United States
and having had a checkup when no symptoms were
present were associated with adherence to cancer screen-
ing (Maxwell, Bastani, & Warda, 2000).
Compared with white Americans, Filipinos have
higher levels of depression. In contrast, strong ethnic
identity characterized by sense of ethnic pride, involve-
ment in ethnic practices, and cultural commitment to
one’s racial and ethnic identity were significant factors
in mitigating depressive symptoms among Filipino
Americans (Mossakowski, 2003). Strong bonds with
members of the community and access to culturally
congruent health services promoted commitment of
older Filipinas to planned physical activity (Maxwell,
Bastani, Vida, & Warda, 2002).
Variations in Drug Metabolism
Studying how ethnicity affects drug response is chal-
lenging, in part because of the tremendous variations
that exists within each ethnic group. Many studies
have used broad categories when classifying partici-
pants without differentiating among subgroups—
for example, using the term Asians to refer to
Filipinos, Korean, and Chinese, among others
(Munoz & Hilgenberg 2006). Ethnographic research
has uncovered significant differences in how people
of color metabolize drugs differently. There are vari-
ations in both pharmacodynamics and pharmacoki-
netics mechanisms of action. Also, certain ethnic
238 Aggregate Data for Cultural-Specific Groups
2780_Ch13_228-249 16/07/12 11:47 AM Page 238

groups have more of these variations than others
(Lin & Smith, 2000).
Compared with white Americans, Asians require
lower doses of central nervous system depressants
such as haloperidol, have a lower tolerance for alco-
hol, and are more sensitive to the adverse effects of
alcohol (Levy, 1993). Owing to the sodium-sensitive
nature of hypertension affecting Filipinos and the
high-sodium content of their diet, use of diuretics
should be considered. Culturally congruent stress
management in addition to dietary modifications and
physical activity should be included in the treatment
plan to control high blood pressure.
Because of availability of over-the-counter antibi-
otics and lack of adequate medical monitoring of these
drugs in the Philippines, Filipino immigrants may be
insensitive to the effects of some anti-infectives. A pos-
itive reaction to tuberculin or the Mantoux test is
observed because of the practice of giving bacille
Calmette-Guérin (BCG) vaccinations in childhood.
Chest x-rays and sputum cultures are recommended
for screening and diagnosis of tuberculosis. More re-
search is needed to determine pharmacodynamics
among Filipinos, including gender differences. Health-
care providers, as with all patients, need to assess
Filipino patients individually when administering and
monitoring medication effects.
High-Risk Behaviors
Gender differences are evident in the Filipino tolerance
and acceptance of high-risk health behaviors related to
alcohol, drugs, cigarettes, and safe sex. More Filipino
men than women are heavy drinkers. Most Filipino
Americans report drinking socially, with a small num-
ber reporting having three or more drinks per day
(Garde et al., 1994). Because denial is closely associated
with alcoholism, the frequency and amount of alcohol
taken are generally underreported.
Cigarette smoking is more prevalent among Filipino
men than women. Smoking rates have been positively
correlated with lower educational levels and income
and a tendency to think or speak in a Filipino language,
and, for women, being born in the United States. Most
Filipino youths reported living with an adult who
smoked, and their first substance of choice was ciga-
rettes, followed by alcohol and inhalants (Maxwell,
Garcia, & Berman, 2007).
Filipinos constitute the largest number of reported
HIV/AIDS cases among APIs in the United States
(Reeves & Bennett, 2004). Low knowledge scores on
information about HIV transmission and unprotected
sex with multiple partners underscore the urgency of
HIV and AIDS education and prevention.
Health-Care Practices
Cultural, social, and economic factors are implicated
as reasons for Filipino Americans’ underutilization of
health services. Typical of the ethnically underserved,
older people in the United States may be unaware of
available services and are reluctant to access social and
health services, particularly when culturally sensitive
and bilingual providers are unavailable. Lack of trans-
portation, fear of going to the area where services are
located, and inappropriate program design are some
of the other reasons for low utilization of services by
this group. More recent Filipino immigrants differ sig-
nificantly from their earlier counterparts in their ac-
cess and utilization of health services. This group is
highly educated and accesses many of the health-care
services in the United States.
A study of the experiences of Filipino women
with breast cancer screening services identified a
pattern of avoidance. Factors contributing to this
behavior included cultural beliefs, lack of health in-
surance, and lack of a familiar source of care (Wu &
Bancroft, 2006). Some believe that undergoing the
test and attempting to know one’s condition could
tempt faith, which can bring bad luck. Avoidance of
an unpleasant diagnosis and concealment of serious
illnesses are consequent behaviors of this belief.
Many Filipinos seek a familiar and consistent health
practitioner who has established a relationship with
them. Gender-congruent health-care providers are
preferred for conditions specific to women’s or men’s
health. Preference for culturally congruent services
and practitioners and the presence of supportive so-
cial connections increased participation and commit-
ment among older Filipinas for health promotion
(Maxwell et al., 2002).
Nutrition
Meaning of Food
Food to any group is symbolic and is associated with
the affective state of the individual. It is a source of
nourishment to the body, as well as a source of pleas-
ure and satisfaction, depending on one’s emotional
and psychological state. To the Filipino, food is a
fundamental form of socialization. Food and meal
patterns are integral to the cultural emphasis on gen-
erosity, hospitality, and thoughtfulness that support
group cohesiveness. No social gathering of Filipinos
occurs without food. Food is offered as a token of
gratitude and caring, to welcome others, to celebrate
accomplishments and important events, to offer sup-
port in times of sickness or crisis, and to reinforce so-
cial bonds in everyday interactions. Sharing food with
others, or at the very least inviting others to share
one’s food, is expected of Filipinos and considered
a sign of good upbringing. The insider versus out-
sider context influences the choice of food offered
(Enriquez, 1994).
In the Philippines, traditional Filipino meals are
labor intensive, requiring the participation of several
People of Filipino Heritage 239
2780_Ch13_228-249 16/07/12 11:47 AM Page 239

family members. Meats are costly, so small amounts
are cut in pieces and expanded using vegetables and
starches to feed an entire family. All family members,
regardless of age, attend social gatherings at which a
variety of dishes are prepared to accommodate indi-
vidual choices. The hosting family serves large
amounts of food to accommodate invited guests and
those who happen to be around. Guests customarily
linger for several meals because the focus is on the
gathering. Latecomers are welcomed and expected to
fully participate in the entire meal and the company
of other guests. Dishes are served all at once from ap-
petizers to desserts so guests are free to eat their
courses without waiting for everyone to arrive. Guests
are encouraged to return to the table to join arriving
guests. More food means more portions for each one
and vice versa.
Common Foods and Food Rituals
Indigenous Filipino cooking is characterized by
boiling, steaming, roasting, broiling, marinating, or
sour-stewing to preserve the fresh and natural taste
of food. Spanish, Chinese, and American influences
are integrated into contemporary Filipino cuisine.
Foods may be sautéed, fried, or served with a sauce.
Because of the tropical climate of the Philippines,
many types of plants and animals flourish. Seafood
(fish and shellfish) forms the bulk of the Filipino
diet. Fresh, dried, and marinated fish are abundant
in the diet.
In the Philippines, animal sources of protein are
chicken and pork because cows and water buffalo are
primarily used for farming. Because protein-rich
foods are costly, meals generally consist of larger por-
tions of carbohydrates, primarily rice. Plants are the
second most important food source and include a va-
riety of seaweeds, edible roots, delicate leaves, tendrils,
tropical fruits, seeds, and some flowers. Fruits and
vegetables are consumed in large quantities in a vari-
ety of ways. Rice is eaten at every meal—steamed,
fried, or as a dessert. Less acculturated Filipinos
tend to prepare and serve more traditional Filipino
foods at home (de la Cruz, Padilla & Agustin, 2000).
Filipino and Asian food stores are abundant in
regions where many APIs reside.
Except for babies and young children, milk is al-
most absent in the Filipino diet. This may be partly
due to lactose intolerance. However, milk in desserts
such as egg custard (flan) and ice cream seems to be
tolerated. In the Filipino food pyramid, milk and
dairy products are incorporated in the major protein
groups rather than as a separate category. Dietary cal-
cium is derived from green leafy vegetables and
seafood. Coconut milk is a common cooking additive
among the Bicolanos of southern Luzon. Salty (soy
sauce, fish sauce/patis, salted shrimp fry, or fermented
fish/bagoong) and spicy sauces known as sawsawan
complement meals. These sauces are distinct from the
salt added during cooking.
In the Philippines, breakfast consists of rice, meat
or fish, and vegetable dishes or dinner leftovers. The
breakfast beverage may be coffee, chocolate, or juice.
In urban areas, Western-style meals are more com-
mon. For many Filipinos, breakfast, lunch, and dinner
are not complete without steamed or fried rice served
with fish, meat (especially pork), and vegetables.
Snacks of bananas, yams, rice cakes, and rice-flour
cakes are served as midday snacks, between meals, and
before bedtime. The midday meal is the heaviest meal
of the day, although this pattern is becoming more
difficult among urban dwellers who cannot go home
during lunchtime.
Dietary Practices for Health Promotion
Filipinos believe health is maintained by moderation.
Although Filipinos enjoy food and love to eat, they
adhere to the wisdom that too much of a good thing
can be harmful. In some parts of the Philippines, it
is considered polite to leave food on one’s plate. For
many Filipino Americans, moderation in food intake
is a special challenge because of the abundance
and great variety of quality products at reasonable
costs. Significant increases in weight patterns among
new immigrants are associated with changes in
dietary habits.
The principle of hot and cold is observed by many
traditional Filipinos to promote health. A warm bev-
erage is served first at breakfast after a long evening
fast, and hot soups are served as the first course to
enhance digestion. Cold drinks may be avoided when
one has a cold or fever to restore balance and pro-
mote harmony between the body and its environ-
ment. Eating rice is considered to be essential to a
healthy life. Arroz caldo, chicken and rice soup, is
generally offered to promote recovery after an illness.
Chicken soup with malunggay leaves is believed to
cleanse the blood.
Garlic and onions are believed to thin the blood
and combat hypertension. Ginger root is boiled and
served as a beverage to relieve sore throats and pro-
mote digestion. Guava shoots are eaten to treat diar-
rhea. Drinking coconut juice and water from boiled
fresh corn silk promotes diuresis. Bitter melon is eaten
as a vegetable to prevent diabetes. Greens such as
malunggay and ampalaya leaves are used in stews to
regain stamina for someone believed to be anemic or
run-down.
Nutritional Deficiencies and Food Limitations
In the Philippines, nutrition is greatly affected by so-
cioeconomic factors. Malnutrition persists in the
country, especially among the poor and less educated,
and is one of the leading causes of infant mortality.
In the United States, Filipino immigrants may be at
240 Aggregate Data for Cultural-Specific Groups
2780_Ch13_228-249 16/07/12 11:47 AM Page 240

risk for nutritional deficiencies during their adjust-
ment period, especially when they come with limited
resources and without a support network of family
and friends. Postmenopausal and pregnant women
may be vulnerable to calcium deficiency owing to
lactose intolerance and decreased intake of seafood
and green leafy vegetables that were plentiful in the
Philippines but limited in availability and variety in
American food stores. Changing food patterns and
lifestyle is associated with migration and accultura-
tion. Filipino Americans experience similar problems
such as obesity, hyperlipidemia, and diabetes seen in
the general population. Knowledge of indigenous
food sources and meal patterns, nutritional content of
foods, changes in nutritional patterns, and accessibil-
ity of traditional ingredients is important for nutri-
tional assessment and counseling.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
The Roman Catholic Church and Filipino family val-
ues significantly influence childbearing and fertility
practices. In marriage, the only acceptable method of
contraception is the rhythm method. Abortion is con-
sidered a sin and is generally not acceptable. Whereas
these beliefs remain strong among many Filipinos, ed-
ucation, global communication, and modernization
are causing changes, particularly in metropolitan cities
such as Manila. Recent Filipino immigrants who
come from large urban areas are more educated and
less committed to the Church’s position on birth con-
trol and premarital sex.
Filipino culture is child-centered, and abortion
evokes strong reactions, even among liberal Filipinos.
Though some may support the right to abortion, they
may have difficulty having one themselves and feel
guilty for considering this option. Pregnancy is consid-
ered normal and is a time when a woman can demand
attention and pampering from her husband and family
members. Health-care providers who do not under-
stand this special period for the pregnant Filipino
woman may feel that the patient is “lazy and spoiled.”
Pregnancy and childbirth are times for the family to
draw closer together. Everyone assists in anticipation
of the new baby, especially the pregnant woman’s
mother, who has a strong influence during this period.
For mother and daughter, this is a special event in
which the bond between them becomes stronger.
In the Filipino American community, women
openly give advice to pregnant women, share their
own birthing experiences, and ask personal questions
that may be considered rather intrusive by outsiders.
Elaborate baby showers are hosted by family members
and friends, and it is customary to invite male spouses,
relatives, and friends as well as children. Male guests
do not join in the activities and congregate separately
from the women.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Childbearing is widely celebrated by Filipino families.
Children are perceived to be God’s blessings and there-
fore to be accepted and be grateful. Filipino practices
surrounding pregnancy are influenced by indigenous
beliefs, Western practices, and socioeconomic factors.
In the Philippines, most mothers receive prenatal care
from a doctor, nurse, or midwife, although two-thirds
of births are delivered at home. Traditional birth at-
tendants (hilots) use massage and are consulted for
physical, spiritual, and psychological advice and guid-
ance (National Statistics Office, Philippines, 2005).
After childbirth, the new mother continues to be
pampered. Relatives help with the new baby and in run-
ning the household. Eighty-eight percent of Filipino
babies are breastfed for some time, with a median
duration of 13 months. However, supplementation of
breastfeeding with other liquids and foods occurs too
early, with 19 percent of newborns less than 2 months
of age receiving supplemental foods or liquids other
than water (National Statistics Office, Philippines,
2005). Lactating mothers are encouraged to take plenty
of hot soups (chicken with papaya) to promote milk
production (Hawaii Community College, 2005).
Some Filipino American women refuse to take vita-
mins during pregnancy for fear that these could deform
the fetus. Some believe that when pregnant women
crave certain foods, especially during the first trimester,
the craving should be satisfied to avoid harm to the
baby. Some women believe that the baby takes on the
appearance of the craved food. Thus, if the mother
craves dark-skinned fruit or dark-colored food, the in-
fant’s skin will be dark. Pregnant women are protected
from sudden fright or stress because of the belief that
this may harm the developing fetus. Table 13-1 provides
a summary of traditional beliefs and practices observed
among some Filipinos in Hawaii. Becoming aware of
the pregnant Filipino woman’s network of family and
community health advisers, whose opinions she re-
spects, is important for building trust and rapport in
the patient–health provider relationship.
Some women prefer to have their mothers rather
than their husbands in the delivery room. Mothers of
pregnant women serve as coaches and teachers and
are often respected over health-care providers for their
experience and knowledge. This may be puzzling to
health-care providers who view pregnancy as an
emancipating event. Conflicts are likely to occur if the
coach and teacher believe in practices that are con-
trary to Western childbearing practices.
During postpartum, exposure to cold is avoided.
Showers are prohibited because these may cause
an imbalance and predispose illness. However, the
People of Filipino Heritage 241
2780_Ch13_228-249 16/07/12 11:47 AM Page 241

mother is given a sponge bath with aromatic oils and
herbs, or a hilot gives an aromatic herbal steam bath
followed by full body massage, including the abdomi-
nal muscles, stimulating a physiological reaction that
has both physical and psychological benefits.
Childbirth experiences of Filipino women immi-
grants in a hospital in Australia revealed language and
communication problems as barriers to seeking ante-
natal care, perceived discrimination by the hospital
staff, and conflicting expectations of delivery practices
between the mothers and the health-care providers.
The women preferred to be examined by female
health-care providers and assume a squatting position
for birthing. Contrary to their birthing practices,
health-care providers expected the husbands to be
with them during delivery. The women felt that they
were not consulted about their care and preferred to
deliver at home (Hoang, 2008).
Death Rituals
Death Rituals and Expectations
Death for Filipinos as a spiritual event is based on the
Roman Catholic belief system and doctrine. Illness
and death may be attributed to supernatural and
magico-religious causes such as punishment from
God, angry spirits, or sorcery. Religiosity and fatalism
contribute to stoicism in the face of pain or distress
as a way of accepting one’s fate (Lipson & Dibble,
2005). Planning for one’s death is taboo and may be
considered tempting fate. Hence, many traditional
Filipinos are averse to discussing advance directives
or living wills (Pacquiao, 2001). When death is immi-
nent, contacting a priest is important if the family is
Catholic. Religious medallions, rosary beads, scapu-
lars, and religious figures may be found on the patient
or at the bedside. Family members generally wish to
provide the most intimate care to the patient.
After death, a wake is planned. In the Philippines,
the wake may last 3 days or longer to allow time for rel-
atives to arrive from distant places. In the United States,
the wake is much shorter because it is costly. Although
a wake is generally held in the home in the rural regions,
funeral parlors are used in urban areas and in the
United States. Families and friends gather to give sup-
port and recall the special traits of the deceased. Food
is provided to all guests throughout the wake and after
the burial.
The burial rites are consistent with the religious tra-
ditions of the family, which may be Judeo-Christian,
Muslim, Buddhist, or other religions. Among Catholics,
9 days of novenas are held in the home or in the church.
These special prayers ask God’s blessing for the de-
ceased. Depending on the economic resources of the
family, food and refreshments are served after each
prayer day. Sometimes, the last day of the novena takes
on the atmosphere of a fiesta or a celebration. Filipino
families in the United States follow variations of this rit-
ual according to their social and economic circum-
stances. Funerals in the Philippines can be simple or
elaborate, with a band accompaniment, several priests
officiating, and a large throng of mourners. Reciprocal
obligation continues in death through the performance
of rituals such as the wake, novenas, and establishing a
burial site acceptable for the entire family.
On the 1-year anniversary of the death, family
and friends are reunited in prayer to celebrate this
242 Aggregate Data for Cultural-Specific Groups
❙❙◗ Table 13-1 Traditional Filipino Beliefs
and Practices Surrounding
Pregnancy and Childbirth
Prenatal Postpartum
Eating blackberries will Use warm water to drink and
make the baby have bathe for a month.
black spots.
Eating black plums will Don’t name the baby before it
give the baby dark skin. is born.
Eating twin bananas will Don’t name the baby after a
result in twin births. dead person.
Eating apples will Give money to charity or the
give the baby needy when a baby comes to
red lips. your house the first time.
When a woman’s Eating sour or ice-cold
stomach is not round, foods may cause abdominal
the baby will be a boy. cramps.
If a woman’s face is Wrap the baby’s abdomen
blemished, the baby with a cloth until the umbilical
will be a boy. cord falls off.
Going outside during The mother and baby should
a lunar eclipse is not go out for a month except
harmful to the baby. to visit a doctor.
Going out in the morning Putting garlic, salt, or a rosary
dew is bad for the baby near the baby’s crib will keep
because evil spirits are evil spirits away.
present.
Funerals are avoided
because the spirit of
the dead person may
affect the baby.
Wearing necklaces may
cause the umbilical cord
to wrap around the
baby’s neck.
Sitting by a doorway
will make the delivery
difficult.
Sitting by a window
when it is dark may let
evil spirits come to the
pregnant woman.
Sweeping at night may
sweep away the
good spirits.
Knitting might tangle
the baby’s intestines
at birth.
Source: Adapted from Hawaii Community College (2005).
2780_Ch13_228-249 16/07/12 11:47 AM Page 242

memorable event. Most Filipino women wear black
clothing for months or up to a year after the death of
a spouse or close family member. The 1-year anniver-
sary ends the ritual mourning. Before this period, fam-
ily members postpone weddings and other celebrations
in deference to the memory of the deceased. Memories
and love for the deceased are shown on All Soul’s Day,
a Catholic feast day celebrated in November, when
families visit and decorate the graves of their loved
ones. Filipino American families may continue these
traditions, particularly when strong kinship is present
and the clan lives in close proximity. Many who die in
the United States are buried in the Philippines, and the
family in that country continues the tradition.
Beliefs related to cremation vary according to indi-
vidual preference. Ordinarily, bodies are buried, but
cremation is acceptable to avoid the spread of disease
and limit the high costs of burial plots. Since the
process of cremation has been accepted by the Roman
Catholic Church in the Philippines, there has been an
increase in this option. In America, some Filipinos
who wish to return their deceased family members to
the Philippines may choose cremation for practical
and economic reasons.
Responses to Death and Grief
Most Filipinos believe in life after death. Caring for
the spiritual needs of the dying is one way of ensuring
peaceful rest of the soul or one’s spirit. Family pres-
ence around the dying and immediate period after
death to pray for the soul of the departed is consid-
ered a priority. If the patient is Catholic, the priest
anoints the patient and gives Holy Communion if the
patient is able to participate. Caring is shown by pro-
viding a peaceful environment, speaking in low tones,
and praying with the ill person.
After death, grief reaction varies. Women generally
show emotions openly by crying, fainting, or wailing.
Men are expected to be more stoic and grieve silently.
Young children are admonished for behaving inappro-
priately because this is considered disrespectful to the
deceased. Family members gather together and pro-
vide physical and emotional support for each other.
Praying for the deceased and following the implicit
guidelines of behavior during mourning are ways of
demonstrating grief appropriately. Wearing black or
subdued colors (gray, white, navy blue, brown); avoid-
ing parties and playing loud, distracting music; post-
poning weddings; or devoting time to one’s studies to
honor the dead are some of the acceptable ways of ex-
pressing grief. Honoring the memory of the deceased
is a continuing obligation among close kin.
Spirituality
Dominant Religion and the Use of Prayer
The Philippines is the only predominantly Christian
country in the Far East. In 2000, Roman Catholics
accounted for 80.9 percent of the total population.
Other religious groups include Muslims, other
Christians, Evangelicals, Iglesia ni Kristo, Aglipay,
and others (CIA World Factbook, 2012). The spread
of the fundamentalist movement within Roman
Catholicism is becoming more evident. Christianity
in the Philippines is a blend of Spanish Catholicism,
American Christianity, and surviving indigenous
animistic traditions (Fig. 13-4).
Although Filipinos seek medical care, they believe
that part of the efficacy of a cure is in God’s hands or
by some mystical power. Novenas and prayers are often
said on behalf of the sick person. Families may bring
religious items such as rosaries, medals, scapulars, and
talismans for the sick person to wear. Talismans and
amulets are believed to protect one from the forces of
darkness, one’s enemies, and sickness. Blessed holy
water or oil is used to rub on the area in the body be-
lieved to be the source of distress. Performance of reli-
gious obligations and sacraments and daily prayers are
some of the ways many Filipinos believe health and
peaceful death are achieved. Providing for spiritual
needs of Filipino patients requires accommodation to
their various ways of practicing beliefs.
Meaning of Life and Individual Sources
of Strength
Filipinos consider a meaningful existence to be a
healthy and appropriate relationship with nature,
God, and kin. Indigenous Filipino beliefs are embed-
ded in the relationship between humans within the
cosmology of the universe. This concept is demon-
strated by the integration of supernatural, magico-
religious, and natural phenomena in the belief system
and practices toward health and illness. Filipinos do
not see themselves as victims but rather as part of the
larger cosmos, subject to both the controllable and
the uncontrollable forces of nature. To the traditional
Filipino, strength comes from an intimate relationship
People of Filipino Heritage 243
Figure 13-4 Filipino folk dance depicting indigenous Muslim
and Malayan influences.
2780_Ch13_228-249 16/07/12 11:47 AM Page 243

with God, family, friends, neighbors, and nature. The
concept of self is formed from the relationship with a
divine being and the social collective.
Many Filipinos find religion to be a source of
strength in their daily lives. Some Filipinos are con-
sidered fatalistic in that they tend to accept fate easily,
especially when they feel they cannot change a situa-
tion. Moreover, the acceptance of fate or destiny
comes from their close relationship and healthy re-
spect for nature. The acceptance of events they cannot
change is tied to their religious faith. A common
expression uttered by Filipinos is bahala na, originat-
ing from bathala na (it is up to God). Bahala na is
often used when the person has used all resources to
deal with a problem, and it is up to a higher power to
take care of the rest (Enriquez, 1994). Nevertheless,
an element of self-reliance exists among Filipinos,
manifested by their confidence that the situation is
within their sphere of influence through education
and hard work.
Spiritual Beliefs and Health-Care Practices
Holism and integration characterize Filipino health-
care beliefs and practices. Religious and spiritual
dimensions are important components in health pro-
motion. The importance of harmony between humans
and nature and the role of natural and supernatural
forces in health and illness are included in their beliefs
about causes of illness and healing modalities. Prayers,
religious offerings, appeasing natural spirits, and
witchcraft may be practiced simultaneously along
with biomedical interventions. Despite increasing
notoriety and scandal associated with Filipino faith
healers, this healing modality is widely sought in the
Philippines. Many Filipinos seek biomedical and in-
tegrative ways of healing and do not subscribe to the
competitive reductionism of the West. They believe in
the synergistic relationship of differing modalities and
have no problem subscribing to both ways of healing.
Many Filipino American health-care providers partic-
ipate in religious pilgrimages to Lourdes, France, and
the shrine of Fatima in Portugal to pray for good
health and healing.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Filipinos seek out family and close kin first for help
when they are ill. When illness is more defined, mobi-
lization of support occurs within the family. Decisions
about when, where, and from whom to seek help are
largely influenced by the intimate circle of family.
Among Filipino older people in the United States, the
choice of health-care providers is based on accessibil-
ity and availability to their working adult children
(Pacquiao, 1993). Linguistically and ethnically con-
gruent health-care providers are preferred. A dual
system of personal health care exists for many Filipinos,
including those who are established in American com-
munities. Filipinos may accept and adhere to medical
recommendations and may use alternative sources of
care suggested by trusted friends and family members.
Often, they adhere to Western and indigenous medi-
cine simultaneously, creating more choices to deal
with their own or their family’s health issues.
Many Filipinos consult an informal network of
friends and family members, including physicians,
nurses, pharmacists, or neighbors, who have had sim-
ilar symptoms. Once the person finds the brand name
of the “effective” medicine, the person can easily pur-
chase the drug by asking family or friends to purchase
medication in the Philippines. Hoarding prescription
drugs and sharing medicine may be practiced by
Filipinos in the United States. Those who do not be-
lieve in wastefulness or who believe that office visits
are expensive may practice these behaviors.
When educating Filipino patients about medica-
tion, health-care providers should stress that medica-
tions need to be taken as prescribed; medications are
ordered specifically for each ailment; unused drugs
should be discarded; and the use of medications by in-
dividuals other than the intended patient may have se-
rious consequences. Assessing these behaviors and
delivering the message in a respectful, courteous, and
244 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 3 . 2
Araceli Montemayor is a 41-year-old single mother with a
2-year-old son. She was recently diagnosed with breast cancer
for which she has initiated chemotherapy. She continues to
work but has periods of fatigue and other side effects of the
treatment, making it very difficult for her to take care of her
energetic 2-year-old. She told the nurse that she believes that
her breast cancer resulted from her son accidentally kicking
her in the breast, which was when she first felt the lump in her
breast. She had not had mammograms previously because of
lack of insurance and reluctance to take time off from work.
She believes that she will be cured through miraculous healing
by praying to Mary, the mother of Jesus. She is contemplating
whether she should continue with chemotherapy and experi-
ence the side effects or ask her community to pray and
intercede for her healing.
1. How would you describe Mrs. Montemayor’s belief system
regarding the cause of illness?
2. How should the nurse respond to the patient’s decision
not to continue treatment for her breast cancer?
3. Who should be included in helping Mrs. Montemayor’s
decision-making process?
4. Do you think factual information about chemotherapy
would be beneficial?
5. If available, would you consider contacting a hilot?
2780_Ch13_228-249 16/07/12 11:47 AM Page 244

unhurried manner may enhance the patient–health-
care provider relationship, especially for traditional
Filipino patients.
Health-care practices stress balance and modera-
tion for the Filipino. Health is the result of balance,
and illness is the consequence of imbalance. Imbal-
ances that threaten health are brought about by per-
sonal irresponsibility or immorality. Care of the body
through adequate sleep, rest, nutrition, and exercise is
essential for health. A high value is also placed on per-
sonal cleanliness. Keeping oneself clean and free of
unpleasant body odors is viewed as essential to health
and social acceptance. To be slovenly and disorderly
is to be shamelessly irresponsible. Aromatic baths are
taken both for pleasure and to restore balance.
Responsibility for Health Care
Parents may seek all possible assistance that they can
personally generate from family, friends, the church,
the community, and the formal health-care system
(often in that order) for a child with a serious illness
such as cancer, eventually accepting the inevitability
of death. From a Western perspective, the outcome
may be slightly different than if formal services were
accessed as early as possible. Adult children, especially
those working in the United States, are responsible for
the health care of their aged parents and extended kin.
Responsibility may be in different forms, such as
decision making, accepting financial responsibility,
providing supportive presence, performing caretaking
tasks, or negotiating with the health-care provider and
the system.
In general, older adult women provide direct care
for younger members. Older men participate in caring
tasks such as driving the patient to the clinic. Deci-
sions and financial support are relegated to family
members who are deemed qualified and able. The fam-
ily acts as a unit, and the individualistic paradigm
commonly used by American caregivers is replaced by
a social ethic of care. Before the decision is made to
inform the patient about his or her terminal condition,
a discussion among family members occurs, and
they may request that the physician not divulge the
truth to protect the patient. The ethical principles of
beneficence and nonmaleficence take precedence over
patient autonomy (Pacquiao, 2003).
Filipino family hierarchy may require consulting
with family members before decisions are made. This
may pose a problem to Western practitioners who be-
lieve in the adult patients’ autonomy to make deci-
sions about their own lives. The same perspective of
Filipinos may result in their inability to question and
assert ideas with physicians, who are regarded to be in
a higher position of authority. Major decisions may
be delegated to the physician rather than the patient
or family taking an active collaborative role in deci-
sion making. Failure to develop a trusting relationship
with the health-care provider can lead to noncompli-
ance with prescribed regimens because of lack of
participation in the decision-making process.
Folk and Traditional Practices
Supernatural and magico-religious beliefs about
health and illness are integrated with scientific medi-
cine. Mental illness may be attributed to an external
cause such as witchcraft, soul loss, or spirit intrusion.
Illness in infancy and childhood may be attributed to
the evil eye. This belief system is consistent with the
variety of Filipino folk healers. Healing rituals may
involve religious rites (prayers and exorcism), sacri-
fices to appease the spirits, use of herbs, and massage.
Balance and moderation are embedded in the hot-
and-cold theory of healing. The ideal environment is
warm, moderate, and balanced. The underlying princi-
ple is that change should be introduced gradually. Sud-
den changes from hot to cold, from activity to inactivity,
from fasting to overeating, and so forth introduce undue
bodily stresses, which can cause illness. After strenuous
physical activity, a rest should precede a shower; other-
wise, the person could develop arthritis. Cold drinks or
foods such as orange juice or fresh tomatoes are not
served for breakfast to prevent stomach upset. Exposure
to sudden cold drafts may induce colds, fever, rheuma-
tism, pneumonia, or other respiratory ailments. Some
Filipinos in the United States avoid hand washing with
cold water after ironing or heavy labor. Exposure to cold
such as showers is avoided during menstruation and the
postpartum period.
The Department of Health in the Philippines
(2005), through its Traditional Health Program, has
endorsed 10 herbs that have been thoroughly tested
and clinically proven to have medicinal value in the re-
lief and treatment of various ailments (Table 13-2).
The Philippine government has encouraged produc-
tion of these herbal medicines to provide affordable
medicines for the populations who have limited or no
access to Western health care. Widespread acceptance
of these herbal medicines is evident among educated
and higher-income groups.
Barriers to Health Care
Studies of Filipinos in the United States show that, for
many reasons, Filipinos generally do not seek care for
illness until it is quite advanced. Some take minor ail-
ments stoically and consider them natural imbalances
that will run their normal course and disappear. Others
claim to watch the progress of their illness so that the
appropriate health-care provider can be consulted. Still
others may not seek help because of economic reasons,
lack of insurance, distrust of the health-care system,
religious reasons, lack of knowledge, or an inability to
articulate their needs (McBride et al., 1995).
Many Filipinos are reluctant to participate in
health-promotion programs such as cancer screening
People of Filipino Heritage 245
2780_Ch13_228-249 16/07/12 11:47 AM Page 245

246 Aggregate Data for Cultural-Specific Groups
❙❙◗ Table 13-2 Herbal Medicines Approved by the Department of Health in the Philippines
Filipino Name/Generic Name English Name Uses
Akapulko (Cassia alata) “bayas-
bayasan”
Ampalaya (Momordica charantia)
Bawang (Allium sativum)
Bayabas (Psidium guajava)
Lagundi (Vitex negundo)
Niyog-niyogan (Quisqualis indica)
Sambong (Blumea balsamifera)
Tsaang gubat (Ehretia
microphylla lam)
Ulasimang bato (Pepperomia
pellucida) “pansit-pansitan”
Yerba buena (Clinopodium
douglasii)
Source: Adapted from Department of Health (2005).
Ringworm bush
Bitter gourd or bitter melon
Garlic
Guava
Five-leaf chaste tree
Chinese honeysuckle
Blumea camphora
Peppermint
Ringworms and skin fungal infections
Non–insulin-dependent diabetes
Cholesterol reduction
Blood pressure control
Antiseptic to disinfect wounds
Mouthwash to treat tooth decay and gum infection
Relief of coughs and asthma
Dried matured seeds to eliminate intestinal worms,
particularly Ascaris and Trichina
Diuretic, helps in the excretion of urinary stones and
treatment of edema
Taken as tea; used in treating intestinal motility and as a
mouthwash because leaves have a high fluoride content
Arthritis and gout; may be prepared as tea or eaten
as a salad
Analgesic to relieve body aches and pain; may be taken
internally or applied locally
and health education. Aging Filipino veterans may be
denied health services because of lack of insurance
and consequently referred to various nonprofit com-
munity clinics. Older Filipino émigrés did not have
adequate health benefits through their place of em-
ployment. Thus, they may have been used to postpon-
ing seeking care until the illness was quite advanced.
Health-care providers should expect wide variations
in health behaviors among Filipino American pa-
tients. A nonjudgmental history taking should be well
documented. Turning on the “multicultural ear” and
listening with care to the context of these actions can
provide insight for a health-care provider, particularly
when the health-care provider is under time pressure.
Cultural Responses to Health and Illness
Filipinos view pain as part of living an honorable life,
as well as part of the process of spiritual purification
while still on earth. Some view this as an opportunity
to reach a fuller spiritual life or to atone for past trans-
gressions. Thus, they may appear stoic and tolerate a
high degree of pain. Health-care providers may need
to offer and even encourage pain relief interventions
for patients who do not complain of pain despite
physiological indicators. Others may have a strong
sensitivity to the “busyness” of health-care providers,
quietly diminishing their own need for attention so
that others can receive care, or they may simply have
little knowledge of how pain management can be
maximized.
Minimal expression of psychological and emo-
tional discomfort may be observed. The discomfort in
discussing negative emotions with outsiders may be
manifested by somatic complaints or ritualistic behav-
iors, such as praying. Exploring the underlying mean-
ing of somatization (loss of appetite, inability to sleep)
and observing the patient’s interactions with others
can provide valuable information. Filipino patients
may display visible evidence of their religion, such as
religious medals, prayer cards, and rosary beads, to
manage anxiety and pain. These artifacts should be
incorporated into their treatment regimen. Using cul-
tural mediators or brokers to probe innermost feelings
of patients may be helpful if used appropriately.
Pain assessment can include the role of prayer by
the patient and members of the support network.
Questions such as “Do you have someone praying
for you?” or “Is there a special prayer to help you
deal with pain?” may provide vital information for
individualizing care.
Most Filipinos believe that mental illness carries a
certain amount of stigma. The first choice is caring by
family members, friends, and relatives rather than
seeking health professionals (Gong, Gage, & Tacata,
2003) to minimize exposing the problem to outsiders.
Among rural residents and less-educated Filipinos
in the Philippines, mental illness is generally attributed
to external causes such as sorcery, soul loss, or spirit
intrusion. Witch doctors, fortune-tellers, and faith
healers are often sought. Filipinos in the United States
seek professional interventions when symptoms are
advanced. Psychiatric symptoms are precipitated by a
loss in self-esteem, loss of status, and shame related
to the stresses of immigration. Separation from family,
inability to find suitable employment, uncertainty,
lack of money, and other relocation stressors create
2780_Ch13_228-249 16/07/12 11:47 AM Page 246

serious psychological reactions among Filipinos.
Among Filipino Americans, religiosity was correlated
with seeking help from the religious clergy, whereas
spirituality was associated with less help-seeking from
professional mental health practitioners (Abe-Kim
et al., 2004). Using sociocultural behaviors learned
early in life, Filipinos have a remarkable ability to
maintain a proper front to protect their self-esteem
and self-image. Mental health-care providers should
recognize that despite the possibility of a Filipino pa-
tient’s refusing professional mental health services, in-
volving a trusted family member or friends; initiating
contact with a Filipino mental health worker, espe-
cially a Filipino physician; or using both practices may
increase the odds of getting the person into a cultur-
ally compatible treatment program. Deference to au-
thority may successfully bring the Filipino patient into
treatment, with the patient’s expectation that the
authority figure will fix the problem.
Blood Transfusions and Organ Donation
The value of blood transfusion is recognized and ac-
cepted by Filipinos. However, organ donation may be
less acceptable, except perhaps in cases in which a
close family member is involved. Many Filipinos who
follow Catholic traditions believe that keeping the
body intact as much as possible until death is a rea-
sonable preparation for the afterlife. Asian Americans,
including Filipinos, hold more negative attitudes to-
ward organ donation than European Americans. They
are less likely to participate in large, urban organ
donor program (Alden & Cheung, 2000).
Health-Care Providers
Traditional Versus Biomedical Providers
Western medicine is familiar and acceptable to most
Filipinos. Many recent Filipino immigrants are edu-
cated in the health-care fields. Some Filipinos accept
the efficacy of folk medicine and may consult both
Western-trained and indigenous healers. Traditional
healers are sought more in the rural areas of the
Philippines. Folk healers are less common in the
United States, with the exceptions of the West Coast
and Hawaii. When available, they contribute by facil-
itating cultural rapport between health-care providers
and the patient and by increasing utilization of needed
health-care services. For example, the hilot is often
willing to be included in the counseling session and
provide support for the patient’s adherence to the
medical treatment. The hilot may provide a special
prayer to be incorporated into the medically pre-
scribed treatment plan to increase the patient’s sense
that all available resources are being used. In some
areas on the West Coast, the hilot has a distinct role
and function in the Filipino community. A few
Filipino health professionals have learned the hilot’s
art, skills, and spiritual approach, which they blend
into their professional practice.
A health-care provider of the same gender and the
same culture may encourage more Filipinos to take
advantage of disease prevention services. The avail-
ability of Filipino primary-care providers and, when-
ever possible, a bilingual person are critical to
improving health care for older Filipinos.
Status of Health-Care Providers
Filipinos generally consider the physician as the
primary leader of the health-care team, and other
providers are expected to defer to the physician. As
Filipino families become more acculturated and
aware of how health-care services are accessed in the
United States, changes in attitude and behavior may
be expected.
When ill, Filipinos may first consult a family mem-
ber or a friend who is a physician or other professional
before arranging a medical appointment. Some prefer
physicians from their own region, when possible,
whereas others indicate preference for physicians who
are knowledgeable and competent and have good bed-
side manners regardless of culture or ethnic back-
ground. Factors considered in choosing health-care
providers by middle-aged immigrant Filipino women
People of Filipino Heritage 247
R E F L E C T I V E E X E R C I S E 1 3 . 3
Concepcion Miraflor had major depression for many years.
Becoming progressively depressed for the past 6 months, she
has expressed to her daughter that everyone would be better
off if she were dead. Her daughter brought her to the mental
health clinic for evaluation, where she was assessed to be a
threat to herself and was admitted to the psychiatric unit
and started on an antidepressant. She is 51 years old, has
completed a sixth-grade education, is unemployed, and has no
health insurance. Although she can speak limited English, she is
unable to respond in English since she became depressed. She
lives with her youngest daughter and her family and takes care
of her two young grandchildren at home. Her son-in-law, who
is from Pakistan, is a practicing Muslim. As a devout Catholic,
Mrs. Miraflor was not happy with this inter-religious marriage.
She is very concerned because her two grandchildren were
not baptized in the Catholic Church.
1. How is the patient’s level of spirituality influencing her rela-
tionship with her family and the possible area of conflict?
2. What issues can the nurse assist the patient in addressing
while she is in the hospital?
3. Would you suggest a visit from a spiritual counselor?
4. Would you suggest involvement with a traditional healer?
5. What are some nursing implications related to ethnophar-
macology that the nurse needs to consider while the
patient is on antidepressant therapy?
2780_Ch13_228-249 16/07/12 11:47 AM Page 247

were concern for privacy, feelings of modesty, ap-
proval from family members (especially the spouse),
and, most important, the overall caring environment
in the system.
Interactions of Filipinos with Canadian nurses in the
hospital reflected their kapwa-oriented worldview, which
categorized nursing approaches and interactions within
the insider-outsider continuum. Patients based their
preferences for which nurses to perform their personal
and private tasks or receive information on the nurses’
ability to provide spontaneous and unsolicited care and
monitoring of their condition. Organizational policies
and protocols, in addition to short hospital stays, were
identified as barriers toward moving the patient–nurse
relationship toward higher intimacy and trust (Pasco
et al., 2004).
R E F E R E N C E S
Abe-Kim, J., Gong, F., & Takeuchi, D. (2004). Religiosity, spiri-
tuality, and help-seeking among Filipino Americans: Religious
clergy or mental health professionals? Journal of Community
Psychology, 32, 675–689.
Agoncillo, T., & Guerrero, M. (1987). History of the Filipino
people (7th ed.). Manila, Philippines: Garcia Publishing.
Alden, D.L., & Cheung, A.H.S. (2000). Organ donation and cul-
ture: A comparison of Asian American and European American
beliefs, attitudes, and behaviors. Journal of Applied Social Psy-
chology, 30(2), 293–314.
Anderson, J.N. (1983). Health and illness in Pilipino immigrants.
Western Journal of Medicine, 139(6), 811–819.
Araneta, M.R.G., & Barrett-Connor, E. (2005). Ethnic differences
in visceral adipose tissue and type 2 diabetes: Filipino, African-
American, and White women. Obesity Research, 13, 1458–1465.
Bateman, W., Abesamis-Mendoza, N., & Ho-Asjoe, H. (Eds.).
(2009). Praeger handbook of Asian American health: Taking
notice and taking action. Simi Valley: CA: ABC-CLIO.
Bautista, V. (2002). The Filipino Americans (1763–present): Their
history, culture, and tradition (2nd ed.). Naperville, IL: Bookhaus.
Brown, D.E., & James, G.D. (2000). Physiological stress responses
in Filipino-American immigrant nurses: The effects of resi-
dence time, life-style, and job strain. Psychosomatic Medicine,
62, 394–400.
Ceniza-Choy, C. (2003). Empire of care: Nursing migration in
Filipino American history. Durham, NC: Duke University Press.
CIA World Factbook. (2012). Philippines. Retrieved from https://
www.cia.gov/library/publications/the-world-factbook/geos/
rp.html
Coughlan, S.S., & Uhler, R.J. (2000). Breast and cervical cancer
screening practices among Asian and Pacific Islander women
in the US, 1994–1997. Cancer Epidemiology Biomarkers and
Prevention, 9, 597–603.
De la Cruz, F.A., Padilla, G.V., & Agustin, E.O. (2000). Adapting
a measure of acculturation for cross-cultural research. Journal
of Transcultural Nursing, 11(3), 191–198.
Department of Health. (2005). Ten herbal medicines approved by
DOH. Retrieved from www.philippineherbalmedicine.org/doh_
herbs.htm
Enriquez, V.G. (1994). From colonial to liberation psychology:
The Philippine experience. Manila, Philippines: De La Salle
University Press.
Espiritu, Y.L. (2003). Homebound: Filipino American lives across
cultures, communities and countries. Ewing, NJ: University of
California Press.
Garde, P., Spangler, Z., & Miranda, B. (1994). Filipino-Americans
in New Jersey: A health study. Final Report of the Philippine
Nurses’ Association of America to the State of New Jersey De-
partment of Health, Office of Minority Health.
Gong, F., Gage, S.-J.L., & Tacata, L.A., Jr. (2003). Help seeking
behavior among Filipino Americans: A cultural analysis of
face and language. Journal of Community Psychology, 31(5),
469–488.
Hawaii Community College. (2005). Traditional Filipino health
beliefs. Retrieved from http://www.hawcc.hawaii.edu/nursing/
tradfil2.htm
Hoang, Ha. (2008). Language and cultural barriers of Asian mi-
grants in accessing maternal care in Australia. International
journal of Language Society and Culture 26(6), 55-61. Retrieved
from http://www.educ.utas.edu.au/users/tle/JOURNAL/issues/
2008/26-6
IBON Foundation. (2007). Retrieved from http://www.ibon.org
Kagawa-Singer, M., & Pourat, N. (2000). Asian American and
Pacific Islander breast and cervical carcinoma screening rates
and Healthy People 2000 objectives. Cancer, 89(3), 696–705.
Levy, R. (1993). Ethnic and racial differences in response to med-
icines: Preserving individualized therapy in managed pharma-
ceutical programmes. Pharmaceutical Medicine, 7, 139–165.
Lim, S., Clarke, C.A., Prehn, A.W., Glaser, S.L., West, D.W., &
O’Malley, C.D. (2002). Survival differences among Asian sub-
populations in the United States after prostate, colorectal,
breast, and cervical carcinomas. Cancer, 94(4), 1175–1182.
Lin, K.M., & Smith, M.W. (2000). Psychopharmacology in the con-
text of culture and ethnicity. In P. Ruiz (Ed.), Ethnicity & psy-
chopharmacology. Washington, DC: American Psychiatric Press.
Lipson, J.G., & Dibble, S.L. (2005). Culture and clinical care.
San Francisco: University of California San Francisco Nursing
Press.
Maxwell, A.E., Bastani, R., Vida, P., & Warda, U.S. (2002). Phys-
ical activity among older Filipino-American women. Women
Health, 36(1), 67–79.
Maxwell, A.E., Bastani, R., & Warda, U.S. (2000). Demographic
predictors of cancer screening among Filipino and Korean im-
migrants in the United States. American Journal of Preventive
Medicine, 36(1), 67–68.
Maxwell, A.E., Garcia, G.M., & Berman, B.A. (2007). Under-
standing tobacco use among Filipino American men. Journal
of Tobacco Research, 9(7), 767–776.
McBride, M., Mariola, D., & Yeo, G. (1995). Aging and health:
Asian Pacific Islander American elders. Stanford, CA: Stanford
Geriatric Education Center.
McBride, M., & Parreno, H. (1996). Filipino American families
and caregiving. In G. Yeo & D. Gallagher-Thompson (Eds.), Eth-
nicity and the dementias. Washington, DC: Taylor & Francis.
Mossakowski, K.N. (2003). Coping with perceived discrimination:
Does ethnic identity protect mental health? Journal of Health
and Social Behavior, 44(3), 318–331.
Munoz, C., & Hilgenberg, C. (2006). Ethnopharmacolgy: Under-
standing how ethnicity affects drug response. Journal of Holis-
tic Nursing Practice, 20(5), 227–234.
Munoz, C., & Luckmann, J. (2005). Transcultural communica-
tion in nursing. Clifton Park: NY: Thomson Delmar Pub-
lishing Inc.
National Statistics Office, Philippines. (2010). Index of demo-
graphic and health. Retrieved from http://www.census.gov.
ph/data/sectordata/datandhs.html
248 Aggregate Data for Cultural-Specific Groups
2780_Ch13_228-249 16/07/12 11:47 AM Page 248

Pacquiao, D.F. (1993). Cultural influences in old age: An ethno-
graphic comparison of Anglo and Filipino elders. Doctoral dis-
sertation, Graduate School of Education, Rutgers University,
New Brunswick, NJ. Ann Arbor, MI: University Microfilms,
Inc. (number 9320788).
Pacquiao, D.F. (1996). Educating faculty in the concept of educa-
tional biculturalism: A comparative study of sociocultural in-
fluences in nursing students’ experience in school. In V.M.
Fitzsimons & M.L. Kelley (Eds.), The culture of learning: Access,
retention, understanding and mobility of minority students in nurs-
ing (pp. 129–162). New York: National League for Nursing
Press.
Pacquiao, D.F. (2001). Cultural incongruities of advance direc-
tives. Bioethics Forum, 17(1), 27–31.
Pacquiao, D.F. (2003). Cultural competence in ethical decision-
making. In M.M. Andrews & J.S. Boyle (Eds.), Transcultural
concepts in nursing care (4th ed., pp. 503–532). Philadelphia:
Lippincott.
Pacquiao, D.F. (2004). Recruitment of Philippine nurses to the
US: Implications for policy development. Nursing and Health
Policy Review, 3(2), 167–180.
Pasco, A.C.Y., Morse, J.M., & Olson, J.K. (2004). Cross-cultural
relationships between nurses and Filipino Canadian patients.
Journal of Nursing Scholarship, 36(3), 239–246.
Quan, H., Fong, A., De Coster, C., Wang, J., Musto, R.,
Noseworthy, T.W., et al. (2006). Variation in health services uti-
lization among ethnic populations. CMAJ: Canadian Medical
Association Journal, 174(6), 787–791.
Reeves, T.J., & Bennett, C.E. (2004). We the people: Asians in
the US. Census 2000 special reports. Washington, DC: U.S.
Department of Commerce.
Ryan, C., Shaw, R., & Pilam, M. (2000). Coronary artery disease
in Filipino and Filipino American Patients: Prevalence of risk
factors and outcomes of treatment. Journal of Invasive Cardi-
ology 12(3), 134–139.
Salazar, L.P., Schuldermann, S.M., Schuldermann, E.H., &
Hunyh, C. (2000). The Filipino adolescents’ parental socializa-
tion for academic achievement in the United States. Journal of
Adolescent Research, 15(5), 564–587.
Spangler, Z. (1992). Transcultural nursing care values and care-
giving practices of Philippine-American nurses. Journal of
Transcultural Nursing, 4(2), 28–37.
Tatak Pilipino. (2007). Profile of the Philippines. Retrieved from
http://www.filipinoheritage.com
U.S. Census Bureau. (2002). The Asian population: 2000. Retrieved
from http://www.census.gov/prod/2002pubs/c2kbr01-16
Wolf, D.L. (1997). Family secrets: Transnational struggles among
children of Filipino immigrants. Sociological Perspectives,
40(3), 457–483.
Wu, T.-Y., & Bancroft, J. (2006). Filipino American women’s per-
ceptions and experiences with breast cancer screening. Oncol-
ogy Nursing Forum, 33(4), 1–11.
Yamane, L. (2002). Native-born Filipina/o Americans and labor
market discrimination. Feminist Economics, 8(2), 125–144.
Yu, S.M., Huang, Z.J., & Singh, G.K. (2004). Health status and
health services utilization among US Chinese, Asian Indian,
Filipino, and other Asian/Pacific Islander children. Pediatrics,
113(1), 101–107.
For reflective exercises, review questions, and additional
information, go to
http://davisplus.fadavis.com
People of Filipino Heritage 249
2780_Ch13_228-249 16/07/12 11:47 AM Page 249

250
Chapter 14
People of German Heritage
Jessica A. Steckler
Overview, Inhabited Localities,
and Topography
Overview
Germans are reserved, formal people who appreci-
ate a sense of order in their lives. Their love of
music and celebrations has permanently influenced
many of the world’s cultures. The Christmas tree
(Weihnachtsbaum) with its brightly decorated orna-
ments, a universal symbol of the holiday season, is
a German creation. Gingerbread houses (Lebkuchen),
Christmas carols (Weihnachtslieder) and cards, the
“Easter hare” (Osterhase), hot cross buns, valen-
tines (Freundschaftskarten), Groundhog Day, chain
letters (Briefe zum Himmel), the tooth fairy, and
Kaffeeklatsch or “gossip sessions” all have their ori-
gins in German culture.
There are 51 million Germans in the United States
(U.S. Census Bureau, 2008) and over 3.1 million in
Canada (Statistics: Canada, 2006). Ethnic groups of
European origin are usually categorized as “white” on
applications, in surveys, and in research studies, so
there is little culturally specific information available
about them. This is unfortunate, because differences
in worldviews, cultural beliefs, and health-care prac-
tices among white ethnic groups hold important
implications for health-care providers.
The Federal Republic of Germany (Bundesrepublik
Deutschland), comprising 16 states, boasts beautiful
landscapes, high and low mountain ranges, sandy
lowlands, rolling hills, lakelands, and ocean borders.
Situated in the heart of Europe, Germany is a link be-
tween the East and the West and between Scandinavia
and the Mediterranean. Germany has the largest
economy in Europe, has the third largest economy in
the world, and is the leading per-capita export nation
in the world (CIA World Factbook, 2011). With a
population of over 82 million, it is one of the most
densely populated countries in Europe. Germany is a
member of the United Nations and NATO and is a
founding member of the European Union (CIA World
Factbook, 2011). Most of Germany is located in the
temperate zone, with temperatures ranging from 27°F
in the mountains to 68°F in the valleys of the south.
Temperatures are comparable with the climate in the
northwest portion of the United States. The Upper
Rhine has a mild climate; Upper Bavaria has warm
Alpine winds from the south; and the Harz Mountains
have cold winds, cool summers, and heavy winter snows.
Heritage and Residence
In the 18th century, the New World colonies from New
England to the Deep South grew and flourished. Even
though the colonial settlers shared an Old World her-
itage, they were a diverse people. German settlers, along
with other immigrants from Britain, France, Scotland,
and Ireland, shared a love of family and land—a love
that would eventually bond them to one another to
form a nation of Americans. The earliest German im-
migrants to the United States settled in the colonies
along the eastern seaboard, including William Penn’s
colony in Pennsylvania. Religious tolerance and equi-
table land distribution contributed to the success of
these Pennsylvania settlements. Mennonites, Dunkers,
Amish, and Moravians from Germany made up the
new Pennsylvania communities. The area in which they
settled, known as Pennsylvania Dutch Country, was ac-
tually mislabeled by English neighbors who thought the
word deutsch, meaning “German,” stood for “Dutch.”
One hundred thousand strong, these Pennsylvania
Germans were the main carriers of German culture to
the mid-Atlantic area (Domer, 1994).
Other religious social idealists from Germany soon
flowed into the colonies. Among them were the Har-
monists, who broke from the German Lutheran Church
under the leadership of George Rapp (Boorstin, 1987).
The Harmonists built Harmony, Pennsylvania; Har-
mony, Indiana; and Economy (Ambridge), Pennsylva-
nia. The Harmonists were followed by other German
sects: the Zoars, who settled in Ohio, and the Inspira-
tionists, who originally settled in western New York and
later moved west to Iowa by “divine command.”
2780_Ch14_250-268 24/07/12 3:05 PM Page 250

The second wave of German immigrants arrived in
the United States between 1840 and 1860. They were
fleeing political persecution, starvation, and poverty
in their homeland and settled on the western frontier
(Weaver, 1979). This group of influential Germans
was less interested in taking root in the United States
than in establishing a German culture. These new im-
migrants kept the German language in their schools,
published newspapers in German, joined their own
singing societies and orchestras, and married only
other Germans.
The 1930s and 1940s saw a third wave of German
immigration. Artists, architects, social scientists,
physicists, and mathematicians came to this country
to escape the Nazi Holocaust. These new arrivals were
highly educated and at the height of their careers.
After witnessing the horrors of the Holocaust, they
had no desire to transplant Old World institutions or
to establish new European-style homelands (Boorstin,
1987). These third-wave immigrants became rapidly
acculturated into American life and greatly enriched
American culture in the fields of music, psychology,
science, and mathematics. Among this prominent
group were Albert Einstein and Hannah Arendt, an
author and political scientist.
Historians have helped to further our understand-
ing of the diffusion of German immigrants into the
American heartland by tracing the existence of the
“two-door house.” These German-built houses, which
architecturally copied their European counterparts,
have two front doors. With their movement across the
United States, two-door houses appeared in Pennsyl-
vania, Maryland, West Virginia, the Blue Ridge Moun-
tains, Ohio, Indiana, Illinois, Missouri, Iowa, Kansas,
Nebraska, Michigan, and Texas (Domer, 1994).
Germans continue to embrace the United States as
their own. The desire to become American has been nur-
tured by the presence of American troops in Germany,
and many Germans have entered the United States as
spouses of military personnel. For others, business ven-
tures and the promise of career opportunities brought
them to this country. Today, about one-fourth of all
American citizens can trace their ancestry to German
roots. Germans are the dominant ancestral group in
St. Louis, Missouri; Milwaukee, Wisconsin; Chicago,
Illinois; Cincinnati, Ohio; Buffalo and New York City
in New York; and Baltimore, Maryland (U.S. Census
Bureau, 2008).
Reasons for Migration and Associated
Economic Factors
Germans have been very much a part of important
events shaping U.S. socioeconomic history. They have
been participants, observers, and victims in the Revolu-
tionary War, the Civil War, the influenza epidemic, the
Great Depression, World Wars I and II, the Vietnam
War, the Persian Gulf War, and the current global re-
cession. The reasons for their immigration to the United
States vary according to historical antecedents and are,
therefore, discussed under Heritage and Residence.
Educational Status and Occupations
Germans have a deep respect for education. In
Germany, credibility, social status, and level of employ-
ment are based on educational achievement. In other
words, Germans are very class conscious. Germans take
pride in their school system, particularly in their crafts-
manship and technology. Unlike in the United States,
education is free at all levels, except kindergarten, which
is optional, but entrance to university education is diffi-
cult and accomplished only by passing the Abitur exam-
ination. Literacy rates of Germany (99 percent) and the
United States (98 percent) are comparable (CIA World
Factbook, 2011).
In Germany, children can begin kindergarten at
age 3 (Educational Aspects in the United States and
Germany, n.d.). This is comparable with our pre-
school. At age 6, they enter grade school, which in-
cludes grades 1 to 4. At grade 5, they begin one of
three tracks of education: Hauptschule, which is spe-
cial education and the most basic educational path;
Realschule, which is general education; or Gymnasium,
which is like U.S. college preparatory courses. German
students graduate at grade 10 and can then enter into
vocational education, which prepares them for a trade
or for working in business, or they can continue col-
lege preparation. Those students wishing to go to the
universities must pass the Abitur test, which is both
verbal and written.
Germans who immigrated to the United States in
the 19th century influenced American preschool and
higher-educational systems. The Johns Hopkins Uni-
versity in Baltimore, Maryland, was founded on the
model of Humboldt University in Berlin, Germany
(McKinnon, 1993). During this same period, many
American historians and political scientists attended
German universities, returning with their doctoral de-
grees, and were instrumental in developing prototypes
for American graduate education. Many of the influ-
ences of the 19th-century German immigrants on the
educational system remain visible today.
By the mid-19th century, Turnvereins were taking
root in midwestern German American communities.
These political and gymnastic organizations believed
in a sound mind and body and provided opportunities
to grow both physically and intellectually (Acton,
1994). In this same era, schools—many of which were
parochial schools—were established in which only
German was spoken. German Catholics also estab-
lished parochial schools in this era, but unlike the
Lutherans, their ethnic identity was not tied to the
church (Coburn, 1992).
People of German Heritage 251
2780_Ch14_250-268 24/07/12 3:05 PM Page 251

German immigrants were viewed as an internal
threat in the United States during World War II and
faced turbulent times. A growing anti-immigrant senti-
ment leading to calls for immigration restriction inten-
sified the political climate. Some German immigrants’
desire to maintain an identity apart from the American
culture was expressed through the founding of the
National German American Alliance. Many German
Americans changed their names, made apologies, and
displayed their loyalties in an effort to attenuate suspi-
cions, embarrassments, and persecutions.
Today, German American families continue to
value education. Most German Americans have
a high school education at minimum. Twenty-four
percent have attained post–high school education.
However, in the age group 65 and older, 43 percent
have less than a high school education (Rowland,
1992); no current information on educational levels of
German Americans could be found. Vocational or
university education is being sought more frequently
by recent high school graduates attempting to prepare
themselves for a highly competitive work environment
and by adults who are pursuing second and third
careers. By German standards, success means being
employed, and education is seen as the way to achieve
this success (McKinnon, 1993).
The earliest German immigrants were primarily
farmers. Tobacco, wheat, rice, cotton, corn, and sugar
were among the most widely grown crops. Plantations
grew from Virginia to the colonies in the South as a
result of these prosperous ventures. Planting and har-
vesting crops required many workers with strong
backs, and because not all Germans could pay for
their passage to the New World, many worked as in-
dentured servants. They suffered many hardships
and worked long hours at the mercy of their owners.
Family members were commonly separated from one
another, and often children were sold to pay the debt
of their parents.
Between the Revolutionary War and the Civil
War, many religious sects, including the Shakers,
Harmonists, Zoars, and Inspirationists, founded hun-
dreds of intentional communities (Boorstin, 1987).
Known historically as the Utopians, they farmed the
land; spun flax, cotton, and wool into beautiful
textiles; and manufactured fine clocks and furniture.
Unlike those who immigrated to the United States
before the Revolutionary War, the Utopians formed
caring and supportive communities instead of living
in isolation from others. They worked happily for the
settlement; built simple, strong dwellings; planted
bountiful gardens; and established strong trade routes
to the American West (Boorstin, 1987).
In the post–Civil War era, Germans who came to
the United States often “chain-migrated” to the west-
ern frontier. Families and friends would leave one area
to join family, friends, and neighbors in another place.
These groups became farmers, miners, millers, construc-
tion workers, shopkeepers, blacksmiths, and locksmiths.
Many were artists and craft workers who created pot-
tery, leather goods, soap, candles, and musical instru-
ments (e.g., the dulcimer). These Germans established
outstanding breweries, beer gardens (biergarten), and
pubs (kneipen) everywhere they settled. They also
brought many trades to the United States, including
butchering, coppering, tailoring, and cabinetmaking.
Whereas they dominated the trades, German immi-
grants were found less frequently in professional and
management positions (Schied, 1993).
In the early decades of the 20th century, the Nazi
Holocaust drove many German immigrants from their
home country. Many who came in the 1930s and
1940s continued their gifted work in the United States.
Germans continue to establish their homes in the
United States. Newly arriving immigrants are highly
educated and vocationally well trained. German work-
ers are among the most skilled in the world. Germany
and the United States have similar industries in man-
ufacturing, construction, and service.
Communication
Dominant Language and Dialects
German, the official language of the Federal Republic
of Germany, is spoken in Germany; Austria; and
Liechtenstein; large parts of Switzerland and South
Tirol; and small parts of Belgium, France, and
Luxembourg. German is the native language of over
100 million people, and many literary works have been
translated into German (Kappler & Grevel, 1993).
Within Germany, there are many dialects along with
high (more formal) and low (less formal and more
conversational) German. Individuals’ home regions
can be easily identified through their speech, and
citizens from neighboring regions may have difficulty
understanding one another because of the differences
in regional jargon and accents.
In addition to the German language, German chil-
dren learn English at grade 5, and at grade 7, they learn
a third language of their choice. At grade 9, Advanced
English or, perhaps, a fourth language can be chosen
(European Education Directory, 2006).
English is the dominant language of German
Americans. Germans who originally emigrated from
Germany learned American English at work, in
school, and through socialization. Their children
grew up speaking English in public schools and
German at home.
Currently, U.S. schoolchildren are learning English,
and some grade schools teach Spanish. In high school,
Russian, French, and Advanced Spanish classes can
be chosen. The opportunity to learn German became
more available in 1997. German immersion programs
were established and took the form of summer camps,
252 Aggregate Data for Cultural-Specific Groups
2780_Ch14_250-268 24/07/12 3:05 PM Page 252

People of German Heritage 253
Saturday and after-school classes, independent, and
private and public schools.
The purpose of the German immersion programs
is to help students use a second language approximat-
ing that of a student who is native to that language.
School-based immersion programs allow the student
to use a second language for communicating in nor-
mal everyday situations as well as in subject content
learning.
Some of the full-time German immersion pro-
grams are supported and accredited by the German
government. The school must satisfy both the state
and German school guidelines. When a student grad-
uates from a German accredited school, they receive
an American diploma and also earn the German In-
ternational ABITUR. The first German immersion
education programs were modeled after the French
immersion programs developed in Canada. German
immersion programs can currently be found in 20 states.
Some German American families turned to tutor-
ing to help their children learn German when the
German immersion programs were inconvenient or
unavailable in their community. German tutors can be
found online, as well as at the American Association
of Teachers of German (AATG), which was estab-
lished in 1926 (http://aatg.org/). The AATG is dedi-
cated to the advancement of the language and culture
of German-speaking countries.
Today, there is a growing awareness of endangered
languages, and this is true about the dialects of
German Americans. A language becomes endangered
when there are so few speakers that it may no longer
be used often enough and could be lost forever. For
example, Texas German, a dialect found in the Texas
hill country, is nearly extinct. This resulted from a
change in school law mandating the use of English in
all schools during World War I (Texas State Historical
Association, n.d.). In German American homes where
the German language is expected to be spoken and
children are faced with speaking English in the
schools, intergenerational conflicts may result. Parents
do not speak English, but the children prefer to speak
English.
Americans and Germans have some similar pat-
terns of speech behavior. German is a low-contextual
language, with a greater emphasis on verbal than non-
verbal communication, showing a high degree of so-
cial approval to people whose verbal behavior in
expressing ideas and feelings is precise, explicit,
straightforward, and direct.
Forty-nine million people in the United States
claim to have German ancestors, and 1.4 million of
them can speak German (U.S. Census Bureau, 2005).
Individuals in some German American communities
mix English and German creatively when expressing
humor. In Dubois County, a German American com-
munity in Indiana, linguistic competence is measured
by a person’s ability to switch between German and
English to reflect bicultural roots and traditions
(Salmons, 1988).
Cultural Communication Patterns
People of German ancestry enjoy discussing topics of
interest after dinner. These conversations, sometimes
debates, cover a range of issues from politics, religion,
food, and work experiences to life in general. Jokes,
funny stories, or anecdotes about family members are
interspersed within the discussion.
Germans carry on their conversations at three lev-
els. The first, Gespräch, is used for casual conversation
and is more informal; the second, Besprechung, is con-
versation carried on in a work setting between
employees and supervisors about performance; and
the third, Diskutieren, is the common form of social
discourse used in discussions about various issues and
is the most formal use of the German language
(S. Maubach, personal communication, 2007). Most
Americans are often ill prepared to enter the debate
on philosophical and political issues that are ad-
dressed at this level and are thus placed at a disadvan-
tage. This cultural barrier can prevent Germans from
developing deeper relationships with outside groups.
Feelings among Germans and German Americans
are considered private and are often difficult to share.
Sharing one’s feelings with others often creates a sense
of vulnerability or is looked on as evidence of weak-
ness. The act of expressing fear, concern, happiness,
or sorrow allows others a view of the personal and pri-
vate self, creating a sense of discomfort and uneasi-
ness. Therefore, philosophical discussions, hopes, and
dreams are shared only with family members and
close friends. Emotions are intensely experienced but
are not always expressed among family or friends.
“Being in control” includes harnessing one’s emotions
and not revealing them to others.
Newer-generation German Americans, influenced
by the cultural values of the United States, are more
overt in sharing their thoughts, ideas, and feelings with
others. They have joined in the American belief that
direct confrontation and open dialogue can be pro-
ductive. In spite of this general pattern of accultura-
tion, pockets of Germans in the United States
continue to be reserved when sharing their private af-
fairs, thoughts, and concerns, including their health
concerns, with strangers. Their reluctance for social-
izing may make them appear unfriendly; yet, under
their stern exterior, they want to be liked.
Good manners are very important to Germans. A
display of politeness and courtesy is viewed as a sign
of respect. Social distance, eye contact, touch, and
facial expression define boundaries. Failure to adhere
to these protocols is considered rude by Germans and
may alienate people who are unaware of them. When
some people think of the handshake in the context of
2780_Ch14_250-268 24/07/12 3:05 PM Page 253

the German culture, they conjure visions of comics
imitating this German greeting—the quick stooping
of the shoulders and the clicking of the heels (Friday,
1989). The handshake, still a structured phenomenon
in Germany (without the clicking!), has been accultur-
ated into a more casual form by German Americans
and is a common method of greeting for both men
and women, but the practice is to always shake hands
with women first. When families and friends gather,
handshaking is practiced along with pats on the arms
or back.
Practices associated with personal touch and dis-
plays of affection, such as hugging and kissing, vary
among German families. In families in which the
father plays a dominant role, little touching occurs
between the father and the children. This relationship,
however, may become more demonstrative as parents
and children age. Affection between a mother and her
children is more evident. In other German families,
there is outward expression of love from both fathers
and mothers, grandparents, and extended family
members; hugs and kisses are expected and often
demanded as a “reaffirmation of love.”
Whereas close friends are often extended warmth
through handshakes, brief embraces, and sometimes
kisses, strangers are kept at arm’s length and greeted
formally. As the author recalls from childhood,
strangers, particularly those who were not German,
were looked on with suspicion, even though some of
these “strangers” were in-laws. Generally, Germans
are careful not to touch people who are not family or
close friends.
The distancing used by Germans to position
themselves in relation to others is greater than the
distancing used by some other cultural groups in the
United States. More acculturated German Americans
may control their space in a manner similar to that of
other Americans. In health-care situations, providers
frequently enter their patients’ personal space. German
Americans understand the need for this intrusion and
voluntarily participate in such encounters, while pre-
serving their dignity and privacy.
Germans place a high value on their privacy.
Germans may live side by side in a neighborhood and
never develop a close friendship. A German neighbor
would not be expected to borrow a cup of sugar from
another neighbor because doing so would be an ad-
mission that she or he failed to adequately stock the
pantry. Germans would never consider dropping in on
another German neighbor because this behavior is in-
congruent with their sense of order. Much prepara-
tion is completed to ready the house for guests. When
invited into the home of a German, the guest may be
surprised to find that the distance between pieces of
furniture is not conducive to conversation; their phi-
losophy is “German space is sacred” (Hall & Hall,
1990). In addition to spacing furniture, Germans use
doors to protect their privacy. A closed door requires
a knock and an invitation to enter regardless of
whether the door is encountered in the home, business,
or hospital. A closed door secures a sense of privacy
and safety for Germans. Germans guard their privacy,
which includes receiving phone calls at home. It is best
to wait for an invitation or ask permission before
contacting a new German acquaintance at home.
Germans maintain eye contact during conversa-
tion, but staring at strangers is considered rude. Even
looking into a room from the outside is considered a
visual intrusion; the interior of a room should not be
entered without permission (Hall & Hall, 1990).
Smiling is reserved for friends and family. Because
smiling does not occur during introductions, Germans
are often considered unfriendly. Work is considered
serious business; thus, Germans smile very little at
work. Dealing with illness is also considered serious
business, calling for “correct responses” (i.e., reserved,
direct, and unsmiling).
Several unacceptable expressions of nonverbal be-
havior for Germans include chewing gum in public,
cleaning one’s fingernails in public, talking with one’s
hands in the pockets, placing one’s feet and legs on
furniture, pointing the index finger to one’s own head
(an insult), and public displays of affection. Younger,
more nontraditional German American youths may
not adhere to these perceptions. Americans cross their
fingers for luck, whereas Germans squeeze the thumb
between index and middle fingers. However, allowing
the thumb to protrude more than its tip length is an
offensive gesture (CultureGram, 1994).
Temporal Relationships
Germans use time to buy the future and pay for the
past. Their focus on the present is to ensure the future.
The past, however, is equally important, and Germans
begin their discussion with background information,
which always includes history. Americans generally do
not understand the German people’s need to lay a
proper foundation for discussion. Conversely, Germans
develop a deep understanding of their historical her-
itage through an intense analysis of past events. Friday
(1989) explained this contradiction as the result of a
difference in educational emphasis in German and
American schools.
Germans pride themselves on their punctuality.
Being on time is an obsession. People who expect to
be late for appointments should call and explain. If
this is not done, the German sense of order is dis-
turbed. Work is completed by setting and meeting
deadlines. “Keeping to the schedule” is extremely im-
portant. There is a sense of impatience and often in-
tolerance in the German American who encounters a
situation in which someone else is not performing on
schedule. This impatience can be stirred to anger in
the work setting, in the supermarket, on the highway, in
254 Aggregate Data for Cultural-Specific Groups
2780_Ch14_250-268 24/07/12 3:05 PM Page 254

the hospital, or in the health-care provider’s office. In
the mind of a German, who is always on time, there are
rarely good excuses for tardiness, delays, or incompe-
tence that disturb the “schedule” of events. Within this
cultural continuum model, Western Europeans and
North Americans attend to details in a linear, orderly
manner, measuring days, hours, and seconds. Time has
value for both groups, often equated with money.
Format for Names
Traditionally, Germans keep social relations on a for-
mal basis. Even neighbors of long-standing acquain-
tance are addressed as Herr (Mr.), Frau (Mrs.), or
Fräulein (Miss) and their last name. Those in author-
ity, older people, or subordinates are always formally
addressed. Only family members and close friends ad-
dress one another by their first names. Many German
Americans born in the 1930s and 1940s continue to be
formal in their social and business interactions. If this
consideration is not returned, or if someone presump-
tuously calls them by their first name, it may be con-
sidered a sign of disrespect or poor upbringing. Hall
and Hall (1990) explain, “The taboo against first-
naming should not be dismissed as an empty conven-
tion.” In their book they describe an old custom,
Brüderschaft-trinken, in which “two friends formalize
their shift to the more intimate form of address. They
hook arms and each sips from a glass. Then they
shake hands and announce their first names” (p. 49).
Germans combine a person’s professional title with
Herr, Frau, Fräulein, or other titles and their last
name. For example, a director of a business is ad-
dressed as Frau or Fräulein Direktorin. The title is
often used without the name. A physician may be ad-
dressed simply as Doktor. Younger generations or
more acculturated Germans may be less formal in
their interactions. Because of cultural blending, health-
care providers will find that German Americans vary
widely in their observance of these rules of etiquette.
Therefore, these health-care providers should ask their
patients how they would like to be addressed. This ap-
proach lessens the possibility of the provider uninten-
tionally offending the patient.
Family Roles and Organization
Head of Household and Gender Roles
Traditional German families view the father as the
head of the household. In the United States, the
husband and wife are more likely to make decisions
mutually and share household duties. Stay-at-home
dads are uncommon in Germany (S. Maubach, per-
sonal communication, 2006). Often, when illness, de-
pendence, and disability interfere and prevent family
members from carrying out their roles, others assume
decision-making responsibilities either temporarily or
permanently.
In Germany, where emphasis is on Ordnung (order),
and Gemeinschaft (community), older people are not
expected to be self-reliant. Health and social programs
for older people are considered part of the institu-
tional approach of European programs. Because of
the comprehensiveness of these benefits, there is less
financial reliance on the family. One home may remain
in the same family for generations. Often, more than
one generation live under the same roof. Older family
members who live with their children are included in
family celebrations as well as in the daily routine of
the families. As they become unable to perform their
roles and duties, other family members assume their
responsibilities.
Older people within German American families are
sought for their advice and counsel, although the
advice may not always be followed. They are admired
for maintaining their level of independence and their
continued contributions to society. Many live alone or
with aging spouses. Helping older parents or grand-
parents to remain in their own home is important to
German American families. By providing a helping
hand with home maintenance, shopping, and finances,
the family is able to safeguard and prolong a state of
independence, even when living hundreds of miles
away. For those who grow dependent, moving in with
children or residing in a nursing home is a viable
choice for German American families.
The differences in the family role for older people
in Germany and in the United States may be due to
the far-reaching mobility of the American popula-
tion that does not exist in Germany, where families
generally live in close proximity. When Americans
moved to the western frontier, they were required to
adopt attitudes that included a degree of individu-
alism, self-reliance, and initiative not demanded
in a more geographically stable and settled society
in which families had support because they were
geographically close. The emphasis on these traits,
as well as the concept of “America, land of unlim-
ited opportunity,” has made life in the United States
difficult.
The Older Americans Act, Medicare, and Medicaid
legislation, which are considered residual approaches
for meeting one’s social needs, support the context of
the German belief in self-reliance and the supportive
role of the family. Such residual approaches are
offered when the normal channels such as family, mar-
ketplace, and church are not sufficient for meeting
needs. Strong advocacy groups such as the American
Association of Retired Persons and the National
Council of Senior Citizens, which have mobilized
older Americans as a self-interest group, also support
this idea of self-reliance (Gelfand, 1988).
In the United States, 24 percent of older people
live alone (Lamanna & Riedman, 2008), whereas
in Germany, 16 percent live alone. The significant
People of German Heritage 255
2780_Ch14_250-268 24/07/12 3:05 PM Page 255

proportion of older women living alone in both coun-
tries can be attributed to the heavy loss of life among
German men in World War II. Although families may
live close to one another, a significant portion of the
older population (24 percent) report feeling lonely
(Rowland, 1992). With both spouses working to main-
tain economic security, many people have less time
available to interact socially with older family mem-
bers living on their own. An interesting fact is that the
Germans love their dogs, and in Germany, it is accept-
able to take the family dog everywhere—restaurants,
visiting, and the hospital. In the United States, however,
animals, except for seeing-eye dogs, are restricted from
most public places. Other pets in German households
may be cats, rabbits, birds, hedgehogs, and, of course,
horses (S. Maubach, personal communication, 2006).
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Prescriptive behaviors for children include using good
table manners, being polite, doing what they are told,
respecting their elders, sharing, paying attention in
school, and doing their chores. Additional behaviors
include keeping one’s nose clean, eating all food that
is placed on their plates, looking at a person who is
talking, and sitting up straight. Prescriptive behaviors
for adolescents include staying away from bad influ-
ences, obeying the rules of the home, sitting “like a
lady,” and wearing a robe over pajamas. Restrictive
and taboo behaviors for children include talking back
to adults, talking to strangers, touching another per-
son’s possessions, and getting into trouble. Restrictive
and taboo behaviors for adolescents include smoking,
using drugs, chewing gum in public, having guests
when parents are not at home, going without a slip
(girls), and having run-ins with the law.
Germany has regulations about noise levels in pub-
lic areas such as athletic fields where people gather to
watch soccer games, tennis, and riding events. These
regulations are enforced for both children and adults.
On occasion, schools in highly populated areas apply
similar restrictions for playground activities (German
Noise Law, 2010).
Family Goals and Priorities
In Germany, history, family, and lifelong friendships
are highly valued. Concern for one’s reputation is a
strong value. One’s family reputation is considered
part of a person’s identity and serves to preserve one’s
social position (good and bad). The author recalls her
mother admonishing her about the proper behavior
for a young woman. She always pointed out, “You
never know whom you will run into.” This admonition
meant that you might meet someone, at any time and
without your being aware, who could draw conclu-
sions from your behavior that might tarnish the
family’s reputation.
Alternative Lifestyles
Pregnancy outside marriage results in disapproval,
which can be overt or subtle. Because German families
are concerned about their reputations in the community,
the presence of an unwed mother taints their reputation
and may result in the family being ostracized. If mar-
riage follows the pregnancy, less sanctioning occurs, but
just the fact that the pregnancy occurred before the mar-
riage creates a stigma for the woman—and sometimes
the child—that may last for the rest of their lives.
The family members rarely forget this embarrassment,
although it may never be discussed openly.
Today, acculturation and realignment of the moral
rules of society, in which one out of four children is
born out of wedlock, have lessened the seriousness of
teenage pregnancy. These changes, together with the
availability of more options for pregnant teenagers
and greater social acceptance for unwed mothers than
existed in the 1970s, have not lessened the shock for
parents.
When couples delay having children, families may
pressure the couple about producing children. Under-
standing a couple’s decision not to have children is
often difficult for German American families, and it
may never be accepted.
Many middle-aged gay and lesbian German
Americans may fear exposure because of the extreme
discrimination homosexuals experienced in Nazi
Germany. In addition, religious education plays an
important role in anchoring family conceptions and
leads to denial of homosexual feelings. When health-
care providers encounter gays and lesbians who need
religious support, a referral to one of the gay and les-
bian religious groups may be helpful (see Chapter 2).
Workforce Issues
Culture in the Workplace
Germans are among the most skilled and educated
workers in the world. Much of Germany’s success is
due to advanced technologies, and it is a leading na-
tion in Nobel Prizes for physiology and medicine.
Some of its most important contributions are in rock-
etry, material science, and chemical products (Solar
Navigator, 2006). German workers are educated to
meet the needs of a highly industrialized country. The
atmosphere of German business is very formal.
Several considerations must be remembered when
working with Germans and some German Americans.
First, it is important to be on time for work and busi-
ness appointments and to complete work assignments
on time. Second, business communication should re-
main formal: shaking hands daily, using the person’s
title with the last name, keeping niceties to a minimum,
and avoiding the adjustment of office furniture during
meetings. Employees are not addressed by their first
names. Third, one should respect privacy by not
256 Aggregate Data for Cultural-Specific Groups
2780_Ch14_250-268 24/07/12 3:05 PM Page 256

entering rooms with a closed door before knocking
and being invited inside. Fourth, dress, opinions, and
activities should be conservative. Finally, learning to
speak German is important if an employee is living in
Germany and working for a German company (Hall
& Hall, 1990).
The current trend toward a global economy has en-
couraged many American companies to establish sites
in Germany and many German corporations to have
subsidiaries in the United States as well as other places
throughout the world. Many German managers are
transferred to the United States by their companies and
easily enter and adapt to the American business climate.
Others trained in the health professions, the physical
sciences and education, and technologies join the ranks
of practicing professionals in the United States.
In the workplace, American values and beliefs often
oppose German traditions. Friday (1989), in exploring
the problems of transcultural adaptation for American
and West German managers, noted that “the manage-
ment style of German and American managers within
the same multinational corporation is more likely to be
influenced by their nationality than by the corporation
culture” (p. 436). Although Friday’s work was done
outside the health-care industry, some of his findings
have implications for relationships across a broad range
of work settings, including health-care services. For
one, German and American managers hold different
perceptions of their relationship with their employer.
Germans see themselves as part of the corporate family,
whereas many Americans do not identify with their
corporation. Germans anticipate lifelong employment
with the same company, whereas Americans may move
to other companies should a good opportunity arise.
Another difference is that American managers expend
much energy to be liked, whereas Germans prefer being
credible in their positions to being liked. To satisfy their
need to be liked, American managers encourage infor-
mality in the workplace, such as by addressing peers,
subordinates, or superiors by their first names; by ask-
ing personal questions; and by believing in equality and
making themselves at home in one another’s offices. For
the German manager, credentials and education con-
firm their credibility and lead to power.
Issues Related to Autonomy
Germans and German Americans expect to receive re-
spect for their work and for their ability to make deci-
sions about their work. They find a hovering supervisor
annoying and demeaning. Balancing control and free-
dom in the workplace is necessary to foster productivity
in German and German American workers (Hall &
Hall, 1990). American and German managers use dif-
ferent styles of assertiveness. Whereas Americans
model their approach within the idea of equality or
“fair play,” Germans, who have no translation for “fair
play,” are assertive by putting other people in their
place. As in all languages, nuances and jargon can frus-
trate the individual whose second language comes only
from the textbook and who does not understand id-
ioms and colloquial expressions. The Germans’ use of
two distinctive manners of communication—gesprach,
casual talking, and besprechung, the workplace discus-
sion about performance—continues into the workplace.
Biocultural Ecology
Skin Color and Other Biological Variations
Germans range from tall, blond, and blue-eyed to
short, stocky, dark-haired, and brown-eyed. Because
many Germans have fair complexions, skin color
changes, and disease manifestations can be easily ob-
served. For those with fair skin, prolonged exposure
to the sun increases the risk for skin cancer.
Diseases and Health Conditions
Because Germany is highly industrialized, Germans suf-
fer from many of the same life-threatening diseases that
afflict groups from other highly industrialized countries.
Leading causes of death for German Americans follow
the patterns of the dominant American society and in-
clude heart disease, cancer, cerebrovascular disease, and
accidents. Because of the poor management of indus-
trial contaminants, people in the Eastern regions often
suffer from pollution-related illnesses (Health Industry
Today, 2011). When assessing recent German immi-
grants, it is helpful for health-care providers to know
where in Germany the patient resided before entering
the United States.
HIV/AIDS rates in Germany are low (0.1% in 2007)
(CIA World Factbook, 2011). Germany offers guidance
and care to those who are infected, as well as a com-
prehensive prevention program for its citizens. Because
prostitution has been legal in Germany since 1987,
frequent health checks are required for those in this
profession (WordIQ Dictionary, 2010).
People of German Heritage 257
R E F L E C T I V E E X E R C I S E 1 4 . 1
Hans Bitner, a German American, has accepted a new com-
puter technology position with a German-owned company.
His job orientation will be in Germany, but he will work in the
United States under a German supervisor. He is very con-
cerned about making a good impression while in Germany
and during his first weeks on the job.
What advice about each of the following issues can be
given to Hans to make his transition into the company as an
employee easier?
1. Conversations
2. Manners in the workplace
3. Privacy
4. Public behavior
2780_Ch14_250-268 24/07/12 3:05 PM Page 257

In 1998, research localized the genetic cause for a
syndrome of symptoms for a new form of myotonic
muscular dystrophy. A second study conducted in
Minnesota, Texas, and Germany identified the same
causative mutation (Mackle, 2001). This new form of
the disease, called DM2, appears to be most common
in Americans of German descent (Mackle, 2001).
Another genetic disease, hereditary hemochromato-
sis, is also found in German Americans. Hemochro-
matosis, a toxic level of iron accumulation, can cause
diabetes, chronic fatigue, liver disease, impotence, and
even heart attacks. The disorder is due to a mutation in
the HFE gene located on chromosome 6. German
Americans can avoid, prevent, and treat these maladies
with genetic testing and early diagnosis. Hemochro-
matosis is treatable through the removal of iron
through phlebotomy (withdrawal of blood or bloodlet-
ting). The person can expect a normal life expectancy
with aggressive treatment. Diagnosis can be established
through a blood test known as an iron profile.
Sarcoidosis, a disorder found mostly in women
between the ages of 20 and 40, occurs in all races, but
people of German descent are at a higher risk
(Gottfried, 2001). Sarcoidosis causes persistent cough
or no symptoms. The cause is unknown, but doctors
speculate that it involves an adverse reaction of the
immune system; the diagnosis is often missed.
Dupuytren’s disease, a slowly progressive disorder,
is a deformity of the hand in which the fingers are con-
tracted toward the palm. This often results in a func-
tional disability. Dupuytren’s disease is frequently
found in people of German descent. Affecting mostly
older males, the disease causes the synthesis of exces-
sive amounts of collagen. The excess collagen is de-
posited in a ropelike fashion from the palm into the
fingers, permanently fixing the fingers in a state of
flexion. Although the cause is uncertain, Peyronie’s
disease is often found in people with Dupuytren’s dis-
ease (NIH, n.d). A benign plaque forms within the
erectile tissue of the penis, which causes it to bend, re-
sulting in reduced flexibility and causing pain during
erection. This can prohibit sexual intercourse. The dis-
ease occurs mostly in middle-age men and often in
men who are related, suggesting that genetic factors
may increase the likelihood of developing this disease.
Some researchers have theorized that Peyronie’s dis-
ease may be an autoimmune disorder. A surgical ap-
proach to treatment has had some success. Candidates
for surgery are men with curvature so severe that it
prevents sexual intercourse.
Lowenfels and Velema (1992) examined the incidence
of cholelithiasis in people from Denmark, Germany,
India, Italy, Norway, and England. Although the study
revealed prevalence rates from each of these countries,
Norway ranked first and Germany ranked second
for the overall incidence of gallbladder disease. Al-
though the study addresses populations in Germany, the
results may be applicable to Germans in other parts of
the world.
A cohort study of white men of Norwegian,
Swedish, and German ancestry conducted between
1966 and 1986 revealed an increased risk of stom-
ach cancer among foreign-born and first-generation
German Americans living in the north-central states
(Kneller et al., 1991). This study suggests an interre-
lationship among ethnic, geographic, and dietary fac-
tors as the cause. High concentrations of immigrants
from northern Europe, which includes the high-cancer-
risk countries of Germany and Scandinavia, settled in
the north-central region of the United States. Low ed-
ucational attainment; employment in laboring and
semiskilled occupations; and ingestion of salted fish
(at least once a month), bacon, milk, cooked cereal,
and apples increased the risk factors for the foreign-
born and first-generation individuals. These findings
support the theory of ethnic risk. Subjects who
smoked 30 or more cigarettes per day exhibited a five-
fold risk for the development of stomach cancer. In
addition, those who smoked a pipe and chewed
smokeless tobacco had an increased risk for stomach
cancer (Kneller et al., 1991).
According to Zielenski and colleagues (1993), an in-
creased incidence of cystic fibrosis (CF) is found among
Hutterite German–speaking communal farmers living
on the Great Plains of North America. Mutations in
the Hutterite population, a genetic isolate with an av-
erage inbreeding coefficient of about 0.05, exhibit an
increased prevalence of CF carriers. Maternal-child
health professionals providing care to this ethnic group
can assist patients by encouraging genetic counseling
to ensure early diagnosis of CF in their infants.
Hemophilia, a genetic bleeding disease found in
Germany and the United States, can be traced from
Queen Victoria of England, who, through a gene mu-
tation, passed hemophilia to her son and through her
daughters (Kilcoyne, 2004). The disease was then
spread into Europe through the royal families, including
the House of Hohenzollern, which consisted of kings
and emperors of Prussia, Germany, and Romania.
World War I led to the German Revolution, and the
House of Hohenzollern abdicated, ending the monar-
chy. Historians believe that the source of hemophilia
in the United States is a woman in Plymouth, New
Hampshire, most likely English. There are currently
over 20,000 people in the United States with hemo-
philia, accounting for over 75 percent of all cases of
hemophilia (CDC, 2011). As in the United States
around 1993, those with hemophilia in Germany were
contaminated with the AIDS virus through the
administration of blood products and anticlotting
factors. Health-care providers may want to be mindful
of the German history of hemophilia and the AIDS
issues while diagnosing bleeding issues in newly
arrived German immigrants.
258 Aggregate Data for Cultural-Specific Groups
2780_Ch14_250-268 24/07/12 3:05 PM Page 258

S. Maubach (personal communication, 2006) de-
scribed the back pain experienced by schoolchildren
who must carry their books everywhere during school
sessions. No lockers are provided in the school build-
ing, so all supplies, including heavy books, are carried
all day long. Only public transportation is available to
transport children to school, and children must carry
their books and personal belongings with them.
Again, during medical examinations of newly arrived
immigrant children complaining of back pain, the
health-care provider should question whether this
situation existed in their former school.
Variations in Drug Metabolism
Few research studies have been completed on varia-
tions in drug metabolism and interactions specific to
people of German ancestry. Aggregate data on white
populations report that there are no slow metabolizers
of alcohol in this population (Levy, 1993). One study
reported that 5 percent of Germans are poor metab-
olizers of debrisoquine (Levy, 1993), and therefore
this group may need lower dosages of propranolol to
control blood pressure.
High-Risk Health Behaviors
Germans are known for their breweries and their
Gasthäuser, or “restaurant that serves spirits.” Beer is
also served at the pubs (kneipen). In Germany, drink-
ing beer is a way of life. German youth can legally
drink beer at age 16 and drive at age 18. Beer is served
with meals, whereas water is rarely consumed.
Sparkling mineral water (mineralwasser) is commonly
served if water is requested by a patron. Even lactating
mothers are encouraged to drink malt beverages to in-
crease breast milk production. This long-standing tra-
dition of beer consumption is not without its abuses.
Health-Care Practices
Germans, whether born in Germany or in the United
States, share a love of nature. They enjoy the great
outdoors. Fresh air and exercise are highly valued.
Hiking, walking, swimming, skiing, cycling, soccer,
horseback riding, and playing tennis are just a few of
the activities enjoyed by people of German ancestry.
Walking is a way of life. Sports are played for exercise
and the pleasure of participating in group activities.
Water sports are very popular and are encouraged
among older people, disabled people, mothers, and
small children. Because many German Americans are
joiners, health club memberships appeal to German
Americans.
Ruhezeit, or quiet time, is nearly sacred in Germany.
This time-honored tradition occurs between 1 p.m.
and 3 p.m. Monday through Saturday and all day
Sunday. During this time, older Germans take naps,
and older retired German Americans may follow this
ritual as well. Stores in Germany close during this time
period. Neighbors and friends are expected not to cre-
ate noise, telephone, or interrupt in any other manner.
This quiet time is often followed by Kaffe and Kuchen,
coffee and cake time, around 4 p.m. (The German
Connection, 2006).
Nutrition
Meaning of Food
Food is a symbol of celebration for Germans and is
often equated with love. Food and food rituals are
powerful identification symbols for ethnic groups. The
diet of immigrants is modified by the availability of
foods and their financial status. The desire to maintain
ethnic food habits has prompted children and grand-
children of immigrants to retain their ethnic heritage.
Common Foods and Food Rituals
Traditional methods of food preparation with high-
fat ingredients add to nutritional risks for many
German Americans. Real cream and butter are used
in German cooking. Gravies and sauces that are high
in fat content, as well as fried foods, rich pastries,
sausages, and boiled eggs, are only a few of the culi-
nary favorites. Germans have traditional ways to pre-
pare their favorite foods. Meats, turkey, chicken, pork,
and fish are stewed, roasted, or marinated and are
often served with gravies. Vegetables (fresh is pre-
ferred) are often served in a butter sauce. Foods are
also fried in butter, bacon fat, lard, or margarine.
Bratwurst (currywurst) served with curry ketchup and
pommes frites (french-fried potatoes) with mayonnaise
are found at the top of the list in Germany.
One-pot meals such as string beans and potatoes,
snipply cabbage and potatoes, chicken pot pie, pork
and sauerkraut, stews, and soups are served as family
meals. Casseroles are also popular. Foods prepared
with vinegar and sugar as flavorings are also favorites.
Potato salad, cucumber salad, coleslaw, chow, pickled
eggs, pickled cucumbers, cauliflower, tongue, and
herring are common examples of favored foods pre-
pared with these flavorings. Sour cream, mayonnaise,
and mustards are used frequently in food preparation.
The nutritional habits of some Germans may be a
significant health risk factor. Food is an integral part
of a German’s life. Food is served at celebrations and
during visits and is taken on trips. The German infat-
uation with food can lead to overeating, which results
in obesity. Children are rewarded for good behavior
with food. Those who are ill receive Jell-O, egg
custards, ginger ale, or tomato soup (not creamed) to
settle their stomachs. Sending food with loved ones
who will be away from the family for a time is quite
common: Homemade cakes, cookies, and jams are a
few of the offerings.
Nothing pleases German cooks more than witness-
ing people with hearty appetites at the table. Generous
People of German Heritage 259
2780_Ch14_250-268 24/07/12 3:05 PM Page 259

amounts of food are prepared, and second helpings
are encouraged. Burping, with an apology, to honor
the good food is acceptable at the German table
(S. Maubach, personal communication, 2006). In
choosing foods for German Americans, the health-care
provider should consider cutting portion size, overcom-
ing harmful food rituals, and reducing fat intake.
Some German American food practices reflect ac-
culturation. For example, the rice pudding enjoyed by
many German Americans is originally a European
American dish. However, unlike European Americans
who serve rice pudding as a common dessert dish,
German Americans reserve it for special occasions
such as weddings. Celebration versions of rice pud-
ding often contain dried fruit, such as raisins or cur-
rants, rum for flavoring, or a meringue topping.
Corn, frequently served as a vegetable in North
America, is not eaten in Germany, where it is consid-
ered food for farm animals. Visitors from Germany
are often startled when corn is served to them, but
once they taste it, they are easily converted. Many
early German immigrants turned to farming to con-
quer starvation, raising grains (including corn), fruits,
and vegetables that were popular in North America.
Foods associated with special events such as weddings,
holidays, and religious occasions are the last to yield to
acculturation. German cooks produce their best culi-
nary efforts for holidays. Weeks of baking and prepa-
ration often precede the actual holidays. Selection of
foods for the meal, proper preservation, and artistic
presentation of tasty dishes are attended with care.
Table 14-1 lists common foods in the German
American diet, based on the author’s experience,
260 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 4 . 2
Marian Graybill is a 27-year-old single mother. She has a 6-year-
old daughter. Marian has been diagnosed with hypertension and
is on Lasix 20 mg daily, which she takes only when she has
swelling in her feet. Her doctor has asked her to be mindful of
her sodium consumption. Marian’s family lives in Germany and
delights in sending packages of German food favorites. Often
these are envelopes of dried seasonings that can be added to
fish and meat. The sodium content of the seasonings is very high.
Marion loves these dishes and prepares them for her daughter
and herself. It is important to Marian that her daughter be
familiar with food from Germany.
1. Marian is only 27 years old and is hypertensive. Under-
standing Marian’s need to enculturate her daughter in light
of German cooking, how would she be impressed with
the importance of following the doctor’s request to lower
her sodium intake?
2. What could be done to help ensure that she will take her
Lasix on a daily basis?
❙❙◗ Table 14-1 Common Foods in the German
American Diet
Beverages
Coffee (with
sugar and cream)
Herbal teas
Kümmel (caraway
seed)
Light and dark
beers
Schnapps
Steinhager (juniper
beverage)
White wine
Breads, Noodles,
and
Dumplings
Rolls
Dumplings
Knöpfle
Potato dumplings
Pretzels
Pumpernickel
Ribbles
Spätzle
Cheese
Camembert
Limburger
Desserts
Baumkuchen
(tree trunk cake)
Kranz (almond
and hazelnut cake)
Lebkuchen
(honey cakes)
Lübecker marzipan
Pfannkuchen
Pfefferkuchen
(gingerbread)
Rice pudding
Springerle
(cookies)
Stollen
Strudel
Fish
Anchovy paste
Carp (karpfen)
Dover sole
Pickled herring
Roe
Rollmops
Smoked cisco
Fruits
Apfel (apple)
Dried apples
Dried pears
Madelkerr (fruits)
Nüsse (nuts)
Prunes
Meats and Fowl
Bacon
Beef
Bratwurst
Chicken
Duck
Frankfurter
Game bird
Gänseleberwurst
(goose liver)
Goose
Knockwurst
Liver dumplings
Mettwurst
Mutton
Pork
Salami
Saage (veal)
Tongue
Veal
Venison
Vonname (smoked
pork chop)
Weissbratwurster
Wild boar
Preserves
Apple butter
Crabapple jelly
Vegetables
Beets
Cabbage
Carrots
Celery root
Mushrooms
Onions
Potatoes
Sauerkraut
White asparagus
White radishes
Miscellaneous
Caraway seeds
Castor sugar (pearl
sugar)
Cilantro
Honey
Juniper berries
Molasses
Paprika
Vanilla beans
personal interviews, the literature, and a marketing
analysis conducted at a meeting of a local DANK
(Deutsch Amerikanischer National Kongress [German
American National Congress]) for a new food chain
planning an international market concept. DANK has
been in existence in the United States since 1959
(DANK, 2010).
Dietary Practices for Health Promotion
Because of apartment living in Germany, many
Germans love to garden, and they bring this love to
the United States. Gardening provides the fresh
vegetables that Germans enjoy. What is not eaten is
canned, pickled, dried, or frozen for future use.
2780_Ch14_250-268 24/07/12 3:05 PM Page 260

Having a full larder is very important to Germans and
German Americans.
A few foods are used to prevent or treat illnesses.
Prune juice is given to relieve constipation. A special
soup from fresh tomato juice is used to treat a migraine
headache. Ginger ale or lemon-lime soda relieves indi-
gestion and settles an upset stomach. After gastroin-
testinal illnesses, a recuperative diet is administered to
the sick family member, beginning with sips of ginger
ale over ice. If this is retained, hot tea and toast are of-
fered. The last step is coddled eggs, a variation of
scrambled eggs prepared with margarine and a little
milk. If these foods are tolerated, the sick person re-
turns to the normal diet. Garlic and onions are eaten
daily to prevent heart disease.
Nutritional Deficiencies and Food Limitations
The literature does not report any enzyme deficiencies
or food intolerances specifically related to Germans.
However, those of lower socioeconomic status may
lack the financial ability to purchase foods essential
for a nutritious diet.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
In her book, Life at Four Corners, Coburn (1992) cap-
tured a bit of the history of maternal-child health in
Block Corners, Kansas, a German Lutheran settle-
ment of the mid-19th century. She provided a glimpse
into the daily life of a woman in the Midwest: “A
woman’s role within the family centered on supporting
the farm economy, childbearing, child rearing, and
providing continuous services to feed, clothe, and nur-
ture all family members” (p. 88).
Coburn’s research showed that large families were
common in Block Corners. Farms needed a labor
force, and a large family often addressed that need.
First-generation Block Corners women had at least
seven or eight children. Babies were born every
2 years, and miscarriages and stillbirths were com-
mon. Accidents and disease claimed the lives of
many children. Second-generation women had
an average of 6.5 children, and third-generation
women had an average of 2.5 children. This drop in
birth rate of the third generation is attributed to
assimilation.
Bearing large numbers of children, coupled with
the hard life of supporting a farm economy and con-
tinuously providing food, clothes, and nurturing,
caused physical strain on women, which often limited
their longevity. In spite of these hardships, birth con-
trol was not sanctioned by the church until the 1930s
and was not openly discussed. Educational informa-
tion was passed verbally from one woman to another.
Although it was known that breastfeeding decreased
the likelihood of pregnancy, little else about preg-
nancy prevention was known.
Large families are rare in Germany. Most couples
have only two children. This may be a result of limited
living space; most Germans rent apartments rather
than own homes. The German government recognizes
the importance of family and provides child-rearing
allowances and work leaves. The state pays a monthly
allotment for each child up to 18 months of age and
allows a child-rearing leave of 3 years for each child.
Employers cannot sever parents from their employ-
ment, and leave time counts toward their pension.
These benefits also apply to the care of sick family
members (Helmert, Beck, Marstedt, Muller, Muller,
& Hebel, 1997; Kappler & Grevel, 1993). Family leave
legislation in the United States is more restrictive.
Although maternity or paternity leave may be avail-
able after childbirth or adoption, it is often provided
without pay and for a shorter duration.
A variety of birth control practices and interven-
tions for improving fertility among Germans are read-
ily available. On the one hand, the German respect for
authority and love for scientific facts and data encour-
age the use of methods to control, as well as to
enhance, fertility practices. On the other hand, the use
of medication or devices might be viewed as interrupt-
ing the natural progression of things. Cathy Seibold
(Personal communication, 1995) explains, “These
approaches may be contradictory to the German love
and appreciation of the world of nature.”
For German Catholics, the influence of religious
beliefs on birth control matters should not be over-
looked. Heterologous artificial insemination, use of
contraceptive pills, and unnatural contraception are
forbidden. In addition, therapeutic or direct abortion
is forbidden as the unjust taking of innocent life.
Teachings of Protestant sects on fertility control vary
from no official position to forbidding the behavior
(see the discussion under Spirituality).
People of German Heritage 261
R E F L E C T I V E E X E R C I S E 1 4 . 3
Fourteen-year-old Lydia Shultz is 2 months pregnant. She is
being seen in the health-care provider’s office and is accompa-
nied by her mother and grandmother. Both her mother and
grandmother occasionally weep as they wait in the office with
Lydia. They tell of their disbelief that Lydia is pregnant at
14 and how embarrassed they are. They ask for names of
homes for unwed mothers.
1. Discuss the impact of teenage pregnancy on this German
American family.
2. Understanding the German American family culture, how
can this family be helped through this life crisis?
2780_Ch14_250-268 24/07/12 3:05 PM Page 261

Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Germans share some of the prescriptive, restrictive,
and taboo practices of other cultures concerning preg-
nancy. Some examples of prescriptive practices in-
clude getting plenty of exercise and increasing the
quantity of food to provide for the fetus. Some restric-
tive practices include not stretching and not raising
the arms above the head to minimize the risk of the
cord wrapping around the baby’s neck.
Predicting the sex of the child was, and may still be,
an important practice. For example, if the child is car-
ried low, it is a girl; if the child is carried high, it is a
boy. If the mother is “all out in the front,” it is a girl,
and if the mother is broad in the back, it is a boy.
A review of the literature and personal interviews
did not reveal any prescriptive, restrictive, or taboo
practices related to the birthing process. Birthing
rooms that allow fathers and other family members to
be present are popular among German Americans. In
Germany, midwives commonly deliver babies (“Birth
and Midwifery in Germany,” 2011). The author’s
grandmother, who assisted with many home deliveries
in the 1930s and 1940s, related one belief concerning
the delivery of an infant. A child born with the mem-
brane (the amniotic sac, also known as a veil) over its
head is believed to be a special child, a belief shared
by many cultures.
Prescriptive practices for the postpartum period in-
clude getting plenty of exercise and getting fresh air
for the baby; if the mother is breastfeeding, she should
eat foods that enhance the production of breast milk.
Many believe that a new baby will soon arrive in the
household that is visited first by a newborn. The au-
thor’s mother often said, “Come visit us, but go some-
where else first.”
Death Rituals
Death Rituals and Expectations
Germans and German Americans traditionally observe
a 3-day period of mourning activities after the death of
a family member. The body of the deceased is prepared
and “laid out” in the home, where support from family
and friends is readily available. Neighbors come to do
the chores and to sit with the family of the deceased
until the burial. A short service is held in the home be-
fore the body is taken to the church, where family and
friends can attend a funeral service. After the church
services, the body is taken to the cemetery for burial.
After a short graveside service, the minister invites every-
one in attendance to the home of the deceased for food.
As embalming practices emerged at the turn of the
20th century and funeral homes became more popu-
lar, particularly in the urban areas, this tradition
changed. Today, German Americans usually have a
family funeral director. The family may go to the
funeral home together to select a coffin. Following the
directions of loved ones about what should be done
after their death is very important. Careful selection
of the clothes to be worn by the deceased and the
flowers that represent the immediate family is equally
important. These selections are based on their knowl-
edge of the deceased’s way of life and on preserving
the family’s reputation and good name. Even in death
rituals, Germans are quick to judge the quality of at-
tention given to these details. The author can recall
her family’s suspicion about the possibility that a cer-
tain family in the community took shortcuts to de-
crease the cost spent on the funeral process. The
insinuation was that the family pocketed the money
instead of honoring the family member.
Responses to Death and Grief
The viewing provides an opportunity for family,
friends, and acquaintances to view the body; offer
their condolences; and extend their offers of assis-
tance should the family need help in the future. Crying
in public is permissible in the author’s family, but in
some German American families, the display of grief
is done privately. A tradition of wearing black or dark
clothing when attending a viewing or a funeral may
be expected of both family and friends. Another ex-
pectation is that the bereaved family limits socializa-
tion activities for the following several months.
The traditions that surround the provision of food
for the mourners have changed over the years. From
the 1940s through the early 1960s, women in the
neighborhood prepared the food and served it as peo-
ple arrived at the home following the burial. More re-
cently, families have become the primary providers of
food and may hire caterers to prepare food or use a
restaurant, as is done in Germany, where homes are
too small to accommodate large groups of people.
For Germans and German Americans, death is
seen as part of the life cycle, a natural conclusion to
life. Individuals who embrace a set of religious beliefs
may look forward to a life after death, often a better
life. Death is a transition to life with God. Because ill-
ness is sometimes perceived as a punishment, the
length and intensity of the dying process may be seen
as a result of the quality of the life led by the person.
Spirituality
Dominant Religion and Use of Prayer
Martin Luther launched the Reformation in the early
16th century. Ninety percent of the population has
some religious affiliation. Protestants and Catholics
share equal portions of the population (33 percent).
Other religions of German Americans include Judaism
(the third largest population of Jews in Western
Europe), Islam, and Buddhism (Solar Navigator,
2006). Similar to the United States, Germany has no
262 Aggregate Data for Cultural-Specific Groups
2780_Ch14_250-268 24/07/12 3:05 PM Page 262

state church; church and state remain separate. Religion
is seen as a personal matter for German Americans, but
those with an active interest in religion often discuss
their beliefs with others (CultureGram, 1994).
A provision made by the Basic Law of Germany
guarantees that “freedom of faith and conscience as
well as freedom of creed, religious, or other beliefs,
shall be inviolable. The undisturbed practice of reli-
gion shall be guaranteed” (Kappler & Grevel, 1993).
Although there is no state church in Germany,
churches, as independent public corporations, have a
partnership relationship with the state. They can claim
state grants, which in turn support schools and kinder-
gartens. Churches can levy taxes on their membership,
but the taxes are collected by the state. German
churches also serve a charitable and social purpose by
running nursing homes, retirement centers, hospitals,
schools, training centers, and consultation and caring
services.
Table 14-2 reflects the formal positions or the rela-
tionships between spiritual beliefs and health prac-
tices of several Protestant religions and the Roman
Catholic Church. The Jewish, Muslim, and Greek
Orthodox faiths are addressed in other chapters.
Health-care providers must recognize that individu-
als’ decisions may vary from the formal position of
their religious groups. Therefore, the table serves only
as a guide, not as an exclusive basis for decision
making in health care.
Most German religious philosophies do not divorce
physical health from the actions of God. Many hold
the view that God works through health-care providers
as well as through the resources of medicine. Prayer is
used to ask for healing, for effectiveness of treatments,
for strength to deal with the symptoms of the illness,
and for acceptance of the outcome of the illness.
Prayers are often recited at the sickbed, with all who
are present joining hands, bowing their heads, and
receiving the blessing from the clergy.
Reading the Bible is also an important spiritual ac-
tivity. Most German and German Americans have a
family Bible, which is passed down through the gen-
erations. It serves as spiritual comfort and as a reser-
voir of family historical data such as the dates of
births, marriages, and deaths.
Meaning of Life and Individual Sources
of Strength
Individual sources of strength for most Germans and
German Americans are their beliefs in God and in
nature. Although they may not attend church on a
regular basis, a German’s faith is deep. Family and
other loved ones are also sources of support in diffi-
cult times. Home, family, friends, work, church, and
education provide meaning in life for individuals of
German heritage. Family loyalty, duty, and honor to
the family are strong values.
Spiritual Beliefs and Health-Care Practices
Teachings of the churches joined by German people
provide direction and counsel on many health-care
issues. Many of these churches have taken a formal
position on abortion, artificial insemination, and pro-
longation of life. The church prescribes when individ-
ual choice is important in deciding on accepting or
refusing treatments and provides advice when seeking
spiritual counseling.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Germans receive regular medical and dental checkups,
immunizations, and routine screening because most of
the population is covered by statutory health insurance.
Germany has one of the slowest-growing economies in
Europe. Supporting the East German modernization,
high unemployment, and a growing aging population
since the mid-1990s have stressed the economy. In ad-
dition, Germany has faced health-care reform, embrac-
ing an approach that mirrors the United States’ HMOs
with protest from German physicians, similar to the re-
actions of physicians in the United States. The health-
care systems are sharing more similarities than in the
past. Germans are facing challenges of access experi-
enced in the United States.
Responsibility for Health Care
Although health care in Germany is considered “the
individual’s own responsibility, it is also a concern of
the society as a whole” (Kappler & Grevel, 1993,
p. 353). The average life expectancy in Germany is
76.41 years for men and 82.57 years for women versus
75.78 years for men and 80.81 years for women in the
United States. Germany’s infant mortality rate of 3.95
per 1000 infants is comparable with the United States’
infant mortality rate of 6.41 per 1000 (CIA World
Factbook, 2011).
Women in the family often administer remedies and
treatments. In traditional families, the mother usually
sees that children receive checkups, immunizations,
and vitamins. German Americans use a variety of
over-the-counter drugs. C. M. Weicksel (personal
communication, 1995) summed up the practice as
“people tend to self-medicate with over-the-counter
drugs until these medications are ineffective; then they
go to the doctor.” The use of over-the-counter drugs
may stem from the belief that individuals are respon-
sible for their own health and from the beliefs and tra-
ditions about the treatment of sickness learned within
the family system. In Germany, however, over-the-
counter drugs can be purchased only from a phar-
macy, which increases the cost to the consumer.
Therefore, over-the-counter drugs are not as accessible
to Germans as they are to German Americans. Today,
prescription drugs are more complex, and numerous
People of German Heritage 263
2780_Ch14_250-268 24/07/12 3:05 PM Page 263

264 Aggregate Data for Cultural-Specific Groups
❙❙
◗
T
a
b
le
1
4
-2
P
o
si
ti
o
n
s
o
f
R
o
m
an
C
at
h
o
li
c
an
d
S
e
le
ct
e
d
P
ro
te
st
an
t
R
e
li
g
io
n
s
R
e
g
ar
d
in
g
V
a
ri
o
u
s
H
e
al
th
-C
ar
e
P
ra
ct
ic
e
s
H
ea
lt
h-
C
ar
e
R
o
m
an

A
m
er
ic
an

M
is
so
ur
i
Sy
no
d
W
is
co
ns
in

C
hu
rc
h
o
f
Sa
lv
at
io
n
Pr
ac
ti
ce
B
ap
ti
st
C
at
ho
lic
B
re
th
re
n
Lu
th
er
an
M
et
ho
di
st
Pr
es
by
te
ri
an
Lu
th
er
an
Lu
th
er
an
C
hr
is
t
A
rm
y
A
dm
in
is
tr
at
io
n
A
cc
ep
ta
bl
e
Ju
st
ifi
ab
le
a
s
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
N
o
p
o
si
tio
n
A
cc
ep
ta
bl
e
o
f
dr
ug
s,
bl
o
o
d,

lo
ng
a
s
fo
r
an
d
va
cc
in
e
th
e
go
o
d
o
f
th
e
w
ho
le
B
io
ps
ie
s
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
En
co
ur
ag
ed
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
N
o
p
o
si
tio
n
A
cc
ep
ta
bl
e
Lo
ss
o
f
lim
b
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
H
as
n
o

A
cc
ep
ta
bl
e
if
N
o
p
o
si
tio
n
A
cc
ep
ta
bl
e
(p
ri
nc
ip
le
o
f
po
si
tio
n
do
ne
t
o
s
av
e
to
ta
lit
y)
a
lif
e
Tr
an
sp
la
nt
s
A
cc
ep
ta
bl
e
Pe
rm
is
si
bl
e
A
cc
ep
ta
bl
e
En
co
ur
ag
ed
A
cc
ep
ta
bl
e
N
o
p
o
si
tio
n
A
cc
ep
ta
bl
e
A
cc
ep
ta
bl
e
N
o
p
o
si
tio
n
A
cc
ep
ta
bl
e
Pr
o
lo
ng
at
io
n
D
isc
o
ur
ag
ed
A
dv
o
ca
te
s
A
llo
w
ed
t
o

Ex
tr
ao
rd
in
ar
y
W
he
n
de
at
h
Q
ua
lit
y
o
f
lif
e
Pe
rm
itt
ed

D
is
ap
pr
o
ve
s
N
o
p
o
si
tio
n
A
cc
ep
ta
bl
e
if
o
f
lif
e
in
c
le
ar
ly

ta
ki
ng
in
to

pr
es
er
ve

an
d
he
ro
ic

in
ev
ita
bl
e,

vi
ew
ed
a
s
m
or
e
o
nl
y
in

of
p
ro
lo
ng
at
io
n
pr
o
lo
ng
at
io
n
te
rm
in
al

co
ns
id
er
at
io
n
in
di
vi
du
al
’s
ef
fo
rt
s
al
lo
w
s
im
po
rt
an
t
th
an

ex
tr
ao
rd
in
ar
y
o
f
th
e
ag
o
ny

o
f
lif
e
is

ca
se
s
be
ne
fit
a
nd

fr
ee
do
m
a
nd

so
m
et
im
es

fr
ee
do
m
t
o

le
ng
th
o
f
lif
e
ca
se
s
af
te
r
o
f
de
at
h
de
si
re
d
by

bu
rd
en
t
o

di
gn
ity
de
em
ed

di
re
ct
o
r
ca
re
fu
l
in
di
vi
du
al
;
pa
tie
nt
ju
st
ifi
ab
le
en
co
ur
ag
e
a
de
lib
er
at
io
n
co
m
fo
rt
a
nd

ph
ys
ic
ia
n
to

ap
pr
o
pr
ia
te

re
m
o
ve

m
ea
su
re
s
ar
tif
ic
ia
l
sh
o
ul
d
be

su
pp
o
rt

pr
o
vi
de
d
sy
st
em
s
Eu
th
an
as
ia
Le
ft
to

N
ot
p
er
m
iss
ib
le
D
ec
is
io
n
le
ft

A
dv
o
ca
te
s
D
is
co
ur
ag
ed
Fa
vo
rs
r
ig
ht

O
pp
o
se
d
A
dv
o
ca
te
s
us
e
Fa
vo
rs
d
ea
th

U
na
cc
ep
ta
bl
e
in
di
vi
du
al

to
d
o
ct
o
r
an
d
de
at
h
w
ith

to
d
ie
o
f
dr
ug
s
to

by
n
at
ur
al

ch
oi
ce
fo
r
no

fa
m
ily
di
gn
ity
re
lie
ve
p
ai
n
m
ea
ns
a
nd

ex
tr
ao
rd
in
ar
y
pr
o
ce
ss
es
m
ea
su
re
s
D
o
na
tio
n
o
f
En
co
ur
ag
ed
D
ee
m
ed

A
cc
ep
ta
bl
e
En
co
ur
ag
ed
En
co
ur
ag
ed
N
o
o
ffi
ci
al

N
o
p
o
si
tio
n
A
cc
ep
ta
bl
e
N
o
p
o
si
tio
n
A
cc
ep
ta
bl
e
bo
dy
p
ar
ts
ju
st
ifi
ab
le
po
si
tio
n
A
ut
o
ps
y
En
co
ur
ag
ed
Pe
rm
is
si
bl
e
A
cc
ep
ta
bl
e
St
ro
ng
ly

En
co
ur
ag
ed
N
o
p
o
si
tio
n
Le
ft
t
o

R
el
at
iv
es

N
o
p
o
si
tio
n
N
o
re
st
ric
tio
n
ap
pr
o
ve
d
in
di
vi
du
al

en
co
ur
ag
ed

ch
o
ic
e
to
g
iv
e
pe
rm
is
si
o
n
D
is
po
sa
l
B
ur
ia
l o
r
B
ur
ia
l
Le
ft
t
o
B
ur
ia
l
B
ur
ia
l a
nd
B
ur
ia
l
A
llo
w
ed
B
ur
ia
l
N
o
p
o
si
tio
n
Le
ft
t
o
o
f
bo
dy
cr
em
at
io
n
fa
vo
re
d;

in
di
vi
du
al
o
r
fa
vo
re
d,
b
ut

cr
em
at
io
n
fa
vo
re
d,
b
ut

if
do
ne
w
ith

fa
vo
re
d,
b
ut

in
di
vi
du
al

pe
rm
itt
ed
cr
em
at
io
n
fa
m
ily
cr
em
at
io
n
pe
rm
itt
ed
,
cr
em
at
io
n
ho
no
r
cr
em
at
io
n
an
d
fa
m
ily
pe
rm
itt
ed
if

ac
ce
pt
ab
le
an
d
cu
st
om
ar
y
ac
ce
pt
ab
le
pe
rm
itt
ed

un
us
ua
l
pr
o
ce
du
re
s
un
de
r
ci
rc
um
st
an
ce
s
fo
r
di
sp
o
sa
l
ep
id
em
ic

ex
is
t
(e
.g
.,
o
f
bo
dy
a
ft
er

co
nd
iti
o
ns
in
fe
ct
io
n)
us
e
fo
r
re
se
ar
ch
2780_Ch14_250-268 24/07/12 3:05 PM Page 264

People of German Heritage 265
Eu
ge
ni
cs
,
N
o
p
o
si
tio
n
O
pp
o
se
d
A
dv
is
ed
fo
r
A
cc
ep
ta
bl
e;

R
es
ea
rc
h
an
d
N
o
p
o
si
tio
n
N
o
p
o
si
tio
n
V
ie
w
ed
a
s
N
o
p
o
si
tio
n
N
o
p
o
si
tio
n
ge
ne
tic
s
as
se
ss
m
en
t
m
ar
ri
ag
e
an
d
pa
re
nt
al

gr
ea
t
bl
es
si
ng
o
f
se
ri
o
us

pr
o
cr
ea
tio
n
co
un
se
lin
g
ill
ne
ss
di
sc
o
ur
ag
ed

en
co
ur
ag
ed
if
o
ffs
pr
in
g
lik
el
y
to
in
he
rit

he
re
di
ta
ry

de
fe
ct
s
B
ir
th
c
o
nt
ro
l
Le
ft
t
o

O
nl
y
na
tu
ra
l
A
cc
ep
ta
bl
e
D
is
ap
pr
o
ve
d
Fa
m
ily

A
cc
ep
ta
bl
e
N
o
p
o
si
tio
n
U
na
cc
ep
ta
bl
e,

N
o
p
o
si
tio
n
A
cc
ep
ta
bl
e
in
di
vi
du
al

m
ea
ns

pl
an
ni
ng

ex
ce
pt
if

w
ith
in

ch
o
ic
e
pe
rm
itt
ed
fa
vo
re
d
he
re
di
ta
ry

m
ar
ri
ag
e
de
fe
ct
s
lik
el
y
bo
nd
to
o
cc
ur
A
rt
ifi
ci
al

N
o
r
es
tr
ic
–
V
ie
w
ed
a
s
Le
ft
t
o

A
cc
ep
ta
bl
e
T
he
o
lo
gi
ca
l
N
o
p
o
si
tio
n
N
o
p
o
si
tio
n
Le
ft
t
o

N
o
p
o
si
tio
n
N
o
p
o
si
tio
n
in
se
m
in
at
io
n
tio
ns
fo
r
ill
ic
it
in
di
vi
du
al

ba
rr
ie
rs
hu
sb
an
d
an
d
m
at
es
ch
o
ic
e
w
ife
; a
do
pt
io
n
ac
ce
pt
ab
le
St
er
ili
ty
t
es
ts
A
cc
ep
ta
bl
e
Pe
rm
is
si
bl
e
Le
ft
t
o

A
pp
ro
ve
d
if
A
cc
ep
ta
bl
e,

N
o
p
o
si
tio
n
Le
ft
t
o

A
cc
ep
ta
bl
e
N
o
p
o
si
tio
n
A
cc
ep
ta
bl
e
in
di
vi
du
al

ne
ce
ss
ar
y
to

bu
t
co
un
se
l
in
di
vi
du
al

ch
o
ic
e
en
su
re
h
ea
lth

w
ith
p
hy
sic
ia
n
ch
o
ic
e
o
f
m
o
th
er
an
d
pa
st
o
r
en
co
ur
ag
ed
T
he
ra
pe
ut
ic

Le
ft
t
o

Pe
rm
itt
ed
o
nl
y
Le
ft
t
o

A
pp
ro
ve
d
if
A
cc
ep
ta
bl
e,

Ju
st
ifi
ab
le
b
y
Pe
rm
itt
ed
t
o

Ju
st
ifi
ab
le
t
o

D
ec
is
io
n
o
f
O
pp
o
se
d
ab
o
rt
io
n
in
di
vi
du
al

in
di
re
ct
ly

in
di
vi
du
al

ne
ce
ss
ar
y
to

bu
t
co
un
se
l
ci
rc
um
st
an
ce
s
sa
ve
li
fe
o
f
sa
ve
m
o
th
er
’s
ph
ys
ic
ia
n
ch
o
ic
e
(e
.g
.,
re
m
o
va
l
ch
o
ic
e
en
su
re
h
ea
lth

w
ith
p
hy
sic
ia
n
(e
.g
.,
ra
pe
o
r
m
o
th
er
lif
e
o
r
in
c
as
e
ac
ce
pt
ed
o
f
ut
er
in
e
o
f
m
o
th
er
an
d
pa
st
o
r
in
ce
st
)
o
f
ra
pe
o
r
ca
nc
er
)
en
co
ur
ag
ed
in
ce
st
A
bo
rt
io
n
o
n
Le
ft
t
o

Pr
o
hi
bi
te
d
O
pp
o
se
d
O
pp
o
se
d
Sa
m
e
as

D
ee
m
ed

N
o
p
o
si
tio
n
O
pp
o
se
d
N
o
p
o
si
tio
n
O
pp
o
se
d
de
m
an
d
in
di
vi
du
al

ab
o
ve
ju
st
ifi
ab
le
b
y
ch
o
ic
e
ci
rc
um
st
an
ce
s
(e
.g
.,
ra
pe
o
r
in
ce
st
)
2780_Ch14_250-268 24/07/12 3:05 PM Page 265

over-the-counter medications have become more acces-
sible to German Americans. The two used in combina-
tion may lead to dangerous drug interactions for
those who practice self-medication. Thus, health-care
providers need to ascertain if over-the-counter and folk
remedies are being used to determine whether there are
contraindications with prescription medications.
Folk and Traditional Practices
Among the early German immigrants, women prac-
ticed folk medicine, which often included singing and
the laying on of hands. Families passed this knowl-
edge on from mother to daughter. Common natural
folk medicines included roots, herbs, soups, poultices,
and medicinal agents such as camphor, peppermint,
and spirits of ammonia. The author’s mother and
grandmother had an arsenal of remedies that were a
combination of folk and over-the-counter prepara-
tions to treat a variety of ills. A list of these remedies
and their uses can be found in Table 14-3.
Magico-religious folk medicine includes “powwow-
ing,” brauche, use of special words, and the wearing
of charms. Some stories told by the author’s mother
referred to the powwow sessions she attended as a
child to cure her frequent ear infections and her in-
ability to gain weight. She attempted to cure a plan-
tar’s wart by rubbing it with a sliced onion and
burying the onion where water flowed. The expecta-
tion was that as the onion deteriorated, so would the
wart. When this failed, an appointment with the po-
diatrist soon followed. Another belief is that carrying
a nut from the buckeye tree guarantees health. Some
individuals have a strong belief that being hexed
brings bad luck, which can manifest itself as illness.
The extent to which today’s German American
population continues to follow these practices is
unknown.
Barriers to Health Care
Germany blends a private health-care delivery system
with universal coverage and social solidarity. The fi-
nancing is inexpensive and equitable with portable cov-
erage. People are never uninsured in Germany, so
families are not burdened with hefty health-care bills
(Underwood, 2009). In the United States, access to care
is limited for those who live in rural areas. Although ef-
forts are being made to reduce these barriers, economic
and geographic barriers to health care continue to exist
for a large number of German Americans.
Cultural Responses to Health and Illness
When asked to describe a German’s response to
pain, the word most often used is “stoic.” Even when
Germans are experiencing pain, they may continue to
carry out their family and work roles. Research reveals
that older German Americans are less likely to com-
plain, more accurate in their description of pain, and
more likely to follow the physician’s advice (Wright,
Saleebey, Watts, & Lecca, 1983). Although results of
studies that examine ethnicity and pain remain prob-
lematic, one significant finding does exist: Regardless
of the degree of acculturation, individual expressions
of pain may follow those of the more traditional
members of the culture. Thus, health-care providers
may not be able to identify verbal or nonverbal cues
among Germans. Careful interviewing and astute ob-
servation must be used to accurately assess the level
of pain experienced by Germans.
Although both Germany and the United States
provide care for the mentally ill, mental illness may
continue to be viewed as a flaw and is perhaps not as
acceptable to German Americans as it is for some
other cultures. If this is accurate, members of this
group may be slow to seek help because of the lack of
acceptance as well as the stigma attached to needing
help. German people’s discomfort with expressing per-
sonal feelings to strangers may impede the counseling
process and influence the counseling methods used.
The German need to discuss the past without expressing
266 Aggregate Data for Cultural-Specific Groups
❙❙◗ Table 14-3 German Folk Remedies for
Various Afflictions
Affliction Remedy
Abrasions, burns Vaseline
Boils Black salve
Bumps and burns Butter
Cleaning cuts and abrasions Hydrogen peroxide
Colds Vicks VapoRub as chest rub
or placed in a vaporizer
Colds Camphorated oil (chest rub;
soft cloth covered with oil is
placed over chest and neck
area)
Colic in infants Catnip and fennel (diluted in
water and flavored with a
little sugar)
Constipation Castor oil
Cuts Mercurochrome
Diaper rash Cornstarch
Diarrhea Paregoric in water
Earache Warm oil
Headaches Warm oil
Menstrual cramps Hot tea
Muscle aches Alcohol with wintergreen
Muscle stiffness Hot or cold compresses
Nervousness Spirits of ammonia in water
Sunburn Noxzema
Teething in infants Whiskey in water (rubbed on
infant’s gums)
To enhance health Cod liver oil
Toothache Oil of cloves
Upset stomach Hot tea with peppermint oil
2780_Ch14_250-268 24/07/12 3:05 PM Page 266

personal feelings should be recognized within the
counseling process.
Even though the people with mental illness have
been assimilated into American culture, many may
remain stigmatized in the German American culture.
Since the passage of the Americans with Disabilities
Act, more people are aware of the needs of the
physically disabled, including acculturated German
Americans. Physical disabilities caused by injury are
more acceptable to German Americans than those
caused by genetic problems. The latter bring feelings
of guilt and a sense of responsibility.
Returning people to the highest level of health pos-
sible appeals to the German nature. The European
American culture believes in helping people, including
older people, to recover their health. Rehabilitation
has become an integral part of patient care in both
Germany and the United States, and rehabilitation fa-
cilities abound in both countries. In Germany, reha-
bilitation is also a vital component of care in
psychiatric facilities (Wuerth, 1993). For Germans, the
rapid return to their roles in society is paramount, and
rehabilitation represents the transition to these roles.
Once others become aware of illness, sick individuals
are excused from their responsibilities. Even through
German Americans are allowed to assume the sick role,
some individuals may have difficulty doing so. The sto-
icism of some may delay their seeking medical care and
allow the problem to become more severe or chronic.
This may result in the need for more complex treat-
ments for relief of symptoms. As individuals recover,
they are expected to relinquish the sick role and resume
their normal responsibilities. It is important to note that
it is the physician in Germany who determines whether
a person can attend work. The physician determines the
length of absence from work, and the employer must
provide employees with their salaries.
Blood Transfusions and Organ Donation
German Americans identify blood transfusions, organ
donation, and organ transplants as acceptable medical
interventions. Many religions followed by German
Americans provide guidance on each of these issues.
See Table 14-2 for a more complete description of
these beliefs and practices.
Health-Care Providers
Traditional Versus Biomedical Providers
In Germany, folk medicine and midwifery are highly
revered. Midwifery is a “family-based tradition”
(Coburn, 1992, p. 93), with skills passed from mother
or close female relatives to daughters. Through inter-
views with the residents of Block Corners, Kansas,
Coburn was able to describe the work of a local mid-
wife, Grandma Block. In addition to her midwifery,
she passed along folk remedies for a variety of
illnesses. The local physicians respected Grandma
Block. She knew when their skills and knowledge were
needed, and if she called them, they knew to come im-
mediately (Coburn, 1992). Adolescent girls were
pressed into service when illness and childbirth oc-
curred. Older or widowed women also provided help
in preparing food, cleaning house, and nursing the sick
in families of both relatives and nonrelatives. Cur-
rently, in Germany, medical-care regulations deem
that a physician must have a midwife (Hebamme) pres-
ent during a birth. However, a physician does not have
to be present if the midwife is doing the delivery
(“Birth and Midwifery in Germany,” 2011). This is the
opposite of the practice in the United States, where a
physician must be present if the birth is complicated.
In Germany, alternative medicine such as acupuncture
and homeopathy is used also during childbirth to
control pain.
The use of certified nurse-midwives is currently
growing in the United States. Choosing a nurse-midwife
over an obstetrician is a personal, not a cultural, deci-
sion for German Americans. German Americans ac-
cept the care of health-care providers of the opposite
gender. However, this is probably due to cultural indoc-
trination rather than an ethnic mandate.
Status of Health-Care Providers
Health-care providers hold a relatively high status
among Germans. This admiration stems from the
German love of education and respect for authority.
German Americans appreciate the status symbols of
money, power, and institutional affiliations held by
these professionals. German families are proud to
have a health-care provider in their midst, and it is
common for family members to seek counsel from
them. Because Germans may find asking for help
difficult, they may feel more comfortable confiding in
a family member.
Health-care providers’ strange language, unusual
practices, and “secret” body of knowledge often create
barriers to forming relationships with patients. Because
of their indoctrination into the culture of the health
professions, health-care providers can become short-
sighted and fail to meet the personal needs of German
patients. To deliver culturally conscious health care,
providers must understand their own ethnic and pro-
fessional culture as well as the ethnic cultures of their
patients. Today, the entry of more women into nontra-
ditional work roles in health care has forced changes
in the health-care environment in the United States.
R E F E R E N C E S
Acton, R. (1994). A remarkable immigrant: The story of Hans
Reimen Claussen. The Palimpsest, 75(2), 87–100.
Birth and midwifery in Germany. (2011). Midwifery Today. Re-
trieved from http://www.midwiferytoday.com/international/
Germany.asp
People of German Heritage 267
2780_Ch14_250-268 24/07/12 3:05 PM Page 267

268 Aggregate Data for Cultural-Specific Groups
Boorstin, D.J. (1987). Hidden history. New York: Harper & Row.
Centers for Disease Control and Prevention (CDC). (2010). Hemo-
philia. Retrieved from http://www.cdc.gov/ncbddd/hemophilia/
facts.html
CIA World Factbook. (2011) Germany. Retrieved from https://
www.cia.gov/library/publications/the-world-factbook/
Coburn, C.K. (1992). Life at four corners. Overland Park, KS:
University of Kansas Press.
CultureGram. (1994). Germany ‘95. Provo, UT: David M.
Kennedy Center for International Studies.
DANK. (2010). Retrieved from http://www.dank.org/
Domer, D. (1994). Genesis theories of the German-American two-
door house. Material Culture, 26(1), 1–35.
Educational Aspects in the United States and Germany. (n.d.).
Retrieved from http://sitemaker.umich.edu/schubert.356/
kindergarten
European Education Directory. (2006). Retrieved from http://www.
euroeducation.net/prof/germanco.htm
Friday, R. (1989). Contrasts in discussion behaviors of German
and American managers. International Journal of Intercultural
Relations, 13(42), 429–446.
Gelfand, D. (1988). Directions and trends in aging services: A
German-American comparison. International Journal of Aging
and Human Development, 27(1), 57–68.
The German Connection. (2006). Autrata family’s home page—
Behavioral norms in German: Siestas and Sundays. Retrieved
from www.seoprofiler.com/analyze/autrata.com
Gottfried, M. (2001). Duff’s a true model patient. Life and Breath
Foundation. Retrieved from www.lifeandbreath.org/
German Noise Law. Retrieved from http://www.guardian.co.uk/
world/2010/aug/16/germany-children-noise-law
Hall, E.T., & Hall, M.R. (1990). Understanding cultural differences.
Yarmouth, ME: Intercultural Press.
Health Industry Today. (2011). Retrieved from http://health.
einnews.com/news/germany-diseases
Helmert, U., Beck, B., Marstedt, R., Muller, G., Muller, H., &
Hebel, D. (1997). Effects of decreasing sick leave benefits:
Results of a survey of social health care insurance members.
Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=PubMed&list_uids=9440911&dopt=
Abstract
Kappler, A., & Grevel, A. (1993). Facts about Germany. Frankfurt,
Germany: Westermann, Braunschweig.
Kilcoyne, R. F. (2004). Hemophilia, musculoskeletal complica-
tions. Medscape, 10. Retrieved from http://emedicine.com/
radio/topic909.htm
Kneller, R.W., McLaughlin, J.K., Bjelke, E., Schuman, L.M., Blot,
W.J., Wachouslder, S., Gridley, G., Cochien, H.T., & Fraumeni,
J.F. (1991). A cohort study of stomach cancer in a high-risk
American population. Cancer, 68, 672–678.
Lamanna, M., & Riedmann, A. (2008). Marriages and families:
Making choices in a diverse society. UK: Cengage.
Levy, R. (1993). Ethnic and racial differences in response to med-
icines: Preserving individualized therapy in managed pharma-
ceutical programmes. Pharmaceutical Medicine, 7, 139–165.
Lowenfels, A.B., & Velema, J.P. (1992). Estimating gallstone inci-
dence from prevalence data. Scandinavian Journal of Gastroen-
terology, 27(11), 984–986.
Mackle, B. (2001). New gene found for myotonia muscular dystro-
phy: Unusual mutation involved. MDA News. Retrieved from
http://www.mdaa.org/news/010803dm_mutation.html
McKinnon, M. (1993). In the American grain: The popularity of
living history farm. Journal of American Culture, 3, 168–170.
National Institutes of Health (NIH). (n.d.). Kidney and urological
disease. Retrieved from http://kidney.niddk.nih.gov/kudiseases/
a-z.asp
Rowland, D. (1992). A fine nation. Health Affairs, 11(3), 205–215.
Salmons, J. (1988). In the social function of some southern Indi-
ana German-American dialect stories. Humor, 1 & 2, 159–175.
Schied, F.M. (1993). Learning in a social context. DeKalb, IL:
LEPS Press.
Solar Navigator. (2006). Retrieved from www.solarnavigator.net
Statistics, Canada. (2006). Retrieved from http://www12.statcan.
ca/census-recensement/index-eng.cfm.
Texas State Historical Association. (n.d.). Retrieved from http://
www.tshaonline.org/handbook/online/articles/ryh02
Underwood, A. (2009). Health care abroad: Germany. Retrieved
from http://prescriptions.blogs.nytimes.com/2009/09/29/health-
care-abroad-germany/
U.S. Census Bureau. (2005). American community survey. Retrieved
from http://www.census.gov/acs/www/
U.S. Census Bureau. (2008). American community survey. Retrieved
from http://factfinder.census.gov/servlet/IPTable
Weaver, W. (1979). Food acculturation and the first Pennsylvania-
German cookbook. Journal of American Culture, 2(3), 420–429.
WordIQ Dictionary. (2010). Prostitution in Germany. Retrieved
from http://www.wordiq.com/definition/Prostitution_in_
Germany
Wright, R., Saleebey, D., Watts, R., & Lecca, P. (1983). Attitudes
toward disabilities in a multicultural society. Social Science and
Medicine, 36, 616–620.
Wuerth, U. (1993). An open psychiatric unit in the U.S. and
Germany. Journal of Psychosocial Nursing, 31(3), 29–33.
Zielenski, J., Fujwara, T.M., Markiewicz, D., Paradis, A.J.,
Anacleto, A.I., Richards, B., Schwartz, R. H., Klinger, K.,
Tsui, L., & Morgan, K. (1993). Identification of the M1101K
mutation in the cystic fibrosis transmembrane conductance
regulator (CFTR) gene and complete detection of cystic fi-
broses mutations in the Hutterite population. American Journal
of Human Genetics, 52, 609–615.
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
2780_Ch14_250-268 24/07/12 3:05 PM Page 268

269
Chapter 15
People of Haitian Heritage
Jessie M. Colin and Ghislaine Paperwalla
*The authors would like to thank Ingrid Parenteau and Sheran Kegerise, graduate students at Barry University, for their
assistance in the literature review and preparation of the manuscript.
Overview, Inhabited Localities,
and Topography
Overview
Haiti, located on the island of Hispaniola between
Cuba and Puerto Rico in the Caribbean, shares the is-
land with the Dominican Republic. With a population
of 9.7 million inhabitants, Haiti covers an area of
27,750 square kilometers (10,714 square miles), about
the size of the state of Maryland (CIA World Fact-
book, 2011).
In 1492, Christopher Columbus landed on the
island and named it Hispaniola, which means “Little
Spain.” Haiti, or Ayti, meaning “land of mountain,”
was given its name by the first inhabitants, the Arawak
and the Caribe Indians. Before 1492, there were five
well-organized kingdoms: the Magua, the Marien, the
Xaragua, the Managua, and the Higuey (Dorestant,
1998). Two-thirds of Haiti contains mountains, great
valleys, and extensive plateaus; small plains mark the
rest of the country.
The capital and largest city, Port-au-Prince, has a
population of over 800,000. Widespread unemploy-
ment and underemployment exist; more than two-
thirds of the labor force do not have formal jobs
owing to the marked decrease in assembly sector jobs.
In addition, Haiti’s economy suffered a severe setback
when a magnitude 7.1 earthquake devastated its cap-
ital city, Port-au-Prince, in January 2010. About
80 percent of the population had already lived under the
poverty line, with 57.4 percent living in abject poverty
(CIA World Factbook, 2011). After the earthquake, the
GDP per capita was $1200 (CIA World Factbook, 2011).
Prior to the earthquake, two-thirds of Haitians de-
pended on the agricultural sector, mainly small-scale
subsistence farming, and are still vulnerable to damage
from frequent natural disasters, exacerbated by the
country’s widespread deforestation. U.S. economic en-
gagement under the Haitian Hemispheric Opportunity
through Partnership Encouragement (HOPE) Act,
passed in 2006, has boosted apparel exports investment
by providing tariff-free access to the United States (CIA
World Factbook, 2011).
The infant mortality rate is high, with 54.02 deaths
per 1000 live births; the average life expectancy is
62.17 years (CIA World Factbook, 2011); and in 2008,
only 70 percent of the urban population (50 percent
in rural areas) had access to improved drinking water
sources (WHO, 2010). The World Health Organiza-
tion (WHO) estimated that prior to the disaster in
2010, diarrheal diseases accounted for 16 percent of
deaths among children less than 3 years of age. In
October 2010, an outbreak of cholera added to the
devastation of the earthquake, killing an additional
3000 people and infecting approximately 130,000
more (BBC News, 2011).
The Haitian population in the United States is not
well documented; this may be because of the U.S.
Census Bureau’s inability to track the large numbers
of undocumented immigrants. According to the 2010
census, over 830,000 Haitians, or 0.3 percent of the
population, live in the United States (U.S. Census
Bureau, 2009). Most of them live in Florida,
New York, Massachusetts, New Jersey, and Connecti-
cut. However, some Haitian leaders and activists
believe that close to 1.5 million Haitians live in the
United States. An additional 122,000 live in Canada,
of which 90 percent live in Quebec (Statistics Canada,
2006). Haitians, like other ethnic groups, are very
diverse. They come from urban and rural Haiti and
represent all socioeconomic classes. Factors affecting
Haitians’ acculturation and assimilation include
variant cultural characteristics (see Chapter 1).
Heritage and Residence
Before the time of Columbus, the various indigenous
tribal groups intermarried. With the arrival of
Europeans, and then Africans, the people of Haiti
2780_Ch15_269-287 16/07/12 11:49 AM Page 269

became more diverse. Today, Haitians range from
light- to dark-skinned, and social identity is shaped
by sharp class stratification and color consciousness.
In 1697, Haiti came under French rule. By the end
of the 18th century, the slave population numbered
500,000. In 1791, a slave insurrection broke the chain
of slavery, and on January 1, 1804, Haiti gained its
independence from France. The French plantation
owners were removed and replaced by the generals of
the indigenous Haitian Army, which ruled mercilessly
(Louis-Juste, 1995). Agricultural workers and peas-
ants were trapped in a semifeudal system: They were
exploited by landowners, terrorized by the section
chiefs of police, and forced to obey laws explicitly. The
coffee fields of the peasants served as the primary
source of revenue for the government coffers, thereby
guaranteeing all government debt payments between
1826 and 1932 (Louis-Juste, 1995). These harsh con-
ditions did not prevent the peasants from rising up
against injustice and exploitation, as evidenced by the
Goman uprising in 1820, the Acaau in 1880, and the
peasant movement of Jean Rabel (Louis-Juste, 1995).
Haitian immigrants have a sense of national pride,
including a high level of self-esteem regarding their
blackness, although in both public and private dis-
course, they may focus on color and class division—
two painful wedges within Haitian society.
Haiti’s independence from France in 1804 did not
resolve the division among the descendants of French
colonists, the African slaves, and the core of the pop-
ulation, who were largely of African descent and cul-
ture. Many members of the upper class used the
markers of mulatto (color), the French culture, and
the French language to differentiate themselves from
the lower class, who were mostly black and Creole and
spoke a predominantly African language.
Ti Manno, a Haitian singer who migrated to
New York, used satire and irony to expose and deride
the type of thinking that divides Haitians in Haiti and
abroad. The following lyrics depict the turmoil and
struggle that promote the division within the Haitian
society (Jean-Baptiste, 1985):
The Black Man
Neg Kwens dil pa Kanmarad neg Brooklyn.
Neg Potopwens dil pa anafe ak neg pwovens.
Mon Che se-m nan fe yon ti pitit.
M’rayi ti pitit la
A fos li led.
Li nwa tankou bombon siwo.
Nen-l pa pwenti.
Ti neg mwe ala nou pa gen chans o.
La vi nou toujou red o.
Nou deyo, pi red.
Se neg nwe cont milat o.
Nou deyo nap soufri.
Nou lakay se pi red.
Translation:
Haitians in Queens feel superior to those who live in
Brooklyn.
Haitians in Port-au-Prince despise those who live in
the provinces.
My dear, my sister had a little baby.
I hate this little kid.
This baby is ugly.
He is as dark as sugarcane syrup cake.
His nose is not pointy.
We Haitians, we are so unlucky.
Life is always hard for us.
Away from home we suffer more.
It’s black against mulatto.
Abroad we suffer.
At home it is even worse.
Despite independence, colonial prejudices about
skin color have persisted. Internal social rivalries and
the scale of Haitian mobility are tied to a European
color, race, and class model. This model relates to skin
pigmentation, hair texture, the shape of the nose, and
the thickness of the lips. Whereas the structure of
Haitian society continues to be built on a neocolonial
model, relationships based on color are extremely
complex. For example, dark skin color tends to be as-
sociated with underprivileged status. Although more
black-skinned people have entered the circle of the
privileged, most blacks are poor, underprivileged, and
unemployed.
Haiti defines itself as a black nation. Therefore, all
Haitians are members of the black race. In Haiti, the
concept of color differs from the concept of race. The
Haitian system has been described as one in which
there are no tight racial categories but in which skin
color and other phenotypic demarcations are signifi-
cant variables.
In the 1940s, a black middle class emerged in Haiti
and claimed to represent the majority. The develop-
ment of this class and its rhetoric served as a spring-
board for Francois Duvalier, a rural physician who
was elected president for a 4-year term in 1957. In
1964, he became president-for-life, using the issue of
black empowerment and a promise to eliminate the
color and class privileges of the mulattos. By the late
1970s, a group of dark-skinned, primarily American-
educated and English-speaking technocrats had at-
tained positions of prominence and influence in the
government. However, the mulatto retained social
prominence, and color continued to play a major role
in the perception of class in Haiti.
Reasons for Migration and Associated
Economic Factors
Haitian immigration and travel to the United States
have continued for many years. Most, but not all, of
those who emigrated were members of the upper class.
270 Aggregate Data for Cultural-Specific Groups
2780_Ch15_269-287 16/07/12 11:49 AM Page 270

Before 1920, Haitians traveled to North America and
Europe only for educational purposes. In 1920, the
United States occupied Haiti, and the first wave of
Haitian migration to North America soon followed.
Over the next decade, more than 40,000 Haitian peas-
ants were forced to go to Cuba and the Dominican
Republic to cut sugarcane in the bateys (plantations).
Haitian land was taken and used for apple and banana
plantations, and many acres of land throughout Haiti
were controlled by the United States (Haiti: Early
History to Independence, 2007).
The late 1950s showed signs of weakness in Haitian
agriculture. The peasants started leaving the provinces
in search of work and a better life. Migrating to the
capital, Port-au-Prince, they established Lasalin, the
first slum of Port-au-Prince (Aristide, 1995). Today,
over 2 million people live in and around the capital,
many in large slums (CIA World Factbook, 2011).
A significant turning point in Haitian migration
occurred in 1964 when Duvalier declared himself pres-
ident-for-life. As a result of his government, many
Haitians began fleeing the island. These immigrants
were primarily relatives of politicians who opposed
the political philosophy of Duvalier. When Duvalier
died in 1971, his son, Jean Claude (a.k.a. “Bébé
Doc”), age 19, was appointed president-for-life. In ad-
dition, during this era, Haiti was suffering from eco-
nomic deprivation, which motivated a major exodus
of urbanites and peasants. Because many Haitians
were unable to pay for their transportation, passports,
and visas, some covertly emigrated to the United States
in small sailboats.
From 1980 until recently, Haitian immigrants have
been divided into two groups: those who have arrived
in the United States legally and those who have en-
tered through the underground. An explosion of im-
migration took place in 1980, in part because of a
short-lived (April to October) change in U.S. immi-
gration policy during the period of the Mariel boat
lift from Cuba. The influx of Cuban refugees required
that a special status be created by the State Depart-
ment called “Cuban-Haitian entrant: status pending.”
According to Health and Rehabilitation Services,
Haitian refugees were included in this status to pre-
vent the policy from being discriminatory. This group
of immigrants were referred to as boat people, a term
associated with extreme poverty. Today, this term
does not evoke as much negativism, although it
continues as a reminder of a painful emigration period
in Haitian history.
From the 1990s to 2010, political unrest, coups,
and protests occurred. The tides of history were
changing, and Jean-Bertrand Aristide was elected in
the first democratically held election in many years.
The democratic process did not last; in that same
year, a coup d’état on Aristide and a hemisphere-wide
embargo was imposed on Haiti. In 2001, Aristide was
reelected in a flawed election. In February 2004, an
armed rebellion led to the departure of President
Jean-Betrand Aristide; an interim government took
office to organize new elections under the auspices of
the United Nations Stabilization Mission in Haiti
(MINUSTAH). Continued violence and technical
delays prompted repeated postponements, but Haiti
finally did inaugurate a democratically elected presi-
dent, Réné Preval, and parliament in May of 2006.
Haitian migration took on a new face when the earth-
quake of January 2010 occurred. Today, more than
1 million people still remain displaced—380,000
being children (Simon, Kleschnitzki, & Shusterman,
2011). Although thousands of Haitians remain in an
immigration holding pattern since before the earth-
quake, 55,000 Haitians have gained family visas
but continue on waiting lists because of immigrations
quotas (Zissis, 2010). The Dominican Republic
has accepted as many as 50,000 people since the
earthquake (Paravisini, 2010). Since the earthquake,
2500 Haitians have been granted temporary resident
visas or permits allowing them to go to Canada. In
addition 3700 students and temporary workers from
Haiti have been permitted to stay in that country
(Power, 2010). France is home to approximately
80,000 Haitians and allowed for a temporary resi-
dence by undocumented Haitians soon after the
disaster in Haiti (McKenzie, 2010).
Prior to the earthquake, more than two-thirds of
the population was living on less than US$2 daily
(PAHO, 2011). Approximately 250,000 people lost
their lives in this catastrophic event, marked as one of
the worst in world history. Roughly 2.8 million people
were affected, and nearly 1.5 million became homeless.
After one year, many countries and organizations, in-
cluding the Pan American Health Organization
(PAHO) and the World Health Organization (WHO)
launched initiatives to assist Haiti in restructuring and
rebuilding their infrastructure. A Post Disaster Needs
Assessment (PNDA) was initiated on February 18,
2010, by the United Nations, the World Bank (2010),
the European Commission, and the inter-American
Development Bank, at the request of the prime min-
ister of Haiti. This group led other groups in assessing
restructuring needs (PAHO, 2011). Disease, structural
instability, hunger, and an inability to reach all those
outside of the city have been some of the many obsta-
cles after the earthquake (Simon, Kleschnitzki, &
Shusterman, 2011).
A special focus was placed on the 1.5 million people
in IDP (internally displaced person) camps (PAHO,
2011). In late October 2010, there was an outbreak of
cholera that required specific reporting and handling
(PAHO, 2011). Many hospitals were totally destroyed,
and many others were seriously damaged. The dis-
posal of medical waste continues to pose an environ-
mental risk to everyone in Haiti. Haiti has suffered a
People of Haitian Heritage 271
2780_Ch15_269-287 16/07/12 11:49 AM Page 271

catastrophic tragedy that will take continued support
from many to rebuild.
Educational Status and Occupations
Following Haiti’s independence in 1804, the new rulers
of Haiti began advocating French cultural patterns
and replicating the French value system. A French
model of education was informally adopted and cod-
ified in 1860, in accord with the Roman Catholic
Church. This resulted in two major changes: The
Catholic Church became the official church of Haiti,
and Catholic missionaries became responsible for ed-
ucation. The accepted language for communication
was now French. During this era, Creole, the language
of the uneducated, was perceived as inferior. Social
mobility was possible only for French-speaking
Haitians. While the educated elite became accultur-
ated into the European value system, the illiterate
masses tended to perpetuate the traditional values and
customs of their African heritage.
Even though Haitians value education, few are
privileged enough to attain a formal education. The
Haitian school system is based on the French model
and offers free primary and secondary education.
Public schools include those operated and controlled
by religious orders as well as those under the direct
jurisdiction of the Minister of Education. Children
from families with financial means attend private
schools. The educational model emphasizes liberal
arts and humanities rather than technical and voca-
tional studies.
The Haitian educational system continues to em-
phasize 19th-century values, which promote good
manners, the classics, literature, philosophy, Latin, and
Greek. It deemphasizes the physical and social
sciences. The Haitian educational system is based on
a two-level curriculum. In the first level, the student
receives a certificate of primary education. To receive
this certificate, the student must sit for a rigorous test,
which includes spelling, reading comprehension, com-
position, Haitian history and geography, general
knowledge, arithmetic, and biology. At this level, the
student can speak, read, and write French at the basic
level.
The next level consists of two parts: The first is
reached after 6 years of secondary education. To re-
ceive this diploma, the student must pass examina-
tions in French, English, and Spanish; Haitian
literature and history; mathematics; and sciences such
as physics, chemistry, biology, and botany. Students in
the classical track also take Latin and Greek exami-
nations. A student who has received the first-level cer-
tificate should be able to enter the first year of college
in American schools. The second-level baccalaureate
is likened to the first year of college in North America;
the emphasis is on the liberal arts. Again, the student
must pass an examination in all the areas covered in
the first level, plus philosophy. The results of these
national examinations are announced on the radio
over a 2-day period or posted on a board in front of
the school.
Although Haiti has several universities, they are
mainly located in Port-au-Prince. Most of them are
state universities. With proper credentials, anyone can
enter the university system. However, since the early
1980s, only those in positions of influence have been
able to benefit from the state universities. Haitian pro-
fessionals mirror those of American society; they are
lawyers, physicians, nurses, engineers, educators, elec-
tricians, plumbers, and construction workers.
The literacy rate, which means that those age 15
and over can read and write, is 52.9 percent (CIA
World Factbook, 2011). The level of illiteracy contin-
ues to be a major concern in Haiti. Since 1940, the
government has conducted several literacy programs.
In 1948, Haiti had its first experience with community
education. This public educational system was based
on the growth model of development, a UNESCO ed-
ucation project, which duplicated experiences in Latin
America (Jean-Bernard, 1983).
Among Haitian immigrants, women work in hotels,
hospitals, and other service industries in domestic and
nursing assistant roles. Men work as laborers and fac-
tory helpers. Many more Haitians are in the workforce
today than there were in the early 1980s, although
data for the years 1974 and 1994 from the U.S. Immi-
gration and Naturalization Service (2006) revealed
that a disproportionate number of legal Haitians were
not employed. In addition, when comparing data by
specific groups, a dramatic increase in the number of
Haitians in all work environments is found. Data
about the work structure of undocumented people
are not available because these people technically are
“underground” and do not exist.
In Haiti, most major industries are owned and op-
erated by the government. Unemployment is 66 percent
(CIA World Factbook, 2011). Those who are employed
often work under such poor conditions that they have
become unmotivated and take little pride in their work,
which results in low productivity. In general, Haitians
are entrepreneurial, operating their own shops, market-
places, or schools. Among these entrepreneurs, the mo-
tivation, spirit, and pride in their work are readily
apparent.
Communication
Dominant Language and Dialects
The two official languages in Haiti are French and
Creole. Creole, a rich, expressive language, is spoken
by 100 percent of the population, whereas French is
spoken by 15 percent of the population. Since 1957,
Creole has been the unofficially accepted language in
the internal affairs of the Haitian government, but in
272 Aggregate Data for Cultural-Specific Groups
2780_Ch15_269-287 16/07/12 11:49 AM Page 272

1987, during the Aristide presidency, it was designated
in the Haitian Constitution as one of the official lan-
guages. Because Creole is the official language, it is
used for internal communication within the island.
In contemporary society, the Haitian dilemma can
best be understood through this dual-language system.
Language is one of the vehicles used to depersonalize
those of the lower classes. French is the dominant lan-
guage of the educated and the elite, whereas Creole is
the language of those who are suppressed, the lower
classes. The emphasis on French served as a barrier to
the early social dynamism that permitted Creole to de-
velop and serve as a unifying force among the African
slaves, who came from many different tribes and spoke
different languages. In spite of its suppression in for-
mal education, Creole has inspired a very rich and in-
teresting oral literature comprising songs, proverbs,
and tales. This oral literature is the most significant
aspect of Haitian folklore.
Understanding the language dilemma and the lit-
eracy issues assists health-care providers in developing
creative tools for educating Haitians. Some of these
tools may include video programs, audiocassettes, and
radio programs in Creole. Because of the masses of
people who are unable to read, printed literature in
Creole is not a helpful educational tool.
Cultural Communication Patterns
Haiti has an oral culture with a long tradition of
proverbs, jokes, and stories reflecting philosophical
systems. These are used to pass on knowledge, convey
messages, and communicate emotions. For example,
the Creole phrase Pale franse pa di lespri pou sa trans-
lates to “To speak French does not mean you are
smart.” Crayon Bon Die pa gin gum (“God’s pencil has
no eraser”) conveys the concept of fatalism. Another
proverb frequently used is Sonje lapli ki leve mayi ou
(“Remember the rain that made your corn grow”),
which means that one must show gratitude to those
who have helped them or done good for them.
Haitians are very expressive with their emotions. By
observing them, one can tell whether they are happy,
sad, or angry. Haitians’ communication patterns in-
clude loud, animated speech and touching in the form
of handshakes and taps on the shoulder to define or
reconfirm social and emotional relationships. Pain
and sorrow are very obvious in facial expressions.
Most Haitians are very affectionate, polite, and shy.
Uneducated Haitians generally hide their lack of
knowledge to non-Haitians by keeping to themselves,
avoiding conflict, and, sometimes, projecting a timid
air or attitude. They smile frequently and often re-
spond in this manner when interacting with Americans
or when they do not understand what is being said.
Many may pretend to understand by nodding; this
sign of approval is given to hide their limitations.
Therefore, health-care providers must use simple and
clear instructions. Because Haitians are very private,
especially in health matters, it is inappropriate to share
information through friends. Many may prefer to use
professional interpreters who will give an accurate
interpretation of their concerns. Most importantly,
the interpreter should be someone with whom they
have no relationship and will likely never see again.
Voice intonations convey emotions. Haitians speak
loudly even in casual conversation among friends and
family; the pitch is moderated in formal encounters.
When the conversation is really animated, the conver-
sants speak in close proximity and ignore territorial
space, especially when emphasizing a point or an issue.
Sometimes, the conversation is at such a high pitch
and speed that, to an outsider, the conversation may
appear disorganized or angry. Haitians love political
discussions. In these instances, the conversation may
appear stressful and hostile; however, to the partici-
pants, the conversation is enjoyable, motivating, and
meaningful.
Traditional Haitians generally do not maintain eye
contact when speaking with those in a position of au-
thority. In the past, maintaining direct eye contact was
considered rude and insolent, especially when speak-
ing with superiors (e.g., children speaking with par-
ents, students with teachers, or employees with
supervisors). However, the influence of American ed-
ucation seems to be changing this trend. Most adults
maintain eye contact, which means “We are on equal
terms, no matter who you are. I respect you and you
respect me as an equal human being.” For children,
however, the custom of not maintaining eye contact
with superiors remains deferential. Thus, health-care
providers may need to assist children in dealing with
conflicting messages.
Haitians touch frequently when speaking with
friends. They may touch you to make you aware that
they are speaking to you. Whereas Haitian women
occasionally walk hand-in-hand as an expression of
their friendship, this trend is disappearing both in
Haiti and in Haitian communities in North America.
This behavior may be changing because of the con-
cept of homosexuality, which is taboo within the
Haitian culture.
Haitians greet one another by kissing and embrac-
ing in informal situations. In formal encounters, they
shake hands and appear composed and stern. Men
usually do not kiss women unless they are old friends
or relatives. Children greet everyone by kissing them
on the cheek. Children refer to adult friends as Uncle
or Auntie out of respect, not necessarily because they
are related by blood.
Temporal Relationships
The temporal orientation of Haitians is a balance
among the past, the present, and the future. The past
is important because it lays the historical foundation
People of Haitian Heritage 273
2780_Ch15_269-287 16/07/12 11:49 AM Page 273

from which one must learn. The present is cherished
and savored. The future is predetermined, and God is
the only Supreme Being who can redirect it. One often
hears Bondye bon (“God is good”), meaning if you
conduct yourself conservatively and the right way,
God will be there for you. The future is left up to God,
who is trusted to do the right thing. In a study by
Prudent, Johnson, Carroll, and Culpepper (2005), sev-
eral of the informants voiced their belief in God’s will
when talking about whether or not they would survive
being HIV positive and/or having AIDS.
Haitians have a fatalistic but serene view of life.
Some believe that destiny or spiritual forces are in con-
trol of life events such as health and death, so they say,
Si Bondye vle (“If God wants”). Given the belief in a
predetermined path of life, one can understand this
view. Haitians believe that they are the passive recipi-
ents of God’s decisions. Health-care providers must
be clear, honest, and open when assessing Haitian
individuals’ perceptions and how they perceive the
forces that have an influence over life, health, and
illness. Acceptance of these beliefs is an important
factor in building trust and ensuring adherence.
Most Haitians do not respect clock time; flexibility
with time is the norm, and punctuality is not valued.
They hold to a relativistic view of time, and although
they try, some find it difficult to respond to predeter-
mined appointments. Arriving late for appointments,
even medical appointments, is not considered impo-
lite. In North America, Haitians may be more readily
compliant with business appointments, but socially,
the margin around expected time is very wide—
anything or anyone can wait. It is not unusual to see
an invitation to a social function listed with an invita-
tion time an hour earlier than the actual time of the
function. For example, a wedding invitation may say
6:00 p.m. when the ceremony is actually scheduled for
7:00 p.m. to ensure that all invitees are there on time.
Health-care providers should be mindful of this time
orientation by making reminder calls for appointments
and encouraging the patient in a respectful and caring
manner about the importance of timeliness. A thor-
ough assessment of time and temporal view helps
health-care providers to plan appointments so that
clinic or office backlogs and disruptions are minimized.
Format for Names
Haitians generally have a first, middle, and last name—
for example, Marie Maude Guinard. Sometimes the
first two names are hyphenated as in Marie-Maude.
The family name, or nom de famille, is very important
in middle- and upper-class society; it helps to promote
and communicate tradition and prestige. However,
friends call individuals by their first names. Families
usually have an affectionate name or nickname for in-
dividuals. The father, mother, grandparent, or any close
family member gives this affectionate name at birth.
When a woman marries, she takes on her husband’s
full name. For example, if Marie-Carmel Guillaume
marries Charles Guy Lespinasse, she is always called
Mrs. Lespinasse. In an informal setting, she might
even be called Mrs. Charles. She loses her name except
on paper. Her name and identity are subsumed by her
husband’s name. This is a reflection of Haitian society
in which women are considered subservient to men.
Haitian names are primarily of French origin, al-
though many Arabic names are now heard since
the migration of Arabs and Jews to Haiti in the 1920s.
Haitians are formal and respectful and, as such,
should be addressed by their title: Mr., Mrs., Miss,
Ms., or Dr.
Family Roles and Organization
Head of Household and Gender Roles
Traditionally, the head of the household was the man,
but in reality, most families today are matriarchal.
Haitian men prefer and choose to believe that they
make the decisions, but most major decisions are
made by the wife and/or mother, with the man re-
maining a distant figure with a great deal of authority.
Today, joint decisions are common. The man is gen-
erally considered the primary income provider for the
family, and governance, rules, and daily decision mak-
ing are considered his province. Sociopolitical and
economic life centers around men. Men are expected
to be sexual initiators, and the concept of machismo
prevails in Haitian life. Women are expected to be
faithful, honest, and respectable. Men are usually
permitted freedom of social interaction, a freedom
not afforded to women. The opportunities offered in
North America for women to become income
providers, together with their observations of different
male-female interactional styles, have encouraged
many Haitian women to reject their native, sub-
servient role. This change in the marital interaction
has created much stress on marital relationships and
an increase in domestic violence, although domestic
violence remains one of those closeted issues that are
not publicly discussed.
Prescriptive, Restrictive, and Taboo Practices
for Children and Adolescents
Children are valued among Haitians because they are
key to the family’s progeny, cultural beliefs, and values.
Children are expected to be high achievers because Sa
ki lan men ou se li ki pa ou (“What’s in your hand is
what you have”). In other words, education can never
be taken away from you. Children are expected to be
obedient and respectful to parents and elders, which
is their key to a successful future. They are not allowed
to express anger to elders. Madichon is a term used
when children are disrespectful; it means that their fu-
ture will be marred by misfortune. Another proverb
274 Aggregate Data for Cultural-Specific Groups
2780_Ch15_269-287 16/07/12 11:49 AM Page 274

used to scare and compel children to behave is Ti
moun fwonte grandi devan baron (“An impudent or in-
solent child will grow under the Baron’s eye [Baron
Samedi is the guardian of the cemetery in the voodoo
religion] and therefore won’t have a long life”).
Physical punishment, which is often used as a way
of disciplining children, is sometimes considered child
abuse by American standards. Fear of having their
children taken away from them because of their meth-
ods of discipline can cause parents to withdraw or not
follow through on health-care appointments if such
abuse is evident (e.g., bruises or belt marks). Haitians
need to be educated about American methods of dis-
cipline and laws so that they can learn new ways of
disciplining their children without compromising their
beliefs or violating American laws.
Many parents feel confused about how to raise
their children in the United States. Their authoritarian
behavior is challenged in American society, which they
perceive as being too permissive. They feel powerless
in understanding how to raise their children in America
while still retaining Haitian traditions. The liberal
American approach to child rearing poses a great
dilemma for Haitian children. They find themselves
living in two worlds: the American world, which
allows and supports self-actualization and oneness,
and the Haitian world, which promotes silence,
respect, and obedience.
In the summer, Haitian parents engage their chil-
dren in certain health-promotion activities such as giv-
ing them lok (a laxative), a mixture of bitter tea leaves,
juice, sugarcane syrup, and oil. In addition, children
are also given lavman (enemas) to ensure cleanliness.
This is supposed to rid the bowel of impurities and re-
fresh it, prevent acne, and rejuvenate the body.
Because Haitian life is centered on males, particu-
larly firstborns, the education of boys is different from
that of girls. The family is more indulgent of the be-
havioral deviations of boys. Boys are given more free-
dom and are even expected to receive outside initiation
in social and sexual life. However, girls are educated
toward marriage and respectability. Their relationships
are closely watched. Even when they are 16 or 17 years
of age, they cannot go out alone because any mishap
can be a threat to the future of the girl and bring
shame to her family. These beliefs increase Haitians’
frustrations and challenges of rearing their children,
especially girls, in America.
Health-care providers need to be aware of these
various challenges and be prepared to assist children
and family members to work through these cultural
differences, while still conveying respect for family and
cultural beliefs. Health-care providers can play a sig-
nificant role by helping children and their parents to
better understand American practices.
Approximately 300,000 restavec children are in
Haiti. Restavec is translated to mean “to live with.” It
was started as an economically motivated action to re-
lieve some parents of the hardship of feeding, cloth-
ing, and paying for the education of their children by
loaning them out to relatives (Saint-Domingue, 2011).
Unfortunately, this has not proven to be true and has
not met its original intent. Restavec children work
long hours and rarely go to school. They are regularly
abused. They usually eat scraps of food and sleep on
the floor (Schaaf, 2009). Although they are not
chained or locked up, they stay to avoid severe abuse
and beatings (Schaaf, 2009). Sixty-five percent of
the population of children are girls between 6 and
14 years old. After the earthquake, the incidence of
restavec rose dramatically because many lost their par-
ents or were abandoned (Schaaf, 2009). Organizations
like International Organization for Migration (IOM)
have started an initiative to end the restavec system
(Saint-Domingue, 2011). Because of the homelessness
and desperation after the quake, there has been a
surge in the practice. In 2009, CNN aired a program
describing the practice and posted it into a blog so
people around the world would become aware of the
situation (Schaaf, 2009). IOM is working to stop it,
along with an organization headed by a man who was
a restavec as a child: the Jean Robert Cadet Foundation
(Saint-Domingue, 2011).
Family Goals and Priorities
The family is a strong component of the Haitian cul-
ture. The expression “Blood is thicker than water” re-
flects family connectedness. An important unit for
decision making is the conseil de famille, the family
council. This council is generally composed of influ-
ential members of the family, including grandparents.
The family structure is authoritarian and includes lin-
ear roles and responsibilities. Any action taken by one
family member has repercussions for the entire family;
consequently, all members share prestige and shame.
The family system among Haitians is the center of
life and includes the nuclear, consanguine, and affinal
relatives, some or all of whom may live under the same
roof. Families deal with all aspects of their members’
lives, including counseling, education, crises, and mar-
riage. Each family has its own traditions, which form
the basis for a family’s reputation and are generalized
to all members of the family. The prestige of a family
is very important and is based on attributes such as
honesty, pride, trust, social class, and history. Even
families who experience economic difficulties are well
respected if they are from a grande famille. Wealthy
families who have no historical background or tradi-
tion are referred to as nouveaux riche and find it diffi-
cult to marry into the more well-established grandes
familles, even though they have money.
The family is an all-encompassing concept in the
Haitian culture. By including family members in the
care of loved ones, health-care providers can achieve
People of Haitian Heritage 275
2780_Ch15_269-287 16/07/12 11:49 AM Page 275

more trusting relationships, which foster greater
adherence to treatment regimens. Haitians believe that
when family members are ill, there is an obligation to
be there for them. If a family member is in the hospi-
tal, all family members try to visit. Many visitors may
cause concern to health-care providers who are not
accustomed to accommodating large numbers of
visitors. Health-care providers need to be patient with
them and facilitate their visits.
When grandparents are no longer able to function
independently, they move in with their children. The
house is always open to relatives. Elders are highly re-
spected and are often addressed by an affectionate title
such as “Aunt,” “Uncle,” “Grandma,” or “Grandpa,”
even if they are not related. Their children are ex-
pected to care for and provide for them when self-care
becomes a concern. The elderly are family advisers,
babysitters, historians, and consultants. Migration to
America poses a tremendous challenge in caring for
elderly Haitians. The nursing home concept does not
exist in the Haitian culture; therefore, Haitians are
generally very reluctant to place their elderly family
members in nursing homes.
Alternative Lifestyles
Homosexuality is taboo in the Haitian culture, so gay
and lesbian individuals usually remain closeted. If a
family member discloses that he or she is gay, everyone
keeps it quiet; there is total denial. Gay and lesbian
relationships are not talked about; they remain buried.
There are no gay bars in Haiti, and overt homosexual
conduct is not publicly displayed, although this trend
seems to be changing.
Although divorce is common among Haitians, before
it becomes final, family members, friends, the church,
and elders try to counsel the couple. Health-care
providers must approach this issue carefully and estab-
lish a trusting relationship before discussing divorce.
Single parenting, widespread in Haiti, is well ac-
cepted and closely tied to the issue of concubinage. In
Haitian society, a well-accepted practice is for men to
have both a wife and a mistress, with the latter relation-
ship referred to as placage. Both women bear children.
The mistress raises her children alone and with minimal
support from the father. These children are often
known by the man’s family but are not known to the
wife. Haitian women in general know that their hus-
bands are involved in extramarital relationships but
pretend not to know. Health education, birth control,
and safe sex are issues that should be approached with
sensitivity and acceptance within cultural boundaries.
Workforce Issues
Culture in the Workplace
Haitians living in America have demonstrated a
very strong motivation for work and a continued
commitment to the entrepreneurial spirit. They can be
found in every sector of the American workforce.
They are hard workers, and many work two jobs to
provide for their American family while sending
money to Haiti for those left behind. In the first year
of migration, they are generally forced to take lower-
status and low-paying jobs. These jobs are used as
stepping-stones to better jobs until they are able to
communicate in English and legalize their immigrant
status. According to the U.S. Census Bureau (2010),
in 2009, 71 percent of Haitians over the age of
16 years were in the civilian workforce, compared with
65 percent of the total workforce. At the same time,
median earnings for Haitian males were $33,000 for
men and $29,000 for Haitian women, compared with
$45,000 for men and $36,000 for women in the total
workforce. In addition, 20 percent of Haitians were
living below the poverty line compared with the total
population of 14 percent. Work is a necessity, and they
conform to the rules and regulations of the workplace.
Haitian immigrants have taken menial, low-paying
jobs that many Americans would not accept even
when unemployed. Haitians appreciate comfort, and
they work to be able to afford the necessities of life.
The economic survival of Haiti is closely tied to the
financial support provided to family members in Haiti
by Haitians who have migrated to the United States
and Canada.
Issues Related to Autonomy
In America, educated Haitians seek job opportunities
in their fields. Those who have a trade try to find em-
ployment in that area. Uneducated, undocumented,
and illiterate individuals experience much more diffi-
culty in entering the job market, where employment
opportunities are restricted to working in places in
which there is overcrowding, poor ventilation, and
high pollution, all of which place them at high risk for
occupational diseases.
Immigrants from various Haitian villages and cities
tend to settle in clusters with their relatives or neigh-
bors from their areas of origin. This pattern of settle-
ment by area of origin helps immigrants adapt to the
demands of their new environment and ensure that
they have someone living nearby whom they can call
on in times of illness or other crises. However, when
people live and work primarily in an ethnic enclave,
the native culture becomes a barrier to assimilation
and acculturation into the dominant society.
The educational level of health-care providers in
Haiti is different from that in America. For example,
medical education is not research-based, and nursing
programs for the most part are at the diploma level
with an apprenticeship. The only nursing baccalaure-
ate program is the Faculté des Sciences Infirmières de
L’ Université Episcopale D’Haiti (Faculty of Nursing
Science of the Episcopal University of Haiti), in
276 Aggregate Data for Cultural-Specific Groups
2780_Ch15_269-287 16/07/12 11:49 AM Page 276

Leogane on the southern coast of the island. Estab-
lishing this school and adopting this name were major
accomplishments. Nursing is finally accepted on
par with the medical community, as well as with the
other professional schools. All other professional
schools start with the words “Faculté des Sciences”
and end with whatever the science is (e.g., medicine,
law, engineering).
Haitian health-care providers who migrate to the
United States have experienced a great deal of diffi-
culty in obtaining licensure to practice. Those who
learned their profession in Haiti were taught in French
and the test-taking approach is different; multiple-
choice examinations are a new and difficult concept
for Haitians.
Haitian nurses are very skilled clinically; however,
sometimes they may experience difficulty in applying
theoretical knowledge to practice. This may be due in
part to language barriers, socialization, and their
diploma education, which focuses on tasks and skills
development. Haitian professionals struggle with pro-
fessional cohesiveness and collegiality. Many groups
have established professional societies whose goals
are to support one another, to promote professional
development, and to promote collegial relationships.
Some examples of these professional groups are the
Haitian Nurses Association, the Haitian-American
Medical Association, the Haitian Educator Association,
the Haitian-American Engineers, and the Haitian-
American Lawyers.
Sometimes Haitians in the workplace greet one an-
other in their native tongue because it is easier to artic-
ulate ideas and feelings and to express support in their
native language. This may be irritating to non-Haitians,
who consider it rude.
Biocultural Ecology
Skin Color and Other Biological Variations
Different assessment techniques are required when
assessing dark-skinned people for anemia and jaun-
dice. One must examine the sclera, oral mucosa, con-
junctiva, lips, nailbeds, palms of the hands, and soles
of the feet when assessing for cyanosis and low blood
hemoglobin levels. To assess for jaundice, one must
examine the conjunctiva and oral mucosa for patches
of bilirubin pigment because dark skin has natural
underlying tones of red and yellow.
Diseases and Health Conditions
Because Haiti is a tropical island, prevalent diseases in-
clude cholera, parasitosis, and malaria. Haiti has no
mosquito control, so newer immigrants should be as-
sessed for signs of malaria such as chills, fever, fatigue,
and an enlarged spleen. Other diseases of increased
incidence among Haitian immigrants are hepatitis, tu-
berculosis, HIV/AIDS, venereal diseases, and parasitosis
from inadequate potable water sources in their home-
land. Actual tuberculosis rates for Haitians are mislead-
ing because, until a few years ago, Haitians living in
Haiti were routinely vaccinated with Bacille bilié de
Calmette-Guérin, thus making all subsequent skin tests
positive, even though they may not actually have had
the disease. Unfortunately, upon immigration, many
Haitians continue to live in overcrowded areas, are mal-
nourished, and live in very poor sanitary conditions, fac-
tors that increase their risk for infectious diseases.
Haitians are prone to diabetes and hypertension—
a reflection of genetics and their diet, which is high in
fat, cholesterol, and salt. Data on the prevalence of
diabetes and hypertension among Haitian Americans
are difficult to assess because they are categorized as
black. In addition to type 1 and type 2 diabetes, there
is a type 3 malnutrition-related diabetes, also known
as tropical diabetes. The prevalence ranges from 2 to
8 percent, accounting for different parts of the island
(Pan American Health Organization, 2001). In addi-
tion, Haitians experience a high incidence of heart dis-
ease. Cerebrovascular diseases are the third leading
cause of death; other cardiopathies are in 5th place,
and arterial hypertension is in 11th place. More deaths
are registered among females than males. In addition
to cardiovascular diseases, there is a high incidence
of cancer. The National Cancer Institute statistics
showed that the most frequent type of cancer treated
was cervical cancer, representing 40 percent of cases.
Breast cancer ranked second with 30 percent. Nasopha-
ryngeal cancer ranked in third position with 10 to
15 percent of the cases (Pan American Health Organ-
ization, 2001). Both cancer and heart disease are re-
lated to a high-fat diet. Today, Haitians in Haiti and
in the United States are very conscious of the need
to limit the fat content in their diets; as a result, the
Haitian diet is not as fatty as it once was.
People of Haitian Heritage 277
R E F L E C T I V E E X E R C I S E 1 5 . 1
Marie-Sandra is a 36-year-old Haitian woman. She was para 2
gravida 2, is 18 months postpartum, and has been breastfeed-
ing her child. She noticed a change in the color of the breast
milk from the right breast. She previously had a lesion in her
right breast that was initially diagnosed as an abscess and ap-
peared to have been there for 3 months. She returned to her
physician after seeing the change in the color of her breast
milk. The examination revealed a mass measuring 8 × 10 cm in
the superior aspect of the breast.
A biopsy confirmed carcinoma infiltrate of the right breast.
Marie had a sister who died of breast cancer at age 31. Her
mother died at age 51 from “some interabdominal cancer.”
The oncologist believed that it was suggestive of breast and
ovarian syndrome of a mutation gene.
Continued
2780_Ch15_269-287 16/07/12 11:49 AM Page 277

Attention-deficit/hyperactivity disorder (ADHD) is
a commonly diagnosed chronic mental condition in
Haitian children (Prudent, Johnson, Carroll, &
Culpepper, 2005). This disease has a large genetic
component (McCann, Scheele, Ward, & Roy-Byrne,
2006). In the Haitian culture, there is no conceptual
term for ADHD, nor is there a Creole term to describe
it. Unfortunately, in the Haitian culture, the behavior
displayed with this diagnosis may be interpreted as an
ill-behaved or a “poorly raised” child or a psychically
victimized child suffering from an “unnatural” condi-
tion. Parents may believe that this behavior can be
controlled by parental discipline, or they may seek an
alternative health consult such a Hougan or voodoo
priest. Although medications are the preferred treat-
ment for ADHD, which may be combined with psy-
chological intervention, Haitians are fearful of
psychoactive drugs because they see them as the cause
of substance abuse and even possibly mental illness
(Prudent et al., 2005). Therefore, assessing the parents’
perceptions of the cause of the ADHD behavior and
assisting them in holistic treatment are important.
Variations in Drug Metabolism
The literature reveals no studies on drug metabolism
specific to Haitians or Haitian Americans. When
Haitians are included in drug studies, it is assumed
that they are included under the category of African
American. Therefore, health-care providers may need
to start with the literature for this broad category of
ethnicity to posit and test theories of ethnic drug me-
tabolism among Haitian Americans.
High-Risk Behaviors
Haitian refugees are one of the most at-risk populations
living in the United States. Therefore, it is important for
health-care providers to consider a number of factors in
providing health-care services. An in-depth assessment
of the person’s environmental, occupational, socioeco-
nomic, demographic, educational, and linguistic status
enables the development of strategies that are culturally
appropriate, adequate, and effective. As a new group of
immigrants, Haitians bring to the health-care system a
different set of beliefs and values about health and ill-
ness. These differences challenge health-care providers
who must try to explain treatments while acknowledg-
ing, but not changing, their patients’ cultural convic-
tions. Attempts to change firmly held beliefs are
counterproductive to establishing trusting health-care
provider–patient relationships.
Behaviors that may be considered high risk in
American society are generally viewed as recreational
or unimportant among Haitians. Alcohol, for exam-
ple, plays an important part in Haitian society. Drink-
ing alcohol is culturally approved for men and is used
socially when friends gather, especially on weekends.
Women drink socially and in moderation. Cigarette
smoking is another high-risk behavior practiced by
Haitian men, whereas Haitian women have a very low
rate of tobacco use. The trend toward decreasing cig-
arette use in America has not influenced Haitian
society. Drug abuse among Haitians used to be low,
but drug abuse in the adolescent population is increas-
ing. In 1982, Haiti became the first developing country
to be incorrectly blamed for the beginning of the
AIDS epidemic. As a result, Haitians have had to en-
dure the stigma associated with the belief that
Haitians are “AIDS carriers.” Unfortunately, HIV/
AIDS has continued to spread in the Haitian commu-
nity both in Haiti and the United States. Heterosexual
transmission is the primary mode of HIV transmis-
sion in the Haitian community and is rapidly becom-
ing an infection of women and children (Santana &
Dancy, 2000). Health-care providers need to recognize
the impact the stigma has had on male–female relation-
ships, as well as familial relationships, in the Haitian
community. Health providers must broaden their scope
and approaches to HIV prevention by incorporating
societal, contextual, and economic factors designed to
modify traditional gender roles germane to influencing
beginning negotiations of safer sex practices.
High-risk behavior in the Haitian culture includes
the nonuse of seat belts and helmets when driving or
riding a motorcycle or bicycle. Most cars in Haiti do
278 Aggregate Data for Cultural-Specific Groups
Marie-Sandra had chemotherapy in Haiti that made her
very ill, so she went to Cuba for continuation to complete
four cycles of chemotherapy. Because definitive care was not
available in Haiti, a university medical center in the United
States enrolled her in a pro bono program. She came for the
first time to the United States alone and that afternoon saw
the surgeon, had a mammogram, and had preoperative diag-
nostic studies. A French translator was used.
The next day, Marie-Sandra had bilateral mastectomies. The
left mastectomy was prophylactic because of her family history
and no ability for mammography monitoring in Haiti. She re-
mained in the United States without any family for 1 year while
undergoing treatment and additional surgery. She received a
1-year course of chemotherapy, radiation therapy to the chest
wall, genetic testing, Herceptin therapy, and prophylactic bilateral
oophorectomies. Genetic BRCA 1 and BRCA 2 results were
negative.
Marie-Sandra did well, and after 1 year, she returned to
Haiti and started working again.
1. Given what you know about Marie-Sandra’s history, how
could she be helped to understand to change this major
health event?
2. What suggestions might be provided for Marie-Sandra
regarding her nutrition?
3. How might the health-care team assist with Marie-
Sandra’s acculturation in the United States?
4. How do traditional Haitians deal with family separation?
5. How might she be helped with being separated from her
family?
2780_Ch15_269-287 16/07/12 11:49 AM Page 278

not have seat belts, and there are no laws regarding the
use of seat belts and helmets. Haitian cities are ex-
tremely overpopulated and traffic laws are very loose,
resulting in hazardous driving conditions. Everyone
tries to gain the upper hand. Haitian Americans must
be educated about traffic laws, seat belt use, car seats
for youngsters, and the need for helmets. Health-care
providers may have to use graphic videos or skits when
instructing patients about these safety practices.
Health-care providers may also use Haitian radio
stations for educational programs when they are avail-
able. Other strategies that may be used to help pro-
mote behavioral changes are through church and
community group activities. Through these avenues,
health-care providers can have a significant impact on
health promotion and health risk prevention among
Haitian Americans.
Health-Care Practices
To Haitians, good health is seen as the ability to
achieve internal equilibrium between cho (hot) and
fret (cold) (see also Nutrition and Health-Care Prac-
tices). To become balanced, one must eat well, give at-
tention to personal hygiene, pray, and have good
spiritual habits. To promote good health, one must be
strong, have good color, be plump, and be free of pain.
To maintain this state, one must eat right, sleep right,
keep warm, exercise, and keep clean.
Haitians who believe in voodoo (see Dominant Re-
ligion and Use of Prayer) and other forms of folk
medicine may use several types of folk healers. These
healers include a voodoo practitioner, a docte fey (leaf
doctor), a fam saj (lay midwife), a docte zo (boneset-
ter), and a pikirist (injectionist). Depending on
whether the individual believes that the illness is nat-
ural or unnatural, she or he may seek help other than
Western medicine from one of these healers.
Nutrition
Meaning of Food
For many Haitians in lower socioeconomic groups,
food means survival. However, food is relished as a
cultural treasure, and Haitians generally retain their
food habits and practices after emigrating. Food prac-
tices vary little from generation to generation. Most
Haitians are not culinary explorers. They prefer eating
at home, take pride in promoting their food for their
children, and discourage fast food. When hospitalized,
many would rather fast than eat non-Haitian food.
Haitians do not eat yogurt, cottage cheese, or “runny”
egg yolk. Haitians drink a lot of water, homemade
fruit juices, and cold, fruity sodas.
Common Foods and Food Rituals
The typical Haitian breakfast consists of bread, but-
ter, bananas, and coffee. Children are allowed to drink
coffee, which is not as strong as that consumed by
adults. Generally, the largest meal for Haitians is eaten
at lunch. At lunchtime, a basic Haitian meal might in-
clude rice and beans, boiled plantains, a salad made
of watercress and tomatoes, and stewed vegetables
and beef or cornmeal cooked as polenta. Table 15-1
lists popular foods in the Haitian community.
Dietary Practices for Health Promotion
Hot and cold, acid and nonacid, and heavy and light
are the major categories of contrast when discussing
food. Illness is caused when the body is exposed to an
imbalance of cold (fret) and hot (cho) factors. For ex-
ample, soursop, a large, green prickly fruit with a white
pulp that is used in juice and ice cream, is considered
a cold food and is avoided when a woman is menstru-
ating. Eating white beans after childbirth is believed
to induce hemorrhage. Foods that are considered
heavy, such as plantain, cornmeal mush, rice, and
People of Haitian Heritage 279
❙❙◗ Table 15-1 Popular Foods in the Haitian
Community
Bouillon Soup made with beef broth mixed
with various green vegetables
(e.g., spinach, cabbage, watercress,
string beans, carrots), meat or
poultry, plantain, sweet potato, and
Malaga, a sweet aromatic wine
Chiquetaille Codfish or smoked herring, unsalted,
shredded finely, mixed with onions,
shallots, finely chopped hot pepper,
vinegar, and lime
Fritters Marinade: flour, water, eggs, parsley,
onions, garlic, salt and pepper,
chicken, hot pepper, and a pinch of
baking soda, mixed together to pan-
cake consistency and deep-fried
Acra: chopped parsley, eggs, garlic,
and onion mixed with Malaga; finely
shredded codfish or smoked herring
and hot pepper may be added
Beignet: sweet ripe banana, sugar, and
eggs, mixed with cinnamon, milk,
margarine, flour, nutmeg, and vanilla
extract
Green plantain Boiled or fried, usually eaten with
griot
Griot Marinated pork cut up in small pieces
and fried
Lambi Conch meat softened and prepared
in a sauce
Legume Vegetables such as chayote and egg-
plant cooked with meat
Patee Pastry dough filled with choice meat,
chicken, or smoked herring
Pumpkin squash soup Meat or poultry mixed with vegeta-
bles and pureed cooked squash and
spices
Tomtom Similar to dumplings, cooked and
made into round balls and eaten with
beef stew and okra
2780_Ch15_269-287 16/07/12 11:49 AM Page 279

meat, are to be eaten during the day because they pro-
vide energy. Light foods, such as hot chocolate milk,
bread, and soup, are eaten for dinner because they are
more easily digested. Table 15-2 presents a classifica-
tion of hot and cold foods.
To treat a person by the hot-and-cold system, a
potent drink or herbal medicine of the class opposite
to the disease is administered. Cough medicines, for
example, are considered to be in the hot category,
whereas laxatives are in the cold category. Certain
food prohibitions are related to particular diseases
and stages of the life cycle. Teenagers, for example, are
advised to avoid drinking citrus fruit juices such as
lemonade to prevent the development of acne. After
performing strenuous activities or any activity that
causes the body to become hot, one should not eat
cold food because that will create an imbalance, caus-
ing a condition called chofret. A woman who has just
straightened her hair by using a hot comb and then
opens a refrigerator may become a victim of chofret.
This means she may catch a cold and/or possibly de-
velop pneumonia.
When they are sick, Haitians like to eat pumpkin
soup, bouillon, and a special soup made with green
vegetables, meat, plantains, dumplings, and yams. The
Haitian diet is high in carbohydrates and fat. Eating
“right” entails eating sufficient food to feel full and
maintain a constant body weight, which is often
higher than weight standards medically recommended
in the United States. Men like to see “plump” women.
Furthermore, weight loss is seen as one of the most
important signs of illness. Additional components of
what Haitians consider a healthy diet are tonics to
stimulate the appetite and the use of high-calorie sup-
plements such as Akasan, which is either prepared
plain or made as a special drink with cream of corn-
meal, evaporated milk, cinnamon, vanilla extract,
sugar, and a pinch of salt.
A thorough nutritional assessment is very impor-
tant to effectively promote nutritional health. Under-
standing food rituals assists health-care providers
in designing individualized dietary plans, which can
be incorporated into the diet to facilitate compli-
ance with dietary regimens that promote a healthier
lifestyle.
Nutritional Deficiencies and Food Limitations
Many Haitian women and children who come from
rural areas have significant protein deficiencies owing
to Haiti’s economic deprivation. A cultural factor con-
tributing to this problem is the uneven distribution of
protein among family members. However, the problem
is not one of net protein deficiency in the community
but, rather, the unwise distribution of the available
protein among family members. Whenever meat is
served, the major portion goes to the men, under the
assumption that they must be well fed to provide for
the household. This same pattern exists today among
Haitian immigrants. Being aware of this cultural
factor enables health-care providers to prepare nutri-
tional plans that meet patients’ dietary needs.
Another major concern in this area is that of food in-
security and short intervals between births, chronic mal-
nutrition, and anemia, which are widespread among
Haitian women of childbearing age. These health in-
equalities result in a high prevalence of low birth weight,
estimated at 15 percent; anemia, ranging from 35 to
50 percent; a body mass index under 18.5 kg/m2, esti-
mated at 18 percent; and a high maternal mortality rate,
estimated at 456 per 100,000 live births (Pan American
Health Organization, 2001).
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Pregnancy and fertility practices are not readily dis-
cussed among Haitians. Most Haitians are Catholic
and are unwilling to overtly engage in conversation
about birth control or abortion. This does not mean
that these two practices do not occur, but rather that
they are just not openly discussed. Abortion is viewed
as a woman’s issue and is left to her and her significant
other to decide. Accurate assessments and teaching re-
lated to these sensitive areas require tact and under-
standing. Initially, health-care providers should be
cautious in assessing and gathering information related
to fertility control. Pregnancy is not considered a health
problem but rather a time of joy for the entire family.
Pregnancy does not relieve a woman from her work.
Because pregnancy is not a disease, many Haitian
280 Aggregate Data for Cultural-Specific Groups
❙❙◗ Table 15-2 Haitian Hot and Cold Food Classification
Very Cold (–3) Quite Cold (–2) Cool (–1) Neutral (0) Warm (+) Very Hot (+2)
Avocado Banana Tomato Cabbage Eggs Rum
Cashew nuts Grapefruit Cane syrup Conch Pigeon Nutmeg
Mango Lime Orange Carrot Soup Garlic
Coconut Okra Cantaloupe Watercress Bouillon Tea
Cassava Watermelon Chayote Brown rice Pork Cornmeal mush
Source: Adapted from M.S. Laguerre (1981, pp. 194–196).
2780_Ch15_269-287 16/07/12 11:49 AM Page 280

women do not seek prenatal care. Pregnant women are
restricted from eating spices that may irritate the fetus.
However, they are permitted to eat vegetables and red
fruits because these are believed to improve the fetus’s
blood. They are encouraged to eat large quantities of
food because they are eating for two. Pregnant women
who experience increased salivation may rid themselves
of the excess at places that may seem inappropriate.
They may even carry a “spit” cup in order to rid them-
selves of the excess saliva. They are not embarrassed by
this behavior because they feel it is perfectly normal.
Fifty percent of women living in Port-au-Prince give
birth in a hospital, compared with 31 percent of births
in other urban areas, and only 9 percent of births in
rural areas. The leading causes of maternal deaths are
obstructed labor (8.3 percent), toxemia (16.7 percent),
and hemorrhage (8.3 percent). The high maternal mor-
tality rate is mainly the result of inadequate prenatal
care (Pan American Health Organization, 2001).
The most popular methods of contraception are
the birth control pill, female sterilization, injections,
and condoms (3 percent each). Among sexually active
women, 13 percent use a modern method of contra-
ception and 4 percent rely on traditional methods.
Among sexually active men, 17 percent use a modern
method (6 percent use condoms) and 16 percent
rely on traditional methods (Pan American Health
Organization, 2001).
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
During labor, the woman may walk, squat, pace, sit,
or rub her belly. Generally, Haitian women practice
natural childbirth and do not ask for analgesia. Some
may scream or cry and become hysterical, whereas
others are stoic, only moaning and grunting. What
they need is support and reassurance; for example, ap-
plying a cold compress on the woman’s forehead
demonstrates caring and sensitivity on the part of the
health-care provider. Since migrating, some Haitian
women have adopted American childbearing practices
and request analgesics. Cesarean birth is feared be-
cause it is abdominal surgery. Women in higher social
strata are more amenable to having cesarean deliver-
ies. Fathers do not generally participate in the labor
and delivery, believing that this is a private event best
handled by women. The woman is not coached; fe-
male members of the family give assistance as needed.
The crucial period for the childbearing woman is
postpartum, a time for prescription and proscription.
The woman takes an active role in her own care. She
dresses warmly after birth as a way to become healthy
and clean. Haitians believe that the bones are “open”
after birth and that a woman should stay in bed dur-
ing the first 2 to 3 days postpartum to allow the bones
to close. Wearing an abdominal binder is another way
to facilitate closing the bones.
The postpartum woman also engages in a practice
called the three baths. For the first 3 days, the mother
bathes in hot water boiled with special leaves that are
either bought or picked from the field. She also drinks
tea boiled from these leaves. For the next 3 days, the
mother bathes in water prepared with leaves that are
warmed by the sun. At this point, the mother takes
only water or tea warmed by the sun. Another impor-
tant practice is for the mother to take a vapor bath
with boiled orange leaves, a practice believed to en-
hance cleanliness and tighten the internal muscles. At
the end of the 3rd to 4th week, the new mother takes
the third bath, which is cold. A cathartic may be ad-
ministered to cleanse her intestinal tract. When the
process is completed, she may drink cold water again
and resume her normal activities.
In the postpartum period, Haitian women avoid
white foods such as lima beans, as well as other foods,
including okra, mushrooms, and tomatoes. These
foods are restricted because they are believed to in-
crease vaginal discharge. Other foods are eaten to give
the new mother strength and vitality. Foods associated
with this prescriptive practice are porridge, rice and
red beans, plantains boiled or grated with the skins
and prepared as porridge (the skin is high in iron,
which is good for building the blood), carrot juice, and
carrot juice mixed with red beet juice.
Breastfeeding is encouraged for up to 9 months
postpartum. Breast milk can become detrimental to
both mother and child if it becomes too thick or too
thin. If it is too thin, it is believed that the milk has
“turned,” and it may cause diarrhea and headaches in
the child and, possibly, postpartum depression in the
mother. If milk is too “thick,” it is believed to cause
impetigo (bouton). Breastfeeding and bottle-feeding
are accepted practices. If the child develops diarrhea,
breastfeeding is immediately discontinued. Practices
that do not put the mother or the child at risk should
be supported and encouraged. Respecting the pa-
tients’ cultural beliefs and practices helps to establish
trust between the patient and the health-care provider
and demonstrates caring. By being familiar with these
health practices and beliefs, health-care providers can
assist women in making culturally safe decisions re-
lated to pregnancy and plans for delivery.
Another prescriptive postpartum practice among
Haitian women is to feed their infant a lok similar to
the one administered to the older children in the sum-
mer. The laxative is administered with the initial feed-
ing and is intended to hasten the expulsion of
meconium. Because Haitians are fearful of diarrhea
in children, health-care providers should stress the
risks associated with lok and any other type of bowel-
cleansing cocktails in infants and children. It is impor-
tant to stress the impact of laxative use on the body
system and educate the woman about the need to
prevent dehydration.
People of Haitian Heritage 281
2780_Ch15_269-287 16/07/12 11:49 AM Page 281

Death Rituals
Death Rituals and Expectations
Generally, Haitians prefer to die at home rather than
in the hospital. Since migrating to America, many
have accepted death in a health-care facility to allevi-
ate the heavy burden on the family during the last
stage of the loved one’s life. When death is imminent,
the family may pray and cry uncontrollably, some-
times even hysterically. They try to meet the person’s
spiritual needs by bringing religious medallions, pic-
tures of saints, or fetishes. When the person dies, all
family members try, if possible, to be at the bedside
and have a prayer service. If possible, and if it is not
too disturbing to other patients, health-care providers
should encourage this practice and involve a family
member in the postmortem care.
Responses to Death and Grief
Death in the Haitian community mobilizes the entire
family, including the matrilineal and patrilineal exten-
sions and affines. Death arrangements in America are
similar to those in Haiti. Generally, a male relative of
the deceased makes the arrangements. This person
may also be more fluent in English and more accus-
tomed to dealing with the bureaucracy. This person is
also responsible for notifying all family members
wherever they might be in the world, an important ac-
tivity because family members’ travel plans influence
funeral arrangements. In addition, he is responsible
for ordering the coffin, making arrangements for
prayer services before the funeral, and coordinating
plans for the funeral service.
The preburial activity is called veye, a gathering of
family and friends who come to the house of the de-
ceased to cry, tell stories about the deceased’s life, and
laugh. Food, tea, coffee, and rum are in abundant sup-
ply. The intent is to show support and to join the fam-
ily in sharing this painful loss. Another religious ritual
is called the dernie priye, a special prayer service con-
sisting of 7 consecutive days of prayer. Its purpose is
to facilitate the passage of the soul from this world to
the next. It usually takes place in the home. On the
7th day, a mass called prise de deuil officially begins the
mourning process. After each of these prayers, a recep-
tion/celebration in memory of the deceased is held.
Haitians have a very strong belief in resurrection and
paradise; thus, cremation is not an acceptable option
(Fr. Darbouze Gerard, personal communication, 2001).
Haitians are very cautious about autopsies. If foul play
is suspected, they may request an autopsy to ensure that
the patient is really dead. This alleviates their fear that
their loved one is being zombified. According to this be-
lief, this can occur when the person appears to have died
of natural causes but is still alive. About 18 hours after
the burial, the person is stolen from his or her coffin; the
lack of oxygen causes some of the brain cells to die, so
the mental facilities cease to exist while the body remains
alive. The zombie then responds to commands, having
no free will, and is domesticated as a slave.
Spirituality
Dominant Religion and Use of Prayer
Patients’ cultural beliefs and religion can have a great
impact on their acceptance of and adherence to health
care and, therefore, on the outcomes of treatment.
282 Aggregate Data for Cultural-Specific Groups
R E F L E X I V E E X E R C I S E 1 5 . 2
Manou is a 59-year-old Haitian American woman who lives in
the Midwest United States. About 6 years ago, Manou lost her
only son, age 20, who died tragically after dropping out of col-
lege and joining the military. Two years after her son’s death,
Manou fell ill and was diagnosed with cancer of the gallbladder.
Her husband, a Lutheran pastor, had moved to Florida to build
a church and to serve the Haitian American population living
in the area. Manou stayed in the Midwest to care for her
youngest daughter, who was then finishing high school. Manou
was able to function for a number of years without ever men-
tioning her illness to her husband or daughter. She isolated
herself from her family, including her parents.
Recently, Manou fell gravely ill while she was alone in the
house. Her husband, who was still in Florida at the time, had
to call a family member to check on her condition. She was
taken to the nearest hospital emergency room and then trans-
ferred to a nursing home. She suffered with pain on her left
abdominal quadrant and had difficulty eating. Her family mem-
bers rushed to care for her, although they were unaware of
her condition. They made leaf teas (parsley, garlic) in the hope
of alleviating her pain and epigastric discomfort.
Manou was transferred from the nursing home to another
hospital for further testing. There, it was revealed to her family
that she was terminally ill and needed to be admitted to a
hospice care facility. The family refused and wanted to take her
home to care for her.
You happen to be a nurse and a member of the family.
Manou’s family was in disbelief; her husband and daughter
looked to you for answers and to assist them in coping with
this news. They need to be prepared for her imminent death.
1. What do you need to know about the health practices
that Manou had engaged in at home? Why would this be
important?
2. How can you help the family come to terms with this
major event that Manou kept from them?
3. Do you think Manou kept her illness a secret because of
lack of trust, or was she trying to protect her family? Is this
behavior typical in the Haitian community, or is this out of
the ordinary?
4. How can you assist this family in their grief?
5. What can you do to assist Manou in coming to terms
spirituality/religiously with her imminent death?
2780_Ch15_269-287 16/07/12 11:49 AM Page 282

Catholicism is the primary religion of Haiti. Since the
early 1970s, however, Protestantism has gained in pop-
ularity throughout the island and has seriously chal-
lenged the Catholic Church, especially among the
lower socioeconomic classes. Even though Haitians
are deeply religious, their religious beliefs are com-
bined with voudou (voodooism), a complex religion
with its roots in Africa (Fig. 15-1). Voudou, in the
most simplistic sense, involves communication by
trance between the believer and ancestors, saints, or
animistic deities. Voudou is not considered paganism
among those who practice it, even though many of the
rituals resemble paganism. Participants gather to wor-
ship the loa or mystere, deities or spirits who are be-
lieved to have received their powers from God and are
capable of expressing themselves through possession
of a chosen believer. With their great powers, the loa
or mystere can provide favors such as protection,
wealth, and health to those who worship and believe
in them.
Meaning of Life and Individual Sources
of Strength
The family system among Haitians is the center of life
and includes the nuclear, consanguine, and affinal rela-
tives. They may all live under the same roof. The family
deals with all aspects of a person’s life, including coun-
seling, education, crises, marriage, and death.
The best way to understand and assess the spiritual
beliefs and needs of Haitian American patients is to
understand their culture. This is especially important
because Haitian patients may express their concerns
in ways that are unique to their cultural and religious
beliefs. To ensure accurate assessments of these pa-
tients, it is essential to ask questions carefully and to
completely understand the answers in order to gain an
understanding of patients’ perceptions of health and
illness as dictated by their culture and religious beliefs.
By recognizing and accepting patients’ beliefs, health-
care providers may alleviate barriers, and patients may
feel more at ease to discuss their beliefs and needs.
Spiritual Beliefs and Health-Care Practices
Voudou believers may often attribute their ailments or
medical problems to the doings of evil spirits. In such
cases, they prefer to confirm their suspicions through
the loa before accepting natural causes as the problem,
which would lead to seeking Western medical care.
For Haitian patients, the belief in the power of the su-
pernatural can have a great influence on the psycho-
logical and medical concerns of the patients.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
For Haitians, illness is perceived as punishment, con-
sidered an assault on the body, and may have two
People of Haitian Heritage 283
R E F L E C T I V E E X E R C I S E 1 5 . 3
Lélé, a young Haitian man, survived the earthquake in Haiti on
January 12, 2010. Prior to the earthquake, he was active, full of
life, and pursing his studies. He lived in one of the small towns
in Haiti and was going to school at the same time. Soon after
the earthquake, Lélé developed some signs and symptoms
that baffled many of the health-care providers who were giv-
ing assistance to the earthquake survivors. Lélé started losing
weight, his skin color changed, and he became discolored. As
his condition became worse, he had difficulty swallowing. Sus-
pecting scleroderma, Lélé was brought along with his mother
to the United States for treatment.
After 6 weeks, Lélé’s mother returned home because there
was nothing that Western/conventional medicine could do for
him. She stated that she did not want to witness Lélé’s death
and would rather remember him alive. After 3 months of a lan-
guishing illness, Lélé died alone and far away from his young
wife, his mother, and the rest of his family. Lélé’s wish was to be
buried in his homeland. Given the high cost of sending the body
home for burial, his wife contemplated cremation and sending
his ashes home. However, Lélé had converted to the Mormon
faith, which prohibits cremation. When Lélé’s wife was informed
of this, she sought out a spiritual leader from the Mormon faith
to assist her in making such an important decision.
1. Should Lélé’s mother be brought into the decision-making
process regarding cremation?
2. How important is family in the Haitian culture?
3. What resources might be made available to have Lélé’s
body returned to Haiti?
4. If the decision was made for cremation, which is contrary
to Haitian culture, how might a nurse assist his wife with
the grieving process?
Figure 15-1 Santeria evolved from two main cultural
antecedents: the worship of orisha among the Yoruba tribe
of Nigeria and the cult of saints from the Roman Catholicism
of Spain.
2780_Ch15_269-287 16/07/12 11:49 AM Page 283

different etiologies: natural illnesses, known as mal-
adi Bondye (“disease of the Lord”), and supernatural
illnesses. Natural illnesses may occur frequently, are
of short duration, and are caused by environmental
factors such as food, air, cold, heat, and gas. Other
causes of natural illness are movement of blood
within the body, disequilibrium between hot and
cold, and bone displacement. Supernatural illnesses
are believed to be caused by angry spirits. To placate
these spirits, patients must offer feasts called manger
morts. If individuals do not partake in these rituals,
misfortunes are likely to befall them. Illnesses of
supernatural origin are fundamentally a breach in
rapport between the individual and her or his pro-
tector. The breach in rapport is a response from the
spirit and a way of showing disapproval of the
protégé’s behavior. In this instance, health can be
recovered if the patient takes the first step in deter-
mining the nature of the illness. This can be accom-
plished by eliciting the help of a voudou priest and
following the advice given by the spirit itself. To ac-
curately prescribe treatment options, health-care
providers must be able to differentiate between these
belief systems.
Physical illnesses are thought to be on a contin-
uum beginning with “Kom pa bon” (“I do not feel
well”). In this phase, the affected person is not con-
fined to bed; illness is transitory, and the person
should be able to return to his or her normal activi-
ties. The next phase is Moin malad (“I am sick”), in
which the individuals stay at home and avoid activity.
The third phase is Moin malad anpil (“I am very
sick”). This means that the person is very ill and may
be confined to bed. The final phase is Moin pap refe
(“I am dying”).
Haitians believe that gas (gaz) may provoke pain
and anemia. Gas can occur in the head, where it en-
ters through the ears; in the stomach, where it enters
through the mouth; and in the shoulders, back, legs,
or appendix, where it travels from the stomach.
When gas is in the stomach, the patient is said to suf-
fer kolik, meaning stomach pain. Gas in the head is
called van nan tet or van nan zorey, which translates
to “gas in one’s ears,” and is believed to be a cause
of headaches. Gas moving from one part of the
body to another produces pain. Thus, the movement
of gas from the stomach to the legs produces
rheumatism, to the back causes back pain, and to
the shoulder causes shoulder pain. Foods that help
dispel gas include tea made from garlic, cloves,
and mint; plantains; and corn. To deter the entry of
gas into the body, one must be careful about eating
“leftovers,” especially beans. Since migrating to
the United States, Haitians have begun eating
leftovers, which is believed to cause many of their
ailments. After childbirth, women are particularly
susceptible to gas, and to prevent entry of gas into
the body, they tighten their waist with a belt or a
piece of linen.
Responsibility for Health Care
Haitians engage in self-treatment and see these activ-
ities as a way of preventing disease or promoting
health. Haitians try home remedies as a first resort for
treating illness. They are self-diagnosticians and may
use home remedies for a particular ailment, or if they
know someone who had a particular illness, they
may take the prescribed medicine from that person.
They keep numerous topical and oral medicines on
hand, which they use to treat various symptoms. For
example, an individual who suspects a venereal disease
may buy penicillin injections and have someone
administer them without consulting a physician. In
Haiti, many medications can be purchased without a
prescription, a potentially dangerous practice. How-
ever, health-care providers must be very discrete in as-
sessing, teaching, and guiding the patient toward safer
health practices. Admonishing patients may cause
them to withdraw and not adhere to instructions.
Haitians may also lead health-care providers to believe
that they are interested, when in fact they have already
discredited the health-care provider. When taking the
patient’s history, the health-care provider should in-
quire if the patient has been taking medication that
was prescribed for someone else. Moreover, when pre-
scribing a potentially dangerous drug, the health-care
provider should be sure to caution the patient not to
give the medication to ailing friends or relatives. Even
though the health-care provider may not be com-
pletely successful at stopping the practice of exchang-
ing medications, with continued reminders, she or he
may be successful later.
Folk and Traditional Practices
Haitians may use others’ experiences with a partic-
ular illness as a barometer against which to measure
their symptoms and institute treatment. If neces-
sary, a person living in the United States may ask
friends or relatives to send medications from Haiti.
Such medications may consist of roots, leaves, and
European-manufactured products that are more
familiar to them. Therefore, it is very important to
ascertain what the patient is taking at home to avoid
serious complications.
Constipation, referred to as konstipasyon, is treated
with laxatives or herbal teas. Sometimes, Haitians use
enemas (lavman). Diarrhea is not a major concern in
adults; however, it is considered very dangerous in
children and sometimes interpreted as a hex on the
child. Parents may try herbal medicine, may seek help
from a voudou priest or hougan, or if all else fails, may
consult a physician. It is very important to assess the
child carefully because he or she may have been ill for
quite some time.
284 Aggregate Data for Cultural-Specific Groups
2780_Ch15_269-287 16/07/12 11:49 AM Page 284

A primary respiratory ailment is oppression, a term
used to describe asthma. However, the term really de-
scribes a state of anxiety and hyperventilation rather
than the condition. Oppression is considered a cold
state, as are many respiratory conditions. A home
remedy for oppression is to take a dry coconut and cut
it open, fill it with half sugarcane syrup and half
honey, grate one full nutmeg and add it to the syrup
mix, reseal the coconut, and then bury it in the ground
for a month. The coconut is reopened, the contents
are stirred and mixed together, and 1 tablespoon is ad-
ministered twice a day until all of the contents have
been consumed. By the end of this treatment, the child
is supposed to be cured of the respiratory problem.
Barriers to Health Care
Because orthodox medicine is often bypassed or per-
ceived as a second choice among Haitians, the poten-
tial delay of medical care can pose an increased risk
to patients. The view that physicians of conventional
medicine do not understand voudou and, therefore,
cannot cure magical illness or that an illness worsens
if the bewitched person seeks a physician is enough to
persuade these individuals to seek unconventional
modes of therapy with which they are more comfort-
able. The health-care team should understand some
of the basic principles and practices of folk medicine,
particularly root medicine, because this can play a sig-
nificant role in determining the progress of the client’s
health status.
Many Haitians are in low-paying jobs that do not
provide health insurance, and they cannot afford to
purchase it themselves. Thus, economics acts as a bar-
rier to health promotion. In addition, for those who
do not speak English well, it is difficult for them to ac-
cess the health-care system, fully explain their needs,
or understand prescriptions and treatments.
Cultural Responses to Health and Illness
The root-work system is a folk medicine that provides
a framework for identifying and curing folk illnesses.
When illness occurs, or when a person is not feeling
well or is “disturbed,” root medicine distinguishes
whether the symptoms and illness are of natural or
unnatural origin. An imbalance in harmony between
the physical and the spiritual worlds, such as dietary
or lifestyle excesses, can cause a natural illness. For ex-
ample, diabetes is considered a natural illness, but
most Haitians do not seek immediate medical assis-
tance when they detect the symptoms of polyuria, ex-
cessive thirst, and weight loss. Instead, they attempt
symptom management by making dietary changes on
their own by drinking potions or herbal remedies.
When the person finally seeks medical attention, she
or he may be very sick. At this point, the health-care
provider should be cautious in explaining the condi-
tion and use a culturally specific approach when ex-
plaining the medical regimen, diet, and medications.
Pain is commonly referred to as doule. Many
Haitians have a very low pain threshold. Their de-
meanor changes, they are verbal about the cause of
their pain, and they sometimes moan. They are vague
about the location of the pain because they believe
that it is not important; they believe that the whole
body is affected because disease travels. This belief
makes it very difficult to accurately assess pain. Injec-
tions are the preferred method for medication admin-
istration, followed by elixirs, tablets, and capsules.
Chest pain is referred to as doule nan ke mwen, ab-
dominal pain is doule nan vent, and stomach pain is
doule nan ke mwen or doule nan lestomak mwen. Oxy-
gen should be offered only when absolutely necessary
because the use of oxygen is perceived as an indicator
of the seriousness of the illness.
Nausea is expressed as lestomak/mwen ap roule,
M santi m anwi vomi, lestomak/mwen chaje, or ke mwen
tounin. Those who are more educated may express their
discomfort as nausea. Because of modesty, they may
discard vomitus immediately so as not to upset others.
Specific instructions should be given regarding keeping
the specimen until the practitioner has had a chance
to see it.
Fatigue, physical weakness known as febles, is
interpreted as a sign of anemia or insufficient blood.
Symptoms are generally attributed to poor diet.
Patients may suggest to the health-care provider that
they need special care—that is, to eat well, take vi-
tamin injections, and rest. To counteract the febles,
the diet includes liver, pigeon meat, watercress,
bouillon made of green leafy vegetables, cow’s feet,
and red meat.
People of Haitian Heritage 285
R E F L E C T I V E E X E R C I S E 1 5 . 4
Marie was raised by her grandmother since typhoid took
the lives of her parents. Marie said that when her brother,
Jean-Claude, contracted the disease, her grandmother used a
paste-like mixture of sour oranges, the leaves of a sour orange
tree, and papaya leaves and placed it on his forehead to
reduce the fever. This was used for 3 days, at which time her
grandmother realized that the treatment was ineffective. At
that point, Marie and her grandmother took Jean-Claude via a
donkey-pulled cart to the nearest clinic. The trip took 8 hours.
Even though the staff immediately started intravenous fluids
and medication, Jean-Claude died the next day.
1. What were some of the major obstacles to treating
Jean-Claude?
2. What are some of the variant cultural characteristics from
the Purnell Model in this vignette?
3. What other traditional remedies do Haitians use?
4. What are traditional Haitian burial practices?
2780_Ch15_269-287 16/07/12 11:49 AM Page 285

Another condition is fright or sezisman. Various ex-
ternal and internal environmental factors are believed
to cause sezisman, thereby disrupting the normal
blood flow. Sezisman may occur when someone
receives bad news, is involved in a frightful situation,
or suffers from indignation after being treated un-
justly. When this condition occurs, blood is said to
move to the head, causing partial loss of vision,
headache, increased blood pressure, or a stroke. To
counteract this problem, the patient may sit quietly,
put a cold compress on the forehead, drink bitter
herbal tea, take sips of water, or drink rum mixed with
black, unsweetened coffee.
Haitian Americans may strongly resist acculturation,
taking pride in preserving traditional spiritual, religious,
and family values. This strong hold on cultural views
sometimes creates stress leading to depression. The
stigma attached to mental illness is strong, and most
Haitians do not readily admit to being depressed. A
major factor to remember is the strong prevalence of
voudou, which attributes depression to possession by
malevolent spirits or punishment for not honoring
good, protective spirits. In addition, depression can be
viewed as a hex placed by a jealous or envious individ-
ual. Factors that may trigger depression are memories
of family in the homeland, thoughts about spirits in
Haiti, dreams about dead family members, or guilt
and regrets about abandoning one’s family in Haiti
for the abundance in America. Health-care providers
need to be sensitive to the underlying causes of problems
and ascertain the need for comfort within specific
religious beliefs.
In the case of an unnatural illness, the person’s poor
health is attributed to magical causes such as a hex, a
curse, or a spell that has been cast by someone as a re-
sult of family or interpersonal disagreement. The
curse takes place when the intended victim eats food
containing ingredients such as snake, frog, or spider
egg powder, which cause symptoms of burning skin,
rashes, pruritus, nausea, vomiting, and headaches
(Fishman, Bobo, Kosub, & Womeodu, 1993). These
symptoms often coincide with psychological prob-
lems manifested by violent attacks, hallucinations,
delusions, or “magical possession.” Because, under
Western medical standards, an evil spirit would be
classified as a true psychiatric problem with “cultur-
ally diverse manifestations” and not as an actual case
of possession, the health-care provider is challenged
in assessing and making the appropriate intervention
(Fishman et al., 1993). If the health-care provider is
aware of witchcraft, voudou practices, and the symp-
toms associated with them, it may prevent (1) incor-
rectly diagnosing an individual as mentally ill,
(2) giving advice that frightens or confuses the patient
into thinking an illness is unnatural in origin, or
(3) initiating symptomatic treatment that does not
reach the underlying stress. The role of the health-care
provider is to be sensitive and understanding toward
the patient who holds a belief in these traditional
practices. Health-care providers should realize that
hesitating to offer a specific diagnosis might be more
detrimental to the patient than a negative diagnosis.
Blood Transfusions and Organ Donation
Most Haitians are extremely afraid of diseases asso-
ciated with blood irregularities. They believe that
blood is the central dynamic of body functions and
pathological processes; therefore, any condition that
places the body in a “blood-need” state is believed to
be extremely dangerous. Patients and their families be-
come emotional about blood transfusions. Thus, these
are received with much apprehension. In addition, as
in all societies, blood transfusions are feared because
of the potential for HIV transmission. Health-care
providers should explain the need for a blood trans-
fusion factually and carefully clarify the procedure
along with the involved risks. Health-care providers
should involve patients and their families in the care
as much as possible. Precautionary measures that have
been taken to prevent blood contamination should
also be explained.
Because Haitians hold strong religious beliefs about
life after death, the body must remain intact for burial.
Thus, organ donation and transplantation are not
generally discussed. Since migrating to the United
States, some Haitians have, with considerable distress,
participated in organ transplantation. A prime con-
cern is transference, believing that through the organ
donor, the donor’s personality will “shift” to the re-
cipient and change his or her being. Health-care
providers should assess Haitian patients’ beliefs about
organ donation and involve a religious leader to pro-
vide support and help facilitate a decision regarding
organ donation or transplantation. Because some
Haitians’ knowledge and understanding in this area is
limited, the health-care provider should be proactive
by promoting health education.
Health-Care Providers
Traditional Versus Biomedical Providers
In general, most Haitians resort to symptom manage-
ment with self-care first and then spiritual care. They
commonly use traditional and Western health-care
providers simultaneously (see Spirituality and Folk
Practices).
Status of Health-Care Providers
Haitians are very respectful of physicians and nurses.
Physicians are men and nurses are women. Nurses are
referred to as “Miss.” By incorporating culturally spe-
cific strategies in their program, health-care providers
inspire confidence and trust. Haitian patients who
have had limited contact with American health-care
286 Aggregate Data for Cultural-Specific Groups
2780_Ch15_269-287 16/07/12 11:49 AM Page 286

systems may have limited understanding of biomed-
ical concepts. Health-care providers need to take the
time to explain and reexplain relevant points to com-
pensate for patients’ deficient knowledge or language
limitations. Health-care providers who show compas-
sion and sensitivity toward Haitian patients achieve
greater success in educating patients, families, and the
community.
R E F E R E N C E S
Aristide, M.V. (1995). Economics of liberation. Roots, 1(2), 20–24.
BBC News. (2011, January 7). Retrieved from BBC: http://www.
bbc.co.uk
CIA World Factbook. (2012). Retrieved from https://www.cia.gov/
library/publications/the-world-factbook/geos/ha.html
Dorestant, N. (1998). A look at Haitian history from a Haitian per-
spective. Retrieved from http://www.geocite.com
Fishman, B.M., Bobo, L., Kosub, K., & Womeodu, R.J. (1993).
Cultural issues in serving minority populations: Emphasis on
Mexican Americans and African Americans. American Journal
of Medical Science, 306, 160–166.
Jean-Baptiste, A.R. (1985). The black man: Ti Manno in public.
New York: St. Aude Records.
Jean-Bernard, L. (1983). Impossible alphabetization. Port-au-Prince,
Haiti: Des Antilles SA.
Haiti: Early history to independence. (2007). Retrieved from
http://www.infoplease.com/ce6/world/A0858544.html
Laguerre M.S. (1981). Haitian Americans. In L. Sana (Ed.), Hand-
book of immigrant health (pp. 194–196). New York, NY: Springer
Publishing Co.
Louis-Juste, A. (1995). Popular education and democracy. Roots,
2(1), 14–19.
McCann, B.S., Scheele, L., Ward, N., & Roy-Byrne, P. (2006).
Childhood inattention and hyperactivity symptoms self-
reported by adults with Asperger syndrome. International Journal
of Descriptive and Experimental Psychopathology, Phenomenol-
ogy and Psychiatric Diagnosis, 39, 45–54.
McKenzie, A.D. (2010, January 17). France: Time to pay back
Haiti. Retrieved from IPS Interpress Service: http://ipsnews.net
Pan American Health Organization (PAHO). (2001). Regional
core health data. Retrieved from http://www.paho.org/English/
SHA/glossary.htm
Pan American Health Organization (PAHO). (2011, February 10).
Disaster in Haiti—One year later. Retrieved from http://www.
paho.org/disasters
Paravisini, L. (2010, February 7). Dominican Republic fears increased
migration from Haiti. Retrieved from http://repeatingislands.com
Power, C. (2010, July 13). Citizenship and Immigration Canada se-
cures fast family reunification or Haitians affected by earthquake.
Retrieved from http://www.cic.gc.ca
Prudent, N., Johnson, P., Carroll, J., & Culpepper, L. (2005). At-
tention deficit disorder: Presentation and management in the
Haitian American child. Primary Care Companion Journal
Clinical Psychiatry, 7(4), 190–197.
Saint-Domingue. (2011, January 24). Stamping down on Haiti’s
restavek shame. Retrieved from http://citizenhaiti.com
Santana, M.A., & Dancy, B.L. (2000). The stigma of being named
“AIDS carriers” on Haitian-American women. Health Care for
Women International, 21, 161–171.
Schaaf, B. (2009, July 16). Child slavery in Haiti: CNN covers Jean
Robert Cadet Foundation. Retrieved from http://haitiinnovation.
org/fr/about/about_haiti_innovation
Simon, J.J., Kleschnitzki, S., & Shusterman, J. (2011, January).
Children in Haiti: One year after—The long road from relief to
recovery. Retrieved from http://unicef.org
Statistics Canada. (2006). Retrieved from http://www40.statcan.gc.
ca/z01/cs0001-eng.htm
U.S. Census Bureau. (2009). The population with Haitian ancestry
in the United States: 2009. Retrieved from http://www.census.
gov/prod/2010pubs/acsbr09-18
U.S. Immigration and Naturalization Service. (2006). Statistical
yearbook of the Immigration and Naturalization Service 2005.
Washington, DC: U.S. Government Printing Office.
World Bank. (2010). The World Bank annual report 2010. Re-
trieved from http://www.worldbank.org
World Health Organization (WHO). (2010, September 3). WHO
weekly epidemiology record. Retrieved from http://www.who.
int/wer
Zissis, C. (2010, January 27). The Haitian migration debate.
Retrieved from http://www.as-coa.org
For case studies, review questions, and additional
information,
go to http://davisplus.fadavis.com
People of Haitian Heritage 287
2780_Ch15_269-287 16/07/12 11:49 AM Page 287

288
Chapter 16
People of Hindu Heritage
Jaya Jambunathan
Overview, Inhabited Localities,
and Topography
Overview
India, located in southern Asia, has a landmass approx-
imately one-third that of the United States. With over
1.18 billion people, India is currently the world’s second
largest country. Of the population, more than 80 percent
are Hindus; 13.4 percent are Muslim; 2.3 percent are
Christian; 1.9 percent are Sikh; 1.8 percent are other;
and 0.1 percent are unspecified ( CIA World Factbook,
2011). These divisions have historically caused tensions
between different religious groups. Although different
religious sectors share many common cultural beliefs
and practices, they differ according to the variant cul-
tural characteristics (see Chapter 1). Hindi and English
are India’s official languages, but there are also 17 regional
languages that are considered official. India has several
cities that have undergone place name changes, such as
Bombay being renamed Mumbai. These changes were
mainly done in an effort to return the city names to local
dialects instead of British translations.
Seventy-two percent of the population of India is
Indo-Aryan, 25 percent Dravidian, and 25 percent
and 3 percent Mongoloid and other, respectively.
Table 16-1 provides the demographic trends related to
population, fertility, mortality, and migration.
The Indus Valley civilization, one of the oldest in
the world, dates back at least 5000 years. Aryan tribes
from the northwest infiltrated onto the Indian subcon-
tinent about 1500 B.C.; their merger with the earlier
Dravidian inhabitants created the classical Indian cul-
ture. Arab incursions starting in the 8th century and
Turkish in the 12th were followed by those of European
traders, beginning in the late 15th century. By the
19th century, Britain had assumed political control of
virtually all Indian lands. Indian armed forces in the
British army played a vital role in both world wars.
Nonviolent resistance to British colonialism led by
Mohandas Ghandi and Jawaharlal Nehru brought in-
dependence in 1947. The subcontinent was divided
into the secular state of India and the smaller Muslim
state of Pakistan. A third war between the two coun-
tries in 1971 resulted in East Pakistan becoming the
separate nation of Bangladesh ( CIA World Factbook,
2011). Despite problems related to overpopulation,
environmental degradation, extensive poverty, and
ethnic and religious strife, India is rising on the
world stage due to rapid economic development. In
January 2011, India assumed a nonpermanent seat in
the UN Security Council for the 2011–2012 term
(CIA World Factbook, 2011).
Physical characteristics influencing the history and
civilization of India are the size of the country and
the comparative isolation provided by the Himalayas.
The country suffers from droughts; flash floods and
widespread and destructive flooding from monsoonal
rains; severe thunderstorms; earthquakes; deforesta-
tion; soil erosion; overgrazing; desertification; air pol-
lution from industrial effluents and vehicle emissions;
and water pollution from raw sewage and runoff of
agricultural pesticides. Tap water is not potable
throughout the country.
India’s long-term challenges include widespread
poverty, inadequate physical and social infrastructure,
limited nonagricultural employment opportunities, in-
sufficient access to quality basic and higher education,
and accommodating rural-to-urban migration. De-
spite these challenges, India has capitalized on its large
educated English-speaking population to become a
major exporter of information technology services
and software workers ( CIA World Factbook, 2011).
Heritage and Residence
Immigrants from India come predominantly from
urban areas and include all major Indian states. Ear-
lier immigrants represented a small and transitory
community of students, Indian government officials,
and businesspeople, and came from a diverse linguis-
tic, religious, regional, and caste population (caste is
a hereditary social class, discussed later under Spiri-
tuality). Asian Indian immigrants to America came in
2780_Ch16_288-309 16/07/12 11:50 AM Page 288

People of Hindu Heritage 289
two waves (Fenton, 1988). The first wave began in the
early 20th century and continued to the mid-1920s.
Conditions such as racial discrimination and lack of
access to economic advancement made it difficult for
the first wave of Asian Indians to sustain themselves
or their culture. More than three-quarters of the
7000 Asian Indian immigrants in this wave came from
the northwest of India, primarily from Punjab, and
90 percent of the Punjabis were Sikhs. Most Punjabis
worked as manual laborers, first in Canada and later
on the West Coast of the United States. Other Asian
Indian immigrants, who were professionals and busi-
nesspeople, were mostly Hindus and Muslims who set-
tled in San Francisco, Los Angeles, New York City,
and the Midwest. The second wave of immigration
began after 1965 and still continues. Most individuals
from this wave are highly educated, skilled profession-
als and were predominantly from the urban middle
class. The colonial authority of the British Raj en-
grained in the Indian mentality that foreign education
is better than indigenous training.
Asian Indians in the United States as reported by
the American Community Survey and reported in Lit-
tle India, currently number over 2.4 million, with the
largest Indian American populations in California,
New York, New Jersey, Texas, and Illinois, in that
order (“Asian Indian Population in 2005,” 2005).
There are also large Indian American populations in
Florida, Georgia, Maryland, Michigan, Pennsylvania,
Ohio, and Virginia. The New York metropolitan area,
consisting of New York City and adjacent areas in
the state of New York, as well as nearby areas in
New Jersey, Connecticut, and Pennsylvania, are home
to approximately 600,000 Indian Americans (“Asian
Indian Population in 2005,” 2005).
In relation to cultural value systems of the first-
generation and second-generation Asian Indian im-
migrants, first-generation Asian Indians are acutely
aware of readily apparent cultural differences. Their
modern and traditional ideas are in conflict, with
Indian culture clashing with American culture, and
theory clashing with practice, inside and outside the
home. The basis for interactions outside the home is
the dominant culture, whereas inside the home, first-
generation Asian Indians attempt to preserve their
cultural and religious heritage and abide by Indian
cultural values. For second-generation Asian Indians,
the conflict of being the “in-betweens” become accen-
tuated. Like their parents, the second-generation In-
dians also compartmentalize their life inside and
outside the home. Conflicts typically arise from the
cultural clash of how second-generation Asian Indians
perceive American Individualism versus Indian com-
munitarianism, in which career decisions are based on
their impact on the family’s financial well-being, not
the individual’s.
Reasons for Migration and Associated
Economic Factors
Asian Indians leave their country for a variety of rea-
sons, the most important of which is to attain a higher
standard of living. The reasons for an overwhelming
❙❙◗ Table 16-1 Demographic Trends in India
Demographic Indicators for India 2011 1995 2005 2015 2025
Population
Midyear population (in thousands) 1,189,173 920,585 1,090,973 1,251,696 1,396,046
Growth rate (percent) 1.3 1.9 1.5 1.2 1
Fertility
Total fertility rate (births per woman) 2.6 3.4 2.8 2.5 2.3
Crude birth rate (per 1000 population) 21 28 23 20 17
Births (in thousands) 24.9 26 25.5 25 23.7
Mortality
Life expectancy at birth (years) 67 60 65 68 71
Infant mortality rate (per 1000 births) 48 75 58 42 30
Under 5 mortality rate (per 1000 births) 65 109 81 56 39
Crude death rate (per 1000 population) 7 10 8 7 7
Deaths (in thousands) 8.9 8.8 8.7 9.2 10.2
Migration
Net migration rate (per 1000 population) –0 –0 –0 –0 –0
Net number of migrants (in thousands) –59 –74 –55 –50 –56
From U.S. Census Bureau, International Data Base (2010).
2780_Ch16_288-309 16/07/12 11:50 AM Page 289

majority were financial factors. Although Asian
Indians did migrate for financial reasons, they also
left for professional, educational, and social oppor-
tunities. For many Asian Indians, emigration was
thought prestigious. The prospect of greater material
prosperity, combined with better working conditions,
enhances the appeal of a wider range of job oppor-
tunities in the United States. Secondary reasons
included opportunities for additional education as
well as Indian perceptions of America as a land of
opportunity and freedom. Immigrants include par-
ents (who come for the sake of their children) and
those who come on student visas and later change to
permanent resident status.
India is a source, destination, and transit country
for men, women, and children trafficked for the pur-
poses of forced or bonded labor and commercial sex-
ual exploitation. The large population of men,
women, and children—numbering in the millions—
in debt bondage face involuntary servitude in brick
kilns, rice mills, and embroidery factories, whereas
some children endure involuntary servitude as do-
mestic servants. Internal trafficking of women and
young girls for the purposes of commercial sexual
exploitation and forced marriage also occurs; the
government estimates that 90 percent of India’s sex
trafficking is internal. Young boys from Afghanistan,
Pakistan, and Bangladesh are trafficked through
India to the Gulf States for involuntary servitude as
child camel jockeys. Indian men and women migrate
willingly to the Persian Gulf region for work as do-
mestic servants and low-skilled laborers, but some
later find themselves in situations of involuntary
servitude, including extended working hours, non-
payment of wages, restrictions on their movement by
withholding their passports or confinement to the
home, and physical or sexual abuse. Despite the re-
ported extent of the trafficking crisis in India, efforts
are in progress to prosecute traffickers and protect
trafficking victims and to rescue victims of commer-
cial sexual exploitation, forced child labor, and child
armed combatants. The critical challenge overall is
the lack of punishment for traffickers, effectively
resulting in impunity for acts of human trafficking
(CIA World Factbook, 2011).
Educational Status and Occupations
Most Asian Indians speak English, and many also
speak another language. Because the immigration
laws of 1965 granted immigrant visas only to people
with certain professional and educational back-
grounds, most Hindus in the United States possess
high educational qualifications. However, those
granted visas on the basis of marriage or relation-
ships, such as parents, do not necessarily have the
same educational backgrounds.
Communication
Dominant Language and Dialects
Although English enjoys associate status in India, it
is the most important language for national, political,
and commercial communication. Hindi, with 1652 di-
alectical variations, is the national language and
primary tongue of 41 percent of the people. Other
official languages are Bengali, Telugu, Marathi, Tamil,
Urdu, Gujarati, Malayalam, Kannada, Oriya, Punjabi,
Assamese, Kashmiri, Sindhi, and Sanskrit. Hindus-
tani is a popular variant of Hindi/Urdu spoken widely
throughout northern India, but it is not an official lan-
guage (CIA World Factbook, 2011).
Because of regional dialects in the main language,
health-care providers must be simple and direct in
their communication and clear in their enunciation.
Communication difficulties may not be apparent in
well-educated Hindus. However, with the arrival of
parents and grandparents who may not speak English,
it is of utmost importance for health-care providers to
have an interpreter available to provide quality health
care. Hindus, especially women, often speak in a soft
voice, making it difficult to understand or decipher
what they say. The speech is coupled with an accent,
further compromising communication with individuals
of other cultures.
Cultural Communication Patterns
Hindus have close-knit family ties. Men especially may
become intense and loud when they converse with
other family members. To an onlooker, it might seem
disruptive, but in general, this form of communication
can be construed as meaningful when it is conducted
with close friends.
Women are expected to strictly follow deference
customs—that is, direct eye contact is avoided with
men, although men can have direct eye contact with
one another. Direct eye contact with older people and
authority figures may be considered a sign of disre-
spect. More often, men and women use head move-
ments and hand gestures to emphasize the spoken
word. Strangers are greeted with folded hands and a
head bow that respects their personal territory. Touch-
ing and embracing are not acceptable for displaying
affection. Even between spouses, a public display of
affection such as hugging or kissing is frowned upon,
being considered strictly a private matter. Despite
these societal constraints regarding the outward dis-
play of affection, Hindus are extremely family ori-
ented and nurture one another in sickness, whether at
home or in the hospital setting.
Temporal Relationships
According to the Hindu theory of creation, time (in
Sanskrit kal) is a manifestation of God. The past, the
290 Aggregate Data for Cultural-Specific Groups
2780_Ch16_288-309 16/07/12 11:50 AM Page 290

People of Hindu Heritage 291
present, and the future coexist in God simultaneously.
Hence, the Hindu concept of time is past, present, and
future oriented, depending on generation, socioeco-
nomic status, and educational level. The Hindu value on
educational attainment denotes a futuristic temporality.
Because of the Indian worldview of the cyclic nature
of the universe and belief in reincarnation, Indians
have a relaxed attitude toward time (Jain, 1992). Due
to the Hindu broad concept of time, adherence to the
North American parameters of time may not be rigid.
Punctuality in keeping scheduled appointments may
not be considered important. Health-care providers
must understand the value placed on time by Hindus
and not misconstrue being late for appointments as a
sign of irresponsibility or not valuing their health.
Format for Names
Women adhere to a specified linguistic style when talk-
ing with their husbands. The hierarchical structure of
interrelationship is built into the structure of language.
The woman refers to the man in the plural Avar and
Aap, meaning “you” (with respect), whereas the man
can use a singular “you” like Ne, Aval, or Thum. Aap
means “thou” and is used for elderly family members
and for strangers. Older family members are usually not
addressed by name but as elder brother, sister, aunt, or
uncle. A woman never addresses a man by name
because the woman is not considered an equal or a
superior. However, exceptions to this practice occur
when the woman is older than the man.
The system of “naming” customs in India is complex
and relative to the social and cultural structures. The
naming customs are closely related to Hindusim, chatur-
varna system of castes (see section on Spirituality), clan,
and lineage (Jayaraman, 2005).
Family Roles And Organization
Head of Household and Gender Roles
No institution in India is more important than the
family. The family was originally patriarchal and the
joint family evolved from it, the transition arising
from the death of the common ancestor or the patri-
arch of the family. The hierarchical structure of au-
thority in the patriarchal joint family, based on
the principle of superiority of men over women, is the
most important instrument of social control. The
rights and duties of individuals are prescribed by
the hierarchical order of power and authority. The male
head of the family is legitimized and considered sacred
by caste and religion that delineate relationships.
The central criteria of the Hindu joint family include
(1) family property jointly owned by men and inherita-
ble only by the male lineage (although by law it is to be
shared equally among both male and female offspring);
(2) the hierarchical structure of authority according to
gender and age; and (3) the dependence of women and
children. Central relationships in this system are based
on continuation and expansion of the male lineage
through inheritance and ancestor worship, related to
the father–son and brother–brother relationships.
Family plays a significant role in the Indian culture.
For generations, India has had a prevailing tradition
of the joint family system. It is a system under which
extended members of a family—parents, children, the
children’s spouses and their offspring, and so on—live
together. Usually, the eldest male member is the head
in the joint Indian family system. He makes all impor-
tant decisions and rules, and other family members
abide by them.
Within the joint family system, the patrilineal sys-
tem created a sense of worthlessness, servitude, and
dependence for women characterized by a lack of free-
dom, as well as constraints and limitations that sup-
pressed individual development. A submissive and
acquiescent role is expected of women in the first few
years of married life, with little or no participation in
decision making. Strict norms govern contact and
communication with the men of the family, including
a woman’s husband. However, in recent times, many
families, especially in urban areas, have stopped abid-
ing by the extended family system and have started
living as a nuclear family.
Although a patrilineal system is not characteristic
of the nuclear family, the distinctions between men and
women persist. This is also true of the matrilineal sys-
tem that exists in a few areas in the southwestern and
northeastern regions of the country. In a matrilineal
system, the lineage is counted through the woman, but
power rests with the men in the woman’s family. Hence,
even in a matrilineal system, constraints abound for
women because of power distribution that promotes
male dominance.
In the Indian household, lines of hierarchy and au-
thority are clearly drawn, shaping structurally and
psychologically complex family relationships. Ideals
of conduct are aimed at creating and maintaining
family harmony. All family members are socialized to
accept the authority of those ranked above them in
the hierarchy. In general, elders rank above juniors, and
among people of similar age, males outrank females.
Among adults in a joint family, a newly arrived daugh-
ter-in-law has the least authority. Males learn to
command others within the household but expect to
accept the direction of senior males. Ideally, even a
mature adult man living in his father’s household
acknowledges his father’s authority on both minor
and major matters. Women are especially strongly
socialized to accept a position subservient to males,
to control their sexual impulses, and to subordinate
their personal preferences to the needs of the family
and kin group. Reciprocally, those in authority accept
2780_Ch16_288-309 16/07/12 11:50 AM Page 291

responsibility for meeting the needs of others in the
family group.
Much has changed in the status and roles of
women; however, most Hindu women remain sub-
servient to their closest male relatives, a situation that
is gradually changing. Hindu society is trying to rede-
fine the role of women in the institution of family and
society. Politically Hindu women today enjoy an equal
status with men and wider opportunities than their
counterparts in many Western countries. Although
there is ongoing discussion to provide them with new
privileges and rights, including inheritance rights,
much still needs to be done on the social and eco-
nomic front. Women in Hindu society still suffer from
gender bias and a number of other problems such as
dowry, inheritance, domestic abuse, sexual exploita-
tion, rape, and harassment.
Changing role status is further illustrated by Varghese
and Jenkins (2009), who studied the variables that might
be related to high cultural conflict among first- and
second-generation Asian Indian immigrant women and
the psychological consequences of cultural value con-
flict. Self-report data from 73 community-dwelling
women were used to examine women’s recollections of
parental overprotection, their reports of cultural value
conflict, and their ratings of self-esteem and depression
symptoms. Varghese and Jenkins found that the results
supported the hypotheses that unmarried and second-
generation women would report greater maternal con-
trol and cultural value conflict than married and
first-generation women. Second-generational status,
high maternal control, and high cultural value conflict
correlated with higher depressive symptoms, while being
married, low maternal control, and low cultural conflict
were related to high self-esteem.
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Hindu parents in general want their children to be suc-
cessful and strongly encourage and emphasize
scholastic achievement in fields that promise good em-
ployment and a high social status. Hindu parents in
America want their children to be successful and
maintain ties with their families and the Indian com-
munity. Thus, parents face a dilemma between aspir-
ing for the American dream of success for their
children and holding on to their desire to maintain
Indian values. Status indicators such as education, in-
come, and community and occupational leadership
tend to replace ascribed social status.
The birth of a male child is considered important,
and the desire for a male child rather than a female
child is often prevalent. Furthermore, widowhood, es-
pecially for women, is considered a negation of mar-
riage (Duvvurry, 1991). In America, Hindu parents
may have reservations about eventual marriage part-
ners for their children and concerns about the issues
of dating, premarital sex, and freedom. Although
many Hindu parents expect and accept the Western-
ization of their children, the question of marriage is
still a concern for Hindu parents who have opinions
about how their children should be married, whether
“arranged” or partly arranged. Hindu parents or
Indians from all religious traditions want their chil-
dren to marry other Indians. Health-care providers
should understand the various types of families (joint,
extended, or nuclear) and should determine which
individual has control within the hierarchy.
Arranged marriages at a young age are considered
most desirable for women. This practice is related to
the importance of virginity and restrictions placed on
marriage within the same clan. For centuries, arranged
marriages have been the tradition in Indian society.
Even today, the vast majority of Indians have their
marriages planned by their parents and other re-
spected family members, with the consent of the bride
and groom. They also demand a dowry, which has
been outlawed by the Indian government, but Indian
society and culture still promote and maintain it. They
avoid detection by not letting authorities know about
any money arrangements. Arranged matches are made
after taking into account factors such as age, height,
personal values and tastes, the backgrounds of their
families (wealth, social standing), their castes, and the
astrological compatibility of the couple’s horoscopes.
In India, since marriage is thought to be for life, the
divorce rate is extremely low, and arranged marriages
generally have an even lower divorce rate. Divorce
rates have risen significantly in recent years. There is
conflict of opinion over what the phenomenon
means—whether, for traditionalists, the rising number
of divorces portends the breakdown of society or, for
modernists, creates a healthy new empowerment for
women.
Although arranged marriages are still a preferred
choice among the younger generation, education and
liberalization of ideas in urban areas have led to
changes in selecting a marriage partner. The practice
of an arranged marriage continues in the United States
to minimize the stress associated with differences in
caste, lifestyles, and expectations between the male and
the female hierarchy.
The two major types of transfer of material wealth
accompanying marriage are bride price and a dowry.
The bride price is customarily prevalent among patri-
lineal tribes and the middle and lower castes of non-
tribal populations. Bride price is payment in cash and
other materials to the bride’s father in exchange for
authority over the woman, which passes from her kin
group to the bridegroom’s kin group. In communities
that follow this custom, a daughter is not regarded as
a burden, and parents do not dread the thought of
marriage. A daughter brings wealth to the family as a
result of marriage.
292 Aggregate Data for Cultural-Specific Groups
2780_Ch16_288-309 16/07/12 11:50 AM Page 292

People of Hindu Heritage 293
Regional variations exist in understanding the
dowry system. Dowry may be seen as the gift given to
the bride and often settled prior to marriage, which
may not be regarded as her property; as a gift given to
the bridegroom before and at the time of marriage; or
as a present to the groom’s relatives. The practice of
dowry in the Hindu community has a number of cul-
tural and social sanctions. Dowry is regarded as es-
sential to obtain a suitable match for a young woman,
ensuring a high standard of life.
The increase in social and economic inequality is
one of the most important inducements for a dowry
and operates at all levels of society. Wealth ranges
from a few hundred to thousands of rupees (Indian
currency), and behind this transaction is a direct de-
sire to improve the daughter’s social status, which in-
directly assists the social status of the bridegroom’s
family. The desire to obtain security and good status
for the daughter places the bride’s parents in a vulner-
able position, in which they are faced with demands
bearing no relation to their economic capacity. This
may reduce them to a state of indebtedness.
Family Goals and Priorities
In the joint family structure, Hindu women are con-
sidered “outsiders” and are socialized and incorpo-
rated in such a way that the “jointness” and residence
are not broken up. This means that a close relation-
ship between the husband and the wife is disap-
proved because it induces favoring the nuclear family
and dissolving the joint family.
The Hindu family’s goals and priorities include
the most important Hindu sacrament, the Vivaha
(marriage), which is a religious and social institu-
tion. The marital union is a matter for the husband
and wife, society, guardians, and supernatural pow-
ers that symbolize spirituality. Therefore, a marriage
is regarded as indissoluble. The sacrament of marriage
impresses on a person that earthly life is not to be de-
spised; rather, it should be consciously accepted and
elevated to the level of a spiritual experience.
In patrilineal societies, marriage signifies a transfer of
a woman from her natal group to that of her husband.
Marriage is not considered primarily an affair of the
man and woman who are getting married but an event
that involves the kin of both spouses. Hence, the insti-
tution of marriage is a means by which alliances are cre-
ated or strengthened between two or more groups.
Family elders are held in reverence and cared for by
their children when they are no longer able to care for
themselves. Families believe that knowledge is transmit-
ted through an oral tradition derived from experience,
and the elderly are repositories of such knowledge.
Alternative Lifestyles
Religion has played a role in shaping Indian customs
and traditions. While homosexuality has not been
explicitly mentioned in the religious texts central to
Hinduism, it has taken various positions, ranging
from positive to neutral or antagonistic. Historical lit-
erary evidence indicates that homosexuality has been
prevalent across the Indian subcontinent throughout
history and that homosexuals were not necessarily
considered inferior in any way. Whereas homosexual-
ity probably occurs as frequently as in any group, this
lifestyle may cause a social stigma, and there is a high
degree of stigma associated with homosexuality in
India. However, attitudes toward homosexuality have
shifted slightly in recent years. In particular, there have
been more depictions and discussions of homosexu-
ality in the Indian news media. In mid-2009, the
New Delhi High Court decriminalized homosexual in-
tercourse between consenting adults, throughout
India, making HIV education and surveillance very
difficult. Outreach workers are often harassed and
even arrested for “promoting homosexuality.” It is es-
timated that 42 percent of all men who have sex with
men are also married, fueling the increasing HIV in-
fection rate among women of India (Cichocki, 2007).
Gay people in India may not be completely liber-
ated, but they are more willing than ever before to chal-
lenge curiosity, even rejection, without allowing it to
damage their conscience. In the past two years, many
18- to 24-year-olds have come out. They are honest
with their parents. This is different from the times when
parents would force a heterosexual marriage on them
to “normalize” things. But in modern India the accept-
ance is different for male gays and lesbians because of
lack of resources or educational opportunities. The
Sahayatrika group of Kerala, which recently did a
R E F L E C T I V E E X E R C I S E 1 6 . 1
Revathy Srinivasan, a Hindu woman aged 25 years, has lived in
the United States for 9 years, and her parents have just arrived.
She wishes to marry Velayudham Mani (Vel), a man she met in
graduate school, who is also a Hindu. However, her parents
will not allow her to marry Vel because he is of a lower caste
than she is. Besides, her parents want her to marry their
friends’ son Ajay, who is well established. Revathy’s parents feel
that both their and their friends’ family backgrounds (wealth
and social standing) are congruent, in addition to the astrologi-
cal compatibility of both children’s horoscopes. If Revathy in-
sists on marrying Vel, they will not give Vel’s family any dowry.
1. How common are arranged marriages among Hindus in
India? In the United States?
2. What is a dowry?
3. What is the significance of a dowry?
4. Describe the caste system of Asian Indians.
5. Should Revathy seek counseling to help her solve her
dilemma? If so, from what type of counselor should she
seek help?
2780_Ch16_288-309 16/07/12 11:50 AM Page 293

study on lesbian suicides, has catalyzed a reconsidera-
tion of same-sexuality. There has been an increase in
support groups with separate help lines catering to
Hindi-speaking, English-speaking, and transgender
groups. In West Bengal, the “coming out” phenome-
non is seen even in smaller districts, with networks like
Manas Bangla, headquartered in Kolkata (Vasudev,
Radhakrishnan, Ravindran, & Dangor, 2004).
A paucity of information exists regarding Hindu gay
or lesbian couples in the professional literature. Health-
care providers can refer lesbian, gay, or bisexual Hindu
Americans to the Gay and Lesbian Vaishnava Associa-
tion Inc. (2005), a resource for Hindus and other South-
east Asian groups. Single-parent, blended, or communal
families are not well accepted by Hindus. In addition,
two magazines, Trikone, the first quarterly magazine for
gay South Asian men and women, and India Currents,
a monthly arts and entertainment magazine, are
targeted to Indo-Americans living in California.
Workforce Issues
Culture in the Workplace
With comparative ease, most Hindus have become part
of the skilled workforce in America. Hard work, inter-
est in saving and investment, and business acumen en-
able many to become financially successful. Because of
their educational and professional background, it is
not difficult for most to find suitable employment and
improve their economic status.
Many Hindus have a singular devotion to their ca-
reer, profession, or business, which results in a per-
sonal cost evidenced in family relationships or in
health status. Demonstrating hospitality is important
to Hindus. A new friendship is not formally acknowl-
edged among Hindus without the reciprocity of home
visits. Thus, Americans who refer to their Indian ac-
quaintances and colleagues as “friends” without hav-
ing extended hospitality to them in their homes might
confuse the Hindu immigrant’s notions of friendship.
At work, Hindus adopt American practices and cul-
tural habits, but at home and at Indian gatherings, they
retain many of their own cultural practices. Active par-
ticipation in Indian organizations is a growing phenom-
enon, especially in the absence of the cultural milieu
available in India. Hindu Americans believe that such
participation is the only way their children can become
aware of their Indian heritage. Currently in America,
numerous regional Indian organizations are available
throughout the country, resulting in a vast network of
communication. Religious revivalism and social con-
viviality are the hallmarks of Hindu adaptation.
Issues Related to Autonomy
An early realization of immigrants in a new country
is that they must build new relationships and find
new reference groups. Hierarchies of age, gender, and
caste prescribe transactions among Hindus. At work,
relationships are a reproduction of the authority-
dependence characteristic of family and social relation-
ships. In seeking to establish a personal and benevolent
relationship, Hindus may be seen as too eager to
please, ingratiating, or docile, all antithetical to the
task of assertion and independence.
Hindus speak English as well as their regional lan-
guages at home. Therefore, they rarely have any diffi-
culty with communication in the American workforce.
However, because most Hindus have learned and
speak British English, those unfamiliar with British
English and idioms may have difficulty understanding
them and should ask for clarification.
Biocultural Ecology
Skin Color and Other Biological Variations
Asian Indian Hindus evidence a diversity of physical
types. Asian Indians can be divided into three general
groups according to the color of their skin: white in the
north and the northwest, yellow in the east, and black
in the south. Whites, Indids, have a light brown skin
color, wavy black hair, dark or light brown eyes; are tall
or of medium height; and are either dolichocephalic
(i.e., long-headed) or brachycephalic (i.e., short-headed).
The physical type of the Indids varies according to re-
gions, ranging from a light to a brown skin color. The
yellow races are found in the periphery of India in the
areas bordering Tibet and Assam.
Black-skinned people, Melanids, are often referred to
as the Dravidians, the population of southern India. The
Melanids have dark skin (ranging from light brown to
black), elongated heads, broad noses, thick lips, and
black, wavy hair; they are usually less than 5 feet 6 inches
tall. The most characteristic Melanids are the Tamils, a
major linguistic and cultural group in South India.
Because skin color varies regionally, health-care
providers must be careful when arriving at a diagno-
sis that may be applicable only to white-skinned peo-
ple. Pallor in brown-skinned patients may present as
a yellowish-brown tinge to the skin. Pallor in dark-
skinned individuals is characterized by the absence
of the underlying red tones in the skin. Furthermore,
jaundice may be observed in the sclera and should
not be confused with the normal yellow pigmenta-
tion of the dark-skinned black patient. In addition,
the oral mucosa of dark-skinned individuals may
have a normal freckling or pigmentation. Cyanosis
can often be difficult to determine in dark-skinned
individuals. A close inspection of the nailbeds, lips,
palpebral conjunctivae, and palms of the hands and
soles of the feet shows evidence of cyanosis.
Diseases and Health Conditions
The rainy season in the tropics is associated with an
increase in malaria. Asian Indians migrating to the
294 Aggregate Data for Cultural-Specific Groups
2780_Ch16_288-309 16/07/12 11:50 AM Page 294

People of Hindu Heritage 295
United States from the tropical regions may be suscep-
tible to malaria, which intensifies during the monsoon
season. Filariasis is prevalent in some parts of India.
Respiratory infections such as tuberculosis and pneu-
monia are also widely prevalent in the midlatitudes and,
in the rainy season, in monsoon areas. Respiratory
infections occur in the most densely populated river val-
leys and coastal lowlands and in dark, intensely crowded
urban areas. Major infectious diseases include food- or
water-borne diseases like bacterial diarrhea, hepatitis A
and E, and typhoid fever; vector-borne diseases like
chikungunya, dengue fever, Japanese encephalitis, and
malaria; animal contact diseases like rabies; and water
contact diseases like leptospirosis. Highly pathogenic
H5N1 avian influenza has also been identified (CIA
World Factbook, 2011).
When performing health assessments, health screen-
ings, and physical examinations, health-care providers
must be alert to possible signs and symptoms of the risk
factors associated with different diseases linked to
migration from different regions of India.
The four leading chronic diseases in India, as meas-
ured by their prevalence, are, in descending order, car-
diovascular diseases (CVDs), diabetes mellitus (diabetes),
chronic obstructive pulmonary disease (COPD), and
cancer. All four of these diseases are projected to con-
tinue to increase in prevalence in the near future given
the demographic trends and lifestyle changes underway
in India (Shetty, 2002). Heart disease tends to develop at
a very early age in Asian Indians. The major causes of
cardiovascular disease are tobacco use, physical inactiv-
ity, and an unhealthy diet. India suffers disproportion-
ately from cardiovascular disease. A 2008 article in The
Lancet (Crosta, 2008) reported that “India will bear
60 percent of the world’s heart disease burden in the next
two years [2008–2010]. In addition, researchers have de-
termined that compared to people in other developed
countries, the average age of patients with heart disease
is lower among Indian people, and Indians are more
likely to have types of heart disease that lead to worse
outcomes.”
Diabetes mellitus, insulin resistance, and central
obesity are also prevalent among this population, as
are high serum levels of lipoprotein (Blesch, Davis,
& Kamath, 1999). Diabetes is second only to CVD
as a health burden in India, and, of course, the two
are highly correlated and interdependent. The Inter-
national Diabetes Federation (IDF) reports a
projected prevalence of 70 million patients in India
by the year 2025 (Sicree, Shaw, & Zimmet, 2006;
Taylor, 2010), and the World Health Organization
(WHO) estimates that India will have 80 million
cases of diabetes by 2030 (Wild, Roglic, Green,
Sicree, & King, 2004).
Hindu immigrants have a higher mortality rate
than that of the local population. Rheumatic heart
disease, together with high blood pressure, is a major
cardiac problem. Dental caries and periodontal
disease affect 90 percent of the adult population.
Sickle cell disease is highly prevalent; the gene is de-
tected in 16.48 percent of selected populations.
Breast cancer is one of the leading causes of mor-
bidity and premature death among women in India
(Sadler, Dhanjal, Shah, Ko, Anghel, & Harshburger,
2001). Based on studies in India, Choudhry, Srivastava,
and Fitch (1998) implied that immigrant women from
India share the same risk as their Western counterparts.
In India, the most prevalent forms of cancer
among men are tobacco-related cancers, including
lung, oral, larynx, esophagus, and pharynx. Almost
50 percent more Indian men smoke than men in the
United States. Among Indian women, in addition to
tobacco-related cancers, cervix, breast, and ovarian
cancers are also prevalent. India currently has the
highest prevalence of oral cancer cases in the world
as a result of the popularity of chewing tobacco in
its rural regions.
Sexually transmitted infections (STIs) in children
are not uncommon in India, though systematic epi-
demiological studies to determine the exact prevalence
are not available. STIs in children can be acquired via
sexual routes or, uncommonly, via nonsexual routes
such as accidental inoculation by a diseased individ-
ual. Neonatal infections are almost always acquired
intrauterine or during delivery.
Sexual abuse and sex trafficking remain important
problems in India. Surveys indicate that nearly half
of the children are sexually abused. Most at-risk chil-
dren are street-based, homeless, or those living in or
near brothels. The last two decades have shown an in-
crease in the prevalence of STIs in children, though
most of the data are from the northern part of the
country and from major hospitals. However, due to
better availability of antenatal care to the majority of
women, cases of congenital syphilis have declined con-
sistently over the past 2 to 3 decades. Other bacterial
STIs are also on the decline. On the other hand, viral
STIs such as genital herpes and anogenital warts are
increasing. This reflects trends of STIs in the adult
population. Concomitant HIV infection is uncommon
in children. Comprehensive sex education, stringent
laws to prevent sex trafficking and child sexual abuse,
and antenatal screening of all women can reduce the
prevalence of STIs in children (Dhawan, Gupta, &
Kumar, 2010).
Variations in Drug Metabolism
Asians are known to require lower doses and to have
side effects at lower doses than whites for a variety of
different psychotropic drugs, including lithium, anti-
depressants, and neuroleptics (Levy, 1993). Asians are
also more sensitive to the adverse effects of alcohol,
resulting in marked facial flushing, palpitations, and
tachycardia.
2780_Ch16_288-309 16/07/12 11:50 AM Page 295

Dietary variations may significantly alter the meta-
bolic rate or plasma levels of medicines in Asian Indians
(Levy, 1993). The metabolism of antipyrine in Asian
Indians living in rural villages in India has been
compared with that of Indian immigrants in England.
The results indicate that drug metabolism among Indian
immigrants becomes more rapid when they adopt the
British lifestyle and dietary habits (Levy, 1993). Hence,
because of ethnic differences in the rates of drug metab-
olism, more consideration should be given to individu-
alizing treatment regimens in special population groups,
such as Hindus. Health-care providers should question
therapeutic regimens that do not consider racial or
ethnic differences.
High-Risk Behaviors
Alcoholism and cigarette smoking among Hindu
Americans, especially among men, may cause signifi-
cant health problems. Adolescents face tremendous
pressure to keep up the image of “wiz kids” and to
meet the expectations of their parents, which may
override individual aptitudes and choices. This may
create anxiety and frustration, thereby leading to
failure and anger toward parents, which may predis-
pose them to using drugs as a coping strategy. How-
ever, adequate literature or studies to substantiate
these behaviors are not available.
Other high-risk behaviors include those that lead to
contracting HIV. According to Cichocki (2007), the
following populations are at the highest risk:
• Sex workers—Because of widespread poverty
throughout India, women often resort to prostitu-
tion as a means of making money for their fami-
lies. Others are forced into sex work due to an
underground of violence and disrespect toward
women. Finally, women involved in marital
breakups will often begin prostituting themselves
as a means of surviving financially after being left
with children to feed and a household to support.
In some areas of India, it is estimated that one in
every two sex workers are HIV infected, many of
whom are unaware of it.
• IV drug use (IVDU)—The recreational use of
drugs often overlaps with the sex trade. While
IVDU seems to be worse in the northeastern parts
of India, it is common throughout the country.
Many attribute the widespread problems of IVDU
and HIV to government policies that do not sup-
port HIV prevention and risk reduction among IV
drug users. Because IVDU is a crime and is consis-
tently enforced and prosecuted, getting prevention
messages to users is very difficult. There have been
instances of prevention workers themselves being
arrested while trying to help and educate IV drug
users. Official estimates actually report the HIV
prevalence among IV drug users to have gone
down from 13 percent in 2003 to 10 percent
in 2005.
• Truck drivers—India’s economy depends a great
deal on its very large trucking network across the
country. While truckers help move goods and serv-
ices throughout India, they also contribute a great
deal to the huge HIV population and the spread of
HIV from one area of India to another. Truckers
will pick up sex workers along their route, engage
in unprotected sex activity, and then drop off the
sex worker at the trucker’s next stop along the
route. This has contributed to the spread of HIV
from urban areas into the rural towns and villages.
The most damaging fact about truckers and their
use of sex workers is that they usually do not know
they are infected.
• Migrant workers—As is the case in the United States,
migrant workers in India are very transient and
mobile, moving from town to town wherever the
work takes them. Unfortunately, they take their
risky behavior along with them, fueling the spread
of HIV throughout India. While there are attempts
at HIV education, the variety of languages, dialects,
and cultures makes HIV education very difficult.
High-risk behaviors contribute to the spread of
HIV, which has progressed from a disease found in
only the highest-risk populations to one found in all
segments of the Indian population, including men and
women, rich and poor, urban and rural. Populations
thought at one time to be low risk are now being in-
fected, as are high-risk groups. Some groups are being
infected at a higher rate than others. For instance,
women are being infected by way of heterosexual
transmission at an alarming rate. Women now make
296 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 6 . 2
Dabeet Singh, a practicing Hindu man aged 22 years, has been a
student majoring in computer technology for 2 years at a nearby
university. His roommate convinced him to see the nurse at the
school health clinic because he has been demonstrating high-risk
behaviors such as smoking two packs of cigarettes a day and
drinking four 12-oz cans of beer every day. In addition, over the
last 2 weeks, he has not been attending his classes but sitting in
his room, acting anxious and frustrated with his friends and
teachers. In a low voice, he tells the nurse that he wants to quit
school and return home where people are more polite and can
understand him better.
1. Give two plausible reasons for Dabeet’s high-risk behav-
iors from a cultural context.
2. What evidence is there to show that Dabeet might be
depressed?
3. What type of spiritual counseling might the nurse suggest?
2780_Ch16_288-309 16/07/12 11:50 AM Page 296

People of Hindu Heritage 297
up about 39 percent of those living with HIV. Most
are being infected by husbands or boyfriends who
have multiple sexual partners, many of whom are in-
fected with HIV and do not know it.
Health-Care Practices
Patterns of health-seeking behaviors among Hindus
are strongly influenced by their sociocultural net-
works. Customs and beliefs often affect medical-care
decisions and choice of health-care services. The
actions of supernatural forces and certain human ex-
cesses are considered important in causing illness, even
among highly educated Hindus. Furthermore, re-
gional variations in the intensity and strength of the
belief system are significant. For example, some indi-
viduals believe that excessive consumption of sweets
may cause roundworms and that too much sexual ac-
tivity and worry are associated with tuberculosis. In
addition, some believe that diarrhea and cholera are
caused by a variety of improper eating habits. There-
fore, health-care providers cannot take for granted
that all Hindu immigrants have the same belief sys-
tems with the same degree of intensity. Deep-rooted
beliefs about illnesses will inhibit the acceptance
of scientific causes for diseases. This may result in
difficulty with treatment.
Nutrition
Meaning of Food
Many cultures have influenced Indian food prac-
tices. Dietary habits within the Indian subcontinent
are complex, regionally varied, and strongly influ-
enced by religion. Hindus believe that food was
created by the Supreme Being for the benefit of
humanity; thus, growing, harvesting, preparing, and
consuming food are steeped in rituals. Sacred Hindu
texts contain aspects related to food, dietary habits,
and recommendations.
The influence of religion is pervasive in food selec-
tion, customs, and preparation methods. Noble and
Dutt (1982) stated that the classification of the re-
gional food habits can be twofold, based on the types of
cereals and fresh foods consumed. In the first category
are rice and bread eaters; in the second category are
vegetarians and nonvegetarians. Whereas Buddhism
and Jainism turned people to vegetarianism, the influ-
ence of the Vedic religion and later the influx of out-
siders made Indians nonvegetarians. In modern India,
vegetarianism is firmly rooted in culture and the term
nonvegetarian is used to describe anyone who eats
meat, eggs, poultry, fish, and, sometimes, cheese.
Many Brahmins in northern India consider eating
meat to be religiously sanctioned. In some parts of
India, Brahmins’ eating fish is acceptable, whereas in
other parts, eating meat of any source is sacrilegious
(Kilara & Iya, 1992). Many Indians are vegetarians
because of agricultural traditions and adverse economic
conditions.
Common Foods and Food Rituals
Although India is essentially an agricultural country,
food production is insufficient to adequately feed the
entire population. Geographic influences favor the
production of grains, rice, wheat, jowar, bajra, jute,
oilseeds, peanuts, and mustard. The principal food
crop consists of rice in the better-watered regions and
wheat in the Punjab. Sesame millet, maize, and peas
grow throughout the country. Sugarcane and jute are
cultivated extensively. The coconut palm is a valuable
resource in the southern coastal areas. Cereals supply
a large percentage of the total calorie requirements.
Rice, wheat, millet, barley, maize, and ragi make up
the bulk of the diet.
A variety of “pulses” (legumes such as lentils),
cooked vegetables, meat, fish, eggs, and dairy products
are also consumed. Heavily spiced (curry) dishes with
vegetables, meat, fish, or eggs are favored, and hot
pickles and condiments are common. Spice choices
include garlic, ginger, turmeric, tamarind, cumin,
coriander, and mustard seed. Vegetable choices in-
clude onions, tomatoes, potatoes, green leaves, okra,
green beans, and root vegetables. Milk is used in coffee
and tea and in preparing yogurt and buttermilk.
Water is the beverage of choice with meals and as a
thirst quencher.
One of the most common food items in southern
India is boiled rice containing spices and vegetables;
it is usually served with a lentil-based sauce, sambar.
Other common foods in the south are rasam (a dilute
liquid made from tomatoes, tamarind, and boiled rice
served with spices) and thayir (yogurt with boiled
rice). The traditional southern Indian vegetarian
preparations of rice and lentil flour dishes are called
idli, dosai, or vadai. Snacks are also consumed either
as breakfast items or substituted in place of regular
meals. Food is usually served in a thali, a round plate.
Coffee is popular in southern India, whereas tea is the
beverage of choice in the rest of the country. In the
north, chapati, a bread made from wheat flour, is com-
mon, as is puris, which is similar to chapati except that
it is deep-fried, whereas the former is baked on a
round iron plate. Seasonal products such as ground-
nuts (peanuts), mangoes, and bananas are consumed
between meals. Savory items such as deep-fried prepa-
rations of grains, vegetables, and spices are also
consumed as snacks between meals. In northern India,
wheat is the staple food. Other cereals are jowar, bajra,
and ragi, which are consumed in porridges, gruels, and
rotis (baked pancakes).
Customs and prejudices often remove certain
food items from the diet, although the prohibitions
vary from place to place. Thus, bajra, a staple food
in Maratha families, is not looked on favorably in
2780_Ch16_288-309 16/07/12 11:50 AM Page 297

Uttar Pradesh. People from Punjab do not favor
fish, whereas people from the south generally dislike
the idea of meat of any kind. In Saurashtra in the
south, fish, fowl, meat, and eggs are taboo practi-
cally everywhere.
Women generally serve the food and may eat sepa-
rately from men. Food preparation has strict rules.
Women are not allowed to cook or have contact with
other members of the family during their menstrual
periods. Brahmins are the preferred cooks because the
cook must be as pure as the eater (Kilara & Iya, 1992).
Health-care providers must assess for food rituals
practiced by Hindus in relation to mealtimes and food
selections before attempting to teach them about
medication regimens.
Dietary Practices for Health Promotion
Foremost among the perceptions of Hindus is the be-
lief that certain foods are “hot” and others “cold,”
and, therefore, should be eaten only during certain
seasons and not in combination. The geographic dif-
ferences in the hot and cold perceptions are dramatic;
many foods considered hot in the north are considered
cold in the south. Such perceptions and distinctions
are based on how specific foods are believed to affect
body functions. The belief is that failure to observe
rules related to the hot-and-cold theory of disease
results in illness. When the three basic principles or
humors— vata, pitta, and kapha—are in the state of
equilibrium, digestion and metabolism are in order,
the foundations of the tissues and excretion of waste
products are normal, and an individual is physically
and mentally happy.
Nutritional Deficiencies and Food Limitations
Nutritional deficiencies are regionally patterned, indi-
cating preferences for a certain variety of cereals. For
example, beriberi is found in rice-growing areas, pellagra
in maize-millet areas, and lathyrism in Central India.
Thiamine deficiency is common among people who are
mostly dependent on rice. Thoroughly milling rice,
washing rice before cooking, and allowing the cooked
rice to remain overnight before consumption the follow-
ing day result in the loss of thiamine.
Commitment to the concept of the “sacred cow”
has a significant impact in India’s economic life and
ecology, most notably by encouraging dairy farming
and milk use. However, lactose intolerance affects up
to 1 percent of infants and more than 10 percent of
adults, resulting in an inability to produce the enzyme
needed to digest lactose, or milk sugar. The ability or
inability to digest lactose may be due to genetic differ-
ences among Asian Indians.
The consumption of a single cereal, such as rice, as
the bulk of a diet results in a poor intake of lysine and
other essential amino acids. Pellagra, a nutritional defi-
ciency causing skin and mental disorders and diarrhea,
occurs largely where people consume mostly maize and
sorghum ( jowar). Both cereals have high leucine content
and provide strong evidence for the pathogenesis of pel-
lagra. Lathyrism is a crippling disease causing paralysis
of leg muscles that is seen mostly in adults who consume
large quantities of seeds of the pulse khesari (Lathyrus
sativus) over a long period of time. Thus, protein mal-
nutrition is serious and widespread in India.
Goiters are common along the sub-Himalayan
tracts, resulting from an iodine deficiency in food and
water. Fluorosis occurs in parts of Punjab, Haryana,
Andhra Pradesh, and Karnataka, resulting from
drinking water with high fluoride content. Osteoma-
lacia is prevalent in northwestern India, where diets
are deficient in calcium and vitamin D. Endemic
dropsy is prevalent in western Bengal as a result of the
use of mustard oil for cooking (Noble & Dutt, 1982).
The high incidence of stomach cancer in the south
may be due to the excessive intake of fried fatty foods
and chilies and rapid food consumption. By contrast,
cancer of the stomach is infrequent in people in the
north who consume milk and dairy products. In several
north Indian states, many people chew betel (paan),
which is offered as a sign of hospitality. Paan contains
arecanut, cardamom, fennel, lime (calcium hydroxide),
tobacco, and other ingredients, and among users can-
cers of the mouth and lip are common, especially since
tobacco can induce oral cancer. Beta carotene from
Spirulina or other sources such as carrots can prevent
such cancer (Garewal, 1995). Strachan, Powell, Thaker,
Millard, and Maxwell (1995) found a vegetarian diet to
be an independent risk factor for tuberculosis among
immigrant Asians in south London. Using a case-
control method, Asian immigrants from India diag-
nosed with tuberculosis during the previous 10 years
were compared with two Asian control groups. The
results confirmed earlier findings that Hindu Asians
had an increased risk for tuberculosis compared with
Muslims. Religion had no independent influence after
adjustment for vegetarianism. The authors concluded
that decreased immunocompetence associated with a
vegetarian diet might result in increased mycobacterial
reactivation among Hindu Asians.
Food practices of the Hindus may remain un-
changed with increasing numbers of immigrants to
America. In a study of the dietary habits of 73 Asian
Indians in relation to the length of residence in the
United States, Raj, Ganganna, and Bowering (1999)
found that, in contrast to recent immigrants (less than
10 years), long-time immigrants reported eating
mostly Indian foods for dinner and weekend meals.
The authors also found that regardless of the length
of residence in the United States, consumption of
white bread, roots, tubers, vegetable oils, legumes, and
tea changed little. Self-reported data indicated that
high serum cholesterol levels, increased weight, hyper-
tension, arthritis, and diabetes were diagnosed in
298 Aggregate Data for Cultural-Specific Groups
2780_Ch16_288-309 16/07/12 11:50 AM Page 298

People of Hindu Heritage 299
respondents older than age 30 years. The authors con-
cluded that despite the small sample size, although
Asian Indians in the study included many American
foods in their diets, they continued to eat many tradi-
tional foods, perhaps in an effort to retain cultural
identity.
All major food groups of the Hindus are generally
available through Indian grocery and spice stores lo-
cated in major metropolitan areas throughout the
United States. The flavor, spices, and diversity of ethnic
foods are making many Indian restaurants popular.
Given the diversity of Hindus in America, health-care
providers must individually assess dietary practices and
nutritional deficiencies of their patients according to
their ethnic origins and area of residence.
For the majority of Hindu Americans who are veg-
etarians, their protein comes from pulses, lentils,
legumes, and dairy products. Because the production
of pulses has not kept pace with increasing poulation,
the protein-calorie imbalance is widened. The scarcity
of commodity such as pulses predisposes to infectious
diseases and nutritional deficient disorders, especially
in young children (Kumar, 2004). Other forms of mal-
nutrition are caused by deficiency of micronutrients
like iron, vitamin A, and iodine. Deficiency of vitamin
A results in nutritional blindness in children. Iodine
deficiency disorders are associated with impairment
of mental and intellectual functions in children and
adults, and in severe case with deafness and mutism,
neuromuscular disorders, and perinatal and infant
mortality (Kumar, 2004).
In remote and inaccessible areas where there is a lack
of qualified physicians and modern health facilities, me-
dicinal plants have traditionally been used. Certain
foods and/or food additives such as Spirulina microalgae
enhance the immune system and have antiaging prop-
erties and, in combination with turmeric and oil from
the neem tree (an evergreen tree found in India), can
ward off many infectious and noninfectious diseases, in-
cuding cancer, gastrointestinal disorders, diabetes, skin
troubles, dental problems, and cardiovascular disorders
(Kumar, 2004). Also, beta carotene as an important an-
tioxidant has been reported to inhibit oral carcinogene-
sis (Sankaranarayanan et al., 1997).
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Methods of birth control among Hindus include in-
trauterine devices (IUDs), condoms, and the rhythm
and withdrawal methods. Because of their cultural ori-
entation, Hindu women may desire education in family
planning from a same-sex health-care provider, as well
as assistance with delivery from female physicians, mid-
wives, or nurse practitioners. Fisher, Bowman, and
Thomas (2003) enumerate the issues surrounding
sexuality and childbirth in Asian Indian women. For
many Indian women, intercourse experiences are
painful because of lack of sex education. In general,
women are not educated about contraceptive options
until after the first child. For this reason, most couples
have their first child within the first year of marriage.
The birth of a healthy first child reassures both families
about the couple’s health and that they are a “good
match.” Couples are commonly sent to fertility special-
ists if a child is not born after the first or second year
of marriage. Husbands do not accompany pregnant
women to physician visits, but mothers do. Only the
nurse and the obstetrician (who is a female) attend to
the patient at the time of delivery, although the
woman’s mother and other female relatives are usually
nearby for assistance with her personal needs. Hus-
bands usually come to the hospital or birth center, but
they are not permitted to watch the delivery. If the
husband is visiting during postpartum rounds, he will
leave the room for the wife’s examination.
Fisher, Bowman, and Thomas (2003) also state that
pregnancy can be a frightening time for a young wife,
especially if there are no female relatives available to
educate her. Indian men might prefer to wait outside
the room or stay away from the hospital during this
time in contrast to American hospitals and birthing
centers, where it is the norm for the new father to be
present at the birth of his child. Most often in the
United States, the woman and her physician discuss
birth control options. In the case of the Asian Indian
woman, it is important for the physician to ask if con-
traception should be discussed first between the physi-
cian and her husband. The physician might want to
ask the husband for his permission to discuss birth
control with his wife.
It is important to understand Indian cultural mores
and values surrounding sexual education, sexual behav-
ior, and the childbirth experience, as otherwise these
might serve as barriers for Indian immigrants in need
of health care. The lack of formal sexual education, im-
portance of the birth of the first child, premarital
contraceptive education, dominance of the husband
in contraceptive decisions, and predominant role of
women and lack of role for men (including the husband)
in the childbirth process are all factors that can enhance
the understanding of the health-care provider in provid-
ing effective care with a positive outcome.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
In the traditional East Indian culture, a family mem-
ber’s advice is highly valued and implemented. Grand-
mothers, mothers, and mothers-in-law are considered
to have expert knowledge in the use of home remedies
during pregnancy and the postpartum period. Many
older women frequently travel to the United States to
assist new mothers in antenatal and postnatal care
2780_Ch16_288-309 16/07/12 11:50 AM Page 299

consistent with traditional customs. For example, in
India, it is believed that colostrum is unsuited for
infants. Most women think that the milk does not
“descend to the breast” until their ritual bath on the
third day; as a result, newborns are fed sugar water or
milk expressed from a lactating woman.
Many East Indian women seek medical advice only
when all available resources fail, so they may not seek
medical advice or go to a health-care provider for reg-
ular prenatal checkups. In addition, health-care
providers may experience difficulty assessing the preg-
nant mother’s sexual history because of the personal
and private nature of the information and the discom-
fort associated with responding to a stranger about
their personal lives.
Physical examinations and procedures, particularly
pelvic examinations, are especially traumatic to Hindu
American women who may not have experienced or
heard about these examinations in the past. It is impor-
tant to explain the procedures, provide privacy, and as-
sign a female health-care provider to decrease the stress
and perceived discomfort associated with a pelvic ex-
amination. Most Hindu women are not accustomed to
being cared for by male health-care providers.
Childbirth is a social and religious event in the
Hindu culture. Pregnancy rituals to protect the preg-
nant mother and the unborn child from evil spirits are
performed during specific months of pregnancy. Preg-
nancy rites are performed in the woman’s house during
the 5th month of pregnancy. Another ritual is per-
formed in the husband’s house during the 8th month
of pregnancy. A bangle, meaning to surround, must
be worn by all auspicious women (barring widows,
who are not considered auspicious) especially during
pregnancy, when women are considered susceptible to
the influence of evil spirits. Bangles act as a sort of
“ring-pass-nots” and are believed to create barriers
that prevent evil spirits from approaching pregnant
women (Duvvurry, 1991).
Dietary restrictions also exist during pregnancy.
There are a diversity of practices related to foods that
can be consumed or avoided during pregnancy, and
the perceptions of foods as “hot” and “cold.” The
general belief is that hot foods are harmful and cold
foods are beneficial during a pregnancy. Since preg-
nancy is thought to produce a state of “hotness,” it is
desirable to to balance it out by eating cold foods
(Nag, 1994). During early pregnancy, cold foods are
recommended to avoid miscarriage, while hot foods
are recommended during the last stages of pregnancy
to aid in the delivery (Choudry, 1997).
Based on the hot-and-cold theory of disease, cer-
tain hot foods like eggs, jaggery (traditional, unre-
fined, whole-cane sugar), coconut, groundnut, maize,
mango, papaya, fruit, and meat are avoided during
pregnancy because of a fear of abortion caused by
heating the body or inducing uterine hemorrhage.
Pregnancy is a time of increased body heat, so cold
foods such as milk, yogurt, and fruits are considered
good. However, certain cold foods, such as buttermilk
and green leafy vegetables, are avoided because of the
belief that these foods cause joint pain, body aches,
and flatulence (Raman, 1988). Whereas increased heat
is deemed natural during pregnancy, overheating is
considered dangerous. Minor swelling of the hands
and feet is seen as increased heat and is not of much
concern. However, a burning sensation during urina-
tion, scanty urine, and a white vaginal discharge are
considered serious signs of significant overheating.
Muhkopadhyay and Sarkar (2009) surveyed 199 women
in Sikkim in northeast India about pregancy-related
food beliefs. The authors found that women of social,
literacy, or economic standing were more likely to eat
special foods. Women with fewer children were more
likely to follow dietary practices, in contrast with moth-
ers who had several children. Pregnant women tended
to increase their intake of foods such as milk and green
vegetables, while decreasing their fruit intake.
Beliefs surrounding what facilitates a good preg-
nancy and associated outcome, as well as negative
sanctions, are often held by immigrating women from
India. Most Indian women have fatalistic views about
life, including pregnancy. The practice of eating less
or “eating down” during pregnancy is common, as it
is believed that excessive eating results in large new-
borns and difficult deliveries (Choudry, 1997). Also,
the consumption of high-protein foods, including
milk, are avoided because they result in an exagger-
ated growth of the baby that may lead to a difficult
delivery.
In addition to concern about the size of the baby,
other factors that influence dietary practices of preg-
nant women include bodily movement, constitution,
and morning sickness. These factors influence both
the quality and the quantity of foods consumed.
Morning sickness is caused by an increase in pitta or
bodily heat. Pitta—an ayurvedic (ayur, longevity;
veda, science; Ayurveda is the traditional system of
medicine in India)—means “bile” and is a symptom
complex associated with dizziness, nausea, yellow
body excretions, a bitter taste in the mouth, and
overheating of the body.
Anemia caused by iron deficiency is one of the nu-
tritional disorders affecting women of childbearing
age. This condition may be aggravated because of the
practice of reducing the consumption of leafy vegeta-
bles to avoid producing a dark-skinned baby.
Other beliefs during pregnancy, such as physical ac-
tivity like fetching water and carrying heavy loads
until labor begins, continue in working-class class and
farm women, in contrast to wealthy women who are
coddled by their families. Although some beliefs can
be rationalized, others may seem to have a lack of ex-
planation. Profuse bleeding prior to delivery is seen as
300 Aggregate Data for Cultural-Specific Groups
2780_Ch16_288-309 16/07/12 11:50 AM Page 300

People of Hindu Heritage 301
a good sign because it will purify the uterus and pro-
duce a clean child; bleeding during the 5th month is a
sign that the baby is a male (Choudry, 1997).
There is no taboo against the father being in the de-
livery room, but men are usually not present during
birthing. The men do not stay in the delivery rooms
and hold their wives’ hands during delivery. Instead,
they tend to wait outside the delivery room and allow
female relatives to support the pregnant mother dur-
ing labor and delivery. Hence, in relation to the role
of men during childbirth, the role of the husband is
minimal. Traditional families are reluctant to accept
the changes such as shared responsibility and joint
decisions. However, these changes are embraced by
affluent, educated, and urban families. An awareness
of these cultural practices will enable nurses to better
understand husbands’ reluctance to be present in the
delivery room. Miller and Goodin (1995) stated that
for Hindu American women, one important factor to
achieve a balance in health and wellness is self-control
of strong feelings. These women often manifest this
belief by suppressing their feelings and emotions dur-
ing labor and delivery. Nurses can assist in meeting
new mothers’ needs by closely observing their nonver-
bal communication such as a change in body posture,
restlessness, and facial expressions.
In the Hindu culture, the birth of a son is consid-
ered a blessing, not only because the son can carry the
family name but also because he can take care of the
parents in their old age. Furthermore, a son is also re-
quired for the performance of many sacred rituals. In
contrast, the birth of a daughter is cause for worry
and concern because of the traditions associated with
dowry, a ritual that can impoverish the lives of those
who are less affluent.
Since the male child is expected to support his
parents in their old age, a male child is regarded to be
superior to a female child, who is considered a liability
because of dowry expectations at the time of marriage
(Ranadive, 1994). Raman (1988) noted that women
fast and consume herbal medicines in the hope of
delivering a son, the birth of which is usually cele-
brated, while that of a daughter is more restrained and
quiet. The preference for a male child exists even
among immigrating women from India.
After the birth of a child, both the mother and the
baby undergo purification rites on the 11th day post-
partum. The postpartum mother is considered to be
impure and is confined to a room. The pollution is
said to last for 10 days (Duvvurry, 1991). This period
of necessitated and mandatory confinement assists in
bonding between the mother and the newborn, with
the mother given adequate rest and time to tend to the
baby’s needs. After the 10th day, a ritual bath and re-
ligious ceremony are performed by the priest to purify
the mother and to end the mandated confinement
(Mahat, 1998). The baby is officially named on the
11th day during the “cradle ceremony,” and several rit-
uals are performed to protect the baby from evil spirits
and to ensure longevity. A sponge bath for the new-
born is recommended until the umbilical cord falls off.
Soft massage to the extremities is recommended prior
to bathing the infant. Washing the infant’s hair daily
is believed to improve the quality of the hair.
During the postpartum period, hot foods such as
chicken drumsticks, dried fish, and greens are consid-
ered good for lactation, whereas cold foods are believed
to produce diarrhea and indigestion in the infant. Cold
foods such as buttermilk and curds, gourds, squashes,
tomatoes, and potatoes are restricted because they pro-
duce gas. Such abstentions are practiced primarily for
the baby’s health because harmful influences might be
transmitted through the mother’s breast milk. Sources
of protein such as eggs, curds, and meat are avoided be-
cause they might adversely affect the baby. A soft mas-
sage for the mother improves the quality and quantity
of breast milk.
Breast milk is commonly supplemented with cow’s
milk and diluted with sugar water. A child’s stomach
is considered weak as a result of diarrhea; therefore,
the child is given diluted milk. The mother’s diet the
first few days is restricted to liquids, rice, gruel, and
bread. Boiled rice, eggplant, curry, and tamarind juice
are added to the diet between 6 months and a year
after the birth of the baby (Edmundson, Sukhatme,
& Edmundson, 1992). Thus, for teaching to be effec-
tive, health-care providers must obtain dietary pref-
erences and practices from the family before planning
nutritional counseling.
During the postpartum period, the mother remains
in a warm room and often keeps the windows closed
to protect herself against cold drafts. Exposure to air
conditioners and fans, even in warm weather, may be
considered dangerous. Nurses can help the new moth-
ers wear warm clothing and provide additional blan-
kets to keep them warm. In summary, in order to
provide culturally congruent care, the health-care
provider must determine the belief systems regarding
prescriptive, restrictive, and taboo practices in the
Hindu American childbearing family.
In the United States and Canada, childbirth is
viewed within the context of the nuclear family
(Choudry, 1997). The role and extent of involvement
of grandparents and other immediate family members
are decided by the new parents. This is in contrast with
the role of the family in the Indian culture, which ex-
tends beyond immediate family relatives because it is
considered a part of social order providing emotional
and social support during a time of need.
The postpartum period has its own taboos in that
the mother’s movements are constrained within the
house. This confinement period is usually 40 days,
during which the mother is assisted in her personal
care, fed a special nourishing diet, and receives body
2780_Ch16_288-309 16/07/12 11:50 AM Page 301

massages. It is believed that pregnancy produces a
state of hotness, with delivery disturbing the balance
achieved during pregnancy, and weakens the woman.
In order to regain the balance, milk, ghee (clarified,
unsalted butter without any solid milk particles), nuts,
and jaggery are included in the diet of the new mother.
Dried ginger is also eaten, since it is believed to help
control postpartum bleeding and acts as a uterine
cleansing agent (Choudry, 1997). The newborn is
cared for by the local “dai” or midwife, who visits
every day to provide massages for both mother and
baby. Cold baths or showers are generally avoided.
Various purification ceremonies are performed on odd
days after delivery.
There are variations in the practices of breastfeed-
ing depending on the education and socioeconomic
status of the women. For example, breastfeeding was
found to be taboo for the first two days among slum
dwellers, while 58 percent of educated mothers in an
airforce community initiated breastfeeding within 4 to
12 hours (Mukopadhya & Achar, 1992). In a cross-
sectional study of 57 lactating mothers in a rural com-
munity, Ray, Biswas, Choudhury, thereference is
correct and Biswas (1993) found that mothers breast-
fed their newborns within 24 hours. Delaying breast-
feeding might be related to beliefs surrounding the
colostrum because it is seen as indigestible or puslike
and is therefore not good for the newborn. To facili-
tate weaning, the bottle is introduced early. Powdered
formula and cow’s milk are common subsitutes for
breast milk. Solid food is introduced when the infant
begins to reach out for food from the mother’s plate.
Ray and colleagues (1993) stated that the most
common first food is soft rice and mashed vegetables.
The introduction of solid food is celebrated with ritu-
als and religious ceremonies and is called annaprasan
(introduction of cereal).
Iyengar, Iyengar, Martines, Dashora, and Deora
(2008) conducted a study on family, community, and
provider practices during labor and childbirth—
factors likely to influence newborn health outcomes.
Data were collected through qualitative methods of
interviews, observations, and focus group discussions.
The authors found that there were still strongly held
beliefs in favor of home-based childbirth, although it
appeared that help was available if the mother needed
to be taken to a health-care facility pending any prob-
lems. Health facility deliveries were preferred for first
births, especially among adolescents. During home
childbirth, a team of birth attendants or an older
female relative made decisions and performed key
functions. Also, to hasten home delivery, providers
were commonly invited to administer oxytocin injec-
tions, whereas health staff did the same during facility
deliveries. The practice of applying forceful fundal
pressure was universal in both situations. Also, mon-
itoring of labor was restricted to repeated unhygienic
vaginal examinations, with little attention to monitoring
fetal or maternal well-being. Babies born at home lay on
the wet floor until the placenta was delivered. The cord
was tied using twine or a ceremonial thread and cut
using a new blade. In facility settings, drying and wrap-
ping of the baby after birth were delayed, and there was
minimal preparedness for resuscitation. Breastfeeding
was postponed until 3 days after birth, when they be-
lieved breast milk became available. Mothers and new-
borns were discharged from the facility without efforts
to initiate breastfeeding. The authors recommended
communication interventions and improvements in the
health system after a clear understanding of people’s be-
liefs about childbirth and their rationale for restrictions
in the use of health facilities for delivery.
Implications for nursing care abound in how nurses
approach and care for the childbearing women immi-
grating from India. Nurses should avoid sterotyping
Asian Indian women because there are regional and
cultural variations, and a lack of understanding of
the variations might lead to misinterpretation of be-
haviors. Choudry (1997) retiterated appreciating cul-
tural meanings, since it sensitizes nurses and helps
them provide appropriate care. Nurses can provide
culture-specific perinatal education and care by
understanding beliefs and practices related to preg-
nancy, since many immigrant families may want to
preserve their tradition and values.
Death Rituals
Death Rituals and Expectations
Death is seen as a family and communal affair. Family
members perform all the rites and rituals, with males
dealing with the male body and females with the female
body, from washing, anointing, and dressing, to the con-
struction of the bier on which the corpse is laid and se-
cured with choir ropes (Laungani, 1996). The deceased
is cremated in less than 24 hours following death for
hygienic, pollution and purification, and spiritual
reasons. Also, Hindus traditionally cremate their dead
for swifter, more complete release of the soul.
Hindus prefer to die at home. The eldest son is re-
sponsible for the funeral rites. In accordance with
Hindu scriptures, it is the sacred duty of the eldest son
to perform the funeral rites of his father. The follow-
ing day, the ashes and charred bones are gathered by
the crematorium attendants for later collection by rel-
atives and performance of the final ceremony on the
banks of the holy Ganges River. The ashes are im-
mersed in the river to ensure the spiritual salvation of
the deceased (Laungani, 1996). Hindus in America
may save their family’s ashes to later scatter them in
holy rivers when they return to their homeland.
The death rite is called antyesti, or last rites. The
basic purpose is to purify the deceased and console
the bereaved. A tenet of Hinduism is that the soul
302 Aggregate Data for Cultural-Specific Groups
2780_Ch16_288-309 16/07/12 11:50 AM Page 302

People of Hindu Heritage 303
survives the death. Therefore, performing a ritual
bath, sprinkling holy river water over the body, cover-
ing the body with new clothes, daubing parts of the
body with ghee, and chanting Vedic utterances purify
and strengthen the deceased for the postmortem jour-
ney (Lipner, 1994). The priest pours water into the
mouth of the deceased and blesses the body by tying
a thread around the neck or wrist. The priest may
anoint with water from the holy Ganges River or put
the sacred leaf from the Tulsi plant in the mouth. At
the yearly death anniversary (according to the lunar
calendar), Shradda ceremonies (usually associated
with funeral and postfuneral activities) are held in the
home with the offering of pinda or balls of cooked rice
(pindadana) to one’s ancestors. Although individual
Hindu community rites vary and can be simple or ex-
ceedingly complex, the basic rationale is the same.
Responses to Death and Grief
Hindu families share sacred moments and celebrate
important events as a unit, and deaths are considered
family events. The eldest son completes prayers for an-
cestral souls, but all male descendants perform the
Shradda rites (Wolpert, 1991). Death is considered re-
birth. Women may respond to the death of a loved one
with loud wailing, moaning, and beating their chests
in front of the corpse, attesting to their inability to
bear the thought of being left behind to handle situa-
tions by themselves. This is significant for women
because widowhood is considered inauspicious.
Mourning is a family as well as a social and com-
munal affair. During the 12 days of mourning, female
mourners visit female members of the bereaved family
at a fixed hour every afternoon. With progression of
days, wailing becomes less intense. The functional
value of these practices may indicate the provision of
intense security and comfort for bereaved people. At
a psychological level, it provides catharsis for the en-
tire family and may assist with speeding up the process
of recovery from the loss of a loved one and making
positive adjustments. Hence, health-care providers
need to offer support and understanding of the Hindu
culture with respect for death and grief beliefs.
Spirituality
Dominant Religion And Use Of Prayer
The cultural heritage of India is found primarily in phi-
losophy and religion. Sources of philosophical ideas
and religious beliefs lie in the Vedas and Upanishads,
repositories of Hindu culture. They explain the two
great objects of human life: duty and liberation. The
relationship between religion and social structure is in-
tricate. Religion provides the legitimacy and ideology
for social and economic practices, whereas social struc-
tures produce particular religious beliefs. Two concepts
are primary in the Hindu belief system: karma (all
human actions lead to consequences (as you sow, so
shall you reap) and dharma (righteousness action).
Dharma forms the basis of karma, and the principles
of dharma come from the karma theory (Rao, 2010).
The doctrine of karma, dharma, reincarnation, the
concept of the four ends or stages of life, and the caste
system are conducive to maintaining these beliefs.
In Hindu philosophy, the external world is seen as
being illusory, called maya. Since the world of the
senses, the empirical world, is constantly changing, it
is seen as an inconstant, illusory world. The ultimate
purpose of human existence is to attain moksha
(Laungani, 2006).
Hinduism represents a set of beliefs and a definite
social organization. Hinduism connotes the belief in
the authority of Vedas and other sacred writings of the
ancient sages, the immortality of the soul and belief in
a future life, the existence of a Supreme God, the theory
of karma and rebirth, the worship of ancestors, a social
organization represented by the four castes, the theory
of the four stages of life, and the theory of the four
Purusarthas, or ends of human endeavor.
The social structure of Hinduism revolves around
two fundamental institutions: The caste and the joint
family (explained earlier in this chapter) relate to
everything connected with the Hindu people outside
their religion. The Orthodox Hindu view is that soci-
ety has been divinely ordained on the basis of the four
castes: Brahmanas, Kshatriyas, Vaisyas, and Sudras.
The fourfold caste system— Chaturvarna—is a theo-
retical division of society in which tribes, clans, and
family groups are affiliated. Yet, the theory of society
based on caste still governs Hindu life (see earlier in
this chapter). All of the innumerable subcastes claim
to belong to one of the four castes. The essential prin-
ciples of Chaturvarna are unchangeable inequality
based on birth, the gradation of professions and their
inequality, and restrictions on marriage outside one’s
own group. Although religion does not bestow the
caste system with a religious sanction, the great Hindu
legal codes are based on the caste system.
In America, individual worship may take different
forms within the Hindu religious tradition. Popular
Hindu forms of worship require no special arrange-
ments and can be carried out in private. A household
shrine is an aid rather than a requirement for worship.
Shrines may be set up in the living room or the dining
room but are most often located in a back room or a
closet. The shrine typically contains representations
or symbols of one or more deities.
Almost all family and group religious observances
take place on the weekend to fit the American work
schedule, even though the lunar liturgical calendar
could fall within the normal workweek. Indian wor-
ship includes praying, singing hymns, reciting scrip-
ture, and repeating the names of deities. For some
Hindus, worship is the identification with, or merging
2780_Ch16_288-309 16/07/12 11:50 AM Page 303

of, the inner self with the ultimate reality, Brahma.
Temples serve as important support institutions for the
practice of the Hindu religion. The installation of a
Hindu temple and the invocation of God into its cen-
tral image make God present in that place, and the land
becomes holy. The first Hindu temple constructed in
America was in Pittsburgh, Pennsylvania, in 1976; it
was modeled after the most popular Hindu temple in
India: the Sri Venkateswara temple at Tirupathi.
Meaning of Life and Individual Sources
of Strength
One of the main concepts that form the basis of the
Hindu attitude toward life and daily conduct is the
Purusartha, the four ends of humanity. The first of these
is characterized by righteousness, duty, and virtue. Other
activities through which a person seeks to gain some-
thing for self or pursue pleasures are material gain and
love or pleasure. Finally, the renunciation of all these
activities is to devote oneself to religious or spiritual
activities for liberation from a worldly life.
Karma stresses the individual’s responsibility for
one’s actions and is interpreted in terms of past life.
One’s present condition is seen as a result of one’s
actions in a past life or lives. Hence, the doctrine of
karma by itself enunciates only the principle of an
individual’s moral responsibility for his or her own
deeds. Actions lead to certain consequences, and an
individual needs to be aware of this when taking an
action. The doctrine of karma has persisted in India
from the Vedic times of about 1000 B.C. and is a vital
concept that permeates the lives and thoughts of the
rich and poor.
To Hindus, religion and family are considered pri-
mary sources of strength. Dharma places a high priority
on the family. Family is considered to be a critical stage
in the path of action, which leads to ultimate spiritual
liberation (Fenton et al., 1993). A number of rituals
and spiritual practices are connnected with the family
because it is through the families that Hindus fulfill
many religious obligations. Common life-cyle rituals of
Hindus in the United States include prenatal rituals,
birth and childhood naming ceremonies, marriage, and
cremation within 24 hours after death. All these involve
the extended family whenever possible.
Hinduism is concerned with questions regarding
ultimate reality and the individual’s relationship with
it. Spiritual support gives hope to life, ensures courage
to face the consequences of illness, and directs the
thinking of the person in a positive direction. Because
of the strength of the kinship organization and a sense
of kinship obligation, the individual seeks solace and
strength in such an organization.
Spiritual Beliefs and Health-Care Practices
Hindus believe that all illnesses attack an individual
through the mind, body, and soul. The body is the
objective manifestation of a subjective mind and con-
sciousness. Spiritual beliefs act mainly as diversional
therapies during illness. Suffering of any kind pro-
duces hope, which is essential to life. Spiritual support
gives hope and helps control emotions and behavior.
The Ayurvedic view of health emphasizes social, en-
vironmental, and spiritual contexts. The key concept
is harmony within the organism and within the system
of which the organism is a part. In the Ayurvedic phi-
losophy, people, health, and the universe are said to
be related, and when these relationships are in imbal-
ance, health problems can result. Herbs, metals such
as copper or zinc, massages, and other techniques are
used to clean the body and restore balance. A goal of
Ayurvedic practice is to cleanse the body of sub-
stances that can cause disease and establish harmony
and balance (Fugh-Berman, 1996).
Misra, Balagopal, Klatt, and Geraghty (2010) con-
ducted a cross-sectional survey on the use of comple-
mentary and alternative medicine (CAM) by gender
and its association with acculturation, health behav-
iors, and access to health care. Subjects consisted of
1824 Asian Indian adults in six states. The majority
of the respondents were male, immigrants, college
graduates, and had access to care. Sixty-three percent
of Asian Indians used at least one type of CAM; most
common was a vegetarian diet, followed by use of di-
etary and herbal supplements and alternative medical
systems. Females reported a significantly higher use
of CAM, a vegetarian diet, and use of dietary and
herbal supplements than males. Older Asian Indians
used Ayurvedic and homeopathic treatments, which
are still widely practiced in India and growing in pop-
ularity in the West. Higher income had an impact on
dietary and herbal supplement use, indicating that
cost is a possible factor associated with its utilization.
The concept of palliative care in India is in a rela-
tively early stage of development. Rajagopal and
Venkateswaran (2003) noted that without government
involvement, the development of the palliative-care
specialty will be hampered at the national level. The
authors examined practices related to the availability
of strong opioids for pain relief in cancer patients.
Stringent narcotic regulations often prevent the avail-
ability of morphine to patients who need this drug.
Hence, patients are administered less potent but more
expensive alternatives. In addition, educating the
family and having open communication among the
patient, family, and health providers can prevent emo-
tional distress and isolation and enhance information
and awareness. The author recommends developing a
system of quality assurance and doing assessments in
the areas of drug availability, education, and policy,
and then developing plans of action based on need.
In India, people who live in the rural areas live below
the poverty line; with approximately 2.5 million people
suffering from cancer at any given time, provision of
304 Aggregate Data for Cultural-Specific Groups
2780_Ch16_288-309 16/07/12 11:50 AM Page 304

People of Hindu Heritage 305
palliative care, although indicated, becomes expensive.
Almost 80 percent of these patients reach hospitals in
an advanced stage of the illness. McGrath, Holewa,
Koilparampil, Koshy, and George (2009) compared as-
pects of palliative care in India and Australia. The
author found that in both countries terminally ill pa-
tients preferred to die at home. Despite the succesful
growth of palliative care in a decade, most people prefer
to spend the last days of their lives at home surrounded
by their family, although patients were encouraged
to spend their last days in the hospital. This is in
contrast to Australia, where the movement was toward
allowing terminally ill patients to go home and rely on
community-based services.
Limited studies have been published on how Asian
Indian immigrants view hospice services as they may
face or are currently facing end-of-life care decisions.
Doorenbos (2003) examined whether absence of infor-
mation about hospice, lack of financial resources, and
cultural differences explain the lack of hospice service
use in Asian Indian immigrant populations. Results in-
dicated that in a sample of 43 first-generation Asian
Indian immigrants, only 12 percent knew what a hos-
pice program was, 22 percent had a little knowledge
of hospice, and 22 percent had no knowledge of hos-
pice. The results also indicated that some hospice staff
misunderstood Asian Indian death and dying rituals.
There was no indication from the participants that
financial resources were a barrier to hospice use. Most
of the respondents (86 percent) indicated their prefer-
ence to die at home. However, only 11 percent were
aware that the individual’s home is the primary site for
hospice care. The results demonstrate that although
hospice would be the appropriate end-of-life care for
this population, the main barrier was knowledge
related to the site of hospice care. The majority also
rated death and dying beliefs and rituals as important
to them.
Gupta (2011) explored Asian Indian American
Hindu (AIAH) cultural views related to death and
dying through three focus group (senior citizens,
middle-aged adults, and young adults) interviews,
using both open-ended and semistructured questions.
Focus group discussions were related to meaning at-
tributed to death and pre- and postdeath practices.
Results indicated that while all three generations
believed in the afterlife and karmic philosophy, they
exhibited differences in the degree to which Hindu
traditions surrounding death and bereavement were
influenced by living in the United States.
Health-care providers should assess the extent to
which religion, beliefs and values, or socioeconomic
status is a part of the individual’s life, as these are
related to the individual’s perception of health and ill-
ness and daily practices. Also, assessing spiritual life
is essential for identifying resources and solutions for
therapy. In the Doorenbos (2003) study, completion
of a cultural assessment at the time of admission into
hospice care would assist hospice staff in identifying
the beliefs that Asian Indian immigrants considered
important.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
In Indian culture, rituals are closely connected with
religious beliefs about the relationships of human be-
ings with supernatural forces. To maintain harmony
between the self and the supernatural world, the belief
that one can do little to restore health by oneself pro-
vides a basis for ceremonies and rituals. Worshipping
goddesses, pilgrimages to holy places, and pouring
water at the roots of sacred trees are believed to have
medicinal effects for healing the sick person.
Asian Indians experience mental distress biomed-
ically and assign it to ill-defined medical conditions,
a phenomenon called somatization. Instead of admit-
ting that they feel sad or depressed, Asian Indian
women may say that they are experiencing weakness.
Since most individuals who present with somatic
complaints report some psychological distress on
closer scrutiny, the health-care provider should probe
about mental distress when presented with ill-defined
somatic complaints.
Responsibility for Health Care
In general, Hindus are responsible for their own health
care, but they mobilize personal, social, and religious
resources in the face of a crisis. The resolution ranges
from a denial of discomfort to acceptance of limita-
tions of somatic or other psychological symptoms.
Medical beliefs are a blend of modern and traditional
theories and practices. In Ayurveda, the primary em-
phasis is on the prevention of illnesses. Individuals have
to be aware of their own health needs. One of the prin-
ciples of Ayurveda includes the art of living and proper
health care, advocating that one’s health is a personal
responsibility. In Ayurvedic theory, the key to health
is an orderly daily life in which personal hygiene,
diet, work, and sleep and rest patterns are regulated.
Depending on an individual’s constitution, a daily rou-
tine has to be established and changed according to the
season. Individuals must have information and aware-
ness about living well. Hence, it is important to include
prevention, health education, and health-care services.
A common health-care problem among Hindus is
self-medication. Pharmacies in India generally allow
the purchase of medications such as antibiotics without
a prescription. Thus, Hindus migrating to America are
accustomed to self-medicating and may bring medica-
tions with them or obtain them through relatives and
friends. Self-treatment is also more likely if the symp-
toms are stigmatizing, such as psychiatric or STI symp-
toms. Use of CAM is widely prevalent among Hindus.
2780_Ch16_288-309 16/07/12 11:50 AM Page 305

Many feel that modern medicine may be good only for
acute conditions, while the traditional systems of med-
icine are better and more effctive for chronic conditions
(Gupta, 2010). The use of CAM depends on the sever-
ity of the illness. Individuals will use CAM for minor
illnesses before taking allopathic medications, while
they use allopathic medications for severe conditions as
the first choice. Often patients do not tell physicians
they are using CAM for fear of offending the physician
(Gupta, 2010).
Folk and Traditional Practices
Numerous practices taken from the hot-and-cold the-
ory of disease causation and folk practices are related
to illnesses. Traditional healers, nattuvaidhyars, use
Ayurvedic, Siddha, and Unani medical systems. These
systems are all based on the Tridosha theory. The
Ayurvedic system uses herbs and roots; the Siddha sys-
tem, practiced mainly in the southern part of India,
uses medicines; and the Unani system, similar to the
Siddha, is practiced by Muslims.
According to the Tridosha theory, the body is
made up of modifications of the five elements: air,
space, fire, water, and earth. These modifications are
formed from food and must be maintained within
proper proportions for health. A balance among
three elements or humors—phlegm or mucus, bile or
gall, and wind—corresponds to three different types
of food required by the body. The following are some
types of foods and the allopathic equivalents of dis-
eases associated with them:
1. Heat-producing foods: Brinjals (Indian eggplant),
dried fish, green chilies, raw rice, and eggs.
Pittham foods include cluster beans, groundnuts,
almonds, millet, oil, and runner beans. Allopathic
equivalents of heat-producing diseases include
diarrhea, dysentery, abdominal pain, and scabies.
Allopathic equivalents of pittham diseases include
vomiting, jaundice, and anemia.
2. Cooling foods: Tomatoes, pumpkin, gourds, greens,
oranges, sweet limes, carrots, radishes, barley, and
buttermilk. Cold, headache, chill, fever, malaria, and
typhoid are allopathic equivalents of cool diseases.
3. Gas-producing foods: Root vegetables like potato,
sweet potato, and elephant yam; plantain; and
chicken drumsticks. Joint pains, paralysis, stroke,
and polio are disorders related to gas-producing
foods.
Heating and cooling effects are produced in the
body and thus are not related to the temperature or
spiciness of foods. An imbalance leads to disease. If
too much heat is in the body from consuming heat-
producing foods, then cold foods need to be eaten to
restore balance.
Blood is considered one of the seven dhatus (body
tissues) in the Tridosha theory of Ayurveda. The
strength or weakness of the dhatus depends on the
“richness or poverty of the blood.” Blood is equated
with life and is preserved with great care. Special foods
like beet root (red foods) are required for good blood,
whereas “no blood” is the concept nearest to that of
malnutrition.
Thus, in terms of health practices, cultural patterns
in India are regionally specific. Health-care providers
must be extremely careful in their assessments and not
stereotype health-care practices. In addition, providers
must also be aware of practices related to the hot-
and-cold theory of disease causation and treatment.
Barriers to Health Care
Dependency and reliance on family and friends may
be considered a barrier among Hindus. In addition,
the practice of self-medicating behaviors may mask
disease symptoms until the health condition is at a
more advanced stage, making treatment regimens
more complex.
In relation to mental health, the stigma associated
with mental illness can serve as a barrier to seeking pro-
fessional treatment. Families may attempt to deny the
illness because they may not want outsiders to know
about the family member’s mental illness (Kumar &
Nevid, 2010).
Barriers to seeking preventive services for terminal
illnesses like cancer are low awareness of cancer risk
and methods of early detection (Surani, Baezconde-
Garbanati, Bastani, & Montano, 2003). A barrier to
mammography and other screening procedures to de-
tect reproductive organ cancer is fear of taking off
clothes or modesty. Hindu women also do not like to
discuss genitourinary symptoms or undress in front
of others, nor do they want to see a physician during
their menstrual periods because it is considered
“dirty.” However, this might be changing as Hindu
women are increasingly more educated and are joining
the workforce (Gupta, 2010).
Cultural Responses to Health and Illness
Hindus have a fatalistic attitude about illness cau-
sation. Because of their religious beliefs of karma,
they attempt to be stoic and may not exhibit symp-
toms of pain. Furthermore, pain is attributed to
God’s will, the wrath of God, or a punishment from
God and is to be borne with courage. As a result,
health-care providers may need to rely more on
the nonverbal aspects of pain when assessing Hindu
patients.
Kodiath and Kodiath (1992; 1995) studied the dif-
ferent attitudes of pain sufferers in India and in the
United States. They found that while Americans
tended to focus on finding a cure for their pain, Indians
tried to find meaning in their pain. Also, while Americans
favored analgesics, Asian Indians preferred herbal
remedies.
306 Aggregate Data for Cultural-Specific Groups
2780_Ch16_288-309 16/07/12 11:50 AM Page 306

People of Hindu Heritage 307
Many Hindus are steadfast in their fatalistic spiritual
belief. An individual’s dharma and karma mold one’s
destiny and worldview. This may be a reason for Hindus’
underutilization of psychological or counseling services
as options for coping. Health-care providers must assess
individual attitudes and comfort levels when counseling
Asian Indian patients.
Because of the stigma attached to seeking pro-
fessional psychiatric help, many Hindus do not ac-
cess the health-care system for mental health
problems. Instead, family and friends seem to be
the best help, and there is a general belief that time
is the best healer. Physical and mental illnesses are
considered God’s will, past karma, and are associ-
ated with a fatalistic attitude. The sick role is as-
sumed without any feeling of guilt or ineptness in
doing one’s tasks. Because of strong family and
kinship ties, the sick role is well accepted. The in-
dividual is cared for and relieved of responsibilities
for that time. Because of strong family ties and
joint and extended families, Hindus are not likely
to use long-term-care facilities.
Psychological distress may be demonstrated
through somatization, which is common, especially
in women. The symptoms may be expressed as
headaches, a burning sensation in the soles of the
feet or the forehead, and a tingling pain in the lower
extremities. Also, the belief in Ayurveda in the inter-
relatedness of mind, body, and spirit may make
those with mental health symptoms delay treatment,
since they seek spiritual, mind, and body treatments
before seeking professional mental health services.
Because family is important and family members
may accompany the patient to the health-care
provider’s office, it may pose a problem for the
American health-care system’s emphasis on auton-
omy and privacy.
Kermode, Bowen, Arole, Pathare, and Jorm (2009)
conducted a cross-sectional mental health literacy sur-
vey in Maharashtra, India. The authors administered
a questionnaire to 240 systematically sampled com-
munity members and 60 purposively sampled Village
Health Workers (VHW). Participants were presented
with two vignettes describing people experiencing
symptoms of mental disorders (depression and psy-
chosis) and were asked about attitudes toward and
desired social distance from the people in the vignettes
(the latter being a proxy measure for stigma). Results
indicated that although the community was relatively
accepting of people with mental disorders, false beliefs
and negative attitudes were still evident. Desired social
distance was consistently greater for the person de-
picted in the psychosis vignette compared to the de-
pression vignette. Furthermore, while a vast majority
verbalized positive answers to all of the questions,
they were not willing to have afflicted people marry
into their family. Participants did not agree that the
problems experienced in the vignettes were “a real
medical illness,” indicating that attitudes toward
people with mental illness were not positive.
Pillai, Patel, Cardozo, Goodman, Weiss, and
Andrew (2008) conducted a study on nontraditional
lifestyles and prevalence of mental disorders in ado-
lescents in Goa, India. The authors found that the
current prevalence of mental disorders in adoles-
cents was very low compared with studies in other
countries. Strong family support was a critical factor
associated with low prevalence of mental disorders,
while factors indicative of adoption of a nontradi-
tional lifestyle (going to the disco) and having an
intimate friend of the opposite gender were associ-
ated with an increased prevalence. Nontraditional
lifestyles may lead to an increased conflict with tra-
ditional values and create stressful environments
that may predispose adolescents to mental disorders.
Health-care providers must understand the role of
the family in promoting mental health of the ado-
lescents, as this study demonstrated the independent
protective effect of family support.
Families tend to be protective of an ill member.
They may not want to disclose the gravity of an ill-
ness to the patient or discuss impending disability
or death for fear of the patient’s vulnerability
and loss of hope, resulting in death. The conflict
between medical ethics and patients’ values may
pose a problem for health-care providers, who need
to be cognizant of the importance of the family
members’ wishes and values regarding the care of
their loved ones.
Blood Transfusions and Organ Donation
Very little literature is available related to blood
transfusion, organ donation, or transplantation
practices among Hindus. Seth and colleagues (2009)
studied the prevalence of brainstem death and
causes of nondonation. Families of those with
brainstem death were approached for organ dona-
tion by the transplant coordinator. Results indicated
that of 33 families counseled, 16 (48 percent) con-
sented to organ donation. In 14 families (42 percent),
organs and tissues retrieved and transplanted in-
cluded 13 livers, 23 kidneys, 25 corneas, and 5 cardiac
valves. Consent was more likely in females (10 out
of 14 compared with 6 out of 19 males; p = 0.037).
Consent did not correlate with age of donor or
medical-legal issues ( p = 0.227 and 0.579, respec-
tively). Trained staff with requisite systems in place
produced significant organ donation rates. Religious
issues and medical-legal concerns were not a major
hurdle for organ donation. Female patients with
brainstem death were more likely to become organ
donors. Thus, no Hindu policy exists that prevents
receiving blood or blood products. Donating and re-
ceiving organs are both acceptable.
2780_Ch16_288-309 16/07/12 11:50 AM Page 307

Health-Care Providers
Traditional Versus Biomedical Providers
Although Hindus in general have a favorable attitude
toward American physicians and the quality of med-
ical care received in the United States, relatives and
friends are consulted first rather than a health-care
provider. Kinship and friendship ties remain strong,
even in medical matters.
Because any open display of affection is taboo,
Hindu women are especially modest. Women gener-
ally seek female health-care providers for gynecologic
examinations. Health-care providers need to respect
their modesty by providing adequate privacy and as-
signing same-gender caregivers whenever possible.
In the area of mental health, traditional healers,
such as Vaids, practice an empirical system of indige-
nous medicine; mantarwadis cure through astrology
and charms, and patris act as mediums for spirits and
demons. Health-care providers must specifically ask
if their Hindu patients are using these folk practition-
ers and what treatments have been prescribed.
Status of Health-Care Providers
The Indian patient’s view of the physician consists of
omnipotence in that God grants cures through the
physician. Indian patients tend to be subservient and
may not openly question physicians’ behaviors or
treatments. If they are not pleased with the treatment,
they just change physicians. However, they tend to be
appreciative of the information that physicians pro-
vide about their illness. The physician is also viewed
as an older person who is protective, authoritative,
and in a teacher–disciple relationship. Through these,
the patient expects the physician to teach her or him
about the disease and how to get cured in a friend-to-
friend relationship.
The physician is seen as the leader of the health-
care team, and other medical personnel take on a
lower status. However, some patients and their family
members may want to be involved in their treatment
and may request information. The acceptance of tra-
ditional and folk practitioners is highly variable
among Western health-care providers and may depend
on their previous experiences with CAM providers.
R E F E R E N C E S
Blesch, K.S., Davis, F., & Kamath, S. (1999). A comparison of
breast and colon cancer incidence rates among native Asian
Indians, U.S. immigrant Asian Indians, and whites. Journal of
the American Dietetic Association, 99(10), 1275–1277.
Choudry, U.K. (1997). Traditional practices of women from India:
Pregnancy, childbirth, and newborn care. JOGNN, 26(5),
533–539.
Choudhry, U.K., Srivastava, R., & Fitch, M. (1998). Breast
cancer detection practices of south Asian women: Knowl-
edge, attitudes, and beliefs. Oncology Nursing Forum, 25(10),
1693–1701.
CIA World Factbook. (2011). India. Retrieved from https://www.
cia.gov/library/publications/the-world-factbook/geos/in.html
Cichocki, M. (2007). HIV around the world—India. Retrieved
from http://aids.about.com/od/clinicaltrials/a/india.htm
Crosta, P.M. (2008). India to carry majority of world’s health dis-
ease burden by 2010. Medical News Today. Retrieved from
http://www.medicalnewstoday.com/articles/105302.php
Dhawan, J., Gupta, S., & Kumar, B. (2010). Sexually transmitted
diseases in children in India. Indian Journal of Dermatology,
Venereology, and Leprology, 76, 489–493.
Doorenbos, A. (2003). Hospice access for Asian Indian immi-
grants. Journal of Hospice and Palliative Nursing, 5(1),
27–33.Duvvurry, V.K. (1991). Play, symbolism, and ritual.
New York: Peter Lang.
Edmundson, W.C., Sukhatme, P.V., & Edmundson, S.A. (1992). Diet,
disease, and development. New Delhi, India: MacMillan India Ltd.
Fenton, J.Y. (1988). Transplanting religious traditions: Asian Indi-
ans in America. New York, NY: Praeger.
Fisher, J.A., Bowman, M., & Thomas, T. (2003). Issues for South
Asian Indian patients surrounding sexuality, fertility, and child-
birth in the U.S. health-care system. Journal of American Board
of Family Practice, 16(2), 180–181.
Fugh-Berman, A. (1996). Alternative medicine: What works.
Tucson, AZ: Odonian Press.
Garewal, H. (1995). Antioxidants in oral cancer prevention.
American Journal of Clinical Nutrition, 62, 1410S–1416S
Gay and Lesbian Vaishnava Association Inc. (2005). Retrieved
from http://www.galva108.org/faq.html
Gupta, R. (2011). Death beliefs and practices from an Asian Indian
American Hindu perspective. Death Studies, 35(3), 244–266.
Gupta, V.B. (2010). Impact of culture on healthcare seeking be-
havior of Asian Indians. (2010). Journal of Cultural Diversity,
17(1), 13–19.
Iyengar, S.D., Iyengar, K., Martines, J.C., Dashora, K., & Deora,
K.K. (2008).
Childbirth practices in rural Rajasthan, India: Implications for neona-
tal health and survivial. Journal of Perinatology, 28, S23–S30.
308 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 6 . 3
Harini Chaturvedi, a Hindu woman aged 60 years, recently
moved to the United States from India to assist her son, his
wife, and their four children (two sons, ages 13 and 11 years,
and two daughters, ages 6 and 2 years) with child rearing while
the parents work. One day, Ms. Chaturvedi complains of lower
abdominal pain. Her son takes her to the emergency room. The
male nurse who is on duty explains that he needs to assess her
in order to obtain data about her pain. Ms. Chaturvedi does
not maintain eye contact with the male nurse, and she is reluc-
tant to let him examine her. She states she would prefer to talk
with a female nurse. She also states that she does not want any
pain medications.
1. Why would Mrs. Chaturvedi not maintain eye contact
with the male nurse?
2. Why is Mrs. Chaturvedi reluctant to let a male nurse
examine her?
3. Identify from a cultural and religious standpoint reasons
for not wanting pain medications.
2780_Ch16_288-309 16/07/12 11:50 AM Page 308

People of Hindu Heritage 309
Jain, N.C. (1992, February). Teaching about culture and com-
municative life in India. Paper presented at the Annual Con-
vention of the Western States Communication Association,
Boise, ID.
Jayaraman, R. (2005). Personal identity in a globalized world:
Cultural roots of Hindu personal names and surnames. The
Journal of Popular Culture, 38(3), 467–490.
Kermode, M., Bowen, K., Arole, S., Pathare, S., & Jorm, A.F.
(2009). Attitudes to people with mental disorders: A mental
health literacy survey in a rural area of Maharashtra, India.
Social Psychiatry & Psychiatric Epidemiology, 44, 1087–1096.
Kilara, A., & Iya, K.K. (1992). Food and dietary habits of the
Hindu. Food Technology, 46, 94.
Kodiath, M.F., & Kodiath, A. (1992). A comparative study of
patients with chronic pain in India and in the United States.
Clinical Nursing Research, 1, 278–291.
Kodiath, M.F., & Kodiath, A. (1995). A comparative study of
patients who experience chronic malignant pain in the
United States. Cancer Nursing,18(3), 189–196.
Kumar, H.D. (2004). Management of nutritional and health needs
of malnourished and vegetarian people in India. In E.L.
Cooper & N. Yamaguchi (Eds.), Complementary and alternative
approaches to biomedicine (pp. 311–321). Kluwer Academic/
Plenum Publishers.
Kumar A., & Nevid, J.S. (2010). Acculturation, enculturation,
and perception of mental disorders in Asian Indian immi-
grants. Cultural Diversity and Ethnic Minority Psychology,
16(2), 274–283.
Laungani, P. (1996). Death and breavement in India and England:
A comparative analysis. Mortality,1(2), 191–212.
Levy, R.A. (1993). Ethnic and racial differences in response to
medicines: Preserving individualized therapy in managed phar-
maceutical programmes. Pharmaceutical Medicine, 7, 139–165.
Lipner, J. (1994). Hindus: Their religious beliefs and practices.
New York, NY: Routledge.
Asian Indian population in 2005. (2005). Little India. Retrieved from
http://www.littleindia.com/news/132/ARTICLE/1389/2006-11-
12.html
Mahat, G. (1998). Eastern Indians’ childbearing practices and
nursing implications. Journal of Community Health Nursing,
15(3), 155–161.
McGrath, P., Holewa, H., Koilparampil, T., Koshy, C., & George, S.
(2009). Learning from each other: Cross-cutural insights on
palliative care in Indian and Australian regions. International
Journal of Palliative Nursing, 15(10), 499–509.
Miller, S.W., & Goodin, J.N. (1995). East Indian Hindu Americans.
In J.N. Geiger & R.E. Davidhizar (Eds.), Transcultural nursing:
Assessment and intervention (pp. 475–499). St. Louis: Mosby.
Misra, R., Balagopal, P., Klatt, M., & Geraghty, M. (2010).
Complementary and alternative medicine use among immi-
grant Asian Indians in the United States: A national study.
Journal of Alternative and Complimentary Medicine, 16(8),
843–852.
Mukhopadhya, J., & Achar, D.P. (1992). Infant feeding practices
among educated mothers in an airforce community. Health and
Population: Perspectives and Issues, 15(3 and 4), 89–93.
Mukhopadhyay, S., & Sarkar, A. (2009). Pregnancy related food
habits among women of rural Sikkim, India. Public Health
Nutrition, 12, 2317–2322.
Nag, M. (1994). Beliefs and practices about food during preg-
nancy: Implications for maternal nutrition. Economic and
Political Weekly, 29(37), 2427–2428.
Noble, A.G., & Dutt, A.K. (1982). India: Cultural patterns and
processes. Boulder, CO: Westview Press.
Pillai, A., Patel, V., Cardozo, P., Goodman, R., Weiss, H.A., &
Andrew, G. (2008). Nontraditional lifestyles and prevalence of
mental disorders in adolescents in Goa, India. The British Jour-
nal of Psychiatry, 192, 45–51.
Raj, S., Ganganna, P., & Bowering, J. (1999). Dietary habits
of Asian Indians in relation to length of residence in the
United States. Journal of the American Dietetic Association,
99(9), 1106–1108.
Rajagopal, M.R., & Venkateswaran, C. (2003). Pallaitive care in
India: Success and limitations. Journal of Pain & Palliative Care
Pharmacotherapy, 17(3–4), 121–128.
Raman, A.V. (1988). Traditional practices and nutritional taboos:
Effect on mothers and perinatal outcome. Nursing Journal of
India, 79(6), 166.
Ranadive., J.R. (1994). Gender implications of adjustment policy
programme in India. Economic and policial Weekly, 29(8),
WS12–WS18.
Rao, R.N. (2010). Talking to the dying: Hindu views, Hindu ways.
International Journal of Sociology of the Family, 36(1), 65–76.
Ray, B., Biswas, R., Choudhury, G., & Biswas, A.B. (1993). Infant
feeding practices in a rural community of West Bengal. Indian
Journal of Public Health, 37(1), 26–28.
Sadler, G.R., Dhanjal, S.K., Shah, R.B., Ko, C., Anghel, M., &
Harshburger, R. (2001). Asian Indian women: Knowledge, at-
titudes and behaviors toward breast cancer early detection.
Public Health Nursing, 18(5), 357–363.
Sankaranarayanan, R., Mathew, B., Varghese, S.P.R., Menon, V.,
Jaydeep, A., Nair, M.K., Mathews, C., Mahalingam, T.R.,
Balaram, P., & Nair, P.P. (1997). Chemoprevention of oral
leukoplakia with vitamin A and betacartoene: An assessment.
Oral Oncology, 33, 231–236.
Seth, A.K., Nambiar, P., Joshi, A., Ramprasad, R., Choubey, R.,
Puri, P., Murthy, M., Naidu, S., Saha, A., & Bhatoe, H. (2009).
First prospective study on brain stem death and attitudes toward
organ donation in India. Liver Transplantation, 15(11), 1443–1447.
Shetty, P.S. (2002), Nutrition transition in India, Public Health
Nutrition, 5(1) 175–182.
Sicree, R., Shaw, J., & Zimmet, P. (2006). Diabetes and impaired
glucose tolerance. In D. Gan (Ed.), Diabetes atlas. International
Diabetes Federation (3rd ed., pp. 15–103). Belgium: Interna-
tional Diabetes Federation.
Strachan, D.P., Powell, K.J., Thaker, A., Millard, F.J.C., &
Maxwell, J.D. (1995). Vegetarian diet as a risk factor fortubercu-
losis in immigrant south London Asians. Thorax, 50, 175–180.
Surani, Z., Baezconde-Garbanati, L., Bastani, R., & Montano, B.
(2003). Improving community capacity to develop cancer awrae-
ness programs. American Journal of Health Studies, 18, 203–210.
Taylor, W.D. (2010). The burden of non-communicable diseases
in India. Hamilton, ON: The Cameron Institute.
U.S. Census Bureau. (2010). International data base. Retrieved
from http://www.census.gov/ipc/www/idb/worldpopinfo.php
Varghese, A., & Jenkins, S.R. (2009). Parental overprotection, cul-
tural value conflict, and psychological adaptation among Asian
Indian women in America. Sex Roles, 61, 235–251.
Vasudev, S., Radhakrishnan, G.L., Ravindran, N., & Dangor, K.
(July, 2004). The gay spirit. India Today, 46, 235–251.
Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. (2004).
Global prevalence of diabetes: Estimates for the year 2000 and
projections for 2030. Diabetes Care, 2, 1047–1053.
Wolpert, S. (1991). India. Berkeley: University of California Press.
For reflective exercises, review questions, and additional
information, go to
http://davisplus.fadavis.com
2780_Ch16_288-309 16/07/12 11:50 AM Page 309

310
Chapter 17
People of Hmong Heritage
Larry Purnell
The author thanks the contribution of Sharon Johnson, PhD, RN, FNP, who contributed a chapter on the Hmong in Guide to
Culturally Competent Health Care, 2nd ed. Philadelphia: F.A. Davis Co.
Overview, Inhabited Localities,
and Heritage
Overview
The Hmong (pronounced Mong; the H is silent) are
thought to originate in the Yellow River Valley of
China and primarily lived in the mountainous areas
shared by China, Burma, Vietnam, Thailand, and
Laos. The Hmong in the United States mostly come
from Laos and were an agrarian society that practiced
“slash and burn” agriculture. Mountainous areas were
cleared of underbrush, burned, and then used for
crops. When the soil became depleted, they moved on,
often moving their village as well. Twenty-one percent
of the Hmong population in the United States are
civilian veterans (U.S. Census Bureau, 2009).
Paj ntaub (pan dow) is a form of embroidery that
Hmong women do to decorate their clothing and
make historical story cloths. Story cloths were the way
the family history was passed from generation to gen-
eration, since literacy was uncommon. Even today, re-
markable story cloths are made that show the Hmong
fighting the communists in the jungles, Hmong being
killed, yellow rain falling on villages, and people flee-
ing through jungles and floating across the Mekong
River to the refugee camps of Thailand. Story cloths
also show the remarkable animals and vegetation of
the areas where the Hmong lived. These are now made
commercially by Thai Hmong and are sold at craft
fairs (Duffy, Harmon, Ranard, Thao, & Yang, 2004).
Heritage and Residence
Over 186,000 Hmong currently live in the United States,
of whom 44 percent were born in the United States.
Thirty-seven percent live below the poverty line, and
they have a very young median age of 16 years (U.S.
Census Bureau, 2009). The overall figure of 204,000 for
Hmong in the United States has been disputed because
many Hmong in census data self-identify as Laotian,
Thai, or Vietnamese; thus, actual numbers may be much
higher (Carroll & Uldova, 2005). Smaller numbers of
Hmong have also settled in France, Canada, Australia,
and Asian countries (Yau, 2005).
Although no Hmong initially settled in the Central
Valley of California, many now live there, with California
having the largest numbers of Hmong residents, fol-
lowed by Minnesota and Wisconsin. Small groups
migrate where they perceive that economic opportuni-
ties exist and are found in North Carolina, Georgia,
Florida, Washington State, Oregon, Michigan, and
Colorado (U.S. Census Bureau, 2009).
Reasons for Migration and Associated
Economic Factors
Hmong began to immigrate to the United States and
other countries in 1975 after the Vietnam War. These
refugees came from the mountainous regions of Laos,
where they had fought on the side of the CIA during
the war. They were targeted for genocide because they
had fought against the communist Pathet Lao, so they
had to flee their county. Many Hmong died because
of the war, from genocide, or in their attempts to leave
Laos. Many Hmong immigrants in the United States
bear the scars of war, bullet and shrapnel wounds, and
the lasting effects of exposure to biological warfare,
which they call “yellow rain” (Lindsay, 2010). The last
large wave of Hmong to the United States occurred
in 2004 when the U.S. State Department officially an-
nounced the acceptance of roughly 15,000 Hmong
refugees from camp Wat Tham Krabok in Thailand
(Grigoleit, 2006). Many lingered for years in these
camps, and some are still in Thailand, although not
all in refugee camps (Doctors Without Borders, 2008;
Duffy et al., 2004).
Educational Status and Occupations
Hmong in Laos generally had no education; they
were primarily illiterate, lived in very primitive cir-
cumstances, and had no access to the modern world
2780_Ch17_310-318 16/07/12 11:51 AM Page 310

or modern medicine. When immigrating to the
United States, many Hmong experience shock in a
world that is completely foreign to them. The Hmong
have embraced the necessity of education in the
United States and other places. More recent immi-
grants have had some education and exposure to the
modern world, with 24 percent having completed
high school and 13 percent holding baccalaureate de-
grees or higher (U.S. Census Bureau, 2009). Hmong
have achieved higher education and degrees as regis-
tered nurses, physicians, psychologists, and social
workers.
Communication
Dominant Language and Dialects
Hmong did not have a written language until the 1950s,
when Christian missionaries began to develop a written
form of their language. That is why Hmong written lan-
guage today uses the Roman alphabet rather than the
characters or scripts that are used in most other re-
gional Southeast Asian languages (Encarta® Online
Encyclopedia, 2003). Because of the lack of written
Hmong language, many Hmong, especially older
adults, are not literate in their own language.
Hmong is a dialectic, monosyllabic, tonal language.
Pronunciation seems highly nonintuitive for English
and Hmong speakers alike. The letter “P” is pro-
nounced as “B”; “PH” as “P”; “X” as “S”; “S” as
“SH”; “T” as “D”; and “R” as something like “DR.”
Tones are indicated by one of the consonants j, g, b, v,
s, or d at the end of each word, or no consonant for
the midrange level tone (Lindsay, 2011).
Hmong in the United States speak either White or
Green Hmong, sometimes called Blue. These lan-
guages may not be understandable to those who speak
the other Hmong dialects, where the same word can
have totally different meaning. Therefore, it is advis-
able to obtain a professional interpreter. Do not pro-
vide Hmong-language written instructions unless
someone in the household can read them. Instructions
written in English may be a better choice because
school-age children may know English.
Cultural Communication Patterns
Many Hmong believe that Americans are rude be-
cause they look directly in the eyes when speaking,
and they are too direct with their questions. Proper
communication when speaking to a Hmong person is
to use fleeting glances without staring. Making light
conversation prior to asking questions about health is
proper and important (Caregiver Minnesota, 2006).
Hmong also use the word “yes” to indicate that they
can hear you, but that does not mean that they under-
stand what you are asking or that they will do what you
are asking them to do (Caregiver Minnesota, 2006).
Health-care providers should not rush to questions;
small talk first is considered more polite (Johnson,
2009). To determine if treatments are understood, the
patient should be asked to provide a demonstration.
Hmong in general have a strong desire to be seen
positively by people in authority. For this reason the
social desirability factor may result in them telling the
health-care provider what they believe the health-care
provider wants to hear, not what is actually happen-
ing; this is considered being respectful (Caregiver
Minnesota, 2006). When questioning Hmong about
their compliance with treatment recommendations, it
is best to ask them to demonstrate what they are
doing—for example, how they do the blood sugar
testing. To determine if they are taking medication
correctly, the number of pills in the bottle and the date
the prescription was filled should be checked.
Obtaining informed consent is a legal requirement
for health-care providers in the United States, but it is
directly oppositional to Hmong traditional decision
making. In the Hmong culture, the male head of the
family or clan makes decisions for family members;
individuals do not have the right to make decisions for
themselves. Because the Hmong lack experience with
Western medicine and surgical procedures, they often
have a great deal of fear of medical situations
(Samovar, Porter, & McDaniel, 2009). They do not un-
derstand what is happening, and they sometimes dis-
trust medical personal, especially if the person is a
student. Rumors persist among the Hmong that they
are used for practice by students, so if a treatment is
called experimental, this confirms their beliefs, and they
will most likely refuse treatment. Needing to obtain
consent from the head of a family may result in delays
for treatment as well, as the head of the clan may live
in another state (Samovar, Porter, & McDaniel, 2009).
To be successful in obtaining consent, it is always
important to respect the wishes of the individual, to
wait until family members have arrived, to meet with
the family members to explain the situation, and to
accept their decision. If the patient’s wishes are differ-
ent from the head of the family, that must be followed,
but most patients will go along with the decisions that
are made for them (Johnson, 2009).
Hmong believe that it is inappropriate to say neg-
ative things in front of sick people. In illiterate soci-
eties, words have great power, and Hmong believe
that if you speak negatively in front of an ill person,
the words themselves can make bad things happen.
Family members usually gather around the bed of a
dying loved one, telling that person they are going to
get better. Thus, telling a person what complications
may occur as part of obtaining informed consent can
create great concern to the family (Samovar, Porter,
& McDaniel, 2009).
In Western culture, the achievement of education
and position engenders respect and authority. In the
Hmong culture, however, patients may not feel the
People of Hmong Heritage 311
2780_Ch17_310-318 16/07/12 11:51 AM Page 311

same way about Hmong health-care providers and
will treat them according to their position in the
Hmong family/community hierarchy. This creates
additional stressors for health-care providers and in-
terpreters who may be expected to defer to the
wishes of Hmong patients who have higher status in
their community. Be aware that Hmong health-care
providers and interpreters may be related to the pa-
tient, and they could be placed in an untenable situ-
ation because of a clan hierarchy that Western
individuals may not understand (Samovar, Porter, &
McDaniel, 2009).
Do not touch the head of a Hmong adult or child.
It is considered the most sacred part of the body. Do
not point with your feet, step over someone else’s feet,
show the bottoms of your shoes, or step in front of a
Hmong person. These behaviors are considered offen-
sive (Caregiver Minnesota, 2006).
Do not signal using an upturned finger, especially the
index finger, since some may use this type of gesture to
call animals. Do not point at a Hmong because it is
considered aggressive and threatening. Do not touch a
Hmong patient’s back or shoulder. For many adults,
male–female touching, including shaking hands, is con-
sidered inappropriate (Caregiver Minnesota, 2006).
Temporal Relationships
Hmong born in Laos may not have their true age on
their documents. In Laos, the Hmong had no calen-
dars or clocks, so these concepts were foreign to them.
Many of them did not know their age, so an age was
assigned to them by immigrant officials when they en-
tered the United States; thus, Hmong may appear
older or younger than the age on official documents.
Appointment times are a difficult concept, and
Hmong may sometimes arrive early in the morning
when they had an afternoon appointment (Johnson,
2009). Therefore, the health-care provider must be
flexible with appointments. When they first arrive,
most Hmong tend to be present oriented. However,
once they become more familiar with U.S. culture,
they become more futuristic, as evidenced by taking
advantage of educational opportunities.
Format for Names
The Hmong naming system is undergoing change.
Today, a clan name often serves as a last name. In
the West, a Hmong man usually has two names, a
first and a last name, but he may have three names:
his first name, an honorific name, and his clan name.
A man uses his original name after marriage until
he is given an honorific name, usually after he be-
comes a father for the first time. The name of a
Hmong man is very important, as his wife and chil-
dren will be identified with it (Stratis Health, 2004).
Hmong do not call each other by their first name.
They address one another by their title, such as aunt,
uncle, brother, etc. Demonstrate respect by asking
Hmong patients how they would like to be addressed
(Stratis Health, 2004).
A married Hmong woman might retain her clan
name as her last name, but this practice is not com-
mon among Hmong Americans. More commonly, a
Hmong woman adopts her husband’s clan name as
her last name or joins her own clan name and her hus-
band’s clan name to form a new hyphenated last name.
For example, Kazoua Kong-Thao is from the Kong
clan but is married to a member of the Thao clan. A
Hmong American may have a first name made up of
two or more words. Ka Ying Yang, Maykao Y. Hang,
and Yue Pheng Xiong are all examples of well-known
young Hmong Americans who have adopted this
practice (Stratis Health, 2004).
Many Hmong American parents have begun to give
their children English first names, using the clan name
or the grandfather’s name as the last name. Hmong
parents tend to name their children according to gen-
der and birth order. Many parents name their oldest
son Toua (“the first”), their second son Lue (“the
second”), and the third son Xang (“the third”). Tou
(“boy” or “master”) is a very common name for a
Hmong boy, and many parents use this nickname for
their sons, even though the actual name is different.
May (“girl” or “miss”) is a common name for a
Hmong girl, and many families use this nickname for
their daughters (Stratis Health, 2004).
The most common names for boys are Long, Pao,
Teng, Thai, Tou, Toua, and Xang. Parents tend to name
their daughters Bao or Bo, Kia, May, May Ia, Mee, Pa,
Xi, and Yi. There are many Hmong names that can be
312 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 7 . 1
Mr. Kong, a Hmong man age 66 years, has been living in
Wisconsin for 25 years. He is a Vietnam War veteran but
speaks very little English. Mr. Kong has been complaining of
shortness of breath and swollen legs for several weeks but has
delayed coming to an allopathic health-care provider because
he prefers the herbs he has been taking, although they do not
seem to be helping him. Because he had severe shortness of
breath this morning, he agreed to come to the local Veterans
Administration Hospital and is accompanied by his daughter
and two sons.
1. How can a Hmong who does not speak English be a
veteran?
2. Would his daughter or sons be used as interpreters? Why?
Why not?
3. When Mr. Kong is discharged, how would it be decided
what language to use for the discharge instructions?
4. How can there be assurance that Mr. Kong and/or his
family understand the instructions?
2780_Ch17_310-318 16/07/12 11:51 AM Page 312

People of Hmong Heritage 313
given to both boys and girls. Some of these are Chue,
Ka, Shua, Tong, and Yeng (Stratis Health, 2004).
Family Roles and Organization
Head of Household and Gender Roles
Hmong are organized into 18 clans, and each clan has
a surname that all men and children use. Although
wives and mothers usually retain the clan name with
which they were born, they are still considered a mem-
ber of their husband’s clan. Hmong have no single
leader, but each clan has leaders who are older males.
Older males are the leaders in each family. If a hus-
band dies, the oldest son is expected to make decisions
for the family. The youngest son is expected to marry
and bring his wife home to live with his parents. Older
sons and their families leave the family home when the
family increases in size. Daughters are expected to
marry and to live with their husbands and in-laws.
Traditionally, Hmong women marry young (13 to
15 years of age) and have assistance with childbearing
from the extended family (Meyers, 1992).
The Hmong patrilineal and patriarchal family system
has changed little since moving their culture to the
Western world. Decisions about any family member of
either gender are still passed down through the
husband’s family elders. Women still contribute a lot of
effort to their families, only in different ways. Marriage
is more modern in that women have a little more free-
dom in choosing their husband. However, the families
of both the bride and the groom still have the final say
in the match (Harrison, Pham Kim, & Kagawa-Singer,
2007). The median number of Hmong individuals in a
household is 7 compared with the U.S. median of 2.6
individuals per household (U.S. Census Bureau, 2009).
A Hmong woman does not live outside the home be-
fore she is married to protect her reputation. Over time,
the women of this group have lost some of their power
or agency. The things they used to control have been
stripped from them as they moved into the Western
world and globalization consumed their lives. Hmong
women no longer provide food for their families in the
same way they once did, they no longer give birth to
children in the traditional manner, standing or in a
squatting position to facilitate a vertical delivery, and
it is becoming increasingly more difficult for them to
perform the ceremonies they find essential to life
(Hang, 1997).
The Hmong community in the United States is well
connected though telephone, email, and frequent family
visits. Family “disgraces” are widely known even among
Hmong who live in different parts of the United States.
Things that might be considered disgraces are birth de-
fects, opium addiction of a family member, or a divorce
in the family. These are considered to reflect on every
family member and may, for example, decrease the
chances of making a good marriage.
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Single Hmong may find mates at the annual Hmong
New Year celebrations held between Christmas and
New Year’s Day. Marriages are thought to be advan-
tageous if they are between first cousins but not for
those who retain the same last name. Hmong young
women may be victims of a ritual called “capture
bride,” where a young girl is abducted from her
home, taken to her future husband’s home, and pro-
nounced married. This process is being discouraged,
however, because often the young woman manages
to escape and reports the kidnapping to the police
(Yang, 1994). Once a Hmong child is 5 years old, his
or her behavior is expected to coincide with adult
behavior (Johnson, 2009).
Hmong boys are not considered adults until they
marry. Young girls are thought to be marriageable
when they become “plump” or enter puberty. This
results in young Hmong girls suddenly disappearing
from schools because they have gotten married.
Great social pressure exists for Hmong girls to marry
in their early teens. These marriages are not legal
marriages but traditional Hmong ceremonies; there-
fore, they do not break state laws. Although these
girls may be in their early teens, their pregnancies
tend to be very healthy, with few of the complica-
tions common to teenage pregnancies. These young
families live with their in-laws, so child rearing be-
comes multigenerational. Hmong girls who go to col-
lege are sometimes thought to be “too old” to marry,
and they have reduced choices of Hmong men to
marry (Johnson, 2009).
Alternative Lifestyles
Plural marriages were common in Laos, and they
persist today. Hmong men may marry as many
women as they can afford to support. This is becom-
ing less common with Hmong who no longer adhere
to traditional beliefs. Same-sex relationships are not
condoned and are a reflection on the entire family.
Same-sex relationships should not be disclosed by
health-care providers to family members or others in
the community.
Workforce Issues
Culture in the Workplace
Hmong have the highest unemployment rate of all re-
cent immigrants and have the lowest socioeconomic
level of all Asians in the United States (U.S. Census
Bureau, 2009). Employment for first-generation im-
migrants is difficult due to poor English-language
skills and few workplace skills. Large family size re-
sults in low employment for women. Hmong men who
gain sufficient English-language skills can find jobs in
factories or agriculture (Johnson, 2009).
2780_Ch17_310-318 16/07/12 11:51 AM Page 313

Issues Related to Autonomy
The Hmong’s desire for social acceptance may result
in them saying “yes” to questions regarding knowing
how to perform something when they actually do not
understand. Requesting demonstrations helps to as-
sess knowledge so that better instructions can be given
in the workplace. Young Hmong are rapidly achieving
higher education and higher socioeconomic status,
resulting in them helping other members of their fam-
ily to live better lives and achieve higher education.
Hmong are now in many professional roles and
government service. They are hard workers and are
loyal to their employers (Johnson, 2002).
Biocultural Ecology
Skin Color and Other Biological Variations
Recent immigrants tend to be shorter than European
Americans; men average 5 feet 3 inches, and women
average about 5 feet tall. Men may weigh 100 to
120 pounds and women 85 to 100 pounds. Since im-
migration, obesity is very common in children and
adults. Skin color is light brown; faces are round, with
almond-shaped eyes. A few Hmong have blond hair,
light skin, and hazel eyes. In Laos, this variation was
considered an aberration. Hmong children who are
born in the United States are achieving greater heights,
most likely due to improved nutrition (Johnson, 2009).
Diseases and Health Conditions
Many Hmong continue to have nightmares and flash-
backs to the terrors they experienced in Laos. Type 2
diabetes and hypertension are common due to the rap-
idly increasing obesity of Hmong children and adults
(Pinzon-Perez, 2006). Many Hmong settle in apart-
ments and rely on public assistance. Their traditional
hardworking agricultural lifestyle has been completely
changed into a sedentary Western lifestyle.
Hmong of all ages in central California have a very
high incidence of asthma (Johnson, 2002). Exacerba-
tions are common when air quality is poor. Instructing
the patients in the proper use of inhalers and other
medications is important. Some older Hmong may
have breathing difficulties due to paragonimiasis or
opium addiction. Paragonimiasis is a parasite con-
tracted in Southeast Asia. The parasites settle in the
lungs, causing a diffuse infection. These patients need
a correct diagnosis with appropriate treatment. The
health-care provider should consider paragonimiasis
when patients have pulmonary infections (Johnson,
Falk, Iber, & Davies, 1982).
Recent immigrants have been diagnosed with tuber-
culosis at high rates; some were infected with drug-
resistant tuberculosis. Hepatitis B occurs in high rates
and tends to be present in all members of a family.
Family members should be assisted to comply with pub-
lic health monitoring, and all new immigrants should
be screened for hepatitis B (Pinzon-Perez, 2006).
Helicobacter pylori also occurs in high rates with peptic
ulcers and adenocarcinoma of the gastrointestinal tract.
Both hepatitis B and H. pylori transmission in families
may be related to two factors: When eating, Hmong
individuals often serve themselves from communal
bowls, using the utensils they have been eating with. Also,
traditional practices such as “cupping” or coin rubbing
is practiced by pricking the skin to release blood; this is
believed to release bad spirits (Pinzon-Perez, 2006). One
method of releasing blood is using sewing needles that
are not sterilized and thus may transmit hepatitis B
(Johnson, 2009). Family members should be taught to
sterilize needles and other sharp instruments.
An unexplained phenomenon among the Hmong is
sudden unexplained death syndrome (SUDS) that has
also been experienced among the Vietnamese in the
United States. Nearly all of these deaths involve physi-
cally healthy, young, adult men who die at night or while
sleeping. The Centers for Disease Control and Preven-
tion (1990) reported 117 cases from 1981 to 1988 and
suggested that a structural abnormality of the cardiac
conduction system and stress may be risk factors for
SUDS (Sheng-mei, 2005; Tobin & Friedman, 1983).
Variations in Drug Metabolism
No information on variations in drug metabolism
could be found in the scholarly literature. Health-care
providers may want to look at variations in drug me-
tabolism among Chinese and Thais, whose dietary
habits and genetic profiles are similar to the Hmong.
High-Risk Health Behaviors
Health-Care Practices
Opium was grown in Laos as a cash crop and was used
by many older Hmong for their aging pains. In the
314 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 7 . 2
Thai Hang, age 24 years, lives with five other Hmong refugees
who came to the United States recently from a refugee
camp in Thailand. They share living space in a two-bedroom
apartment in Central Valley, California. They pool their money
to pay for rent, utilities, food, and other household expenses.
All of them are proud of their heritage but are eager to
participate in American traditions. Thai has had some
respiratory problems since he arrived and is seeking a
traditional healer for assistance. They are taking English
classes two evenings each week at a local church.
1. For what health conditions would Hmong refugees be
screened?
2. What is the name for a Hmong traditional healer?
3. What conditions do traditional healers treat?
4. What is the training for a traditional healer?
2780_Ch17_310-318 16/07/12 11:51 AM Page 314

United States, opium addiction persists, but it is rare
and is considered disgraceful in the Hmong commu-
nity. Individuals who smoke opium are usually very
thin with a cyanotic skin color. They have generalized
crackles throughout all lung fields and have frequent
problems with lung infections such as bronchitis and
pneumonia. Health-care providers should consider
opium addiction with Hmong who are very thin with
cyanosis and respiratory problems (Johnson, 2009).
Some newer immigrants have never heard of cancer,
and some who know about it believe it is contagious.
Many women have never heard of or had a Pap test.
Many have never performed breast self-examination or
had a mammogram. Encourage PAP smears as part of
routine examinations, as well as other times when
women are seen for health care (Johnson, 2009).
Many individuals do not know that cigarette smok-
ing can cause cancer. Explain the adverse effects of
cigarette smoking, and encourage cessation.
Nutrition
Meaning of Food
The rice and vegetables the Hmong worked so hard to
grow are now easily available from grocery stores.
They have also begun consuming American foods
such as sugared soft drinks and high-sugar, high-fat
pastries. When assessing nutrition, the health-care
provider should ask what liquids the patient is con-
suming; this is often not revealed unless asked directly
and may show a high consumption of sugared juices
and drinks. Diet should not be taught using Western
measuring amounts. Measured foods in cups and
tablespoons may not be understood by Hmong
patients because baking is uncommon in traditional
Hmong households, and they may not possess these
utensils. A “cup” may mean a drinking cup to the
patient (Johnson, 2009).
Common Foods and Food Rituals
Hmong were primarily farmers, so many have devel-
oped small farms, where they sell fruits and vegeta-
bles. Even Hmong apartments have small plots
for vegetables, and homes may have chickens in the
backyard.
Rice is the primary staple of the Hmong diet.
Vegetables, fish, chicken, and pork are consumed with
the rice. Very hot peppers are made into a condiment
that accompanies the meal. Occasionally a special dish
called laub is made with raw pork and vegetables and
spices. This increases the risk for trichinosis. Although
this practice may not be common among Hmong in
the United States, the practice continues among a few
(Perez, Jula Moua, & Pinzon-Perez, 2006). Many
younger Hmong prefer American diets such as ham-
burgers and other fast foods. Hmong eat two or three
meals per day (Johnson, 2009).
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Hmong families usually consist of many children, ful-
filling several crucial purposes. First and foremost, it
guarantees the continuation of the lineage and clan.
In an agrarian society, lots of children provided help-
ing hands for farm work, housework, and child care.
Being able to produce many children also adds to a
sense of importance for women, helping them feel a
stronger sense of belonging within their clan. Children
are also very highly celebrated in Hmong culture; a
birth signifies the reincarnation of a soul in a new
body. A new family member is cherished in a society
in which family means everything (Quincy, 1995).
In the United States, most Hmong live with ex-
tended families—if not in the same household, then
in the same apartment complex or neighborhood.
Older adults often help take care of their grandchil-
dren. Hmong women consider regular menstruation
to be a sign of health and may not wish to use birth
control that interferes with the regular menstrual
cycle. Most women marry early and have pregnancies
until menopause. Men tend to marry first when in
their early 20s and 30s (Johnson, 2009; Quincy, 1995).
During pregnancy, women continue with their
day-to-day responsibilities until the day they go into
labor. A Hmong woman follows her food cravings
to guarantee that her child will not be born with a
deformity. Women are prohibited from drinking
cold beverages and spicy foods during pregnancy
(Johnson, 2009).
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
The Hmong believe that a long labor can be eased by
drinking water in which a key has been boiled to “un-
lock” the birth canal. Boiling a key is one example of
the many sacred acts that are a part of Hmong religion
performed before, during, or after childbirth (Fadiman,
1997). In the past, women had a strict postpartum diet
that consisted solely of hot foods and drinks. Cold
foods make the blood congeal in the womb instead of
cleansing it by flowing freely (Fadiman, 1997; Johnson,
2009). Some Hmong may still follow these routines to
ensure a woman’s fertility.
Postpartum, white rice and chicken are the tradi-
tional diet for 1 month, and the mother may not have
cold drinks. New mothers are expected to rest after
delivery. The mother-in-law and husband help the new
mother. New mothers may not want to eat hospital
food, so the family should be permitted to bring tra-
ditional foods from home. Ask the mother what she
prefers; many Hmong are now Christians and no
longer adhere to traditional beliefs and practices
(Johnson, 2009).
People of Hmong Heritage 315
2780_Ch17_310-318 16/07/12 11:51 AM Page 315

Death Rituals
Death Rituals and Expectations
Traditional Hmong view life as a continuous journey.
Death is merely a phase people go through when pass-
ing from this plane of existence to the next. Many be-
lieve that people are destined to live to a certain age,
and when that age is reached, the person departs but
the spirit will reincarnate. Most Hmong believe in mul-
tiple souls that reincarnate—one that stays in the area
of the body and another that stays in the present world,
overlooking and caring for the family (Johnson, 2009;
Stratis Health, n.d.).
Responses to Death and Grief
The deceased is dressed in fine Hmong clothes to
demonstrate to all that the person has lived a good life,
will be missed, and will make a proper entrance into
the next world (Johnson, 2009; Stratis Health, n.d.).
Hmong funerals are distinctive with many rituals
and may last many days to honor the deceased and
their ancestors. The older or more revered the per-
son, the longer the funeral. An animal sacrifice may
be made to honor the deceased. The sacrificed ani-
mal is later used to provide food for the people pres-
ent (Falk, 1996; Johnson, 2009; Stratis Health, n.d.).
During the long funeral, family and friends tell
stories and sing songs relating to the mountains
from home (Falk, 1996).
Spirituality
Dominant Religion and Use of Prayer
Hmong who immigrated when young become more ac-
culturated. Most older and more recent Hmong hold
traditional animist beliefs where ancestors are revered,
and they believe that spirits are widely distributed in the
world and reside in many inanimate objects or places
such as trees, rivers, and houses. Many believe that spir-
its can cause harm, misfortune, illness, or death, or can
be helpful to protect or prevent bad events from occur-
ring. Good spirits are thought to be ancestors who
watch over and protect them (Plotnikoff, Numrich, Wu,
Yang, & Ziong, 2002).
Meaning of Life and Individual Sources
of Strength
The primary religious leader is the shaman (tu txiv
neeb, pronounced “too tse neng”), who takes care of
health and spiritual problems (Plotnikoff et al., 2002).
Family, nuclear and extended, is a primary source of
strength, followed by animistic beliefs for traditional
Hmong. For acculturated Christian Hmong, family
continues to be a primary source of strength and ele-
ments from their chosen new religion. The shaman
may still be sought for help and advice with personal
and health concerns.
Spiritual Beliefs and Health-Care Practices
Christian Hmong have beliefs and practices appropri-
ate to their religion. Some may denounce animist be-
liefs and traditional Hmong beliefs such as soul loss
and soul calling ceremonies by the shaman. Prayers
and chants may be performed for healing (Johnson,
2002, 2009; Plotnikoff et al., 2002).
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Although most Hmong in the United States readily
access health care, they might first use traditional
treatments and even combine them with Western med-
icine. Most Hmong foster the belief that American
medicines are powerful, but they fear that serious side
effects may accompany their use. American medicines
are commonly diluted and/or blended with familiar
indigenous herbs before use (Meyers, 1992). Addition-
ally, there is suspicion among the Hmong that Western
physicians experiment on people from different cul-
tures. They believe surgery allows good spirits to leave
and bad spirits to enter the body (Higgs & Rairdan,
1992; McInnes, 1991). Many distrust autopsies, dental
fillings, and blood tests, believing that persons are rein-
carnated with a handicap if these procedures are per-
formed (Cheon-Klessig, Camilleri, McElmurry, &
Ohlson, 1988; Meyers, 1992). Despite this distrust of
Western medical care, Southeast Asians seek treatment
when their own indigenous practices are unsuccessful.
Responsibiity for Health Care
Most Hmong do not subscribe to preventative and
health maintenance health-care practices. However,
immunizations, which are needed for children to enter
school, are accepted. The concept of germs and pre-
ventive asepsis may not be understood, especially
among older adults. They generally do not subscribe
to the importance of developmental stages and antic-
ipatory guidance in young children (Johnson, 2009).
Folk and Traditional Practices
Diarrhea in Hmong children is traditionally treated
with herbs and plants such as dry wood and plant
roots, sida leaves, and herbs boiled with tea. For
sprains and fractures, some steam leaves and wrap
them around the ankle or wrist. Cords may be tied on
the wrist and then massaged. In some cases, un-
cooked egg is rubbed on a child, as is blood or animal
excrement, depending on the severity of the injury
(Nuttall & Flores, 1997). Raw chicken chopped with
herbs may be wrapped around a broken bone. Bone-
twisting maneuvers are sometimes attempted to treat
the sprain or set the bone. Home remedies include ap-
plication of dung from black chickens to the broken
bone (Nuttall & Flores, 1997). Studies have shown
that these herbs may have pharmaceutical properties.
316 Aggregate Data for Cultural-Specific Groups
2780_Ch17_310-318 16/07/12 11:51 AM Page 316

Ask patients about their use of herbs upon admission
(Johnson, 2009).
Invasive procedures such as intravenous lines, injec-
tions, suturing, and casting are looked on skeptically.
Most parents try herbal and traditional remedies first,
using invasive procedures only if a favorable outcome
is guaranteed. The Christian Hmong participant in
one study believed that the outcome for congenital
deformities should be “left to faith” (Johnson, 2009).
One cause of illness is thought to be loss of soul. It
is believed that some individuals, such as babies and
children, have souls that have difficulty staying in the
body. If the soul leaves for too long, the baby can be-
come ill or die. For this reason, parents may tie a
string around the baby’s neck or wrist soon after birth.
Older children and adults may have strings tied
around wrists, waists, or ankles. These must remain
on until they fall off naturally, because removing them
too soon can result in soul loss and illness or death
(Johnson, 2009). Since immigrating to the United States,
the strings have been replaced with gold necklaces and
bracelets. Hmong who practice shaman ceremonies
may have amulets in small bags around their neck or
waist. These contain objects thought to be protective
against evil spirits (Johnson, 2009). Do not remove
strings, necklaces, bracelets, or amulets without the
parents’ or patient’s permission.
Barriers to Health Care
The greatest barrier to adequate health care for the
Hmong in the United States is accurate and culturally
competent communication ensuring a correct diagno-
sis. For some, transportation and lack of finances can
be significant barriers. The health-care provider must
ensure the availability of interpreters at all times.
Cultural Responses to Health and Illness
Hmong seek Western medical care often; yet, they
may also use traditional healers or shamans who
perform rituals. They may seek herbalists and take
multiple treatments for the same condition. Some
practice home remedies such as coining or cupping.
These traditional practices cause distinctive elon-
gated or round bruises that are generally over the
area where the problem is. For example, a sore throat
will have bruises around the neck, and chest symp-
toms may have cupping over the front and back of
the chest. Pricking the center of the bruise is done to
release bad spirits; unsterilized sewing needles are
generally used for this purpose (Johnson, 2009). The
regular patterns of coining or cupping should not be
mistaken for marks of abuse. Encourage sterilization
of needles.
Blood Transfusions and Organ Donation
Traditionally, blood transfusions and organ donation
are unacceptable to Hmong. Younger Hmong, however,
are more accepting of these medical procedures (Stratis
Health, n.d.).
Health-Care Providers
Traditional Versus Biomedical Providers
Hmong cultural attitudes, values, and behaviors influ-
ence when, where, why, and with whom a Hmong per-
son uses Western medicine. The foremost Hmong
traditional healer is the shaman. There is no equivalent
health professional in Western biomedicine. The scope
of the shaman as a healer extends beyond the capacities
and expertise of physicians (Plotnikoff et al., 2002).
Despite 25 years of Hmong acculturation in the
United States and conversion to Christianity, Hmong
shamanism maintains its traditional role in health and
healing. Many Hmong who see physicians also rely on
shamans for restoring health and balance to their
body and soul. Thus, the Hmong shaman can be con-
sidered a powerful complement to Western health-care
providers.
Shamans do not choose to become shamans; the
occupation is considered a calling and is approved by
the community (Plotnikoff et al., 2002). Shamans
train for many years and learn as apprentices. Shaman
ceremonies are conducted within the home with all the
family present; they go into the spirit world to find out
why the soul was lost or was taken to the spirit world.
Status of Health-Care Providers
The shaman is held in high regard because he or she
is well known to the community and trusted. However,
when traditional treatments do not work, Hmong do
not hesitate to see Western health-care providers.
R E F E R E N C E S
Caregiver Minnesota. (2006). Education and resources for Hmong
families. Retrieved from http://www.caregivermn.org/hmong/
h017carepage.htm
People of Hmong Heritage 317
R E F L E C T I V E E X E R C I S E 1 7 . 3
A Hmong couple, Foua and Nao Xang, bring their 4-year-old
daughter Mai to an urgent care clinic for infected puncture
marks on her chest and back. The parents speak very little
English, but the nurse understands by their demonstration that
they were doing “some type” of traditional treatment.
1. What are some of the traditional treatments used by the
Hmong?
2. What is the most likely cause of these infected puncture
marks?
3. Should child protective officials be notified of possible child
abuse? Why? Why not?
4. What advice should be given to the parents for the future?
2780_Ch17_310-318 16/07/12 11:51 AM Page 317

Carroll, E., & Uldova, V. (2005). Who is Hmong? Hmong Studies
Journal, 6, 1–20.
Centers for Disease Control and Prevention. (1990). Update: Sudden
unexplained death syndrome among Southeast Asian refugees—
United States. Journal of the American Medical Association,
260(14), 2033.
Cheon-Klessig, Y., Camilleri, D.D., McElmurry, B.J., & Ohlson,
V.M. (1988). Folk medicine in the health practice of Hmong
refugees. Western Journal of Nursing Research, 10, 647–660.
Doctors Without Borders. (2008). Retrieved from http://www.
doctorswithoutborders.org/news/article.cfm?id=2714
Duffy, J., Harmon, R., Ranard, D., Thao, B., & Yang, K. (2004). An
introduction to their history and culture, The Hmong Culture
Profile No. 18, Center for Applied Linguistics. Washington, DC.
Encarta® Online Encyclopedia. (2003). Hmong. Retrieved from
http://autocww.colorado.edu/~toldy2/E64ContentFiles/
AnthropologyAndCultures/Hmong.html
Fadiman, A. (1997). The spirit catches you and you fall down: A
Hmong child, her American doctors, and the collision of two
cultures. New York, NY: Farrar, Straus and Giroux.
Falk, C. (1996). Upon meeting the ancestors: The Hmong funeral
ritual in Australia and Asia. Hmong Studies Journal, 1(1), 1–15.
Grigoleit, G. (2006). Coming home? The integration of Hmong
refugees from Wat Tham Krabok, Thailand, into American
society. Hmong Studies Journal, 7, 1–22.
Hang, Maykao Yangblongsua. (1997). Growing up Hmong
American: Truancy policy and girls. Hmong Studies Journal, 2,
1–54.
Harrison, G., Pham Kim, L., & Kagawa-Singer, M. (2007). Per-
ceptions of diet and physical activity among California Hmong
adults and youths. Preventing Chronic Disease, 4(4), A93.
Higgs, Z., & Rairdan, B. (1992). When your patient is a Hmong
refugee. American Journal of Nursing, 92, 52–55.
Johnson, S. (2002) Hmong health beliefs and experiences in the
Western health care system. Journal of Transcultural Nursing,
(13)2, 27–133.
Johnson, S. (2009). People of Hmong heritage. In L. Purnell (Ed.),
Guide to culturally competent health care (pp. 202–214).
Philadelphia,PA: F. A. Davis Co.
Johnson, J.R., Falk, A., Iber, C., & Davies, S. (1982). Paragonimi-
asis in the United States. A report of nine cases in Hmong
immigrants. Chest, 82(2), 168–171.
Lindsay, J. (2010). Hmong life in America: A story of tragedy and
hope. Retrieved from http://www.jefflindsay.com/Hmong_
tragedy.html
McInnes, K. (1991). Ethnic-sensitive work with Hmong refugee
children. Child Welfare, 70(5), 571–580.
Meyers, C. (1992). Hmong children and their families: Consider-
ation of cultural influences in assessment. American Journal of
Occupational Therapy, 46, 737–744.
Nuttall, P., & Flores, P.C. (1997). Hmong healing practices used for
common childhood illnesses. Pediatric Nursing, 23(3), 247–251.
Perez, M.A., Julah Moua, L., & Pinzon-Perez. (2006). Food
preparation practices and safety in the Hmong community.
Hmong Studies Journal, 7, 1–24.
Pinzon-Perez, H. (2006). Health issues for the Hmong populations
in the US: Issues for health educators. International Electronic
Journal for Health Education, 9, 122–133.
Plotnikoff, G.A., Numrich, D., Wu, C., Yang, D., & Ziong, P.
(2002). Hmong shamanism: Animist spiritual healing in
Minnesota. Minnesota Medicine, 85(6), 29–34.
Quincy, K. (1995). Hmong history of a people. Cheney, WA:
Eastern Washington University Press.
Samovar, L., Porter, R., & McDaniel, E. (2009). Intercultural com-
munication: A reader. Boston: Wadsworth Cengage.
Sheng-mei, M. (2005). Hmong refugee’s death fugue. Hmong Stud-
ies Journal 6, 1–36.
Stratis Health. (n.d.). Cultural Orientation Project. (2004). Retrieved
April 28, 2011 from http://www.cal.org/co/hmong/hlaos.html
Tobin, J. J., & Friedman, J. (1983). Spirits, shamans, and night-
mare death: Survivor stress in a Hmong refugee. American
Journal of Orthopsychiatry, 53(3), 439–448.
U.S. Census Bureau. (2009). Factfinder2. American community sur-
vey. Retrieved from http://factfinder.census.gov/servlet/SAFFIt-
eratedFacts?_event=&geo_id=01000US&_geoContext=01000US
&_street=&_county=&_cityTown=&_state=&_zip=&_lang=en&
_sse=on&ActiveGeoDiv=&_useEV=&pctxt=fph&pgsl=010&_
submenuId=factsheet_2&ds_name=DEC_2000_SAFF&_ci_nbr
=039&qr_name=DEC_2000_SAFF_R1010&reg=DEC_2000_
SAFF_R1010%3A039&_keyword=&_industry=
Yang, J. (1994). Hmong marriage by capture: Case in Fresno,
California. Southern California Interdisciplinary Law Journal,
10, 38–48.
Yau, J. (2005). Migration information source. Retrieved from http://
www.migrationinformation.org/usfocus/display.cfm?ID=281
For reflective exercises, review questions, and additional
information, go to
http://davisplus.fadavis.com
318 Aggregate Data for Cultural-Specific Groups
2780_Ch17_310-318 16/07/12 11:51 AM Page 318

319
Chapter 18
People of Japanese Heritage
Misae Ito and Keiko Hattori
Overview, Inhabited Localities,
and Topography
Overview
Nihon, or Nippon, as Japan is called in the Japanese
language, is a 1200-mile chain of islands in the north-
western Pacific Ocean, slightly smaller than California,
and one-quarter the size of the United States (CIA
World Factbook, 2011). Japan’s neighbors are Russia,
Korea, and China, and its modern history has been
shaped by conflict with these countries.
Japan’s territory extends generally from northeast to
southwest. The northern and westernmost areas have
a climate similar to that of the northern United States,
with some heavy snowfalls in the winter; the Ryukyu
Islands in the south are subtropical. The climate of
the Tokyo region, where most of the population
is clustered, is similar to that of Washington, DC.
Winters are moderate, with snows that seldom accu-
mulate except in the north, whereas summers are hot
and steamy.
The population of around 127 million resides
mainly on the four largest islands (U.S. Department
of State, 2010): Honshu, Kyushu, Hokkaido, and
Shikoku. Tokyo, on Honshu Island, is the capital and
largest city with 80 million people residing in its
greater metropolitan area. The Japanese, who refer to
themselves as Nihonjin, share a strong sense of nation-
alism and pride in ethnic purity. Japanese citizenship
is not readily obtained, and currently there are over
2 million foreign residents in Japan, who are required
to register as aliens. The inclusion of even third-
generation Korean residents in the category of for-
eigners has received considerable adverse international
press in recent decades. However, some changes are on
the way as Japan has begun acknowledging that a
long-revered sense of ethnic homogeneity may not be
sustainable. Globalization, low birth rate, an aging
population, and increasing labor shortages are causing
the country to rethink its immigration policies. However,
this has to be balanced against tensions arising from
growing international terrorism, and therefore, stricter
controls on immigration have been implemented
(Kashiwazaki & Akaha, 2005).
Heritage and Residence
The original inhabitants of Japan most likely migrated
from the Korean peninsula. The marked Chinese cul-
tural influence began in the late 400s and included the
Chinese system of writing, the calendar, Confucianism,
Buddhism, and East Asian beliefs about health and ill-
ness. Following World War II, from 1945 to 1952, Japan
was an occupied territory of the United States. As a
bitter legacy of that war, the northernmost Kuril
Islands are still claimed by Russia, and today, Japan still
has U.S. military bases on its soil, in part to counteract
perceived threats from neighboring countries.
Japanese citizens residing in North America have
tended to locate in large commercial and educational
centers. With the establishment or purchase of facto-
ries in the midwestern and southern states by Japanese
companies, communities of Japanese expatriates can
now be found in smaller cities as well.
Reasons for Migration
and Associated Economic Factors
In the late 1800s, Japanese people began to migrate to
the United States and Canada, and from 1891 to 1924,
more than 250,000 Japanese immigrated, settling pri-
marily in the Territory of Hawaii and along the Pacific
coast (Yanagisako, 1985). By 2004, however, an esti-
mated 369,639 Japanese nationals lived in the United
States, of whom 240,000 were considered long-term
and 129,600 permanent (UN Secretariat, 2005).
Japanese love overseas travel, and in 2010 approxi-
mately 3.4 million of them visited the United States
and spent dollars on goods and services (U.S. Com-
mercial Service, 2011).
Educational Status and Occupations
Education is highly valued in Japan, where the illiter-
acy rate is only about 1 percent (U.S. Department of
State, 2010). According to the Ministry of Education,
Culture, Sports, Science, and Technology (2010a), in
2780_Ch18_319-338 16/07/12 11:53 AM Page 319

Japan the ratio of completion of the 12th grade is
about 98 percent, and those of young people ensure a
highly competent workforce. For instance, calculus is
part of the mandatory junior high school curriculum,
and high school graduates complete 6 years of English
instruction. In addition, activities are introduced in
which English is spoken in elementary school.
Many youngsters prepare for high school or college
entrance examinations by attending proprietary juku,
or cram, schools in the evenings or on weekends,
which creates enormous pressure on youth to succeed.
Moreover, over 70 percent of high school graduates
go on to higher education at over 2000 universities,
junior colleges, and technical schools. Entrance exam-
inations for high school and college are very compet-
itive. Because the alumni network helps to provide job
placements, the school that one attends determines to
a great extent where one is employed after graduation.
To gain higher education degrees, Japanese commonly
study at the university where they earned their under-
graduate degree rather than go to different universities
like many of their American counterparts do.
Whereas the concept of adults returning to college
is not common, self-improvement is a huge industry.
Hobbies are taken very seriously and often entail for-
mal study to seek mastery in a particular hobby. For
example, the traditional Japanese arts, such as chadō
or sadō (tea ceremony); ikebana (flower arranging);
bonsai; kimono wearing; shodo (calligraphy); painting;
wood carving; and even doll making, are studied
diligently by large numbers of women and by some
retired men.
Sales of books, periodicals, and daily newspapers
in Japan are among the highest among industrialized
nations, and there is an increasing love of manga,
comics or print cartoons. In fact, almost half of all
periodicals or books are manga (Japan Media Review,
2006). Popular manga are adopted into anime (or an-
imation), and at any time of day, one can witness the
very young to the middle-aged crowding train stations,
bookstores, or convenience stores, voraciously reading
their favorite comics, some with explicit sexual or vi-
olent content. This has a significant impact on the way
in which messages are passed on culturally. Health-
care providers need to consider the use of manga and
anime when promoting health education to Japanese
patients. The national broadcasting system, NHK,
offers high-quality radio and television news and
entertainment, and cable TV is increasingly popular.
Although culture reflects Japan’s recent agrarian
past, at present few Japanese are engaged in agricul-
tural occupations because a significant amount of
foodstuffs are imported. In the United States, issei
(first-generation immigrants) originally tended to
work in agriculture or as small-business owners. More
recent immigrants work in business, the professions,
service industries, and manufacturing. Second- (Nisei)
and third-generation (sansei) Japanese Americans tend
to be highly educated professionals. Most Japanese na-
tionals living in the United States are well-educated
executives, visiting scholars, individuals with technical
expertise, and students.
Communication
Dominant Language and Dialects
Japanese is the language of Japan, with the exception
of the indigenous Ainu people (see biological varia-
tions later in this chapter). The Japanese spoken in
Tokyo is the national standard heard in media broad-
casts; however, regional variations to the language do
exist. Because high school graduates in Japan complete
6 years of English instruction, even newer Japanese im-
migrants and sojourners can understand, read, and
write the English language to some degree. The biggest
problem, however, is conversational English; whereas
many Japanese may have studied the language for
many years, they often lack strong conversational skills
and are frequently embarrassed to try their language
ability with foreigners.
In the United States, issei vary widely in their
English-language ability. Nisei and sansei have been
educated under the American educational system to
the extent that they were permitted; for example, edu-
cational access was limited or segregated during the
World War II internment of American citizens of
Japanese ancestry. Although the language barrier may
be an obstacle to understanding verbal instructions or
explanations in English-speaking health-care settings,
Japanese patients are likely to use written materials ef-
fectively. More recent immigrants to the United States
are likely to understand English but may need prompt-
ing in conversation skills.
Cultural Communication Patterns
Japanese society is both highly structured and tradi-
tional. Politeness, personal responsibility, loyalty, and
people working collectively for the greater good of the
group are very important. One complexity of the
Japanese language is the customizing of speech accord-
ing to relative social status and gender. The Japanese
sensitivity to relative status and the need to constantly
gauge one’s behavior accordingly is one reason the cir-
cle of intimates with whom one can truly relax is quite
limited. In addition, men tend to speak more coarsely
and women with more gentility or refinement.
Light social banter and gentle joking are mainstays
of group relations, serving to foster group cohesive-
ness. Polite discussion unrelated to business, often over
o-cha (green tea), precedes business negotiations, and
sake parties are common during the negotiation pe-
riod. Sake, a fermented beverage with a history of
over 2000 years in Japan, is integral to the culture and
society. Relationship building and respect for personal
320 Aggregate Data for Cultural-Specific Groups
2780_Ch18_319-338 16/07/12 11:53 AM Page 320

privacy are important aspects of working relation-
ships in all sectors.
In a densely populated society that values group
harmony above all else, open communication is dis-
couraged, making it difficult to learn what people
think (Doi, 1971). In particular, among people of
Japanese descent, saying no is considered extremely
impolite; rather, one should let the matter drop.
A high value is placed on “face” and “saving face.”
Asking someone to do something that he or she can-
not do induces loss of face or shame. Proving people
wrong is deeply humiliating to them. People may feel
shame for themselves and their group, but they are ex-
pected to bear that shame in stoic silence. In fact,
Japan is considered to have a shame-based culture
rather than a guilt-based culture (Leonardsen, 2004),
unlike many Western cultures. Suicide over shame is a
common theme in Japanese literature, lore, and media.
Regular reports of suicides occur in the daily media,
often mentioning the name of the suicidee who has
committed the act after embarrassment, shameful
deeds, allegations of corruption, or bullying in the
workplace or at school. Because of ethnic homogene-
ity; an ingrained sensitivity to the feelings of others;
and close contact with one’s family, classmates, and
work group, Japanese believe that vague, intuitive com-
munication, called hara wo yomu (belly talk), is well
understood by fellow group members. Nonverbal com-
munication or innate harmonious relationship is also
expressed a-un no kokyu or a-un no kankei, meaning
people can communicate without gestures or words.
In Japan, presenting a person with choices is re-
garded as a burden, and it is a kindness to spare peo-
ple the burden of decision making. For example, a
hostess may serve drinks in glasses to spare her guests
the burden of deciding what they would like to drink.
Professors do not offer a choice of learning activities
to their students; a teacher may arrange employment
for a former student; and a physician will tell the pa-
tient what to do about a health problem. These actions
are motivated by concern for the well-being of the per-
son in one’s care. Japanese society is sometimes de-
scribed as a web of giri (mutual obligations) that
serves to ensure societal integrity and harmony.
Etiquette and harmony are very important, and
many Japanese people exhibit considerable control
over body language. Anger or dismay may be quite
difficult for Westerners to detect. Smiling and laughter
are common shields for embarrassment or distress.
However, one need only see tearful family partings at
train stations to know that, contrary to Western as-
sumptions, Japanese people do show their feelings but
seldom hug or kiss one another at such partings, as is
so common in many other cultures.
Prolonged eye contact is not polite even within fam-
ilies. Social touching occurs among group members
but not among people who are less closely acquainted.
In general, body space is respected. Intimate behavior
in the presence of others is taboo. When people greet
one another, whether for the first time or for the first
time on a given day, the traditional bow is performed.
The depth of the bow, its duration, and the number
of repetitions reflect the relative status of the parties
involved and the formality of the occasion. An offer
to shake hands by a Westerner is reciprocated gra-
ciously. With an introduction, meishi (business cards)
are exchanged first, enabling the parties to assess their
relative status.
Temporal Relationships
An awareness of Japanese history and legend, a high
regard for older people, the value of family honor, and
veneration of dead ancestors suggest a strong connec-
tion with the past. However, the overall orientation of
the Japanese people, who are known for their postwar
economic miracle, is toward the future. The popula-
tion made huge sacrifices in the decades after the war
for the good of the nation, enabling it to become a
world power. Parents encourage their children to
study hard so that their futures will be bright. House-
wives are diligent savers for future family expenses.
Companies plot their growth, and the government an-
ticipates needs decades in advance. Whereas Zen calls
its providers to attend to the here and now, this tenet
actually has few adherents in Japan. Health-care
providers may find that Japanese patients are aston-
ishingly motivated in health-related decision making
by considering their children’s needs and the economic
future for their family.
Punctuality is highly valued among the Japanese.
Commuter trains run to split-second timing, and peo-
ple are expected to be in attendance at the exact start
of meetings. In an interesting contrast, the clinic system
of health care pervades even the private sector in Japan.
Clinic services are not expected to be efficient, and hos-
pital stays are still longer than in many Western coun-
tries, although the average number of hospitalization
bed-days per illness is falling, owing to economic prob-
lems and some shortages of qualified nurses.
Format for Names
In Japan, family names are stated first, followed by
given names. Seki Noriko would be the name of a
woman, Noriko, of the Seki family, and often women’s
names end with -ko. The family names of both men
and women, married or single, are designated by the
suffix -san, but one does not use that designation when
referring to oneself. Women generally assume their
husband’s family name upon marriage. Schoolchild-
ren may use given names when speaking to one an-
other, also designated with -san. Work groups and
business associates tend to use family names. Infants
and young children are called by their first names fol-
lowed by -chan. Schoolboys are usually referred to by
People of Japanese Heritage 321
2780_Ch18_319-338 16/07/12 11:53 AM Page 321

their first or last names followed by -kun, whereas
schoolgirls’ first names are usually followed by -chan
or -san. Elders are referred to respectfully. The desig-
nation sensei (master) is a term of respect used with
the names of physicians, teachers, bosses, or others in
positions of authority.
Family Roles and Organization
Head of Household and Gender Roles
The predominant family structure among the Japanese
is nuclear, accounting for 58 percent of families in
2005, with 30 percent of households composed of one
person, and the number of these has been increasing
(Ministry of Internal Affairs and Communications,
2010). This contributes to problems in social isolation,
particularly among older people, because the number
of households in which three generations are present
is falling. In feudal Japan, a bride had very limited
contact with her own family after marriage, and the
mother-in-law dominated the household. Now, wives
often determine the household budget, their husbands’
pocket money, investments, family insurance, real-estate
decisions, and all matters related to child rearing.
Even today, with higher education widely available
to women, the role of wife and mother remains domi-
nant. Young women in the workplace may have jobs
with little substantive responsibility, even if they are
college graduates, but matters are slowly changing. In
2009, the Ministry of Internal Affairs and Communi-
cations (2010) reported that the ages for first marriages
are rising (30.4 years for men and 28.6 for women).
Moreover, the natural increase rate per 1000 population
showed –0.6; –0.2 (in 2005) was the first negative result
recorded since statistics gathering began in its present
form in 1899. With this knowledge, the government
is attempting to reduce the strong social pressure
confronting women who try to continue working after
motherhood, primarily because of Japan’s need for
skilled workers.
International Longevity Center Japan (2006) de-
scribed a new law in 2005 that gave workers the op-
portunity to take leave to care for sick children and
other family members, developed corporate strategies
to support workers or other family members who take
care of children, permitted shorter working hours for
workers who are raising a young child, and allowed
more generous family-care provisions. The effects of
this law are yet to be seen; it is still difficult for women
to return to work after childbearing. An equal rights
amendment has been part of Japan’s constitution
since the U.S. occupation of Japan. Whereas Japan
has protected women’s interests in matters such as
property ownership and voting, women are treated far
from equally in the workplace. Conversely, increasing
numbers of child-care centers assist families in which
both parents are working, and a few of the larger cor-
porations have begun to offer child care. Daily news-
papers are filled with discussions about how Japan can
increase its birth rate, and any reforms to date have
failed to stop the trend of increasing numbers of
working women, women who choose not to marry, or
couples who choose to have few or no children at all.
The difficulty of paid employment or a career after
motherhood and the desire for two incomes to main-
tain a middle-class lifestyle often cause couples to
delay having a family.
Wives in Japan care for their husbands to a degree
that many Western women would not tolerate. Japanese
men are presumed not to be capable of managing
day-to-day matters, and some salarymen (white-collar
workers) or office workers may leave for work at 7 a.m.
and return after 10 p.m., Monday through Saturday.
On Sundays, men may be so exhausted that they sleep
a good part of the day, or they may be obligated to
socialize with colleagues. Wives and children often
stay behind when husbands are transferred by their
companies within Japan or overseas, leaving women
to raise children singlehandedly. Not surprisingly, one
focus of the Ministry of Health, Labour and Welfare
(2011a) in addressing the low birth rate is to convince
men to assume more responsibility for child care and
housework and for companies to change policies to
keep families from being separated.
The paramount family concern is for the children’s
education, and it is the mother’s responsibility to over-
see the completion and quality of homework. When
the children grow up and leave home, women tend to
become involved in volunteer activities, community
groups, travel, arts, and the previously mentioned
self-improvement classes.
Western observers would be wrong to presume that
married Japanese couples do not love each other. But
in Japan, love sometimes has not been valued highly
322 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 8 . 1
Mr. and Mrs. Tanaka, a Japanese-issei couple in their 80s, come
to day care at the local community center to attend the craft
and art classes. Mrs. Tanaka always follows Mr. Tanaka, and
he speaks with her in a strong tone. They have been
feeling isolated and ashamed to talk to others. Their family
members—their son, daughter-in-law, and grandchildren—are
not able to spend much time with them because of work and
school.
1. How can they be introduced to others?
2. How would the communication patterns of this couple be
assessed?
3. What elements of communication might be important to
make this couple feel welcome?
4. Is this communication style congruent with issei? With
nisei? With sansei?
2780_Ch18_319-338 16/07/12 11:53 AM Page 322

as a prerequisite for a successful marriage, and men
and women have tended to be more motivated by duty
to fulfill societal expectations than by the desire for
spousal companionship. Conversely, domestic violence
has begun to be openly acknowledged. The Gender
Equality Bureau (2010) explained that according
to statistics provided by the National Policy Agency,
the majority of the victims in arrest cases involving
murder, injury, or violence inflicted by a spouse are
females. The Law for the Prevention of Spousal Vio-
lence and the Protection of Victims was implemented
in 2001 and then amended in 2004. Under this law,
shelters for victims were established and counseling
programs offered. Moreover, restraining orders and
orders to vacate are now issued at a rate of about 100
a month. With this law, a number of public education
programs are in place, and some women’s shelters have
opened. In a society marked by strict norms differen-
tiating the public and the private realms, couples
have lacked resources to learn how to deal with
tension and conflict.
Health-care providers need to be aware of differences
in spousal relationships when assessing the quality of
family dynamics and communication, sexual health,
and sensitivity to risk for sexually transmitted infec-
tions. Health-care providers who work with college-age
and young adults may find that Japanese youth are
less autonomous than their American counterparts.
Conflicts between traditional and American values
may arise among these young people and within their
families.
Prescriptive, Restrictive, and Taboo Practices
for Children and Adolescents
The primary relationship within a Japanese family is
the mother–child relationship, particularly that of
mothers and sons. It is customary for the mother,
and sometimes both parents, to sleep with the
youngest child on futons, or mattresses, on the floor
or in adult beds (Fukumizu, Kaga, Kohyama, &
Hayes, 2005) until a child is age 10 years or older.
When a new baby is born, the older sibling may sleep
with the father or a grandparent. A special child bed
is used for neonates to prevent the parents rolling on
the child during sleep. Fukumizu and colleagues
(2005) found that 80 percent of Japanese parents
sleep with their young infants and young children.
The primacy of the mother–son relationship and the
absence of fathers contribute to the known problem
of mother–son incest. Father–daughter incest occurs,
but a stronger taboo prohibits public discussion of
it (Kanazumi, 1997), and so it is very difficult to find
data on it. Despite the occasional occurrence of fam-
ily dysfunction in this area, health-care providers
working with childbearing couples and children need
to be aware of Japanese family sleeping practices and
refrain from judgment.
The maternal role is so important for women in
Japan that it is not unusual for a young mother to
spend hours watching her infant sleep. If she observes
the reflexes of urination, she changes the diaper
immediately. Babies are not allowed to cry; they are
picked up instantly. Women constantly hold their
babies in carriers on their chests and sleep with them
(Sharts Engel, 1989). “Skinship” or direct contact, is
a value to be desired.
Young Japanese children tend to be indulged, espe-
cially if they are single children. At the same time, they
are socialized to study hard, make their best effort, and
be good group members. They are taught to take care
of one another, and self-expression is not highly valued.
Corporal punishment has been more accepted in
Japan than in some Western cultures, and shitsuke (to
discipline) has traditionally included it to instruct a
child to follow a particular pattern of behavior. And
the word punishment, for example, is often used in the
daily English newspapers to describe actions to coun-
teract the transgressions of government workers.
Cases of punishment by school officials or ijime
(bullying) by their peers at school have resulted in the
suicide of young children recently—matters debated
hotly in the local press. The fears are that bullying is
reaching epidemic proportions. Children who are bul-
lied by schoolmates typically have different appear-
ances, interests, or family structures, and health-care
providers need to be aware of this among Japanese
American children.
In 2006, the Ministry of Education, Culture, Sports,
Science, and Technology (2011b), under the directives
of the new prime minister, Abe, has begun a review of
school education across the country, intending to in-
corporate content on national values. The government
has also begun to address ways for families and schools
to more effectively foster the development of Japanese
children. It has been a serious matter that has radically
increased the reports of child abuse in recent years,
most of which have involved violence and neglect. It is
now mandatory for teachers and health professionals
to report child abuse cases. The Equal Employment,
Children and Families Bureau implements the support
for abused children as well as the early detection of and
the prevention of child abuse.
Despite strong social pressure to conform, many
adolescents in Japan have their rebellious streaks and
use popular music, pornography, unconventional
clothing, and illicit drugs and alcohol to escape social
restrictions. Increasing numbers of young people are
expressing themselves through their clothing, hair, and
makeup, but vandalism is a minimal concern in the
country. Teenagers and college students in Japan gen-
erally do not date to the degree that Western youth do.
They typically join clubs, membership in which is
taken seriously; most social activities, such as ski trips,
are club activities. However, sex education in school
People of Japanese Heritage 323
2780_Ch18_319-338 16/07/12 11:53 AM Page 323

and/or university settings is minimal, despite teenagers
having sexual encounters. The use of contraceptives
as a preventive measure is not common among
teenagers, and about 2 percent of Japanese girls have
had abortions by the time they reach their late teens.
The number of abortions in women in their early 20s
continues to increase annually (Sato & Iwasawa,
2006). The HPV vaccine was first approved by the
Ministry of Health, Labour, and Welfare (2011b) and
domestically sold in 2009. The vaccine has been
started at the governmental expense.
Japan, however, has one of the lowest incidences of
births to teenagers in the world. American health-care
providers cannot assume that dating holds the degree
of concern for Japanese young people as it does for
American teenagers, nor can they assume that Japanese
youths are well informed about sexuality and sexual
health risks.
Other health concerns among young people include
the pressures to conform within a peer group and to per-
form well in school, pressures that may lead to depres-
sion and suicide (Takakura & Sakihara, 2000). Interest
in studying eating disorders is increasing, although
research indicates lower rates among Japanese youths
than among U.S. youths and in college students
rather than high school students in Japan (Makino,
Hashizume, Yasushi, Tsuboi, & Dennerstein, 2006).
One reason for this may be young students’ increasing
identification with very thin models from the West,
increasingly portrayed in the media.
After graduation from high school or college, young
adults are traditionally expected to be employed
through their network of school contacts or family
friends. Young women now typically live with their par-
ents for many years after they finish school, whereas
young men are likely to live in company housing until
marriage, and even after.
Family Goals and Priorities
Promoting success in school is the mother’s main
focus in child rearing. Children compete for their jun-
ior and senior high school admission, and high
schools vary in the caliber of universities to which
their graduates are admitted. The schools from which
individuals graduate determine such major issues as
career prospects for men and the status of husbands
with whom young women are likely to marry.
Children are highly valued, and motherhood tradi-
tionally has been revered in Japan. The recent extreme
drop in the birth rate has taken the society by surprise,
although in prior decades, the expense of rearing and
educating children triggered its beginning. Nothing is
permitted to interfere with child-rearing responsibili-
ties. Japanese women may be less likely than North
American women to engage in activities, including
health-care appointments that require them to leave
their children with babysitters.
The ideal of romantic love plays less of a role in
marriage in Japan than in the United States, and the
marriage rate in 2009 was 5.6 per 1000 population in
Japan (Ministry of Internal Affairs and Communi-
cations, 2010), lower than in the United States, with
6.8 per 1000 population (Tejada-Vera & Sutton,
2010). Traditionally Japanese marriage has been
arranged, often by employers or family friends. The
o-miai is the ritual of the first arranged meeting
between prospective partners. Although about 30 percent
of marriages were arranged, the ratio of the mar-
riages has been reduced.
As mentioned previously, Japanese couples are
marrying later in life. The groom’s goals for marrying
focus on advancement of his career and a desire to be
cared for. For the bride, economic security and child
rearing are traditional goals. A “honeymoon baby” is
becoming less common, and couples are delaying hav-
ing a family early in the marriage. Few Japanese
women bear children outside of marriage, and abor-
tion is one of a number of contraceptive practices,
with the use of condoms more prevalent than the use
of the contraceptive pill.
Japanese couples place less emphasis on companion-
ship and sexual fulfillment than do North American
couples and are far less likely to live together without
being married. The divorce rate has declined. In 2010,
there were about 2 divorces in Japan per 1000 popula-
tion (Ministry of Internal Affairs and Communica-
tions, 2010) compared with 3.4 in the United States
(Tejada-Vera & Sutton, 2010).
The Japanese family (especially the eldest son, who
has a sense of obligation to his parents) has tradition-
ally cared for and respected older people and children.
However, with the drift to living in urban areas in
small apartments and with more couples working, it
is increasingly difficult to care for older parents.
Retirement and nursing homes are growing in number
across the country, although many of the latter have
a poor public image and are poorly regulated. With
the longevity of its people, Japan is aging more rapidly
than any other nation. The government has begun to
address how to care for older people, who now
account for 22 percent of the total population. North
American health-care providers must be sensitive to
Japanese patients’ sense of obligation and commit-
ment. Helping families network within the Japanese
American community both for social support and for
resources or good long-term-care facilities is a useful
strategy.
Elements of social status include age, gender, edu-
cational background, and work group affiliation of
oneself or one’s husband. Though there is a peerage
system, and some old families are known to be descen-
dants of samurai, Japan is largely a meritocracy. Ex-
ceptions include Korean descendants or descendants
of the burakumin, the untouchable caste (hereditary
324 Aggregate Data for Cultural-Specific Groups
2780_Ch18_319-338 16/07/12 11:53 AM Page 324

social class) who cared for the dead and tanned leather
in feudal times. In this largely middle-class society,
schoolchildren can reasonably expect to study hard and
go on for higher education if that is the family goal.
Biases that may be evident among Japanese people
who reside in North America are directed at minority
groups such as African Americans, Jews, and individ-
uals with limited education, as well as women in high-
status positions. This prejudice is seldom overt, but it
may threaten the comfort of Japanese people, who are
likely to encounter such diversity among health-care
providers in North America.
Alternative Lifestyles
In Japan, a small segment of women have long lived
outside the usual constraints for their gender. Women
of “the floating world,” or the entertainment industry,
enjoy a fair degree of autonomy. The most traditional
of these, the geisha, live in all-female communal
arrangements, but they are reducing in number annu-
ally. Geisha are not prostitutes but are considered
highly skilled artists, and they are now recognized as
a cultural treasure. However, other women in the en-
tertainment industry fulfill men’s need to relax in a so-
ciety highly constrained by social norms; therefore, the
sex trade is flourishing, and occasional mention is
made of the sex slave trade in Japan. Hostesses at bars
look after their male customers, pour their drinks, and
listen to them. In earlier eras, concubines were ac-
cepted within families. Today, infidelity by married
men is more tolerated than in North America, but
much less so for married women.
An increasing number of the Japanese population
remains single throughout life, and only a few men
and women enter monastic life. The small proportions
of heterosexual couples who live together outside of
marriage find greater tolerance in urban settings in
Japan. Marriage of a Japanese person to a foreigner
is less tolerated than it is in the United States. The
existence of a gay and lesbian social network and of
cross-dressing clubs is evident in English-language
publications in Tokyo.
The pornography industry thrives, and prostitution
is big business. Rape and other sexual abuses are ac-
knowledged in Japanese society and are now being
more openly discussed. In fact, there have been a num-
ber of incidences since 2005 regarding harassment; rape
and murder cases are on the increase. In Tokyo, com-
muter trains for women now run at night to combat
sexual harassment. Health education about avoiding
rape and inappropriate touching, when approached in
a matter-of-fact way, is very appropriate for Japanese
in North America.
Workforce Issues
Culture in the Workplace
Japanese employees in North American institutions
need to be carefully oriented to the legal and profes-
sional requirements of patient autonomy and of ac-
countability in reporting, solving, and documenting
problems that occur. An overview of dominant
American society values may prepare them for the
directness of communication they will encounter.
Claims for medical malpractice are growing slowly in
Japan but are far less common than in the United States;
for example, in 2003 in Japan, only 1019 newly accepted
lawsuits in the Supreme Court were associated with
medical malpractice across the country (Ehara, 2005).
American practices designed to avoid liability, such as
informed consent, are not routinely implemented in
Japanese health-care settings. Patient autonomy is rec-
ommended in health-care settings; however, the real pri-
ority in Japan is meeting dependency and recuperation
needs, and a family has a crucial role in health-care
decision making (Ito, Tanida, & Turale, 2010).
Like most Japanese workers, nurses in Japan work
long hours, often between 8 and 10 hours per day,
5 days per week. Nurses often work extra time after
their shift without pay. Their pay is low in relation to
their cost of living compared with that of other
health-care providers. With the advance of a univer-
sity education, nursing is slowly becoming a respected
profession. Staffing is complicated by federal restric-
tions on shift work among women, although change
is underway because Japan, like North America, is
experiencing a nursing shortage.
The mix of people providing nursing care in Japan
represents many levels of educational preparation,
and nurses may be prepared for registered nursing
(RN) practice in a number of different ways. Bac-
calaureate degrees, representing 4 years of education
at university, are growing. RNs are still being prepared
in colleges of nursing and schools attached to hospi-
tals offering diploma and associate degree programs.
In the face of the nursing shortage and the growing
People of Japanese Heritage 325
R E F L E C T I V E E X E R C I S E 1 8 . 2
Mrs. Ishikawa, a 34-year-old mother and housewife, has lived in
the United States for almost 1 year. Her husband is a business-
man and works hard away from the family home. Mrs. Ishikawa
takes care of their 1- and 3-year-old sons. She has Japanese
friends, and they exchange information and help one another.
Mrs. Ishikawa brings her sons to a pediatric clinic. In a tearful
voice, she tries to explain why she came to the clinic.
1. What cultural factors need to be considered in this
situation?
2. How can the nurse help Mrs. Ishikawa to express her
concerns?
3. What agencies or persons could be called for assistance?
2780_Ch18_319-338 16/07/12 11:53 AM Page 325

health-care needs of a rapidly aging population, aides
are likely to be used more extensively, and Japan is now
actively seeking to recruit nurses from selected Asian
countries, especially the Philippines and Indonesia.
According to the Ministry of Health, Labour and
Welfare (2011a), 15 Indonesians and 1 Filipino passed
the national examination for nurses in 2011.
After RN preparation, an additional year of courses
prepares individuals for certification as midwives or as
public-health nurses. A recent nursing role is that of
clinical specialist in a variety of settings. In addition,
the number of master’s and doctoral degree programs
across the country has experienced a strong growth over
the last decade. Like nursing students, medical students
enter medical school immediately after high school, and
after graduation, they complete a clinical residency.
Issues Related to Autonomy
Japanese workers are quite sensitive to the desires and
expectations of colleagues and superiors. Because say-
ing no or delivering bad news is extremely difficult,
they may avoid issues or indicate that everything is fine
rather than state the negative. Of course, sensitive
Japanese workers who are attuned to nonverbal cues
may understand the true situation. In addition, many
Japanese workers tend not to leave work before their
boss does, nor do they take their full complement of
paid vacation time each year, which may contribute to
worker stress and tiredness. North American employ-
ers should explicitly discuss expectations about starting
and quitting times and vacation leave with Japanese
employees. Japanese workers do not assert individual
rights. Japanese health-care providers working in
North America accept the need to assert themselves if
it is presented within the context of legal and profes-
sional requirements to protect their patients.
Japanese nurses are less likely than North American
nurses to confront or question physicians or to suggest
strategies. Workers tend to do what the head of the
group tells them to do and make every effort to do it
very well. Japanese health-care providers seeking to
practice in the United States have studied English from
grade 7 throughout professional school, and will have
passed an examination certifying minimal competency,
but their verbal skills may still be weak. Specific ap-
proaches to documentation, such as problem-oriented
record-keeping, are now being more widely taught and
used in Japan. However, these may still be unfamiliar
to some nurses and need to be addressed specifically in
employees’ orientation.
Biocultural Ecology
Skin Color and Other Biological Variations
Racial features of Japanese people include the epican-
thal skin folds that create the distinctive appearance
of Asian eyes, a broad and flat nose, and “yellow” skin
that varies markedly in tone. Hair is straight and nat-
urally black with differences in shade. Health-care
providers who are not accustomed to assessing racially
diverse patient groups may need to rely on color
changes in the mucous membranes and sclerae to
assess oxygenation and liver function in Japanese
patients. The average stature of Japanese adults is
smaller than that of Americans, although the gap has
steadily decreased as national wealth has increased
and a greater percentage of the population is able to
improve their dietary practices.
The Ainu people of northern Japan, described
earlier in this chapter, who number only about 23,000
in the Hokkaido area, are a fair-skinned people whose
racial and linguistic origins are inconclusive. Estimates
of ethnic Japanese with Ainu ancestry vary between
50,000 and 150,000. Recent genetic studies have sug-
gested that the ancient Ainu may have been among the
peoples who came from Asia to settle in North America.
In previous centuries, the Ainu underwent significant
discrimination (New World Encyclopedia, 2007). The
Okinawa people of the Ryukyu Islands are darker-
skinned than “mainlanders” and have a stockier build.
Diseases and Health Conditions
The three leading causes of death in Japan are malig-
nant neoplasm, heart disease, and cerebrovascular dis-
eases. These account for over 50 percent of deaths in
both sexes. In descending order, other causes are pneu-
monia, accidents, traffic accidents, suicide, renal disease,
liver disease, diabetes mellitus, hypertensive diseases, and
tuberculosis (Ministry of Health, Labour and Welfare,
2011b). Moreover, men have a life expectancy of
78.9 years, whereas women have a life expectancy of
85.7 years, making the Japanese the longest-lived people
in the world (CIA World Factbook, 2011). An increasing
focus is on reducing suicide, particularly among de-
pressed men, because Japan ranks ninth in the world for
suicides (Nakao & Takeuchi, 2006). Asthma and other
allergic reactions related to dust mites in the tatami
(straw mats that cover floors in Japanese homes) are
considered some of the few endemic diseases, along with
illnesses related to air pollution in urban areas. In rural
areas, allergic reactions to the pollen from numerous
sugi (cedar) trees are a seasonal problem.
Variations in Drug Metabolism
In general, drug dosages may need to be adjusted for
the physical stature of Japanese adults, and racially
linked genetic differences in drug metabolism can be
important. More Asians than whites are poor metab-
olizers of mephenytoin and related medications, po-
tentially leading to increased intensity and duration
of the drugs’ effects (Levy, 1993). Asians tend to be
more sensitive to the effects of some beta blockers,
many psychotropic drugs, and alcohol. A greater
proportion of Japanese people rapidly metabolize
326 Aggregate Data for Cultural-Specific Groups
2780_Ch18_319-338 16/07/12 11:53 AM Page 326

acetylate substances, which has an impact on the me-
tabolism of tranquilizers, tuberculosis drugs, caffeine,
and some cardiovascular agents. Asians often require
lower doses of some benzodiazepines, such as di-
azepam, and neuroleptics. Opiates may be less effective
analgesics, but gastrointestinal side effects may be
greater than those among whites. Health-care providers
need to take all patients’ body mass into consideration
in dosing; even with that precaution, patients’ responses
to drugs need to be monitored carefully.
High-Risk Behaviors
The smoking rate for Japanese men has declined since
the mid-1990s to around 40 percent of all men aged
over 20 years in 2009, but it is slightly decreasing in
women (12 percent). Around 16 to 18 percent of
women in the 20- to 39-year-old age group now smoke
(Ministry of Health, Labour and Welfare, 2010a).
Many restaurants, aware of the dangers of second-
hand smoke, now offer nonsmoking areas, and plans
are to make all restaurants smoking-free in the not too
distant future. Public facilities, hospitals, schools, pub-
lic transportation vehicles, and many offices prohibit
smoking. Cigarettes are available at shops or in vend-
ing machines with a special card “Taspo” as Tabako
no Pasupoto introduced in 2008 for sale to those over
20 years of age.
Alcohol has ritual significance. For example, in the
marriage ceremony, the bride and groom drink sake or
miki (rice wine), which is also an appropriate offering at
Shinto shrines and at the butsudan, or household ances-
tral shrine. In addition, alcohol is part of many social
rituals, such as picnics to celebrate cherry blossoms,
autumn leaves, or moon viewing. Adults commonly
drink beer and sake in the home, and college students
drink beer when they socialize, although the legal age
for drinking is 20 years.
The most serious concerns about alcohol use reflect
the informal work requirement for men in Japan to so-
cialize after hours or during weekends. Considerable
alcohol may be consumed, and it is common to see in-
toxicated businessmen snoozing on the trains or stum-
bling home late in the evening. In part, this extensive
use of alcohol reflects the stress of Japanese corporate
life and the rigid protocols that dictate social interac-
tions. Once alcohol is consumed, workers can relax
and speak freely. This is called bureiko, which means
a gathering at which a man can say whatever is on his
mind; they are forgiven because the blame is placed
on the alcohol. Although diminished in the recent eco-
nomic downturn, entertaining is expected in the
Japanese business culture, and drinking is tolerated as
an obligation to one’s company.
Public acknowledgment of alcoholism is limited, and
alcoholism rates are very difficult to determine. Accord-
ing to the Ministry of Health, Labour and Welfare
(2010a), the rate of customary alcohol drinking in male
and female adults in 2009 was 36.4 percent and 6.9 per-
cent, respectively. Higuchi (2009) reported that the an-
nual average rate of alcohol consumption per person
from 2000 to 2007 was about 7 to 8 liters, an increase
from about 5 liters in 1963. The rate of youth abuse of
alcohol is increasing (Tsuchiya & Takei, 2004). Over sev-
eral decades, the Maryknoll Missionaries established al-
cohol treatment centers throughout the country and
were among the first to publicize the problem of alco-
holism among housewives, opening the first treatment
center for women in the mid-1980s. Health-care
providers need to be aware of the prevalence of smoking
and heavy alcohol consumption among Japanese peo-
ple, particularly men. An effective strategy for curtailing
these abuses is to give individuals specific medical rea-
sons why they must abstain, thus providing a socially
acceptable excuse to do so.
Over the last few years, Japan has witnessed a soar-
ing abuse of illicit drugs by young people, particularly
in high-density urban districts. The drugs used are
mostly narcotics and stimulants, which have caused an
increase in mental health problems, school dropout
rates, and drug-related crimes. The most serious is
methamphetamine use, which has been increasing since
the 1990s and is connected to mental illness. Distribu-
tion of methamphetamines is believed to be controlled
by the yakuza, the Japanese mafia (Tsuchiya & Takei,
2004). Also increasing are serious crimes involving
guns, which have often been smuggled into the country.
The government instituted the Drug Abuse Prevention
Center in 1987 and continued to implement the Third
Five Year Drug Abuse Strategy in 2008. The govern-
ment increased efforts to combat the smuggling of
drugs and guns into the country by sea (Customs
and Tariff Bureau, 2009). Punishment is harsh and
swift, and there is no popular sentiment for liberaliza-
tion. Despite such problems, the crime rate is quite low,
and in most cities, the streets are safe at all hours.
Students and workers in Japan also make heavy use
of over-the-counter stimulants. Students and young
professionals are commonly seen consuming high-
dosage caffeine drinks at train stations in the morning.
In Japan, as in a number of Western countries, the
rate of new cases of HIV and AIDS is on the increase,
and in 2008, the number of people living with HIV
was twice as high as in 2000 (UNAIDS, 2010). This
shows the great need for early-detection efforts and
treatment and for education on prevention. Every
health-care contact with Japanese businessmen and/or
their wives should be considered an opportunity to in-
form them about infectious disease risks. The United
States is perceived as a place with a high risk for con-
tracting HIV, and concerns among Japanese who
come to the United States tend to focus on casual con-
tact as a possible modality.
Other growing concerns are the rise in inactivity
and obesity levels of Japanese children. Success in the
People of Japanese Heritage 327
2780_Ch18_319-338 16/07/12 11:53 AM Page 327

educational system demands long hours of study each
day, thus reducing participation in physical activities,
and this is compounded by the growth in the fast-food
industry and the predilection for computer and elec-
tronic games usage among the young. Another problem
is the prevalence of dental caries, which is high owing
to unfluoridated water supplies across the country.
Health-Care Practices
Japanese people are likely to attribute their generally
high level of well-being to the centuries-old tradition
of the daily bath. The o-furo (Japanese bathtub) is
deep enough for an adult to enjoy a leisurely soak in
neck-deep water, and the temperature is typically set
around 105°F. The purpose of the bath is relaxation.
Scrubbing for cleanliness and thorough rinsing are
done before climbing into the tub. Families share the
same water; in fact, they may soak together in the
bath. Bathwater may be reheated for several days be-
fore the tub is drained; depending on the type of bath,
the water may be recycled for washing clothes or wa-
tering plants. Herbs or bath salts with therapeutic
properties are sometimes added.
Young people in Japan do not drive until age 18,
and an expensive and lengthy course of instruction is
mandatory. Driving under the influence of alcohol or
reckless operation of a vehicle carries stiff penalties.
Rigorous inspection standards mean that people drive
recent models of vehicles that are fully equipped with
standard safety features. One major problem, however,
is the rise in injury by rear seat passengers not using
seat beats, a common feature in busy traffic, even
though Japanese generally exhibit a high degree of
public safety consciousness.
Traditional housing materials and the close proximity
of buildings have made fire a common and large-scale
hazard. Each neighborhood has modern fire stations.
Japanese readily use public services. Explicit instructions
for accessing the local police, fire station, paramedics,
and an emergency medical facility in a given North
American community may be necessary, as well as the
circumstances under which access is appropriate.
Nutrition
Meaning of Food
Many Japanese social and business interactions begin
or end (or both) with the serving of o-cha (green tea and
sweets) or an o-bento (boxed lunch). Business entertain-
ing can be lavish. Part of the atmosphere of congeniality
depends on the artistic presentation of the food.
Common Foods and Food Rituals
In Japan, all food groups are well represented, even in
small shops, and the national diet is steadily becoming
more Western, particularly among young people. In a
wealthy, cosmopolitan society in the big cities, one can
find just about any food or drink in common use in
North America and Europe.
Large-scale agricultural production within Japan
provides rice, beef, poultry, pork, seafood, root vegeta-
bles, cabbage, persimmons, apples, and mikan (tanger-
ines). Rice, or gohan, the mainstay of the traditional
diet, is included in all three meals as well as snacks. The
electric rice cooker is a household necessity.
A traditional breakfast includes fish, pickles, nori (a
sheet of seaweed that is often used to wrap rice balls),
a raw egg stirred into the hot rice, miso (soybean-based)
soup, and green tea. Some people prefer a Western
breakfast of toast or cold cereal and coffee.
Schoolchildren lunch on their o-bento, packed with
rice, pickles, vegetables, and meat or fish. Elementary
schools generally provide a school lunch for pupils. A
popular lunch among working people is o-bento,
which can be ordered to be delivered quite cheaply to
workplaces, or cold noodles on a hot summer day. In-
stant broth, or instant noodles, though high in
sodium, is another popular quick lunch.
A traditional dinner style would be ichiju-nisai: one
bowl of soup, two kinds of entrees, and rice. In major
cities, Japanese housewives and working people have
easy access to an enormous range of take-out food or
home-delivery service, including Japanese, Chinese,
and Western selections. American or Japanese fast-
food hamburger chains can be found in all cities. The
daily intake of sweets can be high and often includes
European-style desserts, sweet breads and cookies,
sweet bean cakes, soft drinks, and heavily sweetened
coffee, which may contribute to the high incidence of
tooth decay.
For people in Japan, rice has a symbolic meaning
related to the Shinto religion, analogous to the con-
cept of the “bread of life” among Christians. One of
the emperor’s duties is to ceremonially plant the first
rice in the spring and harvest the first rice in the late
summer. A staple of schoolchildren’s o-bento is a
bed of white rice garnished with a red plum pickle,
328 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 8 . 3
Mr. Murakami, a 54-year-old business executive, has led a very
busy life. He traveled a lot inside and outside the country,
worked long hours, and socialized frequently with his clients.
He usually does not eat much dinner and drinks alcohol every
night with his colleagues and clients. He has been diagnosed
with diabetes mellitus at his health checkup.
1. What are the culturally sensitive elements to consider
when advising Mr. Murakami about his alcohol
consumption and diet?
2. Who needs to be involved in the decision making about a
plan for his lifestyle changes?
2780_Ch18_319-338 16/07/12 11:53 AM Page 328

reminiscent of the Japanese flag. Meals combine ele-
ments of land and sea.
Holidays and family celebrations are times for rit-
ual use of food. O-bon, in the summer, is a holiday for
remembering family members who have died and a
time when many travel to their family home, causing
transport congestion across the country. Vegetables,
especially daikon (large white radishes), are carved
into animals, which are said to carry dead ancestors
back to the afterlife after the holiday. Likewise, the
new year’s festival, O-shogatsu, is a 3-day celebration
with food that has been prepared in advance. Japanese
may ring in the new year by standing in line at a
Shinto shrine to ring a gong and then drinking a cup
of warm sake. Another traditional new year’s food is
mochi, a ball of sticky rice dough that celebrants take
turns pounding out with a heavy mallet. Red rice, or
rice with red beans, is a celebratory food, as are vari-
ous sweet bean desserts. A meal customarily begins
with the simple grace, Itadakimasu, with the palms of
hands facing together, and ends with the compliment
“Gochisosama deshita.” Western food rituals, includ-
ing birthday cakes, wedding cakes, Christmas cakes,
Valentine’s chocolates, and Halloween trick or treats,
have been incorporated into Japanese life, no doubt
spurred on by a consumer-driven market economy.
Dietary Practices for Health Promotion
Increasingly Westernized food tastes, resulting in higher
fat and carbohydrate intake, have contributed to the rise
in obesity, particularly in young children, in modern
Japan as it has in many Western countries. These
dietary changes and other lifestyle factors are causing
great concern about an increase in conditions such as
type 2 diabetes and heart disease (Urakami, Morimoto,
Nitadori, Harada, Owada, & Kitagawa, 2007).
A huge Japanese diet industry has arisen that in-
cludes weight-loss clinics and programs and an amazing
array of diet foods and medications in supermarkets
and pharmacies. Public education programs continue
to warn the public about the high sodium content of
soups and the overuse of food additives, soy sauce, and
table salt. General principles of nutrition are the same
in America as in Japan, although the food preferences
may differ significantly.
Green tea, although high in caffeine, is a good
source of vitamin C. Garlic and various herbs are
widely used for their medicinal properties. In larger
cities, health-food stores offering organically grown
produce are available. Sales in Japan’s health food in-
dustry, including supplements, have grown to almost
US$20 billion (Kenko Sangyo Shinbun, 2010).
Nutritional Deficiencies and Food Limitations
Although some Asian people, including the Japanese,
may have difficulty digesting milk products owing
to lactose intolerance, increasing amounts of dairy
products, including milk, cream, cheese, butter, ice
cream, and yogurt, are on sale throughout the coun-
try, although these are not used to the same extent as
in Western diets. Reduced-lactose milk is now avail-
able, as are low-fat milks and cheeses. Calcium is sup-
plied in other foods such as tofu (soybean curd) and
small, fileted fish. Water supplies are not fluoridated,
and dental caries continue to be widespread. Fluori-
dated dental products can be recommended to Japanese
patients, with the rationale for their use provided. Iron
deficiency anemia is a concern among young women
and can be alleviated with dietary counseling or
dietary supplements. Nori (seaweed) is a traditional
food source for iron.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
After a national debate that lasted nearly 40 years, oral
contraceptives became legal in Japan in 1999, and
shortly afterward, sildenafil citrate (Viagra) was quickly
approved. The use of oral contraceptives, however, still
remains fairly limited, and they are still not often used
to treat menstrual cycle problems. In fact, Japan has
managed to achieve a low birth rate without the major
use of contraceptive pills. Condoms remain the most
common contraceptive method used in Japan. Although
the number of reported abortions has steadily declined
each year in Japan (just over 240,000 in 2008), the inci-
dence is the highest in the 20- to 30-year-old age group
(Ministry of Health, Labour and Welfare, 2010). Some
temples have mizuko jizo shrines where women give of-
ferings of gifts and money to attendants who watch over
aborted or miscarried fetuses (Orenstein, 2002), and
often a woman or a couple will place jizo at a temple or
shrine in memory of their aborted or miscarried fetus
(Fig. 18-1).
People of Japanese Heritage 329
Figure 18-1 Misuko jizu are implored to protect the souls of
aborted fetuses in the Japanese Buddhist tradition.
2780_Ch18_319-338 16/07/12 11:53 AM Page 329

The decline in the Japanese birth rate, which was
1.3 in 2008, is regarded as a national crisis, and the
economic implications are devastating as the country
ages. An educated female population, in a society in
which women are oppressed, has asserted itself in a
way that has certainly caught the nation’s attention.
As a result, many social structures and policies re-
garding female labor laws and child-care and social
support systems are under scrutiny. Japan’s status as
a low-birth-rate country has created great interest in
assistive reproductive technology within the last
few years, and the Ministry of Health, Labour and
Welfare (2010b) supports a part of the costs for
infertility treatments.
Within traditional Japanese culture, pregnancy is
highly valued as a woman’s fulfillment of her destiny.
Women may enjoy attention and pampering that they
get at no other time, and our observations are that they
take their role as mother-to-be very seriously, including
health and diet. When a pregnancy is first detected in
Japan, it is registered with the local government office,
which distributes a special mother/child handbook that
becomes a comprehensive longitudinal health record
for the child right up until kindergarten. Japanese
nationals in the United States want to access the hand-
book (Nakamura, 2010).
Maternity clothes are now often very fashionable.
Some believe that keeping one’s feet warm will pro-
mote uterine health. Pregnant women may undergo a
ceremony involving the wrapping of a hara obi (a
bleached cotton abdomen sash) obtained and purified
at a Shinto shrine. The sash is wrapped around the ab-
domen for protection as part of a small ceremony per-
formed on the Day of the Dog in the 5th month of
pregnancy (Ito & Sharts-Hopko, 2002). Because dogs
give birth easily, the Chinese word for “dog” may be
drawn on the obi by the obstetrician or midwife before
they wrap it on the woman. Some women wear this
sash throughout the rest of the pregnancy, but others
may use a maternity girdle, a stomach band, or a
special amulet to ensure a safe delivery.
Continuity of care throughout pregnancy is gener-
ally different in the United States and Japan. In Japan,
a woman usually receives medical care and birthing
support, including ultrasonography and physical
examinations, from the same medical staff. In the
United States, these may occur in different locations.
Japanese women often return to their mother’s home
for the last 2 months of their pregnancy (called
satogaeri bunben) and through the first 2 months post-
partum. Alternatively, mothers may come to stay with
their daughter during this period, even traveling
abroad to be with her. American health-care providers
should explore a Japanese woman’s expectations dur-
ing pregnancy and the possibility that she might re-
turn to Japan. Finding another Japanese woman who
has experienced childbearing in the United States and
who can share her experiences can provide support for
the pregnant patient.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Health teaching for pregnant women in Japan em-
phasizes rest and restraint from stressful activities.
Women who are found working until late in their
pregnancy are given special considerations in the
workplace. Loud noises, such as trains or very loud
music, are believed to be bad for the baby. Shinto
shrines sell amulets for conception and easy delivery,
and women may pray for their safe delivery at these
shrines. Some women now attend exercise classes for
pregnant women but are rarely accompanied by their
husbands.
In the past, it was not so common for husbands to
attend the births of their children; however, this is
changing and varies considerably across Japan. Some
hospitals still do not allow husbands to be present.
Most Japanese women choose private obstetric care
and give birth in 1 of the 2500 maternity hospitals in
which most births occur with a physician delivering
the baby. Certified nurse-midwives often give perinatal
massages during childbirth. They may deliver the
baby, sometimes observed by a physician who assists
if complications occur. However, the strong tradition
of local community-based midwifery, with independ-
ent midwives offering services at their own birthing
houses, is regaining popularity. Currently, about 350 of
these across the country cater to about 2 percent of
the births. Birthing houses are quite separate from
hospitals and are supported by the community.
Birthing at home is quite rare in Japan.
Episiotomies may still be performed for first de-
liveries, but shaving and the use of enemas predeliv-
ery are not common in Japan. In addition, Japanese
midwives often use perinatal massage. Oxytocics are
common in the second stage of delivery if contrac-
tions are weak, and antibiotics are often prescribed
after delivery even though there may be no sign of
infection. Pregnant women are educated about bal-
anced natural foods, and easily digested foods are
preferred during the first stage of labor.
The differences in birthing procedures need to be
explained to women giving birth in the United States,
especially when they may have knowledge only of pro-
cedures in their home country. It is important for
midwives and obstetricians in the United States to re-
member that Japanese families want the dried umbilical
cord that falls from the newborn’s abdomen, which they
store in boxes made of kiri (paulownia) wood. This
tradition comes from several cultural and regional
beliefs. One of them is that its spiritual energy would
protect the baby throughout his or her life.
330 Aggregate Data for Cultural-Specific Groups
2780_Ch18_319-338 16/07/12 11:53 AM Page 330

Physicians are skilled at mid- and high-forceps de-
liveries because cesarean delivery is viewed as hard on
the mother; such surgery is reserved for emergency
cases. Vaginal deliveries are usually performed with
minimal medication, and the mother tries to be very
stoic, using the breathing exercises taught during preg-
nancy. Ito and Sharts-Hopko (2002) explained that
Japanese women prefer nonpharmacological interven-
tions such as the Lamaze method whenever possible.
To give in to pain dishonors the husband’s family, and
mothers are said to appreciate their babies more if
they suffer in childbirth.
Japan enjoys one of the lowest rates of infant and
maternal mortality in the world. Maternal mortality,
4.8 per 10,000 births in 2009, is most commonly
caused by hemorrhage and is associated with delivery
in small, single-physician birthing hospitals (Ministry
of Health, Labour and Welfare, 2010b).
Japanese women in the United States are not likely
to have a birth plan when they are admitted to a
health-care facility. They prefer natural methods of
child delivery as they would in Japan and to avoid ce-
sarean delivery and pain relief whenever possible.
Their husbands may choose not to attend the actual
delivery, in which case, women will need additional
supportive nursing care.
In the postpartum period, time to recover from
childbirth is taken seriously because chi-no-michi
(pathway of blood) is believed to be an indication of
the woman’s health. In Japan, a woman may stay in
the hospital 5 days to 1 week while learning to breast-
feed and attending daily mother-care classes. Japanese
hospitals vary about allowing rooming-in of babies.
Culturally, postpartum women often do not wash
their hair for a few days postpartum. Because the new
mother often stays with her mother, the new father
may not see his baby for a few months until he comes
to take the mother and baby home from the grand-
mother’s house. Because of the perceived risk of
infections, it is unusual to see infants in public before
the age of 3 months.
Mothers will often be asked about the feeding
method they used for their baby—for example, on
kindergarten admission forms. Maternal rest and re-
laxation are deemed essential for success. Lactation
nurses are widely available, and breast massage is one
of their strategies for promoting milk production and
flow. A number of promotional campaigns have been
held recently to encourage women to breastfeed, and
concerns do exist about its decline when women
choose to reenter the workforce.
Japanese women who give birth in the United States
may resent the American expectation that they will re-
sume self-care and child-care activities quickly, which
they believe is harmful to them and their relationship
with the baby. Although American health-care providers
cannot provide the length of hospital stay the women
would have experienced in Japan, they can explain the
expectations for postpartum care, exercise sensitivity,
and help plan for assistance upon discharge.
Death Rituals
Death Rituals and Expectations
In Japan, death, serious illness, and mental illness are
usually not common subjects for discussion, but re-
cently, the daily media have begun to include more
awareness and discussion about depression, and demen-
tia. In the last decade, physicians are more commonly
revealing diagnoses of cancer or other life-threatening
illnesses to patients only when there is a clear family
agreement to do so. In the past, patients were rarely told
of the possibility of their impending death. This pater-
nalistic approach was meant to relieve the patient of
emotional suffering. In recent years, the biomedical lit-
erature has begun to reflect open discourse on pain
management in terminal illness, the need for greater
national investment in intensive-care services, the need
to increase organ transplantation, and the need for
end-of-life decision making.
The most extraordinary cultural differences be-
tween Japan and Western societies are the roles and
responsibilities of family members for end-of-life de-
cision making (Hattori, McCubbin, & Ishida, 2006).
Currently families are expected to perform as reliable
decision makers for a dying patient: however, analysts
predict that the Japanese people will become more
self-oriented rather than family-oriented in regard to
People of Japanese Heritage 331
R E F L E C T I V E E X E R C I S E 1 8 . 4
Hisako Suzuki is a 30-year-old Japanese woman living in a high-
rise apartment. She is 15 weeks pregnant, and she just moved
to the United States 6 months ago. She is not a fluent English
speaker but understands written English well. She has no social
or family support networks except her Japanese husband. She
is met by the nurse at the antenatal clinic for help planning for
the delivery of her baby.
1. What specific factors would need to be taken into consid-
eration when trying to ensure that Hisako’s prenatal care
is culturally and socially appropriate?
2. How could she be helped to find ways to learn about the
American health system, particularly in relation to prenatal
and postnatal care?
3. What are some of her health beliefs that need to be taken
into consideration during her pregnancy, labor, and the
postpartum period?
4. What types of information should be supplied to her hus-
band in relation to pregnancy and childbirth?
2780_Ch18_319-338 16/07/12 11:53 AM Page 331

their health decision making. Western individualism
is expected to increase in the Japanese end-of-life
health-care structure.
Responses to Death, Grief, and Suffering
When considering the death and grief reactions of
Japanese, one must not neglect the close intertwining
of Buddhist and Shinto beliefs at large in the popula-
tion. In Shinto, death is believed to be impure and one
should not spend time dwelling on it. According to the
first Noble Truth of Buddhism, all human beings suf-
fer. When a Japanese person is dying, the family
should be notified of the impending death so they can
be at the dying person’s bedside. Traditionally, the eld-
est son has particular responsibility during this time.
Many homes have a Buddhist altar, butsudan, where
deceased family members are honored and remem-
bered. Photographs of the deceased are displayed, floral
arrangements are placed within and outside of the
home, and a special altar may be constructed when a
person dies. An alternate version of this custom dictates
that if the dead is satisfied with the amount of money,
then the inheritance is freed for the survivors. Visitors
bring gifts of money and food for the bereaved family.
White flowers are the symbol of death in Japan and are
used at funerals; therefore, these should not be sent to
someone who is ill.
Modern corporate life in Japan does not allow for
taking more than a few days off from work for official
mourning. However, in terms of religious practice, the
mourning period is 49 days, the end of which is
marked by a family prayer service and the serving of
special rice dishes. At this time, the departed has
joined those already in the hereafter. Perpetual prayers
may be donated through a gift to the temple. In addi-
tion, special prayer services can be conducted for the
1st, 3rd, 7th, 13th, and 17th anniversaries of the
death. The common belief is that the dead need to be
remembered, and failure to do so can lead the dead to
rob the living of rest. Proper funeral rites and reassur-
ance that they are remembered during temple and
family prayers alleviate the agitation of the dead. In
addition, it gives the family a sense of relief and pro-
tection from their ancestors.
Spirituality
Dominant Religion and Use of Prayer
Japan does not have a clearly articulated theology or re-
ligious belief system. Tradition holds that the Japanese
people are descendants of the Sun goddess and that the
emperor is a god (Keene, 1983), although the Occupa-
tion forces required Hirohito to publicly renounce this
status after World War II ended. Some say that the de-
motion of the emperor from god to mortal has left the
Japanese with a spiritual vacuum. Reischauer and
Jansen (1995) believed this secularization of Japanese
society began when Confucianism, imported during the
9th century, grew in influence during the 17th century.
Confucian values, including faith in education, hard
work, and the emphasis on interpersonal relationships
and loyalty, continue to be important today.
Shinto, the indigenous religion, is the focus of joy-
ful events such as marriage and birth. Many matsuri
(festivals) are marked by offerings, parades through
the streets, and a carnival on the grounds of the shrine.
Buddhism, brought to Japan in the 6th century, has
permeated Japanese artistic and intellectual life. Very
few Japanese people regularly attend services, but
most are registered temple members, if only to ensure
a family burial plot. One percent of Japanese people
are Christian (CIA World Factbook, 2011), and Chris-
tianity has been known, although at times not well tol-
erated, in Japan since the 16th century. Most Japanese
do not identify themselves solely with one religion;
even a baptized Christian might have a Shinto wed-
ding and a Buddhist funeral. These days, some young
people get married in a commercial-style chapel that
looks like a Christian chapel but has nothing to do
with religion.
Meaning of Life and Individual Sources
of Strength
This crossover of Shinto and Buddhist beliefs and cus-
toms may be a surprise to visitors from overseas.
Many Japanese believe in reincarnation, a Buddhist
belief, and also accept the Shinto recognition of the
eternal life of the soul, which needs purification in the
earthly life. Ancestor worship is widespread, and
many Japanese believe that their ancestors can be
called back to earth. Such beliefs play a large part in
mourning the dead. Other valid interpretations in-
clude honoring one’s family and country, working
332 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 8 . 5
Mr. Yamamoto is a 76-year-old Japanese man who has been
living in the United States for 30 years. He became wid-
owed 1 month ago. When his daughter visited him a week
ago, he had fallen and had been on the floor, calling for help
for several hours. She called a community health nurse for
consultation. When the nurse visits Mr. Yamamoto, he seems
depressed. He has been able to manage his daily life and has
no cognitive impairment. He refuses to leave his home,
which is full of happy memories.
1. In order to help Mr. Yamamoto to deal with his wife’s
death, what culturally congruent rituals could the nurse
and the social worker suggest to assist him?
2. Who else might be called to help him?
3. What are some challenges the nurse might encounter
while working with him?
2780_Ch18_319-338 16/07/12 11:53 AM Page 332

hard, being a good group member, and joining one’s
deceased ancestors (Woss, 1992).
Spiritual Beliefs and Health-Care Practices
Japanese religions play a significant role in health-care
practices. People or objects such as cars are taken to
special shrines for purification from evil by priests. Peo-
ple often buy protective omamori (amulets) at shrines
or temples for a wide variety of reasons. At the temple
or shrine, a person might be seen scooping incense
smoke onto an ailing body part or praying for good
health. Prayer boards might bear requests for special
healing. Gifts of toys or devices used in child care may
be left with Buddha statues. Shichi-go-san (7-5-3) cere-
bration is a special family event to take newborns
(about 1 month old) and children (3, 5, and/or 7 years
old) to a shrine for blessings for their health and wis-
dom (Fig. 18-2). Visits to shrines and temples in Japan
are social, recreational, and spiritual outings. Souvenirs
and refreshments are usually available, and the hike into
the prayer area provides exercise, with access to many
temples or shrines involving a climb up steps (Shinto
Online Network Association, 2006).
Various types of diviners, soothsayers, and prophets
may be present at shrines, temples, and even along the
most fashionable streets in Tokyo. Statues depicting
folktale heroes, often animals, are believed to bring
luck. Americans may have difficulty understanding
and accepting the reliance of sophisticated and well-
educated people on what may be viewed as supersti-
tions. But these measures appear to be more sources
of comfort than deciding factors in health-care deci-
sion making. They should be accepted as a very im-
portant part of what it means to be Japanese.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
The general health of the populations of Japan and
the United States are similar, with a shift in leading
causes of morbidity and mortality from infections to
chronic illnesses and diseases. However, behaviors and
underlying belief systems differ markedly between
Japan and the United States. The Japanese are more
tolerant of self-indulgence, even during minor ill-
nesses. Because Japanese are less likely to express
feelings verbally, this indulgence may be a way for
people to affirm caring for one another nonverbally.
Hypochondriasis among the Japanese has been de-
scribed in the medical literature and is more tolerated.
Bodily flaws—for example, birthmarks—are a source
of concern, and body piercing is now becoming more
fashionable in the young.
In Japan, people seem less inclined to seek correc-
tion of minor orthopedic and dental variations than
those in middle-class American society, although im-
migrant families make full use of services offered in
the United States. Health-care providers engaged in
health promotion and screenings need to be aware of
this difference. Function, rather than appearance, may
be a more appropriate emphasis.
Humankind is a part of nature, subject to its forces,
and a person is an integrated whole. Whereas Chinese
tradition calls for a restoration of balance when one
is ill, Shinto calls for purging and purification. Both
influences operate in modern Japan. In the past,
Shinto was the source of principles of prevention,
whereas Buddhist priests healed the sick. Centuries
before the germ theory was known, Shinto effectively
distinguished between spaces and body parts that were
dirty versus those that were clean and pure. For exam-
ple, taking off one’s shoes at the doorway keeps one’s
home clean, and people wear slippers inside. However,
only socked or bare feet are used on grass matting or
tatami. Family members will also change their slippers
when entering bathroom or toilet areas. People with
colds in Japan customarily wear disposable surgical
masks in public to shield others from their infection.
Americans who visit Japanese homes should usu-
ally assume that outside shoes are taken off before
People of Japanese Heritage 333
Figure 18-2 Siblings’ informal kimono wear for Shichi-go-san
(7-5-3) celebration.
2780_Ch18_319-338 16/07/12 11:53 AM Page 333

entering the home, and the hostess will usually offer
guests slippers to wear. The same thing may occur in
special types of businesses, in some restaurants, or in
areas in aged-care homes or special clinics.
Responsibility for Health Care
Newsstands and vending machines, particularly in
commuter rail stations in Japan, provide large quan-
tities of flavored caffeine elixirs, high-potency vitamin
elixirs, and electrolyte replacement drinks. These prod-
ucts are promoted to give workers and students an
edge in their daily work. Health-care providers need
to ask specifically what remedies are being used and
why. Japanese patients in North America find general
principles of nutrition to be the same as those taught
in Japan, although their food preferences may differ.
The health of pregnant and nursing mothers and of
children has the highest priority in the Japanese health-
care system, and all schoolchildren and workers have
comprehensive annual checkups at the expense of their
school system or employer. National insurance is avail-
able to all Japanese, including foreigners, for a sliding-
scale fee and covers both medical and dental care.
Treatment by osteopaths, chiropractors, and traditional
providers is covered if patients have been referred
by a physician. Generally, national insurance covers
80 percent of medical expenses for children under age 3,
70 percent for those ages 3 to 69 years, and 90 percent
for those ages 70 years and over. Mothers can receive
¥350,000 (approximately US$3800) upon their delivery,
because the medical costs regarding healthy natural de-
livery are not covered by such insurance. To respond to
the growing need for nursing care for the elderly, a nurs-
ing care insurance fee is deducted from the salaries of
working people age 40 to 64.
Japanese residents in the United States frequently
carry Japanese health insurance. Japanese nationals
working for American institutions or companies may
be eligible for the same coverage as other employees,
but they often need assistance in understanding how
their benefits work. Students and others can continue
their Japanese national health insurance while in
America, but they may need assistance in seeking care
and understanding the American billing and payment
process.
Many American over-the-counter medications, or
their Japanese equivalents, are widely available in
Japanese pharmacies. In addition, many pharmacies
stock kampo (traditional Chinese medicine) prepara-
tions, as well as a large amount of stomach prepara-
tions for gastric upset.
Japanese people make liberal use of both modern
medical and traditional providers of health care. Influ-
enced by German and American medical science, the
Japanese health-care system incorporates local primary
care, neighborhood hospitals, specialty clinics, aca-
demic medical centers, and national research institutes.
There is no similar concept with American GPs. The
Japanese patients need to self-examine what is wrong
on their body first. Then they are expected to find and
make an appointment to see a specialist by themselves.
Most hospital beds are found in tiny, unregulated,
physician-owned neighborhood clinics, and it is not
common for patients to have their own room, even if
they have private insurance. A sophisticated public
health system offers prenatal and well-child care, school
health initiatives, visiting nursing services, home health
services, senior centers, and health education at little or
no cost to the public.
Japanese residents in the United States have Inter-
net and mail order access to traditional medications,
if they are not available locally. As with any patient
population, a complete health assessment includes in-
quiry about home therapies. From the second genera-
tion of immigrants onward, the tendency is to rely
fully on the American health-care system.
Folk and Traditional Practices
Morita therapy, one of the most popular indigenous
models of psychotherapy in Japan, is used to address
shinkei shitsu, excess sensitivity to the social and nat-
ural environment. Morita therapy focuses on con-
structive physical activities that help patients adjust to
and accept the reality in their lives and the intercon-
nectedness to others (Tamura & Lau, 1992). This form
of psychotherapy is very different from Western psy-
chotherapy in that it tries to avoid introspection and
deep analysis of self in an individualistic sense.
Naikan therapy is another indigenous psychotherapy
of reflection on how much goodness and love is re-
ceived from others and is very much focused on well-
being in Japanese culture. A third indigenous therapy,
Shinryo Naika, focuses on bodily illnesses that are
emotionally induced.
334 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 8 . 6
Mika Tsuji is a 19-year-old Japanese international student
studying at the local university. She has been referred to the
mental health clinic by one of her tutors because she has been
missing classes, appears not to be taking care of herself, and is
withdrawn and uncommunicative. She would not visit the
health center at the university or visit her local doctor. When
the nurse meets her, it is clear that she seems depressed and
unhappy, and she says she misses her family in Japan.
1. What specific cultural factors could be contributing to
Mika’s present state?
2. Why has she been reluctant to seek help?
3. How could the nurse provide education about depression
to her in a culturally sensitive fashion?
2780_Ch18_319-338 16/07/12 11:53 AM Page 334

Within the last several decades, Western-style psychi-
atry has been fully incorporated into Japanese health-
care services. Indeed, psychiatric care in Japan in the
early 1990s was predominantly given in overcrowded in-
stitutions. Today, it is moving toward a community-
based emphasis. However, according to Tsuchiya and
Takei (2004), substantial changes are needed in forensic
psychiatry, child and adolescent psychiatry, substance
misuse, and the naming of psychiatric disorders. One
major problem is inadequate provision of mental health
care for children and adolescents. Japan today has
351,762 psychiatric beds for a population of nearly
27 million people, approximately three times higher than
the 10 psychiatric beds per 10,000 population in the
United Kingdom in 2007 (Ministry of Health, Labour
and Welfare, 2010c). Despite the greater availability of
psychiatric inpatient care, increased stress and violent
attacks in the community continue to fill the daily news-
papers without any sign of improvement. This is of
great concern to Japanese people at large, especially
when Tsuchiya and Takei (2004) pointed out that there
is no special provision for violent mentally ill offenders
other than in regular psychiatric hospitals.
Health-care providers need to be sensitive to work-
place or family issues that may underlie illnesses among
Japanese patients, as among all patients. If a health-care
provider believes that psychotherapy is indicated, the
therapist must be someone familiar with the Japanese
culture. Guidance in locating resources may be obtained
through large academic medical centers or universities
in coastal (particularly the Pacific coast) cities, as well
as through professional associations, Japanese churches,
or other religious organizations.
Health care is easily obtained in Japan. However,
the system of referrals is unique. When a physician
leaves medical school, she or he becomes part of that
school’s “family.” She or he is unlikely to refer patients
to specialists or hospitals outside the “family” of her
or his fellow alumni or former professors. Personal ac-
quaintance is essential for doing business in Japan,
and it is also reflected in health-care practice.
Japanese people may be unlikely to assert them-
selves in American settings, and their efforts to do so
may seem inappropriate to American health-care
providers. Their high regard for the status of physi-
cians decreases the likelihood of asking questions or
making suggestions about their care. The idea that
patients should be given care options may be alien to
Japanese patients. Health-care providers need to pro-
vide ample opportunity for dialogue and explain the
choices that are offered. Japanese and Japanese Amer-
ican health-care providers may be an important re-
source in bridging gaps in understanding.
Cultural Responses to Health and Illness
Pain, itami, may not be expressed, and bearing pain is
considered a virtue and a matter of family honor.
Medications that specifically relieve pain, such as opi-
oids, are used less frequently in Japan than in the
United States. Addiction is a strong taboo in Japanese
society. Around 90 percent of deaths in Japan occur in
a hospital (Ministry of Health, Labour and Welfare,
2011c), compared with 60 percent in the Western soci-
ety. There is a great need to increase an opportunity to
access to palliative care in the Japanese community.
American health-care providers may use a schedule
of analgesic administration rather than an as-requested
or a patient-controlled approach to ensure adequate
pain management. Japanese patients may respond pos-
itively to the information that physiological status and
healing are actually enhanced by pain control.
Physically and intellectually handicapped children
and adults are not commonly seen in public in Japan.
In fact, most handicapped children, if they attend
school, go to special schools rather than being inte-
grated in the public school system. In addition, many
public areas in Japan are not designed to cope with
people with disabilities, making it very difficult for
people who use wheelchairs or other assistive mobility
devices. However, recently, the number of public toi-
lets with facilities for handicapped people has in-
creased. Many Japanese families hide knowledge of
deformity or disability in family members because of
shame, and there are still instances of people with
physical handicaps—for example, cerebral palsy—
being admitted to psychiatric hospitals owing to a lack
of suitable facilities elsewhere. Japanese families resid-
ing in the United States need encouragement to avail
themselves of community resources and to under-
stand that shame associated with disability is not as
prevalent in American society.
Assumption of the sick role is highly tolerated by
families and colleagues, and a long recuperation pe-
riod is encouraged by Japanese health-care providers.
For example, in Japan, a patient with a myocardial in-
farction may be hospitalized for a month, with out-
comes comparable with those found in the United
States (Kinjo et al., 2004). However, changes to the
national insurance system to extend care for rehabili-
tation, to shorten hospital stays, and to provide for
more rehabilitation are now starting to have an effect,
particularly in rehabilitation after stroke (Miyoshi,
Teraoka, Date, Kim, Nguyen, & Miyoshi, 2005). Re-
habilitation to achieve the full level of activities of
daily living after serious illness or injury is less aggres-
sive than in the United States. However, the number
of higher-education programs to train occupational
and rehabilitation specialists is slowly growing across
the country, and the importance of rehabilitation is
becoming more recognized and implemented.
Blood Transfusions and Organ Donations
Giving blood is encouraged in the Japanese culture.
The Japanese Red Cross is a very active and highly
People of Japanese Heritage 335
2780_Ch18_319-338 16/07/12 11:53 AM Page 335

respected organization that runs 92 Red Cross hospi-
tals in the country and collects blood in 79 centers,
using over 340 bloodmobiles, which travel around the
country. Donors are not paid for their contributions.
Blood usage is accounted for by 100 percent of
domestic usage; however, 41 percent of albumin and
5 percent of immunoglobulin have to be imported
(Japan Red Cross, 2010). People with negative blood
types account for less than 1 percent of the population;
therefore, RhoGam, used to protect an Rh-positive
fetus from antibodies from an Rh-negative mother, is
not commonly stocked in Japanese hospitals.
Under the Organ Transplant Law of 1997, organ
transplant was not performed without having ob-
tained the brain-dead patient’s signature for the trans-
plant in advance. In addition, children under the age
of 15 were not permitted to donate organs. By March
2010, 374 transplants were conducted from 86 eligible
donors (Japan Organ Transplant Network, 2010). In
July 2009, the parliament passed a controversial bill
that defines patients who are medically brain dead as
legally dead and allowed to be a donor with family
consent only, regardless of age. In addition, it allows
children under 15 who are brain dead to become a
donor with family consent. The first case of organ
transplant between children occurred in April 2011.
Such news was broadcasted nationwide.
Health-Care Providers
Traditional Versus Biomedical Providers
In modern Japan, physicians are clearly in charge of
the health-care team. Some physicians may have a
high degree of understanding of kampo, or Japanese
herbal medicine, and may offer patients their choice
of Western medicine, kampo, or a combination of
both. More than 72 percent of physicians employ
kampo in their daily practice. Kampo may be used in
various symptoms, such as psychiatric care, bronchitis,
constipation, dullness, irregular menstruation, and
more. Japanese health providers who come to the
United States face a different type of health-care sys-
tem, with greater diversity and autonomy for many
professionals. The authority of insurers to dictate care
is novel for them, as is the extent of concern for
malpractice liability.
Status of Health-Care Providers
Physicians, referred to as sensei, are highly esteemed.
Self-care as a philosophy is not evident in Japan. Being
told what to do by the physician or kampo practitioner
is expected, and his or her authority is not questioned.
Physicians control most health-care delivery in Japan,
running public and private hospitals and owning most
private hospitals. Hospital administration is not an es-
tablished field, and administrators in public hospitals
are generally physicians elected to their post.
In Japan, females account for only about 15 percent
of physicians, and male nurses account for about
6 percent. However, the professions and their interre-
lationships generally tend to reflect traditional gender
roles. In the past, nurses were titled according to gen-
der: kango-shi (士) if a male and kango-fu if a female.
The former means approximately “Mr. Nurse,”
whereas the latter means “Ms. Nurse.” Since 2002, the
unified kango-shi (師), literally “person to be a nurse
by profession,” has started to be used.
Nurses in Japan today believe that nursing is still
not highly regarded in Japanese society, but the raising
of educational levels to a baccalaureate will undoubt-
edly change this, as has been the case in the United
States. However, as noted previously, Japanese women
do not hold high status in society, so this reflects
strongly on the status of a largely feminine occupa-
tion. Japanese residents in the United States need con-
siderable assistance in understanding how the
health-care delivery systems work and the functions
of the different health-care providers they encounter.
In particular, they need to understand the autonomy
of a diverse group of health professionals. Home care,
and the orchestration of many community-based
providers, may be overwhelming for Japanese resi-
dents who expect longer recuperations in the hospital.
Japanese health-care providers working in the
United States need careful orientation to laws and in-
stitutional regulations about appropriate male–female
interactions and professional requirements for ac-
countability in communicating problems. Japanese
residents seeking health care in America may be sur-
prised by the assertiveness and autonomy of non-
physician professionals. An overview of the details of
their care, and who will be doing various aspects of
that care, can be helpful. Japanese residents in the
United States may need assistance in seeking care.
Their verbal English skills may be an impediment to
making their needs known and to understanding
the care they are offered, although their ability to
336 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 8 . 7
Yuji Nakata, age 10 years, was admitted to intensive care fol-
lowing a serious car accident in which he sustained ruptured
kidneys as well as other injuries. He is currently on renal dialy-
sis. His attending and other physicians believe he requires a
kidney transplant. Yuji was on vacation in California with his
Japanese parents when the accident happened.
1. Given that Yuji and his parents are Japanese, what are
some cultural issues that may be involved in this case?
2. What specific information should be given to the parents
about organ donation in the United States?
3. What may cause his parents to hesitate about approving a
kidney transplant for their son?
2780_Ch18_319-338 16/07/12 11:53 AM Page 336

understand written information is often very good.
Japanese people tend to believe that they are physio-
logically different from non-Japanese people, and they
may be skeptical of recommendations. The family
members, including daughters-in-law, are expected to
be involved in clinical decision making. Calling on the
local Japanese community for support and encourage-
ment may be a useful strategy with these patients.
R E F E R E N C E S
CIA World Factbook. (2011). Japan. Retrieved from https://www.
cia.gov/library/publications/the-world-factbook/geos/ja.html
Customs and Tariff Bureau. (2009). Trends in illicit drugs and
firearms smuggling in Japan (2009 edition). Retrieved from
http://www.customs.go.jp/english/enforcement/report2009_e/
index.htm
Doi, T. (1971). The anatomy of dependence (J. Bester, Trans.)
Tokyo: Kodansha International Ltd.
Ehara, A. (2005). Lawsuits associated with medical malpractice
in Japan [Letter to the editor]. Pediatrics, 115(6), 1792–1793.
Fukumizu, M., Kaga, M., Kohyama, J., & Hayes, M.J. (2005). Sleep-
related nighttime crying (yonaki) in Japan. A community-based
study. Pediatrics, 115, 217–224.
Gender Equality Bureau. (2011). Women and men in Japan 2011. Re-
trieved from http://www.gender.go.jp/english_contents/category/
pub/pamphlet/women-and-men11/index.html
Hattori, K., McCubbin, A.M., & Ishida, N.D. (2006). Concept
analysis of good death in the Japanese community. Journal of
Nursing Scholarship, 38(2), 165–170.
Higuchi, S. (2009). The drinking realities and intervention for a
large amount of drinking in Japan. Retrieved from http://
www.mhlw.go.jp/topics/tobacco/houkoku/dl/100222f
International Longevity Center Japan. (2006). The spread of cor-
porate measures to support child care and family care. One di-
mension of action in response to the declining birth rate in Japan.
Retrieved from http://longevity.ilcjapan.org/f_issues/0605.html
Ito, M., & Sharts-Hopko, N. (2002). Japanese women’s experience
of childbirth in the United States. Health Care for Women In-
ternational, 23(6–7), 666–677.
Ito, M., Tanida, N., & Turale, N. (2010). Perceptions of Japanese
patients and their family about medical treatment decisions.
Nursing and Health Sciences, 12(3), 314–321.
Japan Media Review. (2006). Publishers push the return of the
E-book. Retrieved from http://ojr.org/japan/media/1082135229.php
Japan Organ Transplant Network. (2010). Newsletter, 14. Japan
Organ Transplant Network.
Japan Red Cross. (2010). 2009 business report (blood business).
Retrieved from http://www.jrc.or.jp/
Kanazumi, F. (1997). Interview. In S. Buckley (Ed.), Broken si-
lence: Voices of Japanese feminism (pp. 70–81). Berkeley: Uni-
versity of California Press.
Kashiwazaki, C., & Akaha, T. (2005). Japanese immigration pol-
icy: Responding to conflicting pressures. Retrieved from http://
www.migrationinformation.org/Profiles/display.cfm?ID=487
Keene, D. (1983). Ise. In D. Richie (Ed.), Discover Japan: Vol. 2.
Words, customs and concepts (pp. 196–197). Tokyo: Kodansha
International, Ltd.
Kenko Sangyo Shinbun. (2010). Supplement market has been rap-
idly recovered by 1.8 trillion yen (sapri shijo 1chou 1800okuen
kyukaihukuhe). Retrieved from http://www.kenko-media.com/
health_idst/006188.html
Kinjo, K., Sato, H., Nakatani, D., Mizuno, H., Shimizu, M.,
Hishida, E., Ezumi, A., Hoshida, S. Koretsune, Y., & Hori, M.
(2004). Predictors of length of hospital stay after myocardial
infarction in Japan. Circulation Journal, 68(9), 809–815.
Leonardsen, D. (2004). Japan as a low-crime nation. New York:
Palgrave Macmillan.
Levy, R. A. (1993). Ethnic and racial differences in response to
medicines: Preserving individualized therapy in managed phar-
maceutical programmes. Pharmaceutical Medicine, 7, 139–165.
Makino, M., Hashizume, M., Yasushi, M., Tsuboi, K., & Den-
nerstein, L. (2006). Factors associated with abnormal eating
attitudes among female college students in Japan. Archives of
Women’s Mental Health, 9(4), 203–208.
Ministry of Education, Culture, Sports, Science, and Technology
in Japan. (2010). School basic survey FY2010. Retrieved from
http://www.mext.go.jp/b_menu/toukei/chousa01/kihon/kekka/
k_detail/1296403.htm (Japanese)
Ministry of Education, Culture, Sports, Science, and Technology.
(2011). Vital statistics tables 2005. Retrieved from http://www.
mhlw.go.jp/
Ministry of Health, Labour and Welfare (2010a). Outline of National
Health and Nourishment Investigation Results. Retrieved from
http://www.mhlw.go.jp/stf/houdou/2r9852000000xtwq.html
Ministry of Health, Labour and Welfare. (2010b). Population
movement status. Retrieved from http://www.mhlw.go.jp/toukei/
list/81-1.html
Ministry of Health, Labour and Welfare. (2010c). Annual change
in the number of hospitals with beds for psychiatric patients, the
number of beds for psychiatric patients, the number of inpatients
at month-end, and the rate of bed utilization at month-end. Re-
trieved from http://www.mhlw.go.jp/english/wp/wp-hw3/dl/9-
13
Ministry of Health, Labour and Welfare. (2011a). Press release
material on March 23, 2011. Retrieved from http://www.mhlw.
go.jp/stf/houdou/2r98520000016bot.html
Ministry of Health, Labour and Welfare. (2011b). Vital statistics
in Japan—_he latest trends. Retrieved from http://www.mhlw.
go.jp/english/database/db-hw/dl/81-1a2en
Ministry of Health, Labour and Welfare. (2011c). Research on the
palliative care program in the community. Retrieved from
http://www.mhlw.go.jp/seisaku/11e.html
Ministry of Internal Affairs and Communications. (2010). The
statistical handbook of Japan 2010. Retrieved from http://
www.stat.go.jp/English/data/handbook/c02cont.htm
Miyoshi, Y., Teraoka, J.K., Date, E.S., Kim, M.J., Nguyen, R.T.,
& Miyoshi, S. (2005). Changes in stroke rehabilitation out-
comes after the implementation of Japan’s long-term care in-
surance system: A hospital-based study. American Journal of
Physical Medical Rehabilitation, 84(8), 613–619.
Nakamura, Y. (2010). Maternal and child health handbook in
Japan. JMAJ, 53(4), 259–265.
Nakao, M., & Takeuchi, T. (2006). The suicide epidemic in Japan
and strategies of depression screening for its prevention. Bul-
letin of the World Health Organization, 84(6), 492–493.
New World Encyclopedia. (2007). Ainu. Retrieved from
http://www.newworldencyclopedia.org/entry/Ainu#Origins
Orenstein, P. (2002, April 21). Mourning my miscarriage. New
York Times. Retrieved from http://www.nytimes.com
Reischauer, E.O., & Jansen, M. (1995). The Japanese today. New
York. Longitude Books.
Sato, R., & Iwasawa, M. (2006). Contraceptive use and induced
abortion in Japan: How is it so unique among developed coun-
tries? The Japanese Journal of Population, 4(1), 33–54.
People of Japanese Heritage 337
2780_Ch18_319-338 16/07/12 11:53 AM Page 337

Sharts Engel, N. (1989). An American experience of pregnancy
and childbirth in Japan. Birth, 16(2), 81–86.
Shinto Online Network Association. (2006). Retrieved from
http://www.jinja.or.jp/
Takakura, M., & Sakihara, S. (2000). Gender differences in
the association between psychosocial factors and depressive
symptoms in Japanese junior high school students. Journal of
Epidemiology, 10(6), 383–391.
Tamura, T., & Lau, A. (1992). Connectedness versus separateness:
Applicability of family therapy to Japanese families. Family
Process, 4, 319.
Tejada-Vera, B., & Sutton, P.D. (2010). Births, marriages, divorces,
and deaths: Provisional data for 2009. National Vital Statistics
Reports; Vol. 58, No. 25. Hyattsville, MD: National Center for
Health Statistics. 2010. Retrieved from http://www.cdc.gov/
nchs/data/nvsr/nvsr58/nvsr58_25
Tsuchiya, K.J., & Takei, N. (2004). Mental health care in Japan:
An overview. The British Journal of Psychiatry, 184, 88–92.
UNAIDS. (2010). Japan—2010 country progress report. Retrieved
from http://www.unaids.org/en/dataanalysis/monitoringcoun-
tryprogress/2010progressreportssubmittedbycountries/japan_
2010_country_progress_report_en #search=’Country
progress report: Japan
UN Secretariat. (2005). Possibilities and limitations of Japanese
migration policy in the context of economic partnership in
East Asia. Retrieved from http://www.un.org/esa/population/
meetings/ittmigdev2005/P07-iguchi
Urakami, T., Morimoto, S., Nitadori, Y., Harada, K., Owada, M.,
& Kitagawa, T. (2007). Urine glucose screening program at
schools in Japan to detect children with diabetes and its
outcome-incidence and clinical characteristics of childhood
Type 2 diabetes in Japan. Pediatric Research, 61(2), 141–145.
U.S. Commercial Service. (2011). Japanese tourism marketing
opportunities. Retrieved from http://www.tourism.jp/english/
statistics/outbound.php
U.S. Department of State. (2010). Background note—Japan.
Retrieved from http://www.state.gov/r/pa/ei/bgn/4142.htm
Woss, F. (1992). When blossoms fall: Japanese attitudes towards
death and the other world: Opinion polls 1953–1987. In R.
Goodman & K. Refsing (Eds.), Ideology and practice in modern
Japan (pp. 72–100). New York, NY: Routledge.
Yanagisako, S.J. (1985). Transforming the past: Tradition and
kinship among Japanese Americans. Stanford, CA: Stanford
University Press.
For reflective exercises, review questions, and additional
information, go to
http://davisplus.fadavis.com
338 Aggregate Data for Cultural-Specific Groups
2780_Ch18_319-338 16/07/12 11:53 AM Page 338

339
Chapter 19
People of Jewish Heritage
Janice Selekman
Overview, Inhabited Localities,
and Topography
Overview
Being Jewish refers to both a people and a religion, not
a race. Judaism is more than a religion; it is a people
and a culture. Throughout history, the terms Hebrew,
Israelite, and Jew have been used interchangeably. In the
Bible, Abraham’s grandson, Jacob, was renamed Israel.
His 12 sons and their descendants became known as the
children of Israel. The term Jew is derived from Judah,
one of Jacob’s sons. Hebrew is the official language of
the state of Israel and is used for religious prayers by
all Jews wherever they live. While the people are called
Jewish, their faith is called Judaism, their religious lan-
guage is Hebrew, and their ‘homeland’ is Israel, regard-
less of where their relatives were born.
The religion of Judaism is practiced along a wide
continuum that includes liberal Reform with 28 percent,
Conservative with 22 percent, Reconstructionist with
2 percent, and strict Orthodox with 9 percent. Another
39 percent just identify as Jewish without identifying
their affiliation (American Jewish Committee, 2010).
Reform Judaism maintains that traditions should be
modernized and compatible with participation in the
surrounding community, and Progressive Judaism, an
umbrella term used by strands of Judaism, embrace
pluralism, modernity, equality, and social justice
as core values (Myers, 1988). Although Reform and
Progressive Jews might not engage in any special daily
practices, they still observe holidays, religious rites,
and selected dietary or cultural customs. The tradi-
tional Orthodox Jew attempts to adhere to most of
the religious laws. Ultra-Orthodox groups also exist.
No caste system or social hierarchy exists within the
Jewish community. However, instances occur within
the ultra-Orthodox communities, where individuals
cannot make life and health-related decisions without
consulting their rabbis.
A significant issue within Orthodox communities in
Israel, frequently debated in America is “Who is a
Jew?” A child born to a Jewish mother is Jewish. As
mixed marriages have increased, a debate over patri-
lineal descent has ensued. A child born from the union
of a Jewish father and a non-Jewish mother is recog-
nized as Jewish by those in more liberal branches of
Judaism, especially if they are raised as a Jew, but not
by those in the Orthodox movement (DeLange, 2010).
Although Judaism does not actively proselytize, the
vast majority welcome converts as full members of
their community. Clergy offer preconversion classes
for adults and perform conversions.
Whereas the goal of this chapter is to provide an
understanding of all Jewish Americans, the focus is
on the needs of the more traditional religious individ-
uals and their families. These descriptions may vary
somewhat for Jewish people according to variant char-
acteristics of culture (see Chapter 1) and the other
parts of the world where they live.
Heritage and Residence
The initial group of 23 Jews in North America ar-
rived in 1624, having fled the Office of the Inquisition
in Brazil. As a result of European immigrations, their
numbers grew to between 1000 and 2500 individuals
by the time of the American Revolution, when many
fought for the colonial army. Haim Solomon, a
banker, raised significant funds in Europe and the
colonies and dedicated all his personal resources
and finances to George Washington’s army. Their
numbers reached approximately 250,000 by the 1880s,
close to 6 million a century later, and finally stabi-
lized by 2002. According to American Jewish Demo-
graphics (2011), there are 5,275,000 Jews in the
United States, accounting for 2.7 percent of the U.S.
population. States with over 3 percent of their popu-
lation being Jewish include New York (8.4 percent),
New Jersey (5.5 percent), Massachusetts (4.3 percent),
Maryland (4.2 percent), Florida (3.7 percent), and
California (3.3 percent) (Jewish Virtual Library, 2011).
Although many prefer to live in or within reach
of large Jewish communities in order to have access
to specific services, Jews make their homes in rural
as well as urban centers in the United States. In
2780_Ch19_339-356 16/07/12 11:54 AM Page 339

comparison, 76 percent of the State of Israel is
Jewish (Jewish Virtual Library, 2011).
Depending on how one defines being Jewish, a 2010
unpublished study by Saxe and his Brandeis re-
searchers indicated that there may be as many as
6.5 million Jews in America (Beckerman, 2010). These
are thought to be individuals who consider themselves
Jewish by their culture but do not participate in the
Jewish community or in Jewish life-cycle events.
Reasons for Migration and Associated
Economic Factors
Migration of Jews from Europe began to increase in
the mid-1800s, often because of religious persecution
and economic opportunities. However, the greatest in-
flux of immigrants occurred between 1880 and 1920.
Many of these immigrants came from Russia and
Eastern Europe after a wave of pogroms, anti-Jewish
riots and murders (Jewish American Committee,
2011). Once in America, acculturation became their
motivation to live in safety and practice their religion.
Most Jewish families in America today are descen-
dants of these Eastern European and Russian immi-
grants. They are referred to as Ashkenazi Jews. Ashkenazi
Jews make up more than 80 percent of the world’s
Jewish population (Hebrew University of Jerusalem,
2009). This becomes an important concept when explor-
ing diseases prevalent among the Jewish population.
Many American Jews of Ashkenazi descent have stories
of how some members of their families escaped to
America, whereas others had relatives who were part of
more than the 6 million Jews killed in the pogroms and
the Holocaust. Sephardic Jews, conversely, are originally
from Spain, Portugal, the Mediterranean area, and
North Africa. They represent a more diverse group. A
Sabra is a Jew who was born in Israel.
In the 1980s and 1990s, a significant increase
occurred in the number of Jewish immigrants from
Russia. Because the practice of religion was illegal
there for over half a century, these Jews often have a
relatively relaxed connection to religious and cultural
practices. The same was true of the Falasha Jewish
community in 1984. These black Jews from Ethiopia
participated in a mass exodus to Israel, and subse-
quently, a small number continued on to America.
Educational Status and Occupations
Despite bias against Jews in every century, they have
made major contributions to society, across the arts
and professions, including the fine arts, sciences, and
health care. Throughout their history, they have
placed a major emphasis on education and social jus-
tice through social action.
Continued learning is one of the most respected val-
ues of the Jewish people, who are often called the People
of the Book (Diamant, 2007). Education is considered
a lifelong obligation regardless of age or status. Whereas
this usually refers to the study of Torah, it includes both
Jewish and secular learning. Formal education is highly
valued, and advanced degrees are respected. Overall,
this population is well educated. Jews have won 22 per-
cent of all Nobel Prizes awarded between 1901 and
2010. This includes 20 percent of the Nobel Prizes in
chemistry, 25 percent in physics, 42 percent in econom-
ics, and 27 percent in physiology and medicine (Jewish
Nobel Prize Winners, 2011).
Well-known American composers with Jewish an-
cestry include George Gershwin, Aaron Copland,
Leonard Bernstein, Jerome Kern, Richard Rogers,
Irving Berlin, and Stephen Sondheim; the American
theater counts Arthur Miller as one of its most
celebrated of playwrights, along with Woody Allen,
Mel Brooks, Oscar Hammerstein II, Alan Lerner,
and Neil Simon. The 20th century finally saw
the first Jewish Supreme Court justices in Louis
Brandeis and, most recently, Ruth Bader Ginsburg
and Elena Kagan.
Because of their emphasis on education, a high per-
centage of Jewish Americans have succeeded in sci-
ence, medicine, law, and dentistry. Thirty-nine percent
of Jewish men and over 36 percent of Jewish women
list their occupation as “professional,” compared with
only 15 percent of the American white population.
With respect to higher education, over 10 percent of
professors in American colleges and universities are
Jewish; the majority of American Jews attend college
(Diamant, 2007). Their traditional values of study
and preserving life have contributed to directing many
into the life sciences, medicine, and research.
In addition to receiving a regular elementary, sec-
ondary, and college education, many Jewish children
are also provided a Jewish education. Many attend
Hebrew school classes 1 or 2 days a week, as well as
classes on Judaism, commonly referred to as Sunday
School.
Throughout their history, Jews were repeatedly for-
bidden to own land, and the Christian Church barred
its members from moneylending. As a result, since the
early Middle Ages, Jews frequently became money-
lenders, peddlers, and tailors because these were the
only options available to them. The early Jews in
America were businessmen and craftsmen (Center for
Jewish History, 2007). They became well respected for
their expertise in trade and commerce, and thus many
went into banking or retail sales.
Social action, volunteerism, and involvement in
helping others are common vocations or avocations.
Health-care professions, social work, teaching, and
the legal profession became other popular occupa-
tional pursuits. The term tzedakah (justice) is used to
indicate charity or righteous giving, a central concept
to Judaism. Jewish children are raised with the
340 Aggregate Data for Cultural-Specific Groups
2780_Ch19_339-356 16/07/12 11:54 AM Page 340

concept of giving tzedakah by sharing with others who
have less than they do (Diamant, 2007).
Communication
Dominant Language and Dialects
English is the primary language of Jewish Americans.
Although Hebrew is the official language of Israel
and is used for prayers and is the language of the
Torah, it is generally not used for conversation in the
United States.
Many older Ashkenazi Jews who immigrated
early in the 20th century or who are first-generation
Americans speak Yiddish, a Judeo-German dialect.
Many Yiddish terms have worked their way into the
English language, including kvetch (to complain);
chutzpah (clever audacity); bagel (a boiled roll with a
hole in the middle); challah (a rich, braided white
bread); knish (a dumpling with filling); mitzvah
(a good deed); nosh (to snack); zaftig (plump); tush,
tushie, or tuchus (buttocks); ghetto (a restricted area
in which certain groups live); klutz (a clumsy person);
mentsch or mensh (a respected person with dignity);
shlep (to drag or carry); kosher (technically applying
to food preparation, but idiomatically meaning legal;
and oy or oy vey (oh my), and oy veys mier (woe is me).
Common Hebrew expressions include “l’chaim” (to
life), which is said after blessing wine or giving a toast;
“shalom alechem” (peace be with you), a traditional
salutation; “mazel tov” (congratulations); and “shabbat
shalom” (a good and peaceful Sabbath), which is said
from Friday evening at sunset until Saturday at sunset.
Cultural Communication Patterns
No religious ban or ethnic characteristics prevent Jews
from openly expressing their feelings. Communication
practices are more related to their American upbring-
ing than to their religious practices.
Humor is frequently used as a coping mechanism
and as a way to communicate with others. However,
jokes are considered to be insensitive when they rein-
force mainstream stereotypes about Jews, such as im-
plying that Jews are cheap or pampered (e.g., Jewish
princess). Any jokes that refer to the Holocaust or
concentration camps are also inappropriate. Jewish
self-criticism through humor is acceptable, but it is
usually expressed by insiders.
Modesty is a primary value in Orthodox Judaism.
It is seen in the style of dress and in all behavior. Mod-
esty involves humility. Jews are encouraged not to
“show off ” or try to impress others.
In Hasidic Judaism, the ultra-Orthodox fundamen-
talists, men are not permitted to touch a woman other
than their wives. They often keep their hands in their
pockets to avoid touch. They do not shake hands with
women, and their failure to do so when one’s hand is
extended should not be interpreted as a sign of rude-
ness. Because women are considered seductive by na-
ture, Hasidic men may not engage in idle talk with
them or look directly at their faces. Non-Hasidic Jews
may be much more informal and may use touch and
short spatial distance when communicating. Health-
care providers should touch Hasidic men only when
providing direct care. Hands-on “therapeutic touch,”
as in holding a patient’s hand to give comfort, is not
appropriate with these patients.
Temporal Relationships
Jews live with regard for, and in, the present, conscious
of being a part of a long historical tradition and
with both hope and a wary eye to the future. The last
2 millennia have seen a succession of struggles to sur-
vive external pressures, yet the tradition affirms their
belief in survival and a better time to come. They are
raised with stories of their past, including the rela-
tively recent Holocaust. They are warned to “never
forget,” lest history be repeated. Therefore, their time
orientation is simultaneously to the past, the present,
and the future.
The Jewish calendar is based on both a lunar and a
solar year, with each month beginning with the ap-
pearance of the new moon and lasting 29 to 30 days.
The festivals and holidays are based on lunar phases,
whereas the seasons are based on the solar year, which
is 11 days longer than the lunar year. Therefore, an
extra month is periodically added, usually during the
end of winter (7 times in every 19 years). The Jewish
day starts at sunset; therefore, all holidays, as well as
the Sabbath, begin when the sun sets, usually identified
as the evening before the date identified on a calendar.
The basis for this practice is the line in Genesis “And
there was evening and there was morning.”
Format for Names
For secular use, the Jewish format for names follows
the Western tradition. The given name comes first, fol-
lowed by the family surname. Only the given name is
used with friends and in informal situations. In more
formal situations, the surname is preceded by the ap-
propriate title of Mr., Miss, Ms., Mrs., Dr., and so on.
Babies may be named after someone who has died
to keep their memory alive or after a living person to
honor him or her (the latter only in Sephardic fami-
lies). In ultra-Orthodox circles, children are not
referred to by their names until after the bris or brit
milah (circumcision). The biblical traditions are
preserved for religious occasions. Infants are given a
Hebrew name that is used when they are older and are
called to read from the Torah at age 13 or older,
following their bar or bat mitzvah). An example
would be Ephraim ben Reuven (Frank, son of
Robert). Although one’s Hebrew name may be the
People of Jewish Heritage 341
2780_Ch19_339-356 16/07/12 11:54 AM Page 341

same as one’s birth certificate “official” name, parents
may choose a non-Hebrew, main-culture name for the
birth certificate that is entirely different or one that
preserves the initial letter (i.e., Reuven could become
Robert).
Family Roles and Organization
Head of Household and Gender Roles
The family is the core of Jewish society, and whereas
the man is traditionally considered the breadwinner
for the household and the woman is recognized for
running the home and being responsible for the
children, in recent times there is more flexibility for
gender roles, even in very observant homes. According
to Jewish law, the father has the legal obligation to ed-
ucate his children in Judaism, to teach them right from
wrong, to teach them to swim, and to teach his sons a
trade (Cohn-Sherbok, 2010). He must provide his
daughters with the means to make them marriageable.
With acculturation, little difference is seen today
between Jewish and non-Jewish white families with re-
gard to gender roles. In most Jewish families, both
parents share the responsibilities for supporting the
home and raising the children. However, it is still com-
mon to find the mother lighting the Sabbath candles
and the father blessing the wine (DeLange, 2010).
The Orthodox ideology puts increased responsibil-
ity on males to study the Torah and perform mitzvoth
(religious commandments). While the reform move-
ment embraces feminism, the orthodox movement is
more skeptical. According to the Talmud, Jewish
husbands are required to provide their wives with
food, clothing, medical care, and conjugal relations,
in addition to meeting other needs. The ketubah—
marriage contract—usually includes wording that
entitles the wife to the same dignity and social standing
as her husband.
Although traditional Jewish law is clearly male-
oriented, Jewish women have been at the forefront of
activities to demand and protect all human rights, es-
pecially those of women. They were prominent in
movements to gain women’s suffrage, reproductive
health-care rights, and equal rights for all segments of
society. Women are now expected to achieve an opti-
mal level of education and to seek gainful employ-
ment if they so desire. Both sexes are expected to give
service to their community.
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Children are the most valued treasure of the Jewish
people. They are considered a blessing and are to be
treated with respect and provided with love. Jewish
children are to be afforded an education, not only in
studies that help them progress in society but also in
studies that transmit their Jewish heritage and the
laws. Jewish school-age children may attend Hebrew
school as least two afternoons a week after public
school throughout the school year. Children are wel-
comed and incorporated into most holiday celebrations
and services.
Respecting and honoring one’s parents is the fifth
of the Ten Commandments. Children should be
forever grateful to their parents for giving them the
gift of life. Jewish parents are expected to be consistent
and fair to all their children, avoiding favoritism. In
addition, parents should not promise something to
their children that they cannot deliver. They must be
flexible and yet caring and attentive to discipline. The
individuality of each child’s special traits should be
recognized.
In Judaism, the age of adulthood is 13 years and
1 day for a boy, and 12 years and 1 day for a girl
(Cohn-Sherbok, 2010; Jacob & Zemer, 2006). At this
age, children are deemed capable of differentiating
right from wrong and capable of committing them-
selves to performing the commandments. Recognition
of religious adulthood and assumption of its respon-
sibilities occur during a religious ceremony called a
bar or bat mitzvah (son or daughter of the command-
ment, respectively); during this ceremony, the child
reads from the Torah and Haftorah, prophetic writ-
ings, for the first time (Kranson, 2010). None of the
denominations require girls to have this ceremony,
although with the feminist movement as impetus, it
has increased in prevalence among modern Jews. In
America, this rite of passage is usually accompanied
by a family celebration. However, because sons and
daughters are still teenagers living at home, it is rec-
ognized that they are still the responsibility of their
parents. In Orthodox communities, boys who have
reached their bar mitzvah are now responsible to
perform the multiple religious rituals expected.
Family Goals and Priorities
The goal of the Orthodox family is to live their lives
as prescribed by halakhah, which emphasizes main-
taining health, promoting education, and helping oth-
ers. In addition, each individual is considered unique
and must maximize their potential. The family is cen-
tral to Jewish life and essential to the continuation of
Judaism from one generation to the next.
Marriage is considered the ideal human state for
adults; it is considered a sacred bond between adults
and a means of personal fulfillment (Cohn-Sherbok,
2010). The Bible states that man should not be alone.
The goals of this union are to build a home, procreate,
and provide companionship, allowing an individual
to focus on another person. Marriages are monoga-
mous, and limitations on whom one may marry ex-
clude close blood relatives and—although this has
changed considerably with the increase in interfaith
unions—non-Jews.
342 Aggregate Data for Cultural-Specific Groups
2780_Ch19_339-356 16/07/12 11:54 AM Page 342

Sexuality is a right of both men and women. The sex
instinct is neither sinful nor shameful, but restraint is ex-
pected (Jacob & Zemer, 2006). In addition to procre-
ation requirements, conjugal rights for women exist.
Nonprocreative intercourse is required, if desired, for
married women who may be pregnant or are unable to
conceive, and after menopause as this is not considered
“wasting seed” (Jacob & Zemer, 2006). Sexual inter-
course is viewed as a pure and holy act when performed
mutually within the relationship of marriage. With some
exceptions, a husband’s refusal to have sex with his wife
is grounds for a divorce. However, the act of sex, if
not performed with sobriety and modesty and the
wife’s willingness), is considered against Jewish values
(DeLange, 2010). Premarital sex is not condoned.
Among the ultra-observant, women must physically
separate themselves from all men during their men-
strual periods and for 7 days after (DeLange, 2010).
No man may touch a woman or sit where she just sat
until she has been to the mikveh, a ritual bath, after
her period is over. Sexual contact for this group may,
therefore, occur only during 2 weeks of each month.
Judaism supports the need for sex education. The
Jewish community sees this as its responsibility. This
belief was reemphasized during the AIDS epidemic,
with the goals of protecting the next generation and
providing them with accurate information so they can
make informed choices.
Whereas it is recognized that the later years are a
time of physical decline, older people receive respect,
especially for the wisdom they have to share. Old age
is a state of mind rather than a chronological age; one
may continue to “give” to society in a variety of ways
other than employment. In addition, one may never
“retire” from practicing the commandments.
Honoring one’s parents is a lifelong endeavor and
includes maintaining their dignity by feeding, cloth-
ing, and sheltering them, even if they suffer from
senility. Respect for older people is essential even when
their actions are irrational. The care of an older family
member is the responsibility of the family; when the
family is unable to provide care owing to physical, psy-
chological, or financial reasons, the responsibility
falls to the community. This role has always been a
hallmark of Jewish communal life.
Few Jewish American families now have three gen-
erations living together. Older immigrants who experi-
enced imprisonment in concentration camps during the
Holocaust in the 1940s, or those more recently incar-
cerated in Russia, may refuse to enter long-term-care
facilities for fear of returning to an institutional envi-
ronment that robs them of their freedom (Martha
Braverman, personal communication, 2007).
Alternative Lifestyles
The Jewish view on homosexuality varies with the
branch of Judaism. As might be expected, the Orthodox
are largely unanimous in scripture-based (Lev. 18:22)
nonacceptance of same-sex unions. The Bible, especially
as interpreted by the Orthodox, prohibits homosexual
intercourse for men; it says nothing specifically about
sex between lesbians (DeLange, 2010). Some of the ob-
jections to gay and lesbian lifestyles include the inability
of these unions to fulfill the commandment of procre-
ation and the possibility that acting on the recognition
of one’s homosexuality could ruin a marriage. The offi-
cial position of the Conservative movement had sided
with the Orthodox until as recently as 2006, when it re-
vised its position to increase inclusivity of views within
Jewish philosophy. They can now perform same-sex
commitment ceremonies. They can also ordain gay and
lesbian clergy. The liberal movement within Judaism,
however, supports full legal and social equality for
homosexuals (Cohn-Sherbok, 2010).
Workforce Issues
Culture in the Workplace
Specific workforce issues may occur, especially with
Sabbath observance. Jews who observe the Sabbath
must have Friday evenings and Saturdays off. They
may work on Sundays. Supervisors must be sensitive
to the needs of Jewish staff and recognize the holiness
of the Sabbath. Jewish staff should be allowed to re-
quest time off for the major Jewish holidays. Remem-
bering that all holidays begin the evening before, they
must have off the evening shift before and the follow-
ing day. Staff should not be penalized by having to use
this time off as unpaid holidays or vacation time, but
they should have the option to exchange for the
Christmas and Easter holidays, time usually afforded
to Christian staff.
Jewish health-care providers are fully acculturated
into the American workforce. Judaism’s beliefs are
congruent with the values American society places on
the individual and family. As English is the primary
language for Jewish Americans, no language barriers
to communicating in the workplace exist. For some
newer Jewish immigrants (e.g., those from Russia),
English may pose a challenge.
Issues Related to Autonomy
Jewish nurses have begun to speak out on their needs
in the workplace. With the recent emphasis on cultural
competence, including cultural sensitivity, many are
now addressing this long-ignored area. In 1990, a
National Nurses Council was established through
Hadassah, the Zionist women’s organization (Benson,
1994). This group promotes solidarity and empower-
ment to enhance sensitivity within the health-care
community. Still proportionally underrepresented
among American nurses, Jewish nurses have a higher
percentage of advanced degrees and positions in man-
agement, education, and research (Benson, 2001).
People of Jewish Heritage 343
2780_Ch19_339-356 16/07/12 11:54 AM Page 343

Ways in which the professional nursing community
demonstrates its insensitivity to Jewish nurses are by
scheduling major nursing conferences during the High
Holy Days in the fall or during Passover in the spring,
by serving pork products during catered affairs, or
reciting a prayer before the conference meal invoking
the name of Jesus.
Biocultural Ecology
Skin Color and Other Biological Variations
According to DeLange (2010), “there are no racial
characteristics that are shared by Jews and that distin-
guish them from non-Jews” (p. 3). Ashkenazi Jews have
the same skin coloring as white Americans. They may
range from fair skin and blonde hair to darker skin and
brunette hair. Sephardic Jews have slightly darker skin
tones and hair coloring, similar to those from the
Mediterranean area and those who lived for centuries
in nearby regions such as Yemen. There are also Jewish
groups throughout Africa who are black, most notably
the Jews originally from Ethiopia, known as Falasha.
Diseases and Health Conditions
Because Jews are integrated throughout the United States,
no specific risk factors are based on topography.
Genetic risk factors vary based on whether the family
immigrated from Ashkenazi or Sephardic areas. There
is a greater incidence of some genetic disorders among
individuals of Jewish descent, especially those who
are Ashkenazi. It is estimated that 1 in 16 to 1 in
110 Ashkenazi Jews carries one of these mutations
(Hebrew University of Jerusalem, 2009). Most of
these disorders are autosomal recessive, meaning
that both parents carry the affected gene. Although
the best known is Tay-Sachs disease, Gaucher’s disease
is more prevalent. Others include Canavan’s disease,
familial dysautonomia, torsion dystonia, Niemann-
Pick disease, Bloom syndrome, Fanconi’s anemia,
and mucolipidosis IV (Center for Jewish Genetic
Diseases, 2011).
Gaucher’s disease is the most common genetic dis-
ease affecting Ashkenazi Jews, with 1 in 10 carrying
the gene (Center for Jewish Genetic Diseases, 2011).
Gaucher’s disease is a lipid-storage disorder. This in-
born error of metabolism results in a defective enzyme
that normally breaks down glucocerebroside, a lipid
by-product of erythrocytes. The glucocerebroside ac-
cumulates in the body, resulting in weakening and
fracturing of the bones owing to infarctions, anemia,
and platelet deficiencies. The spleen becomes painfully
enlarged. There are 34 different genetic mutations of
the disease; 4 of them account for 95 percent of cases
in Ashkenazi Jews. The disorder can be detected by a
blood test for both those affected and carriers. Gene
therapy treatments are now being tested (National
Gaucher Foundation, 2011).
The gene for Tay-Sachs disease (also called infantile
cerebromacular degeneration) is carried by 1 in 25 to
1 in 30 Ashkenazi Jews and 1 in 250 Jews of Sephardic
origin. This autosomal recessive condition is a lysoso-
mal sphingolipid storage disorder caused by an absence
of hexosaminidase A, resulting in an accumulation of a
lipid called GM2 ganglioside in the neural cells. The
onset of intellectual and developmental delay begins in
the middle of the first year of life, with progressive de-
terioration, increasing seizure activity, blindness, deaf-
ness, and death by approximately age 4 (Center for
Jewish Genetic Diseases, 2011). Because of the ease of
testing for carriers as well as testing the fetus during
pregnancy, and because of a concerted effort among the
Jewish American community to provide testing, the in-
cidence of Tay-Sachs disease has decreased significantly
since the early 1980s. Because the ultra-Orthodox are
opposed to abortion, this group recommends the testing
only before marriage (Washofsky, 2000). It should be
noted that because there are 50 different mutations, test-
ing can only identify 95 percent of carriers with a Jewish
background and 60 percent of non-Jewish individuals
(Center for Jewish Genetic Diseases, 2011).
Canavan’s disease is a rare, fatal, degenerative brain
disease caused by a defective gene that impairs the for-
mation of myelin in the brain. Approximately 1 in
40 Ashkenazi Jews carry the gene. The resulting symp-
toms begin in mid-infancy and include developmental
delay, loss of vision, and a loss of reflexes resulting
in death by the age of 10 years (Center for Jewish
Genetic Diseases, 2011).
Familial dysautonomia, or Riley-Day syndrome, is
also an autosomal recessive genetic disease, with the
gene located on chromosome 9q31. It causes dysfunc-
tion of the autonomic and peripheral sensory nervous
systems. Affected children have decreased myelinated
fibers on nerves that lead to afferent impulses but
maintain a normal intelligence. Symptoms include a
decrease in the number of taste buds; altered pain sen-
sation; increased salivation and sweating; abnormal
sucking or swallowing difficulties and vomiting, result-
ing in failure to thrive; decreased tears, resulting in in-
creased risk of corneal ulceration; and temperature
and blood pressure fluctuations. Fifty percent of
newly diagnosed infants will live to the age of 40. One
in 27 Ashkenazi Jews is a carrier (Center for Jewish
Genetic Diseases, 2011).
Other conditions that have a higher incidence
among Ashkenazi Jews include the following:
• Torsion dystonia, an autosomal dominant condi-
tion, is carried by 1 in 1000 to 1 in 3000 Ashkenazi
Jews in the United States. The disease leads to
rapid progression in loss of motor control and
twisting spasms of the limbs, resulting in contrac-
tures. Affected individuals lead a full life and have
a normal intelligence.
344 Aggregate Data for Cultural-Specific Groups
2780_Ch19_339-356 16/07/12 11:54 AM Page 344

• Niemann-Pick disease type A is an autosomal re-
cessive severe neurodegenerative disorder that
starts at 6 months of age. It involves an abnormal
storage of sphingomyelin and cholesterol in organs
caused by an enzyme deficiency and leads to cen-
tral nervous system degeneration. Whereas those
with type A usually die by age 3, those with type B
survive into their 50s and have a milder presenta-
tion, with the sphingomyelin building up in their
liver, spleen, lymph nodes, and brain. The gene for
Type A is carried by 1 in 90 Ashkenazi Jews.
• Bloom syndrome, a rare genetic condition that re-
sults in abnormal breakage of chromosomes, re-
sults in respiratory and gastrointestinal infections,
erythema, telangiectasia, photosensitivity, and
dwarfism. Whereas the intelligence of those af-
fected is usually normal, they face an increased
risk of infertility, malignancy, and diabetes. The
average age of death is 27; the gene is carried by
1:110 Ashkenazi Jews.
• Fanconi’s anemia also results in chromosomal
alterations. Symptoms include pancytopenia
and an increased risk of cancer. Many die before
early adulthood. Type C is found more frequently
among Ashkenazi Jews; 1 in 89 are carriers.
• Mucolipidosis IV is found in 1 of 100 Ashkenazi
Jews. This lipid-storage disease results in central
nervous system deterioration during the first year
with motor and mental retardation, as well as vari-
ous eye disorders. The prognosis varies (Center for
Jewish Genetic Diseases, 2011).
Orthodox rabbis usually do not support genetic test-
ing because it might cause couples to refrain from mar-
rying or having children, thus preventing them from
fulfilling the mitzvah of procreation. The Reform move-
ment supports a couple’s right to make the decision as
to whether or not to have the testing done. Because the
knowledge is available, and for the emotional and psy-
chological well-being of a couple, testing is allowed.
Some Orthodox rabbis allow the practice of preimplan-
tation screening of in vitro fertilized zygotes if both
husband and wife are known carriers of Tay-Sachs and
then to only use the healthy ones for implantation. “The
discarding of the affected zygotes is not considered as
abortion, since the status of a fetus or a potential life in
Judaism applies only to a fetus implanted and growing
in the mother’s womb” (Jewish Virtual Library, 2011).
Other conditions with increased incidence in the
Jewish population include inflammatory bowel disease
(ulcerative colitis and Crohn’s disease), which is seen
2 to 8 times more often in Ashkenazi Jews than in
other ethnic groups; colorectal cancer occurs in 6 per-
cent of Ashkenazi Jews; and the BRCA1 and BRCA2
genes that cause breast and ovarian cancer are found
in 1 out of every 50 Jewish women of Ashkenazi back-
ground (Rosenberg, 2011).
Variations in Drug Metabolism
One of the few drugs found to have a higher rate of side
effects in people of Ashkenazic ancestry is clozapine,
used to treat schizophrenia. Twenty percent of Jewish
patients taking this drug developed agranulocytosis,
compared with about 1 percent of non-Jewish patients.
A specific genetic haplotype has been identified to ac-
count for this finding (Schatzberg & Nemeroff, 2009).
Thus, health-care providers must order testing for
agranulocytosis when Jewish patients are prescribed
clozapine.
High-Risk Behaviors
According to Jewish law, individuals may not inten-
tionally damage their bodies or place themselves in
danger. The basic philosophy is that the body must be
protected from harm. To the religious, the body is
viewed as belonging to God; therefore, it must be
returned to Him intact when death occurs. Conse-
quently, any substance or act that harms the body is
not allowed. This includes smoking, suicide, taking
nonprescription or illegal medications, and permanent
tattooing (Jewish Virtual Library, 2011).
Alcohol, especially wine, is an essential part of re-
ligious holidays and festive occasions and is a tradi-
tional symbol of joy. The Jewish attitude toward
wine is ambivalent. The Bible speaks of the undesir-
able effects of wine on the person, as well as its
positive use as a medicine. Consequently, wine is
appropriate and acceptable as long as it is used in
moderation.
Health-Care Practices
Because of the respect afforded physicians and the
emphasis on keeping the body and mind healthy,
Jewish Americans are health conscious. Taking care
of one’s body is a mitzvah. In general, they practice
preventive health care, with routine physical, dental,
and vision screening. This is also a well-immunized
population. Although the older generation is still
more likely to defer to medical authority, Jewish
adults tend to want to participate in health-care
decision making.
Nutrition
Meaning of Food
Eating is important to Jews on many levels. Besides
satisfying hunger and sustaining life, it also teaches
discipline and reverence for life. For those who follow
the dietary laws, a tremendous amount of attention is
given to the slaughter, preparation, and consumption
of food. In addition, the family dinner table is often
the site for religious holiday celebrations and services,
especially the Sabbath, Passover, Rosh Hashanah
(Jewish New Year), and breaking the fast for Yom
Kippur (Day of Atonement). Jewish dietary practices
People of Jewish Heritage 345
2780_Ch19_339-356 16/07/12 11:54 AM Page 345

serve as a spiritually refining act of self-discipline and
are a unifying factor in ethnic identity.
Common Foods and Food Rituals
Perhaps the food identified as “Jewish” that receives
the most attention is chicken soup. This has frequently
been referred to as Jewish penicillin, and it is often
served with knaidlach or matzoh balls (dumplings
made of matzoh meal). Although it has no intrinsic
meaning or religious value, it is a staple in religious
homes, especially on Friday evenings to usher in the
Sabbath and during times of illness. It is frequently as-
sociated with a mother’s warmth and love.
Other common foods include gefilte fish (ground
karp molded into oblong balls, steamed, then served
cold with horseradish), challah (a rich, braided white
bread), kugel (noodle pudding, either sweet or savory),
blintzes (crepes filled with a sweet cottage cheese),
chopped liver (served cold), hamentashen (a triangu-
lar pastry with different types of filling), and Nova
Scotia or “belly” lox (cold smoked salmon) served
with cream cheese and salad vegetables on a bagel.
Slow-cooked beef brisket is often the entrée at Rosh
Hashanah (New Year) dinner.
The laws regarding food are found in Leviticus and
Deuteronomy. They are commonly referred to as the
laws of kashrut, or the laws that dictate which foods
are permissible under religious law. The term kosher
means “fit to eat” (Hoffman, 2008); it is not a brand
or form of cooking. Whereas some believe that the
mandatory statutes were developed and implemented
for health reasons, religious scholars dispute this view,
claiming that the only reason for following the laws is
that they are mandatory commandments of God.
Therefore, the laws are followed as a personal attach-
ment to the religion and as a belief that God has man-
dated them. The laws’ promotion of health is only a
secondary gain. Kashruth issues may be a significant
part of an inpatient stay, making it helpful to know
what is and is not acceptable.
Foods are divided into those considered kosher
(permitted or clean) and those considered treyf (for-
bidden or unclean). A permitted animal may become
treyf, or forbidden, if it is not slaughtered, cooked, or
served properly. Because life is sacred and animal cru-
elty is forbidden, kosher slaughter of animals must be
done in a way that prevents undue cruelty to the ani-
mal and ensures the animal’s health for the consumer.
The jugular vein, carotid arteries, and vagus nerve
must be severed in a single quick stroke with a sharp,
smooth knife, causing the animal to die instantly. No
sawing motion and no second stroke are permitted
(DeLange, 2010). This also allows the maximal
amount of blood to leave the body. Care must be
taken that all blood is drained from the animal before
it is eaten. Drinking of blood is prohibited. An animal
that dies from old age or disease may not be eaten, nor
may it be eaten if it meets a violent death or is killed
by another animal. In addition, flesh cut from a live
creature may not be eaten.
Milk and meat may not be mixed together in cook-
ing, serving, or eating in order to respect the sensitivity
of living creatures (“You must not boil a calf in its
mother’s milk” [Deut. 14:20]). To avoid mixing foods,
utensils and plates used to serve them are separated.
Religious Jews who follow the dietary laws have two
sets of dishes, pots, and utensils: one set for milk prod-
ucts (milchig in Yiddish) and the other for meat
(fleishig). Some homes have different sets of dish tow-
els and even different sinks. Because glass is not ab-
sorbent, it can be used for either meat or milk
products, although religious households still usually
have two sets. Therefore, cheeseburgers, lasagna made
with meat, and grated cheese on meatballs and
spaghetti are unacceptable. Milk cannot be used in
coffee if it is served with a meat meal. Nondairy
creamers can be used instead, as long as they do not
contain sodium caseinate, which is derived from milk.
Thirty minutes is the minimum time between eating
milk and meat products, but some families wait up to
6 hours, with the premise that food takes that long to
digest from the stomach (Hoffman, 2008).
A number of foods are considered parve (neutral)
and may be used with either dairy or meat dishes.
These include fish, eggs, anything grown in the soil
(vegetables, fruits, coffee, sugar, and spices), and
chemically produced goods. Vegetables and fruits
must be washed carefully to ensure that they are free
of insects. A “U” with a circle around it is the seal of
the Union of Orthodox Jewish Congregations of
America and is used on food products to indicate that
they are kosher. A circled “K” and other symbols may
also be found on packaging to indicate that a product
is kosher.
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 patient ad-
heres to kosher standards. If the patient keeps a
kosher home, do not use any cooking items, dishes, or
silverware without knowing which are used for meat
and which for dairy products. Health-care providers
must fully understand the dietary laws so they do not
offend the patient, can advocate for kosher meals if
they are requested, and can plan medication times
accordingly.
Mammals are considered clean if they meet the
other requirements for their slaughter and consump-
tion and have split (cloven) hooves and chew their
cud. These animals include buffalo, cattle, goat, deer,
and sheep. The pig is an example of an animal that
does not meet these criteria. Although liberal Jews
decide for themselves which dietary laws they will fol-
low, many still avoid pork and pork products out of
a sense of tradition and symbolism. Serving pork
346 Aggregate Data for Cultural-Specific Groups
2780_Ch19_339-356 16/07/12 11:54 AM Page 346

products to a Jewish patient, unless specifically
requested, is insensitive.
Birds of prey are considered “unclean” and unac-
ceptable because they grab their food with their claws.
Acceptable poultry are chicken, one of the most fre-
quently consumed forms of protein; turkey; goose; and
duck. Fish can be eaten if it has both fins and scales.
Nothing that crawls on its belly is allowed, including
clams, lobsters, and other shellfish; tortoises; and frogs
(DeLange, 2010).
In religious homes, meat is prepared for cooking by
soaking and salting to drain all the blood from the
flesh. As increased residual salt may result, patients
with sodium restrictions may need counseling to assist
them in making dietary adjustments. Broiling is ac-
ceptable, especially for liver, because it drains the
blood. Care must be taken in serving cheese to ensure
that no animal substances are served at the same time.
Breads and cakes made with lard are treyf, and breads
made with milk or milk by-products (e.g., casein) can-
not be served with meat meals. Eggs from nonkosher
birds, milk from nonkosher animals, and oil from
nonkosher fish are not permitted. Butter substitutes
are used with meat meals. Honey is allowed.
Kosher meals are available in most hospitals or can
be obtained from frozen food suppliers. They arrive
on paper plates and with sealed plastic utensils.
Health-care providers should not unwrap the utensils
or change the foodstuffs to another serving dish.
Frozen kosher meals are available on a commercial
basis. Help may be needed for a patient to choose from
a facility’s menu options. No milk or yogurt should
be placed on a tray with meat, and butter cannot be
served with bread. Even salad dressing needs to be
made without dairy ingredients. If health-care
providers have difficulty locating a supplier, they
should contact a local rabbi. Determining a patient’s
dietary preferences and practices regarding dietary
laws should be done during the admission assessment.
Dietary Practices for Health Promotion
Many Jewish dietary practices are thought to afford
the secondary gain of preventing disease, their inten-
tion is for observance of a commandment. Many Jews
understand the dietary laws as a guide to raising the
act of eating to a spiritual level, which is also true of
the practice of washing one’s hands and praying be-
fore and after eating.
Nutritional Deficiencies and Food Limitations
No nutritional deficiencies are common to individuals
of Jewish descent. As with any ethnic group, nutritional
deficiencies may occur in individuals in lower socioeco-
nomic groups because of the expense of certain foods.
In addition to the dietary laws discussed previously,
other dietary laws are followed at specified times. For
example, during the week of Passover, no bread or prod-
uct with yeast may be eaten. Matzoh (unleavened bread)
is eaten instead. Any product that is fermented or can
cause fermentation may not be eaten (Hoffman, 2008).
Rather than attend synagogue, the family conducts the
service (seder) around the dinner table during the first
2 nights and incorporates dinner into a service that in-
cludes all participants in study, singing, and retelling the
story of Moses and the Exodus from Egypt.
The Jewish calendar has a number of fast days. The
most observed is the holiest day of the year, Yom
Kippur. On this Day of Atonement, Jews abstain from
food and drink as they pray to God for forgiveness for
the sins they have committed during the past year.
They eat an early dinner on the evening before the hol-
iday begins and then fast until after sunset the follow-
ing day. Ill people, older people, the young, pregnant
or lactating mothers, and the physically incapacitated
are absolved from fasting and may need to be re-
minded of this exception to Jewish law. Maintaining
an ill person’s health supersedes the act of fasting. If
concerns arise, a consultation with the patient’s rabbi
may be necessary.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
God’s first commandment to humanity is “Be fruitful
and multiply” (Genesis 1:28). Children are considered
People of Jewish Heritage 347
R E F L E C T I V E E X E R C I S E 1 9 . 1
Mr. Orr, an 80-year-old Jewish patient, originally from Eastern
Europe, has heart disease and a pancreatic deficiency. He is
being cared for in his home by visiting nurses. His wife of
55 years has some physical limitations but is self-sufficient to
maintain her home. The visiting nurse discovers that Mr. Orr is
not taking his pancreatic enzymes as ordered. He states that he
found out that the enzymes are made of pork products, and he
does not eat pork. The nurse may want to teach his wife how
to make meals that will meet his health needs and enters the
kitchen to obtain a measuring cup. Concerned because she has
a kosher kitchen, Mrs. Orr starts yelling at the visiting nurse.
1. What options are available regarding pancreatic enzymes
that do not contain pork?
2. What responses regarding his medication might be made
to Mr. Orr?
3. What questions should the nurse ask Mrs. Orr about her
degree of kashrut (keeping kosher)?
4. What might be an approach to planning kosher meals
appropriate for someone with cardiac and pancreatic
problems?
5. What needs to be known in advance before entering
Mrs. Orr’s kitchen?
2780_Ch19_339-356 16/07/12 11:54 AM Page 347

a gift and a duty, with men considered more impor-
tant by the ultra-Orthodox because they can say
kaddish (the prayer for the dead) for their parents. In
other branches of Judaism, both sexes may recite the
kaddish. Families are encouraged to have at least
two children to fulfill the biblical commandment to
propagate the people (Jacob & Zemer, 2006).
Couples who are unable to conceive should try all
possible means to have children. This includes infer-
tility counseling and interventions, comprising egg
and sperm donation. In Orthodox communities, arti-
ficial insemination is usually allowed if the sperm and
egg are from the married Jewish partners (Hoffman,
2008). If the source is other than the married couple,
it could be considered incest or adultery. Others argue
that it cannot be considered adultery if no sexual in-
tercourse has occurred. When all natural attempts
have been made, adoption may be pursued. Having
children allows religious parents to fulfill many of the
commandments.
The lower number of children born to Jewish
Americans and the high interfaith marriage rate have
resulted in a decreased Jewish population. While the
average-size Jewish family in the United States is fewer
than 2 children, in Israel, the average Jewish family in
2009 had 2.96 children (Jewish Virtual Library, 2011).
Because one-third of all Jews were killed during the
Holocaust, some believe that today’s Jews have a
moral obligation to bring one more child into the
world than they would have normally.
Prevention of pregnancy in the more Orthodox view
implies deferring the commandment to be fruitful and
multiply. While birth control is not against religious
law, birth suppression is (Jacob & Zemer, 2006). Unless
pregnancy jeopardizes the life or health of the mother,
contraception is not looked on favorably among the
ultra-Orthodox (Hoffman, 2008). Liberal Judaism rec-
ognizes that children have the right to be wanted and
that they should be born into homes in which their
needs can be met. Therefore, the use of temporary
birth control may be acceptable. Condom use is sup-
ported, especially if unprotected sexual intercourse
would pose a medical risk to either spouse.
To the Orthodox, it is important to know the mech-
anism of action of the birth control. Coitus interrup-
tus and masturbation (referred to as solitary sex) are
not acceptable because they result in the needless ex-
penditure of semen, although most Jews consider the
former practice a normal, healthy activity. The ban on
masturbation does not apply to women (DeLange,
2010). Barrier techniques are not acceptable because
they interfere with the full mobility of the sperm in its
natural course. The birth control pill does not result
in any permanent sterilization, nor does it prevent
semen from traveling its normal route. Therefore,
use of this method is the least objectionable to
most branches of Judaism (Hoffman, 2008). Some
Orthodox groups do allow the use of birth control
once the mitzvah of having children is achieved
(DeLange, 2010). Sterilization implies permanence,
and Orthodox Jews generally oppose this practice, un-
less the life of the mother is in danger; vasectomy is
regarded by the ultra-Orthodox as mutilation of the
body and thus is not permitted (Hoffman, 2008). Re-
form Judaism leaves the choice of what to use and
whether to use contraceptives up to the parents.
Recognizing that Judaism’s primary focus is the
sanctity of life, it is important to identify when life be-
gins. The fetus is not considered a living soul or person
until it has been born. Birth is determined when the
head or “greater part” is born (Judaism 101, 2005).
Until that time, it is merely part of the mother’s body
and has no independent identity. The unborn is not
actually a person and has no independent life (Jacob
& Zemer, 2006).
The mother and her health are paramount. If her
physical or mental health is endangered by the fetus,
all branches of Judaism consider the fetus the aggres-
sor, which must be aborted (Hoffman, 2008). There-
fore, any ban on abortion could be a violation of
religious freedom. Whereas saving the mother’s life is
certainly grounds for abortion, random abortion is
not permitted by the Orthodox branch because the
fetus is part of the mother’s body, and one must not
do harm to one’s body. Progressive Jews allow abor-
tion, if the mother desires it, if there is physical or psy-
chological danger to the mother or in the case of
incest or rape (Jacob & Zemer, 2006).
Reform Judaism believes that a woman maintains
control over her own body, and it is up to her whether
to abort a fetus. Although no connotation of sin is at-
tached to abortion, the decision is not to be made
without serious deliberation. Most Jews favor a
woman’s right to choose regarding abortion.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
While pregnancy is an exciting time for parents, in re-
ligious Jewish homes, baby showers are not held and
nothing is purchased for the potential child. Baby
names are not discussed until after the child is born
(Judaism 101, 2005). This is based on superstition that
drawing attention to the pregnancy will result in bad
luck for the child-to-be.
A Hasidic husband may not touch his wife during
labor and may choose not to attend the delivery, be-
cause by Jewish law he is not permitted to view his
wife’s genitals. These behaviors should never be inter-
preted as insensitivity on the part of the husband.
During the delivery of a child to an ultra-Orthodox
family, these interventions should be initiated: The
mother should be given hospital gowns that cover her
in the front and back to the greatest extent possible.
She may prefer to wear a surgical cap so that her hair
348 Aggregate Data for Cultural-Specific Groups
2780_Ch19_339-356 16/07/12 11:54 AM Page 348

remains covered. The father should be given the op-
portunity to leave during procedures and during the
birth, or, if he chooses to stay, the mother can be draped
so that the husband may sit by his wife without viewing
her perineum, including by way of mirrors, in order to
protect her dignity. Because he is not permitted to touch
his wife, he may offer only verbal support. The female
nurse may need to provide all of the physical care. Pain
medication during delivery is acceptable.
For male infants, circumcision, which is both a
medical procedure removing the foreskin and a reli-
gious rite, is performed. The origin of this ritual dates
back to Abraham and Isaac in the Book of Genesis.
A brit milah (sometimes referred to as a bris) symbol-
izes the covenant made between the Jewish people and
God (Diamant, 2007). The procedure itself and the
accompanying ceremony are performed on the 8th day
of life by person called a mohel, an individual trained
in the circumcision procedure, asepsis, and the reli-
gious ceremony. Although a rabbi is not necessary, it
is also possible to have the procedure done by a physi-
cian with a rabbi present to say the blessings. Jewish
parents who are not very observant and/or are
unaffiliated may still opt for medical circumcision,
illustrating how the power of this ritual endures over
thousands of years.
Attending a brit milah is the only mitzvah for which
religious Jews must violate the Sabbath so that the brit
can be completed at the proper time (Diamant, 2007).
The naming of the newborn son occurs during the bris
ceremony (girls are named in the synagogue). The brit
milah is a family festivity, and many relatives are in-
vited. In most cases today, the ceremony is performed
in the home; however, if the child is still in the hospi-
tal, it is important for the hospital to provide a room
for a small private party to celebrate. Whereas the
medical community sometimes debates the practice of
circumcision, to even suggest to Jewish parents that
the practice is “barbaric” is insensitive.
A circumcision may be delayed for medical reasons,
including unstable condition owing to prematurity,
life-threatening concerns during the early weeks after
birth, bleeding problems, or a defect of the penis,
which may require later surgery (Diamant, 2007).
At birth, a child is free of all sin; failure to circumcise
carries no eternal consequences should the child
die. Although there is no rule against designating
godparents for a newborn, it is considered a local, not
traditional, custom.
Death Rituals
Death Rituals and Expectations
Death is an expected part of the life cycle. Yet, each
day is to be appreciated and lived as fully as possible.
Religious Jews start each day with a prayer of appre-
ciation for having lived another day. The goal is to
appreciate things and people while one still has them.
Brain death as a criterion for organ donation remains
controversial, with some sects agreeing to this crite-
rion, while others do not (DeLange, 2010). Many also
accept a flat electroencephalogram as a determination
of death.
Traditional Judaism believes in an afterlife in which
the soul continues to flourish, although many dispute
this interpretation because it is not mentioned in the
Torah. Most Jews do not dwell much on life after
death and are unconcerned about it; their focus is on
how to conduct one’s present life.
Active euthanasia, in which something is given or
done to result in death, is forbidden for religious
Jews. One of the Ten Commandments is “Thou shalt
not kill,” and euthanasia is considered murder. A
dying person is considered a living person in all
respects. Sufficient pain control should be provided,
even if it decreases the person’s level of consciousness
(Beitowitz, 2006). Withholding food from a deformed
child to speed its death is considered active euthanasia
and is forbidden.
Passive euthanasia may be allowed, depending on
its interpretation. Nothing may be used or initiated
that prevents a person from dying naturally or that
prolongs the dying process. Therefore, anything that
artificially prevents death (e.g., cardiopulmonary re-
suscitation, use of ventilators) may possibly be with-
held, depending on the wishes of the patient and his
or her religious views. Regardless of the decisions
made, pain control must be maintained.
Taking one’s own life is prohibited and is viewed as
a criminal act and morally wrong because it is forbid-
den to harm any human being, including oneself. To
the ultrareligious, suicide removes all possibility of
repentance. Adult Jews who commit suicide, who
are not mentally ill or depressed, and who belong to
ultrareligious factions of Judaism are not afforded full
burial honors. They are buried on the periphery of the
Jewish cemetery, and mourning rites are not observed,
unless the individual was not mentally competent.
However, the more liberal view is to emphasize the
needs of the survivors, and all burial and mourning
activities proceed according to the usual traditional
rites and wishes of the family. Children are never con-
sidered to have intentionally killed themselves and are
afforded all burial rights.
The dying person should not be left alone. It is con-
sidered respectful to stay with a dying person, unless
the visitor is physically ill or their emotions are out of
control. Judaism does not have any ceremony similar
to the Catholic sacrament of the sick. Any Jew may
ask God’s forgiveness for her or his sins; no confessor
is needed. However, it is not commonly known that
Jews have a personal confession called Viddui, which
is recited when death is imminent. It may be said by
the dying person or by somebody for her or him. Some
People of Jewish Heritage 349
2780_Ch19_339-356 16/07/12 11:54 AM Page 349

Jews feel solace in saying the Shema in Hebrew or
English. This prayer confirms one’s belief in one God.
At the time of death, the nearest relative can gently
close the eyes and mouth; the face is covered with a
sheet. The body is treated with respect and revered for
the function it once filled. Health-care providers need
to ask the closest relative of the deceased specifically
about the practices to follow after death. Health-care
providers who have acquired some familiarity with
Jewish practices associated with death go a long way
toward helping their patients and families. They are
performing mitzvot (good deeds) with their informed
presence that will continue to benefit all involved as
the long process of integrating loss into their lives
continues.
Ultra-Orthodox Jews follow a ritual that is not
conducive to hospital protocols and is more com-
monly observed for those who die at home. After the
body is wrapped, it is briefly placed on the floor with
the feet pointing toward the door. A candle may be
placed near the head (Cohn-Sherbok, 2010). How-
ever, this does not occur on the Sabbath or holy days.
The dead body is not left alone from the time of
death until the funeral, so as not to leave it defense-
less (Diamant, 2007).
Autopsy is usually not permitted among religious
Jews because it results in desecration of the body, and it
is important that the body be interred whole (Hoffman,
2008). Allowing an autopsy might also delay the burial,
something that is not recommended. Conversely, au-
topsy is allowed if its results would save the life of
another patient (Diamant, 2007). Many branches of
Judaism currently allow an autopsy if it is required by
law; the deceased person has willed it; or it saves the life
of another, especially an offspring (Diamant, 2007). The
body must be treated with respect during the autopsy.
Any attempt to hasten or retard decomposition of
the body is discouraged. Cremation is prohibited
because it unnaturally speeds the disposal of the dead
body (Hoffman, 2008). Embalming is prohibited
because it preserves the dead. However, in circum-
stances in which the funeral must be delayed, some
embalming may be approved. Cosmetic restoration
for the funeral is discouraged.
Jewish funerals and burials follow certain practices;
they usually occur within 24 to 48 hours after the
death. The funeral service is directed at honoring the
departed by speaking only well of him or her. It is not
the practice to have flowers at either the funeral or at
the cemetery; this was a Christian custom used to off-
set the odor of decaying bodies. A donation to a char-
ity in the name of the deceased is a more meaningful
tribute. The casket is often a simple pine box with no
ornamentation. The body may be wrapped only in a
shroud to ensure that the body and casket decay at the
same rate. A wake or viewing is not part of a Jewish
funeral. The prayer said for the dead, the kaddish, is
usually not said alone, but is recited in and with the
company of others. The prayer says nothing about
death, but rather, it praises God and reaffirms one’s
own faith. A funeral according to halachah (Jewish
law) emphasizes that death is death. Realism and
simplicity are the characteristics of the Jewish burial.
After the funeral, mourners are welcomed at the
home of the closest relative. Water to wash one’s hands
before entering is outside the front door, symbolic of
cleansing the impurities associated with contact with the
dead. The water is not passed from person to person,
just as it is hoped that the tragedy is not passed. At the
home, a meal is served to all the guests. This “meal of
condolence” or “meal of consolation” is traditionally
provided by the neighbors and friends; it frequently in-
cludes hard-boiled eggs to remind all of the continuing
cycle of life (Diamant, 2007).
Shiva (Hebrew for “seven”) is the 7-day period that
begins with the burial. Shiva helps the surviving indi-
viduals face the actuality of the death of the loved
one. During this period when the mourners are “sit-
ting shiva,” they do not work. When health-care
providers are the ones experiencing the loss, it is im-
portant for supervisors to understand the mourning
customs. In some homes, mirrors are covered to de-
crease the focus on one’s appearance; no activity is
permitted to divert attention from thinking about the
deceased; and evening and morning services may be
conducted in the closest relative’s home. Condolence
calls and the giving of consolation are appropriate
during this time.
350 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 9 . 2
Samuel is an older Jewish adult who is in the final stage of
terminal cancer. His nurse has developed a close relationship
with him, but has never discussed religion. Samuel states that
he is not afraid of dying. The nurse asks him if he wants a
clergy in order to make confession; he says no and appears an-
noyed. Samuel decides he wants to end all treatments, but the
nurse tries to encourage him to continue the treatments in
the hope that his cancer will enter remission. Then the nurse
tells Samuel’s wife, “God doesn’t give you anything that you
can’t handle” and “This is your cross to bear.” The nurse is
perplexed as to why her well-intentioned comfort modalities
are not effective with either the patient or his wife.
1. What does the nurse need to understand about a Jew’s
relationship with God?
2. What does the nurse need to understand about the
Jewish view of death?
3. Why are the comments made to Samuel’s wife
inappropriate?
4. What interventions might be most helpful to the family in
the final stage of life?
2780_Ch19_339-356 16/07/12 11:54 AM Page 350

After shiva, the mourning period varies based on
who has died. Mourning for a relative lasts 30 days,
and for a parent, 1 year. Judaism does not support
prolonged mourning. A tombstone is erected within
1 year of the death, at which time a graveside service
is held. This is called an unveiling. According to the
Jewish calendar, the anniversary of the death is
called yahrzeit, and at this time, candles are lit and
the kaddish is said.
Understanding some specific practices related to
death and dying may have an impact on other aspects
of health care, including the death of premature in-
fants and the care of amputated limbs. Mourning is
not required for a fetus that is miscarried or stillborn.
This is also true of any premature infant who dies
within 30 days of birth. However, parents are required
to mourn for full-term infants who die at birth or
shortly thereafter (Washofsky, 2000). Although the
baby should be named, not all of the traditional burial
customs are followed.
Within Orthodoxy, when a limb is amputated be-
fore death, the amputated limb and blood-soaked
clothing are buried in the person’s future gravesite.
This custom might not be practiced by recent Russian
immigrant Jews because they were not allowed to
practice their faith under Communism and, therefore,
lost many of the traditional practices. Because the
blood and limb were part of the person, they are
buried with the person. No mourning rites are re-
quired. In the case of an amputation, the health-care
provider may need to assist with arrangements for
burial of the body part.
When one visits a Jewish cemetery, one of the most
noticeable differences is that small stones are left on
the top of the gravestone. While the original reason
for this practice is unknown, it is now used as a token
to indicate that the grave has been visited and the per-
son has not been forgotten (Diamant, 2007).
Responses to Death and Grief
The period following a death has discrete segments
to assist mourners in their adjustment to the loss.
The period of time between the death and the burial
is short, and it is the time for the emotional reaction
to the death. The burial may be delayed only if re-
quired by law, if relatives must travel great distances,
or if it is the Sabbath or a holy day. Mourners are
absolved from praying during this time. Crying,
anger, and talking about the deceased person’s life
are acceptable. A common sign of grief is the tear-
ing of the garment that one is wearing before the
funeral service. In liberal congregations, a black rib-
bon with a tear in it is a symbolic representation
of mourning (Diamant, 2007). During shiva, the
mourner sets the tone and initiates the conversation.
Because there are such discrete periods of mourn-
ing, Judaism tells the mourner that it is wrong to
mourn more than 30 days for a relative and 1 year
for parents (Hoffman, 2008).
Spirituality
Dominant Religion and Use of Prayer
Judaism, one of the oldest monotheistic religions, is
over 4000 years old (BBC Religions, 2011). Its early his-
tory and laws are chronicled in the Torah, called the Old
Testament by Christians. Jews consider only the Torah
as their Bible. They have a history of being singled out
as a people and have often been persecuted, expelled
from countries and forbidden to practice their religion;
“black-balled” from jobs, housing, and admission to
college; rounded up and killed; and mass-exterminated.
Many Jews in America have immediate family members
who were killed in the pogroms in Russia in the
early 1900s and in the Holocaust in Eastern Europe.
Yet, throughout this persecution, Judaism has lived
and flourished.
Judaism is a monotheistic faith that believes in one
God as the Creator of the universe. The watchword
of the faith is found in Deuteronomy (6:4): “Hear O
Israel, the Lord is our God, the Lord is One.” No
physical qualities are attributed to God, and making
and praying to statues or graven images are forbidden
by the second commandment.
The spiritual leader is the rabbi (teacher). He (or
she, in liberal branches) is the interpreter of Jewish
law. Rabbis are not considered to be any closer to God
than common people are. All Jews pray directly to
God. They do not need the rabbi to intercede, to hear
confession, or to grant atonement. The following are
some of the major principles that guide Judaic
bioethics:
• Man’s purpose on earth is to live according to cer-
tain God-given guidelines.
• Life possesses enormous intrinsic value, and its
preservation is of great moral significance.
• All human lives are equal.
• Our lives are not our own exclusive private posses-
sions (Perlin, 2006).
The first five books of the Bible, also known as the
five books of Moses, are handwritten in Hebrew on
parchment scrolls called Torah. These scrolls are kept
in the “Holy Ark” within each synagogue under an
“eternal light.” The Torah directs Jews on how they
should live their lives; it provides guidance on every
aspect of human life. The rest of the Bible includes sa-
cred writings and teachings of the prophets.
The 613 commandments within the Torah (also
called Mitzvot) and the oral law derived from the bib-
lical statutes determine Jewish law, or halakhah. These
commandments ask for a commitment in behavior
and also address ethical concerns. Thus, the com-
mandments reflect the will of God, and religious Jews
People of Jewish Heritage 351
2780_Ch19_339-356 16/07/12 11:54 AM Page 351

feel it is their duty to carry them out to fulfill their
covenant with God. This makes Judaism not only a
religion but also a way of life.
The current practice of Judaism in America spans
a wide spectrum. Whereas there is only one religion,
there are multiple branches or denominations of
Judaism. The Orthodox are the most traditional.
They adhere most strictly to the halakhah (Code of
Jewish Law) of traditional Judaism and try to follow
as many of the laws as possible while fitting into
American society. They observe the Sabbath by
attending the synagogue on Friday evening and
Saturday morning and by abstaining from work, spend-
ing money, and driving on the Sabbath. Orthodox
Jews observe the Jewish dietary laws; men wear a
yarmulke or kippah (head covering) at all times in
reverence to God, whereas women usually wear long
sleeves and modest dress. In many Orthodox syna-
gogues, the services are primarily in Hebrew, and
men and women sit separately.
Orthodox Jews and some Conservative men and
women use the tefillin, or phylacteries, during morning
prayer services. These are two small black boxes, with
parchment containing biblical passages, that are con-
nected to long leather straps. These are wrapped around
the arms and forehead as reminders of the laws of the
Torah. The tallis (or tallit) is a rectangular prayer shawl
with fringes. This is also used only during prayer but is
frequently used by both Conservative and Orthodox
Jews. Ultra-Orthodox men wear a special garment
under their shirts year-round; the tzitzit has long fringes
as a reminder of the laws of the Torah.
A mezuzah is a small elongated container with
scripture inside and marked with a Hebrew letter on
the outside that denotes God. Its origin was a sign en-
suring God’s protection; it serves as a reminder of the
presence of God, His commandments, and a Jew’s du-
ties to Him. Jewish homes have a mezuzah on the
doorframe of the house. A number of individuals also
wear a mezuzah as a necklace. Other religious symbols
include the Star of David, a six-pointed star that has
been a symbol of the Jewish community since the
1350s, and the menorah (candelabrum).
The Conservative branch is not quite as strict in its
traditions. Whereas Conservative Jews observe most
of the halakhah, they do make concessions to modern
society. According to DeLange (2010), “The aim
of the founders [of Conservative Judaism] was to
embrace the liberalism and pleuralism of American
Reform while safeguarding traditional practice”
(p. 13). Many drive to the synagogue on the Sabbath,
and men and women sit together. Many keep a kosher
home, but they may or may not follow all of the di-
etary laws outside the home. Women are ordained as
rabbis and are counted in a minyan, the minimum
number of 10 required for communal prayer. (These
practices are unacceptable to the Orthodox.) Whereas
a yarmulke is required in the synagogue, it is optional
outside of that environment.
The liberal or progressive movement is called Reform
Judaism. Reform Jews claim that postbiblical law was
only for the people of that time, and only the moral
laws of the Torah are binding. They practice fewer rit-
uals, although they frequently have a mezuzah for their
homes, celebrate the holidays, and have a strong ethnic
identity. They consider education and ethics of para-
mount importance in one’s personal life and try to link
Jewish religious values with American political liberal-
ism. They may or may not follow the Jewish dietary
laws, but they may have specific unacceptable foods
(e.g., pork) that they abstain from eating. Men and
women share full equality, and they engage in many
social-action activities.
Of the many small groups of ultra-Orthodox fun-
damentalists, the Hasidic (or Chasidic) Jews are per-
haps the most recognizable. They usually live, work,
and study within a segregated area. They are visually
identifiable by their full beards, uncut hair around the
ears (pais), black hats or fur streimels, dark clothing,
and no exposed extremities. Women, especially those
who are married, also keep their extremities covered
and may have shaved heads covered by a wig and
often a hat as well.
A relatively new denomination, Reconstructionism
is a mosaic of the three main branches. It views Judaism
as an evolving religion of the Jewish people and seeks
to adapt Jewish beliefs and practices to the needs of the
contemporary world. It bridges the Conservative reli-
gious world with the secular world of Judaism.
“‘Secular Jew’ is a term that refers to Jews who have
chosen to abandon the belief in God” (DeLange,
2010, p. 78). They have not rejected their Jewish iden-
tity or their attachment to the Jewish people. They re-
main very supportive to Jewish causes without a belief
in a supernatural being. Many Jews, however, do not
indicate any affiliation.
The Jewish house of prayer is called a synagogue,
temple, or shul. It is never referred to as a church.
Jews may pray alone or communally when 10 male
Jews over the age of 13 who have had their bar
mitzvah are gathered together for prayer. This group
is called a minyan. Orthodox Jews pray three
times a day: morning, late afternoon, and evening.
They wash their hands and say a prayer on awaken-
ing in the morning and before meals. Reform and
Reconstructionist groups may allow women to form
a minyan.
Religious patients in hospitals may want their
prayer items (yarmulke or kippah, tallit, tzitzit, tefillin)
and may request a minyan. Hospital policies regarding
the number of visitors in the sick person’s room may
have to be ignored in such instances.
One of the most common religious practices related
to patients involves “visiting the sick” (bikkur cholim).
352 Aggregate Data for Cultural-Specific Groups
2780_Ch19_339-356 16/07/12 11:54 AM Page 352

This commandment is one of the social obligations of
Judaism and ensures that Jews look after the physical,
emotional, psychological, and social well-being of
others and provides hope as well as companionship.
Moreover, one must consider the patient’s welfare and
not stay too long, tire the patient, or come only to
satisfy one’s own needs.
Meaning of Life and Individual Sources
of Strength
The preservation of life is one of Judaism’s greatest
priorities. Even the laws that govern the Sabbath
may be broken if one can help save a life. Health-
care providers should do everything to save a life
(Hoffman, 2008). Each individual is considered spe-
cial, and the individuality of the human experience
is one of the precepts of the faith. Good health is
considered an asset.
Spiritual Beliefs and Health-Care Practices
The second of the Ten Commandments is to remem-
ber the Sabbath day and keep it holy. The Sabbath be-
gins 18 minutes before sunset on Friday. Lighting
candles, saying prayers over challah and wine, and par-
ticipating in a festive Sabbath meal usher in this weekly
holy day. It ends 42 minutes after sunset (or when three
stars can be seen) on Saturday, with a service called
Havdalah. The Sabbath serves as a release from week-
day concerns and pressures. During this time, religious
Jews engage in congregational study and do no manner
of work, including answering the telephone, operating
any electrical appliances, handling money, driving, or
operating a call bell from a hospital bed.
If an Orthodox patient’s condition is not life-
threatening, medical and surgical procedures should
not be performed on the Sabbath or holy days. How-
ever, extenuating circumstances such as illness or foul
weather are legitimate reasons for not attending the
services. Although the Sabbath is holy, and holidays
that require fasting are part of Jewish law, matters
involving human life take precedence over them.
Therefore, a gravely ill person and the work of those
who need to save her or him are exempted from
following the commandments regarding the Sabbath
and fast days. This even includes eating nonkosher
food if there is the slightest chance that human life will
be saved (Jewish Virtual Library, 2011).
In addition to the Sabbath, a number of Jewish hol-
idays are celebrated with special traditions. Rosh
Hashanah (Jewish New Year) and Yom Kippur (Day
of Atonement) are called the High Holy Days, and
usually occur in September or early October. They
mark a 10-day period of self-examination and repen-
tance. This is a time when Jews apologize for wrongs
they have committed knowingly or unknowingly
against others (Cohn-Sherbok, 2010). According to
tradition, during these 10 days, each person stands
before God, and their fate for the coming year is
determined. Thus, the greeting during this time is
“May you be written into the book of life for a good
year.” As noted earlier, Yom Kippur is the most
solemn of the Jewish holidays.
Rosh Hashanah is started by eating apples and
honey to wish for a sweet year, and on Yom Kippur,
one fasts for a day to cleanse and purify oneself. As
noted before, fasting for Yom Kippur may be broken
for reasons of critical illness or labor and delivery
or for children under the age of 12. The holiday
includes the blowing of the shofar (a ram’s horn)
that is to remind individuals to repent or atone for
their sins.
Other major holidays include Passover, the Feast of
the Unleavened Bread, which lasts 8 days and cele-
brates the Exodus from Egypt and freedom from
slavery; Sukkot, a festival of the harvest in which in-
dividuals may live in temporary huts built outside
their homes or synagogues for a week; and Shavuot,
which celebrates the giving of the Ten Command-
ments. Minor holidays include Chanukah, an 8-day
holiday, and Purim, both of which celebrate religious
freedom. Table 19-1 provides a list of Jewish holidays
for the years 2011 through 2017.
People of Jewish Heritage 353
❙❙◗ Table 19-1 Jewish Holidays: 2011–2017
2011–2012 2012–2013 2013–2014 2014–2015 2015–2016 2016–2017
Holiday (5772)* (5773)* (5774)* (5775)* (5776)* (5777)*
Rosh Hashanah 9/29–9/30 9/17–9/18 9/5–9/6 9/25–9/26 9/14–9/15 10/3–10–/4
Yom Kippur 10/8 9/26 9/14 10/4 9/23 10/12
Sukkot 10/13–10/18 10/1–10/6 9/19–9/24 10/9–9/14 9/28–10/3 10/17–10/22
Chanukah 12/21–12/28 12/9–12/16 11/28–12/5 12/17–24 12/7–12/14 12/25–1/1
Purim 3/8 2/13 3/16 3/5 3/24 3/12
Passover 4/7–4/14 3/26–4/2 4/15–4/22 4/4–4/11 4/23–4/30 4/11–4/18
Shavuot 5/27–5/28 5/15–5/16 6/4–6/5 5/24–5/25 6/12–6/13 5/31–6/1
Note: Jewish holidays always begin at sundown the evening before the date recorded on this type of calendar ;
holidays end at sundown on the date shown.
*Dates on the Jewish calendar.
2780_Ch19_339-356 16/07/12 11:54 AM Page 353

Health-Care Practices
Health-Seeking Beliefs and Behaviors
According to Jewish law, all people have a duty to
keep themselves in good health. This encompasses
physical and mental well-being and includes not only
early treatment for illness but also prevention of ill-
ness. Judaism teaches its members to “choose life.” To
refuse lifesaving medical treatment is seen by some as
committing suicide, as one is choosing death over life.
All denominations recognize that religious require-
ments may be laid aside if a life is at stake or if an in-
dividual has a life-threatening illness. However, once
it is clear that an individual is dying and that medical
treatment is no longer working, individuals may
choose not to interfere with death. Hospice care is
fully consonant with Jewish beliefs.
In ultra-Orthodox denominations of Judaism, tak-
ing medication on the Sabbath that is not necessary to
preserve life may be viewed as “work” (i.e., an action
performed with the intention of bringing about a
change in existing conditions) and is unacceptable.
This belief may result in some people with conditions
such as asthma not recognizing the severity of their
condition; they may also be unaware of the laws
that allow them to take their necessary medications.
These patients need to be taught about the potential
life-threatening sequelae of their condition as well as
the exceptions to Jewish law that permit them to take
their medications. In the Jewish faith, all individuals
have value regardless of their condition. This includes
individuals with developmental disabilities and AIDS.
Preventing disease, restoring health, and prolong-
ing life are acceptable goals within Judaism. There-
fore therapeutic genetic engineering via gene therapy
is permitted if it prevents disease and disability in
future generations (Solomon, 2006). Extending life
gives more time for an individual to be involved in
doing good deeds. Because genomics is the interac-
tion between one’s genes and the environment, im-
proving the environment to improve healthy lives is
also valued.
Responsibility for Health Care
Although it is the responsibility of health-care
providers to heal, individuals must seek the services
of the physician to ensure a healthy body. Once indi-
viduals have the knowledge necessary to effect their
healing, it is their obligation to do so. To abstain
from healing would be equivalent to murder. Jews be-
lieve that God provides human beings with “the tools
and the knowledge to tamper with the Divine
arrangement of the world” (Solomon, 2006, p. 134);
it is up to them to use that wisdom to create a better
world. This includes the discovery of new medica-
tions and treatments to eliminate or modify disease
and suffering; therefore, man can help God heal
and cure. Jews also believe that God gives humans
freedom of choice.
Because the preservation of life is paramount, all
ritual commandments are waived when danger to life
exists. Physical and mental illnesses are legitimate rea-
sons for not fulfilling some of the commandments.
Because adult Jews are often well read, they may be
interested in trying the newest available treatments.
This could have both positive and negative conse-
quences. The literature reveals no studies regarding
Jews’ self-medicating practices.
Folk and Traditional Practices
Jewish folk practices are historically and biblically
based. Jews have adopted and adapted to customs
from the cultures and countries in which they have
lived during the centuries of the diaspora. Specific
practices are explained in the sections of this chapter
on Nutrition and Spiritual Beliefs and Health-Care
Practices.
Barriers to Health Care
Aside from the unavailability of health insurance for
some people, or being underinsured secondary to eco-
nomic situations, no major barriers to health care for
Jews in contemporary America exist. The Jewish com-
munity helps those in need, including new immigrants,
354 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 1 9 . 3
Emma is 8 years old and hospitalized for an acute infection re-
quiring a central line and antibiotics. It is December 24, and
the hospital is decorated for Christmas. Multiple organizations
have paraded through the unit with someone dressed as Santa
Claus handing out presents. Emma thinks it is “neat” to get all
these presents. However, when the staff ask her if she is ex-
cited that Santa Claus is there, she says “no.” When they ask if
she misses putting up a Christmas tree, she also says “no.”
The nurse is even more perplexed when she finds out that
there are no decorations in the home at all, including a wreath
on the door. The nurse asks if she wants to hang up a stocking,
and she does not know what they are talking about. When
Emma’s mother hears the nurse telling her that this is the
night to celebrate Jesus’s birth, she becomes angry. When the
mother explains that they do not believe in Jesus, the nurse
responds, “I feel sorry for you.”
1. What discussion could have been held with Emma’s
parents in the days before Christmas?
2. How might Emma still enjoy the “presents” without
attaching it to religion?
3. How might the nurse have handled the situation better?
4. It is inappropriate to compare Christmas with Chanukah.
How else might the nurse have recognized the assets of
Judaism?
2780_Ch19_339-356 16/07/12 11:54 AM Page 354

and assists fellow Jews in becoming self-sufficient.
Community organizations, especially the Jewish Fed-
eration in each state, include programs to help the
needy; these agencies are ubiquitous today wherever
Jews live in the United States.
Cultural Responses to Health and Illness
The verbalization of pain is acceptable and common.
Individuals want to know the reason for the pain, which
they consider just as important as obtaining relief from
it. The sick role for Jews is highly individualized and
may vary among individuals according to the severity
of symptoms. As prescribed in the halakhah, the family
is central to Jewish life; therefore, family members share
the emphasis on maintaining health and assisting with
individual responsibilities during times of illness.
Many Jews have become physicians, psychoanalysts,
psychiatrists, and psychologists. In addition, many of
their patients are Jewish. The maintenance of one’s
mental health is considered just as important as the
maintenance of one’s physical health. This designation
includes psychiatric conditions. However, requirements
for those who are rational but have cognitive deficien-
cies are decided on an individual basis. According to
Jewish law, individuals must be taught the Torah re-
gardless of their age or level of disability; this speaks
to the unique value of each individual.
Blood Transfusions and Organ Donation
Jewish law views organ transplants from four perspec-
tives: the recipient, the living donor, the cadaver donor,
and the dying donor. Because life is sacred, if the recip-
ient’s life can be prolonged without considerable risk,
then transplant is favorably viewed. For a living donor
to be approved, the risk to the life of the donor must
be considered. One is not obligated to donate a body
part unless the risk is small. Examples include kidney
and bone marrow donations (Lamm, 2000). If there is
more than a 50 percent chance of either the patient or
the donor dying, the organ donation is not permitted
(Hoffman, 2008). The action of donating an organ to
save another is considered a great mitzvah.
Conservative and Reform Judaism approve using
the flat EEG as the determination of death so that or-
gans, such as the heart, can be viable for transplant.
Burial may be delayed if organ harvesting is the cause
of the delay. However, among other groups, this defi-
nition of death remains controversial (Beitowitz,
2006). Health-care providers may need to assist Jewish
patients to obtain a rabbi when they are making a de-
cision regarding organ donation or transplant.
The use of a cadaver for transplant is generally ap-
proved if it is to save a life. No one may derive eco-
nomic benefit from the corpse. Although desecration
of the dead body is considered purposeless mutilation,
this does not apply to the removal of organs for trans-
plant. Use of skin for burns is also acceptable.
Health-Care Providers
The ancient Hebrews are credited with promoting hy-
giene and sanitation practices and basic principles for
public health care. From the religious mandate of visit-
ing the sick and the desire to initiate measures to prevent
the spread of disease, Lillian Wald, a well-known Jewish
nurse, developed the Henry Street Settlement in New
York City as a prototype of public health nursing for
those in need and initiated the idea of school nursing.
Jewish physicians have made significant contributions,
ranging from development of immunizations (Baruch
Blumberg [hepatitis B] and Jonas Salk and Albert Sabin
[polio]) to psychotherapy (Aaron Beck [cognitive
therapy] and Sigmund Freud [psychoanalysis]).
Status of Health-Care Providers
Physicians are held in high regard. Whereas physicians
must do everything in their power to preserve life, they
are prohibited from initiating measures that prolong
the act of dying (Hoffman, 2008). Once standard ther-
apy has failed, or if additional treatments are unavail-
able, the physician’s role changes from that of curer to
providing supportive care, such as food and water,
good nursing care, and optimal psychosocial support.
R E F E R E N C E S
American Jewish Committee. (2010). Retrieved from http://www.
ajc.org/site/apps/nlnet/content3.aspx?c=ijITI2PHKoG&b=
846741&ct=8801845
American Jewish Demographics. (2011). Retrieved from http://
www.jewishvirtuallibrary.org/jsource/US-Israel/jewdemotoc.html
Beckerman, G. (December 22, 2010). New study finds more Jews
in the United States than previously thought. Forward.com.
Retrieved from www.forward.com/articles/134138
Beitowitz, Y.A. (2006). Brain death controversy in Jewish Law.
Retrieved from http://www.jlaw.com/Articles/brain.html
Benson, E. (1994). Jewish nurses: A multicultural perspective.
Journal of the New York State Nurses Association, 25(2), 8–10.
Benson, E. (2001). As we see ourselves: Jewish women in nursing.
Indianapolis, IN: Center Nursing Publishing.
British Broadcasting Company. (2011). Religions. Retrieved from
http://www.bbc.co.uk/religion/religions/judaism/
Center for Jewish Genetic Diseases. (2011). Retrieved from http://
www.mssm.edu/research/programs/jewish-genetics-disease-
center/screening-program/current-screenings
Center for Jewish History. (2007). Retrieved from www.cjh.org/
Cohn-Sherbok, D. (2010). Judaism today. London: Continuum
International.
DeLange, N. (2010). An introduction to Judaism. Cambridge, UK:
Cambridge University Press.
Diamant, A. (2007). Living a Jewish life. New York, NY: Harper.
Hebrew University of Jerusalem. (2009). Ashkenazi Jews. Retrieved
from http://hugr.huji.ac.il/AshkenaziJews.aspx
Hoffman, C. (2008). Judaism. London: McGraw-Hill.
Jacob, W., & Zemer, M. (2006). Sexual issues in Jewish law. Pittsburgh,
PA: Rodef Shalom Press.
Jewish Nobel Prize Winners. (2011). Retrieved from http://www.
jinfo.org/Nobel_Prizes.html
People of Jewish Heritage 355
2780_Ch19_339-356 16/07/12 11:54 AM Page 355

Jewish Virtual Library. (2011). Jewish population of the United States
by state. Retrieved from http://www.jewishvirtuallibrary.org/
index.html
Judaism 101. (2005). Birth and the first month of life. Retrieved
from www.jewfaq.org/birth.htm
Kranson, R. (2010). More bar than mitzvah: Anxieties over bar
mitzvah receptions in postwar America. In L. Greenspoon
(Ed.), Rites of passage (pp. 9–23). West Lafayette, IN: Purdue
University Press.
Lamm, M. (2000). The Jewish way in death and in mourning. Mid-
dle Village, NY: Jonathan David.
Myers, M. (1988). Response to modernity: A history of the reform
movement in Judaism. New York: Oxford University Press.
National Gaucher Foundation. (2011). Retrieved from http://www.
gaucherdisease.org
Perlin, E. (2006). Jewish bioethics and medical genetics. Journal
of Religion and Health, 33(4), 333–340.
Rosenberg, Y. (2011). Jewish genetic diseases. Retrieved from
www.mazornet.com/genetics/index.htm
Schatzberg, A., & Nemeroff, C. (2009). Textbook of psychophar-
macology. Arlington VA: The American Psychiatric Publishing.
Solomon, L. (2006). The quest for designer children. In W. Jacob
& M. Zemer (Eds.), Sexual issues in Jewish law. Pittsburgh, PA:
Rodef Shalom Press.
Washofsky, M. (2000). Jewish living: A guide to contemporary re-
form Jewish practice. New York: Union of American Hebrew
Congregations Press (UAHC).
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
356 Aggregate Data for Cultural-Specific Groups
2780_Ch19_339-356 16/07/12 11:54 AM Page 356

357
Chapter 20
People of Korean Heritage
Eun-Ok Im
Overview, Inhabited Localities,
and Topography
Overview
This chapter focuses on the commonalities among
people of Korean heritage, with historical reference to
the mother country, South Korea. The word Korea
limitedly refers to the Republic of Korea. Because some
information may not be pertinent to every Korean, this
chapter serves as a guide for health-care providers rather
than as a mandate of facts. Differences in beliefs and
practices among Koreans in Korea, the United States,
and other countries vary according to variant cultural
characteristics as presented in Chapter 1. An under-
standing of Korean culture and history gives health
providers the insight needed to perform culturally
appropriate assessments, plan effective care and follow-
up, and work effectively with Koreans in the workforce.
South Korea is a peninsula separated by North Korea
to the north at the 38th parallel and surrounded by the
former Soviet Union to the northeast, the Yellow Sea to
the west, and the East Sea to the east. South Korea has
a landmass of 98,480 square kilometers (38,031 square
miles), which is about the size of the state of Indiana,
and a population of 48 million (CIA World Factbook,
2010). South Korea has 1 percent of the landmass of
the United States, but has one-sixth as many people,
making it 16 times more densely populated than the
United States (Kohls, 2001). The mega-modern metro-
politan area of Seoul, the capital, has a population of
10.3 million people (Asianinfo, 2010a). A new interna-
tional state-of-the-art airport is located in Incheon,
60 kilometers from the center of Seoul. Other large cities
are Busan (Pusan) and Daegu (Taegu). Planes, trains,
and buses link all South Korean major cities, making
travel easy and efficient. With the recent increase in the
number of automobiles and the construction of high-
ways, motorways are becoming more congested. Major
industries are electronics, telecommunications, automo-
bile production, chemicals, shipbuilding, and steel (CIA
World Factbook, 2010). South Korea is now well known
as riding on the “hallyu movement” or the “Korean
wave,” which is the globalization of Korean dramas
throughout Singapore, Malaysia, Japan, China, and the
United States. Since the 1990s, the entertainment indus-
try of South Korea has grown explosively, producing
Asia-wide successes in music, television, and film
(Asianinfo, 2010b).
The continental and monsoon climate of Korea is
fairly consistent throughout the peninsula, except dur-
ing the winter months. North Korea has cold, snowy
winters, with an average temperature in January of
17°F. South Korea is milder, with an average January
temperature of 23°F. During the summer months, the
monsoon winds create an average temperature of
80°F, with high humidity throughout the peninsula.
August is the hottest month of the year, when temper-
atures reach over 100°F in many areas. Precipitation
occurs mostly during the summer months and is heav-
ier in the south. The peninsula is mountainous; only
20 percent of the terrain is located in lowlands. Such
topography encourages the development of concen-
trated living areas. Most cities and residential areas
are located along the coastal plains and the inland val-
leys opening to the west coast.
Heritage and Residence
Korea is one of the two oldest continuous civilizations
in the world, second only to China. Koreans trace
their heritage to 2333 B.C. In the 1st century A.D.,
tribes from central and northern Asia banded together
to form this “Hermit Kingdom,” littering the coun-
tryside with palaces, pagodas, and gardens. Over the
ensuing centuries, Mongols, Japanese, and Chinese in-
vaded the Korean peninsula. Japan forcibly annexed
Korea in the early 20th century, ruling it harshly and
leaving ill will that persists to this day. As a result of
the Potsdam Conference after World War II, the
United States took over the occupation of South
Korea, with the USSR occupying North Korea. By
1948, Korea’s new government was recognized by the
United Nations, only to be followed by the North
Korean Communist forces invading South Korea in
1950. The result was the Korean War, which lasted
2780_Ch20_357-373 16/07/12 11:54 AM Page 357

until 1953 and caused mass devastation, from which
the country has made a remarkable recovery. Open
aggression between North and South Korea again
occurred in 1998 and 1999. In 2000, the two Koreas
signed a vague, yet hopeful, agreement that the two
countries would be reunited. However, North Korea’s
recent resumption of its nuclear weapons program has
set its neighbors and much of the rest of the world on
edge (CNN, 2010).
In 1988, the year Seoul hosted the Olympic Games,
elections were held, and relations were reestablished
with China and the Soviet Union. Intermittent
corruption among political officials has continued to
surface, threatening internal relationships and the
economy. In 1997, South Korea’s economy tumbled
dramatically, resulting in economic and democratic
reforms. With unwavering persistence, Koreans have
rebuilt their major world economy, reflecting a 4 to
5 percent annual growth rate with moderate inflation
from 2003 to 2007 but decreased to .2 percent in 2009
(CIA World Factbook, 2010). The United States con-
tinues to maintain a strong military presence through-
out South Korea (Fig. 20-1).
Reasons for Migration and Associated
Economic Factors
Koreans are one of the most rapidly increasing immi-
grant groups in the United States (Migration Infor-
mation Source, 2010). The first major immigration
from Korea to the United States occurred between
1903 and 1905, when the Korean government prohib-
ited further emigration; about 10,000 Koreans had
entered Hawaii, and 1000 reached the U.S. main-
land. The U.S. Immigration Act of 1924 practically
closed the door to Japanese and Koreans. During the
civil rights movements of the 1950s and 1960s, new
immigration laws repealed the earlier limitations on
Asian immigration. Koreans continue to immigrate to
America to pursue the American dream, to increase
socioeconomic opportunities, and to attend colleges
and universities. In addition, many Koreans and
Americans marry, making both Korea and America
their homes. In a 2005 U.S. Census Bureau survey, an
estimated 432,907 Koreans in the United States were
native-born Americans, 1 million were foreign-born
Korean, and more than 57 percent were women (U.S.
Census Bureau, 2006).
Most of the population pursues higher education,
and South Korea has more citizens with PhDs per
capita than any other country in the world. Owing to
Confucian cultural influence, education is emphasized
as a virtue of human beings (all human beings should
be educated) and is highly valued in the Korean
culture (Im, 2002).
Before the late 19th century, education was primarily
for those who could afford it. State schools educated
the youth from the yangban (upper class), focusing on
Chinese classics in the belief that these contained the
tools of Confucian morality and philosophy that also
apply in politics. In the late 1800s, the state schools were
opened to all citizens. Early Christian missionary work
introduced the Western style of modern education to
Korea. Initially, many Koreans were skeptical of the
radical curriculum and instruction for females, but the
popularity of this style grew rapidly.
After the takeover of Korea by the Japanese in
1910, two types of schools emerged—one for Japanese
and another for Koreans. The Korean schools focused
on vocational training, which prepared Koreans for
only lower-level positions. Japanese colonial education
was designed to keep Koreans subordinate to ethnic
Japanese in all ways (Sorensen, 1994). In 1949, South
Korea allowed for the implementation of an educa-
tional system similar to that of the United States. This
6–3–3–4 ladder (6 years in elementary school, 3 years
in junior high, 3 years in high school, and 4 years in
college) continues today in contemporary South
Korea. Anti-Communism and morality are taught
throughout elementary and secondary schools.
In the United States, many Koreans own their own
small businesses, which vary from mom-and-pop
stores and gas stations to grocery stores and real estate
agencies to retail shops. Their reputation for hard
work, independence, and self-motivation has given
them the label “the model minority.” However, this
has caused a backlash in some communities, such as
Washington, DC, where they have been compared
with other minority groups. The message has become
“If the Koreans can do it, why not other groups?” The
turmoil and riots that took place in Los Angeles in
April 1992 between the African American community
and the Korean American merchants are examples of
conflicts that arise from such labeling.
Many Korean small businesses are located in
African American neighborhoods because of low cap-
ital investment requirements and limited resources of
the owners. Korean merchants begin dealing in inex-
pensive consumer goods as a practical way to start a
business in a capitalistic society. Koreans often assist
each other in establishing businesses by pooling their
358 Aggregate Data for Cultural-Specific Groups
Figure 20-1 Traditional Korean games that are played in the
beginning of a new year.
2780_Ch20_357-373 16/07/12 11:55 AM Page 358

money and taking turns with rotating credit associa-
tions to provide each family with the opportunity for
financial success.
Communication
Dominant Language and Dialects
The dominant language in Korea is Korean, or han’gul,
which originated in the 15th century with King Se Jong,
and is believed to be the first phonetic alphabet in East
Asia. Several dialects exist in the Korean language,
called saturi in Korean (Korean Language, 2010). The
Korean standard language in South Korea is based on
the dialect of the area around Seoul, and the Korean
standard language in North Korea is based on the
dialect of the area around Pyongyang. All the dialects
of Koreans are similar to one another except that of
Jeju Island (Korean Language, 2010). The most notable
difference among dialects is the accent. For example,
the Korean standard language has a very flat intona-
tion, while the Gyeongsang dialect has a very strong
accent and intonation (Korean Language, 2010).
The Korean language has four levels of speech that
are determined based on the degree of intimacy be-
tween speakers. These varying levels reflect inequali-
ties in social status based on gender, age, and social
positions. Use of an inappropriate sociolinguistic level
of speech is unacceptable and is normally interpreted
as intended formality to, disrespect for, or contempt
to a social superior.
Chinese and Japanese have influenced the Korean
language. Before the Japanese occupation in Korea,
highly educated Koreans used Chinese characters, and
Chinese characters were taught in Korean traditional
schools. Then, during the Japanese occupation in the
early 20th century, the Japanese forbade public use of
the Korean language, requiring the use of the Japanese
written and spoken language, which introduced some
Japanese terms and words into contemporary Korean
language.
Most Koreans in the United States can speak, read,
write, and understand English to some degree. How-
ever, some Americans may have difficulty understand-
ing the English spoken by Koreans, especially those
who learned English from Koreans who spoke with
their native intonations and pronunciations.
Cultural Communication Patterns
Sharing thoughts, feelings, and ideas is very much
based on age, gender, and status in Korean society. Tra-
ditionally, the Korean community values the group over
the individual, men over women, and age over youth.
Those holding the dominant position are the decision
makers who share thoughts and ideas on issues.
Koreans prefer indirect communication because
they perceive direct communication as an indication
of intention or opinions as rude. Moreover, Koreans
may agree with the health-care provider in order to
avoid conflict or hurting someone’s feelings, even if
something is impossible (Im, 2002). Thus, it is impor-
tant to read between the lines when working with
these families and remember those growing up in the
United States may adopt the dominant American
communication style.
Koreans tend to avoid eye contact, especially with
older people, perceived authorities (e.g., health-care
providers), and strangers. Avoiding direct eye contact
with older people and perceived authorities indicates
respect, and women’s avoiding direct eye contact with
men shows modesty. Younger generations of Koreans
educated in the United States may adopt the domi-
nant communication style of eye contact. Koreans are
usually comfortable with silence owing to the Confu-
cian teaching “Silence is golden.” Silence was tradi-
tionally emphasized as a virtue of educated people.
Even among Korean Americans, people who are
silent, especially men, are viewed as humble and well
educated. However, the social fabric and cultural
norms of Koreans are changing as they interact with
Western societies and culture. Younger generations of
Koreans, even in South Korea, are noted as being very
sociable and kind to visitors (Asianinfo, 2010a).
Close personal space (less than a foot) is shared
with family members and close friends, but it is inap-
propriate for strangers to step into “intimate space”
unless needed for health care (Im, 2002). Visitors from
America may be uncomfortable with Koreans’ spatial
distancing in public spaces. Koreans stand close to one
another and do not excuse themselves if they bump
into someone on the street. This may be due to the
high population density in the metropolitan areas
of South Korea and Koreans’ cultural attitudes to-
ward strangers (e.g., they usually do not speak with
strangers). Among family members and close friends,
touching, friendly pushing, and hugging are accepted.
However, among strangers, touching is considered dis-
respectful unless needed for care. Also, touching
among friends and social equals of the same sex is
common and does not carry a homosexual connota-
tion as it might in Western societies. However, more
social etiquette rules apply when it comes to touching
older family members or those of higher social status.
Hugging and kissing recently have become common
among parents and young children, as well as among
young children and aunts or uncles.
Feelings are infrequently communicated in facial
expressions. Smiling a lot shows a lack of intellect and
disrespect. One would not smile at a stranger on the
street or joke around during a serious conversation.
Joking and amusement have their designated times. In
Korea, men frequent bars after work and may express
their sense of humor in this setting. Men and women
alike appreciate and encourage jokes and laughter in
appropriate settings. Koreans generally do not express
People of Korean Heritage 359
2780_Ch20_357-373 16/07/12 11:55 AM Page 359

their emotions directly or in public; expressing emo-
tions in front of others, including family members, is
regarded as shameful, especially among men (Im,
2002). A common Korean belief related to men’s emo-
tions is that men should cry only three times in their
lives: when they are born, when their parents die, and
when their country perishes (Im, 2002). Given these
cultural communication patterns, health-care providers
should not interpret these nonverbal behaviors as
meaning that Korean patients are not interested in, or
do not care about, information presented during health
teaching and health promotion interventions.
Temporal Relationships
Traditional Koreans are past oriented. Much atten-
tion is paid to the ancestry of a family. Yearly, during
the Harvest Moon in Korea, chusok (respect) is paid
to ancestors by bringing fresh fruits from the autumn
harvest, dry fish, and rice wine to gravesites. However,
the younger and more educated generation is more
futuristic and achievement oriented.
In Korea, Korean traditional shamans (called
modang and/or jumjangi) are visited to determine the
best home to purchase, the best date for having a wed-
ding, and the best time to start a new business. The
busiest time of the year for the shaman is just before
the Chinese New Year. Koreans are eager to know
their fortune for the coming year. Many believe that
misfortunes occur because ancestors are unhappy.
During these times, families show respect to ancestors
by more frequent visits to their gravesites in the hope
of appeasing the spirits. Shamans, who may be used
by Koreans of all socioeconomic levels, are also used
in Korea to rid homes and new places of business of
spirits. The Korean concept of time depends on the
circumstances. Koreans embrace the Western respect
for time for important appointments, transportation
connections, and working hours, all of which are rec-
ognized as situations in which punctuality is necessary.
Yet, socially, Korean Americans arrive at parties and
visit family and friends up to 30 minutes later (and
sometimes 1 to 2 hours later) than the agreed-upon
time. This is socially acceptable when the person or
family is waiting at home. If the social meeting is
being held in a public setting, a half-hour time span
for arrival at the meetingplace can be expected.
Format for Names
The number of surnames in Korea is limited, with the
most common ones being Kim, Lee, Park, Rhee or Yi,
Choi or Choe, and Chung or Jung. Korean names
contain two Chinese characters, one of which de-
scribes the generation and the other the person’s given
name. The surname comes first; however, because this
may be confusing to many Americans, some Koreans
in the United States follow the Western tradition of
using the given name first, followed by the surname.
Adults are not addressed by their given names unless
they are on friendly terms; individuals should be
addressed by their surname with the title Mr., Mrs.,
Ms., Dr., or Minister.
Given the diversity and acculturation of Korean
Americans, health-care providers need to determine
the Korean patient’s language ability, comfort level
with silence, and spatial-distancing characteristics. In
addition, Koreans should be addressed formally until
they indicate otherwise.
Family Roles and Organization
Head of Household and Gender Roles
Fundamental ideas about morality and the proper or-
dering of human relationships among Koreans are
closely associated with kinship values derived mainly
from Confucian concepts of filial piety, ancestor wor-
ship, funerary rites, position of women, the institution
of marriage, kinship groups, social status and rank, and
respect for scholars and political officials. Although
constitutional law in South Korea declares equality for
all citizens, not all aspects of society have accepted this.
Korean culture is largely based on patriarchal and Con-
fucian norms that subordinate women (Im, 2002). In
Confucian traditional Korean families, the father was
always the head of the family; he had power to control
the family, and the family had to obey any order from
the father. Wives did not share household tasks with
their husbands, so they tended to be physically over-
loaded and psychologically distressed. Wives’ exploita-
tion was hidden under Confucian norms that praised
women who sacrifice themselves for their families and
nation (Im & Meleis, 2001). Also, the wife was confined
to the home and bore the major responsibility for
household tasks; the husband was the breadwinner.
360 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 2 0 . 1
Lisa, a school nurse, is examining Mina Lee, who was referred
by her teacher because of her reluctance to speak in class.
Mina Lee is a first-grader whose family has recently immigrated
from South Korea. She is the second child of her family, and she
is living with her mother, father, and brother who do not speak
English fluently.
1. What should the nurse to do assess Mina’s reluctance to
speak in class?
2. Could language be a possible barrier?
3. What cultural barriers besides language might explain
Mina’s silence in class?
4. What are the traditional Korean cultural attitudes and
values related to silence and teacher–student relationships?
5. What are some implications for nursing practices for
children who recently immigrated from Korean culture?
2780_Ch20_357-373 16/07/12 11:55 AM Page 360

Nowadays, this typical family structure has been
changed, especially among younger generations. Many
women and men remain single until their 30s and 40s.
Even when they marry, they sometimes do not have a
child; they choose to enjoy their lives rather than raise
the next generation.
Among Korean immigrants in the United States,
women hold the family together and play a vital role
in building an economic base for the family and com-
munity, often sacrificing themselves in the immigra-
tion process. The Korean immigrant woman may have
started as a cleaning woman or seamstress, then
worked at a fast-food restaurant, and then in a small
shop owned with her husband. However, the women’s
financial contributions to the family usually do not
change the gender roles; their husbands still occupy
center stage, exercise the authority, and make the
major family decisions (Im & Meleis, 2001).
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
In contrast to the Western culture in which mother-
ing is individually fashioned and relies on the expert-
ise of health-care providers, in the highly ritualistic
Korean culture mothering is molded by societal
rules and information is less frequently sought from
health-care providers. In this context, mothers tend
to view infants as passive and dependent, and they
seek guidance from folklore and the extended family
(Choi, 1995). In Korea, children over the age of
5 years are expected to be well behaved because the
whole family is disgraced if a child acts in an embar-
rassing manner. Most children are not encouraged
to state their opinions. Parents usually make the
decisions.
Korean families have high standards and expecta-
tions for their children, and “giving a whip to a
beloved child” is the basis for discipline of children
(Im, 2002). Thus, the pressure of high performance in
school and entering a highly ranked university is
prevalent among Korean children and adolescents
(Im, 2002). Usually, Koreans are not happy with very
masculine girls or very feminine boys (Im, 2002).
“Teaching to the test” is also common in Korea, but
the role of teachers is also to encourage self-study. The
future of Korean students is determined by their
teachers’ recommendations, and this pressure can be
extremely intense for students who are not doing well.
The teaching style is one in which students listen and
learn what is being taught. Regardless of private
doubts, a student rarely questions a teacher’s author-
ity. Korean children in America must be taught the
teaching style in American schools, in which question-
ing is positive and is valued as class participation.
Even if Korean American students understand the
style of teaching, it can be difficult to know the ap-
propriate timing for asking questions.
The pressure of doing well in school and attending
a university of high quality leaves Korean adolescents
little room for social interactions. Activities that inter-
fere with one’s education are considered taboo for
adolescents. In Korea, students frequently attend
study groups after school or special tutoring sessions
paid for by their families in preparation for examina-
tions to enter a university. Short coffee breaks or
snacks at local coffee shops or noodle houses are
permissible, but then it is “back to the books.”
Dating is now common among high school students
in South Korea. Even an elementary student would say
that she or he has a boyfriend or a girlfriend. Yet, ado-
lescent girls are usually not allowed to spend the night
at their friends’ houses, virginity is emphasized, and sex-
ual activities and pregnancy at puberty stigmatize the
family across social classes. Although talking about sex-
uality, contraception, or pregnancy in public is taboo,
close girlfriends or boyfriends exchange information on
these topics or get their information from women’s mag-
azines. Neither the school system nor the family assumes
responsibility for sex education. Girls in elementary
school are given a class regarding their menstrual cycle,
but no information is given about sexual relations.
Once young adults have entered a university, they
receive their freedom and are then permitted to make
their own decisions about personal and study time.
Group outings are common for meeting the opposite
sex. Dating may occur from these group meetings and
consists of movies, dinner, and walks in the park.
Issues arise between the first-generation Korean im-
migrant parents and the second-generation children in
relation to conflicting values and communication. With
rapid acculturation, the second generation often takes
on the values of the dominant society or culture. Thus,
parents who are of the first generation in most cases are
challenged when their second-generation children do
not accept traditional values and ideals that they may
still hold dear. The different cultures between the first-
generation parents and the second-generation children
are sometimes the cause of domestic violence. Most of
the first generation of Korean immigrants were edu-
cated in Korea, and they have a strong stereotype of
Korean patriarchal culture. However, because the sec-
ond generation is educated in the United States (some
of them never visited Korea), most second-generation
individuals feel a spirit of insubordination and often
quarrel. For some, physical abuse might be involved if
they do not follow orders (Kim, Cain, & McCubbin,
2006; Kim & Chung, 2003; Park, 2001).
Family Goals and Priorities
In a Korean traditional family, family members have
specific rights and duties within their family. For ex-
ample, the first son inherits all the properties of his
parents and has the duty of caring for his elderly par-
ents until they die. A family member replaces the roles
People of Korean Heritage 361
2780_Ch20_357-373 16/07/12 11:55 AM Page 361

of another family member who dies. Thus, if the first
son dies, the second son is in charge of all the duties
of the first son. However, this traditional family sys-
tem is dissolving among both Koreans and Korean
Americans. Usually in Korean Americans, both par-
ents work to provide every opportunity possible for
their family. As each family member learns to adjust
to the changing roles in the new country, conflict can
result. Children adapt most easily to the new culture
and may even take on the dominant culture’s values.
Lee and Lee (1990) studied the adjustment of
Korean immigrant families in the United States in
relation to roles, values, and living conditions between
husbands and wives, and parents and children. The
findings showed a transition from an independent
family structure, in which the woman had little knowl-
edge of the man’s activities outside the home, to a
joint family structure. Many activities were carried
out together with an interchange of roles at home.
Conflict centered on undefined role expectations. In
Korea, the roles of men and women were very clear.
However, upon immigrating to the United States, men
and women were faced with conflicting roles in the
new culture and had to struggle to redefine them.
Other conflict areas were the couple’s ability to speak
English, the woman’s inability to drive, the degree
of acculturation, the limited social contact, and the
stressors of living in a new culture.
In Korea, education is a family priority. The out-
come of having a highly educated child was a secure
old age for the parents. Because of the dependent re-
lationship between parents and their children, parents
were more willing to make drastic sacrifices for the ad-
vancement of their children’s education. Today, status
is achieved rather than inherited in Korea. Education
in Korea is a determinant of status, independent of its
contribution to economic success.
Traditionally in Korea, parents expected their chil-
dren to care for them in old age. Hyo (filial piety), which
is the obligation to respect and obey parents, care for
them in old age, give them a good funeral, and worship
them after death, was a core value of Korean ethics. The
obligation to care for one’s parents is written into civil
code in Korea. The burden was on the eldest son, who
was obliged to reside with his parents and carry on the
family line. Such an arrangement made the generations
dependent on each other. The son felt obligated to care
for his parents because of the sacrifices they made for
him. Similarly, he made the same sacrifices for his chil-
dren and expected them to provide for him and his wife
in their old age. Many of these traditions in Korea have
changed. Some of the eldest children emigrated, leaving
the responsibility for their parents to the siblings who
remained in Korea.
Some older Koreans were brought to the United States
without their friends and with minimal or no English
skills. They often felt obligated to assist the family in
any way possible by preparing meals or taking care of
the children when the parents were not home. Deci-
sion making for older people was hampered in their
new culture. Korean older people were frequently con-
sulted on important family matters as a sign of respect
for their life experiences. Older people’s roles as decision
makers in the United States have shifted with the
younger generation of Korean Americans wanting the
final decision-making authority in their young families.
Traditionally, Koreans give great respect to their
elders. Old age begins when one reaches the age of
60 years, with an impressive celebration prepared for
the occasion. The historical significance of this cele-
bration is related to the Chinese lunar calendar. The
lunar calendar has 60 cycles, each with a different
name. At the age of 60, the person is starting the cal-
endar cycle over again. This is called hwangap. This
celebration was more significant in the past when life
expectancy in Korea was much lower than it is today.
Despite a change in the direct role of older people in
their families, older Koreans are socially well respected
in Korea. In public, an older woman is called Halmoni
(grandmother), and those who are not blood relatives
call an older man Harabuji (grandfather). Older people
are offered seats on buses out of respect and honor.
However, recent changes in Korean culture have made
this tradition change as well. Sometimes quarrels be-
tween older people and young people, usually about
respect, are reported in the daily news in South Korea.
Traditionally, the extended Korean family played an
important role in supporting its members throughout
the life span. With the breakup of the extended family,
Korean Americans support one another through sec-
ondary organizations such as the church. The church
assists new immigrants with the transition to life in the
United States. The church is a resource for information
about child care, language classes, and social activities
(Im & Yang, 2006). Korean Americans without family
support may seek other Korean Americans who live in
the area. With Korean Americans dispersed through-
out the United States, this task can be difficult.
Whereas some Koreans inherit social status, many
have the ability to change their status through their
education and professions. Traditional Korean culture
espouses respect not only for older people but also for
those of valued professions. In modern Korea, profes-
sors, bureaucrats, business executives, physicians, and
attorneys receive a high level of respect. Historically,
those with the highest education were handsomely
paid. Even though the salary differences between uni-
versity professors and other professions have nar-
rowed significantly in recent years in Korea, the status
of the intellectual remains high. Similarly, the bureau-
cratic officer has a high social status, wielding much
respect and influence.
362 Aggregate Data for Cultural-Specific Groups
2780_Ch20_357-373 16/07/12 11:55 AM Page 362

Alternative Lifestyles
Alternative lifestyles are usually frowned upon in
Korean culture. Women who divorce suffer social
stigma, the degree of which depends on the situation.
However, recent changes in the Family Law in South
Korea now permit women to head a household, rec-
ognize a wife’s right to a portion of the couple’s prop-
erty, and allow a woman to maintain greater contact
with her children after a divorce. South Korea now
has one of the highest divorce rates in the world;
Korea has the highest divorce rate among 33 Organi-
zation for Economic Cooperation and Development
(OECD) countries (OECD, 2010). Yet, the stigma of
divorce remains strong among Koreans in both South
Korea and the United States, and there is little gov-
ernment or private assistance for divorced women in
South Korea. Mixed marriages, between a Korean and
a non-Korean, are highly disregarded by some, and
the Korean government makes it very difficult for
these marriages to occur. Korean women who have
married American servicemen are often the objects of
Korean jokes and are ridiculed by some.
Living together before marriage is not customary
in Korea. If pregnancy occurs outside marriage, it
may be taken care of quietly and without family and
friends being aware of the situation. However, with re-
cent changes in Korean culture, some celebrities began
to announce their pregnancies before marriage, and a
pregnancy right before marriage is not looked upon
as harshly as in the past. In the United States, preg-
nancy outside of marriage may not carry such a great
stigma among the more acculturated.
As in other Asian cultures, homosexuality has not
been accepted in Korean culture (Kimmel & Yi,
2004). Also, Korean’s understanding and knowledge
of homosexuality are ambiguous and limited (Kim &
Hahn, 2006). Koreans believe that homosexuality
is an abnormal and impure modern phenomenon.
Despite the recent coming out of several Korean
homosexual entertainers in South Korea, those who
have relations with a person of the same sex still
remain “in the closet.” Personal disclosure to friends
and family usually jeopardizes the family name and
may lead to ostracism. The community may stigma-
tize both the family and the individual, making it
difficult to conduct their personal lives.
Workforce Issues
Culture in the Workplace
Korean Americans come from a culture that places a
high value on education. Many Korean immigrants
are college educated and held white-collar jobs in
Korea. Moreover, it is difficult for Korean immigrants
to obtain work in the United States commensurate
with their experience because of language difficulties,
restricted access to corporate America, and unfamil-
iarity with American culture (Im & Meleis, 2001). The
skills and work experiences they had in Korea are
often not accepted by American businesses, forcing
them to take jobs in which they may be over skilled
while they save money to start their own businesses.
Korean American women frequently need to find jobs
to assist the family financially, which may cause role
conflicts between more traditional husbands and wives.
Korean Americans have a strong work ethic. They
work long hours each week for the advancement of
family opportunities. Family is the priority for Korean
Americans, but on the surface this may not always be
apparent when long hours are devoted to work. The
goal is to save money for education and other oppor-
tunities so the family can provide for their children in
the future.
The number of Korean medical personnel working
in the American health-care system is unknown. Sig-
nificant numbers of Korean nurses and physicians are
practicing in the United States and Canada; many
have received part or all of their education in the
United States. Yi and Jezewski’s study (2000) of
12 Korean nurses’ adjustment to hospitals in the
United States identified five phases of adjustment.
The first three phases—relieving psychological stress,
overcoming language barriers, and accepting American
nursing practices—take 2 to 3 years. The remaining
two phases—adopting the styles of American prob-
lem-solving strategies and adopting the styles of
American interpersonal relationships—take an addi-
tional 5 to 10 years. Accordingly, orientation pro-
grams need to address language skills, practice
differences, and communication and interpersonal re-
lationships to help Koreans adjust to the American
workforce. These same phases may occur with other
Korean health-care providers.
Issues Related to Autonomy
Those in supervisory positions need to recognize the
roles and relationships that exist between Koreans and
their employers. A supervisor is treated with much re-
spect in work and in social settings. Informalities and
small talk may be difficult for Korean immigrants. For
an employee to refuse an employer’s request is unac-
ceptable, even if the employee does not want or feel
qualified to complete the request. Supervisors should
make an effort to promote open conversation and the
expression of ideas among Korean Americans. Asking
Korean employees to demonstrate procedures is better
than asking them whether they know how to perform
them. Those who have adjusted to the American busi-
ness style may be more assertive in their positions, but
an understanding of this work role gives supervisors
the tools to more readily use Korean Americans’ skills
and knowledge.
People of Korean Heritage 363
2780_Ch20_357-373 16/07/12 11:55 AM Page 363

As with any new language, it is often difficult to un-
derstand American slang and colloquial language.
Employers and other employees should be clear in
their communication style and be understanding of
miscommunications. Ethnic biases are often directed
at Korean Americans who speak English with an ac-
cent. Employers’ and coworkers’ preconceived notions
of immigrants can also be a deterrent to Korean
Americans in the workforce.
Biocultural Ecology
Skin Color and Other Biological Variations
Koreans are an ethnically homogeneous Mongoloid
people who have shared a common history, language,
and culture since the 7th century A.D. when the penin-
sula was first united. Common physical characteristics
include dark hair and dark eyes, with variations in
skin color and degree of hair darkness. Skin color
ranges from fair to light brown. Epicanthal skin folds
create the distinctive appearance of Asian eyes. With
the popularity of drastic plastic surgeries in recent
years, Koreans’ typical facial characteristics might not
be easily found in some cases.
Diseases and Health Conditions
Schistosomiasis and other parasitic diseases are en-
demic to certain regions of Korea, and Koreans love
sushi and sashimi (raw fish). Therefore, health-care
providers should consider parasite screening with
Korean immigrants, when appropriate. South Korea
continues to manufacture and use asbestos-containing
products and has not taken the precautions necessary
to adequately protect employees and meet interna-
tional standards. Thus, Korean immigrants to the
United States need to be assessed for asbestos-related
health problems (Johanning, Goldberg, & Kim, 1994).
The high prevalence of stomach and liver cancer, tu-
berculosis, hepatitis, and hypertension in South Korea
predispose recent immigrants to these conditions. High
rates of hypertension lead to an increase in cardiovas-
cular accidents and renal failure. The high incidence of
stomach cancer is associated with environmental risks,
such as diet and infection (Helicobacter pylori), and in
some cases, genetic predisposition (Kim, 2003). As with
other Asians, a high occurrence of lactose intolerance
exists among people of Korean ancestry. Dental hygiene
and preventive dentistry have recently been emphasized
in health promotion in South Korea. Because of
the high incidence of gum disease and oral problems,
however, these conditions deserve attention.
Variations in Drug Metabolism
Growing research in the field of pharmacogenetics has
found variations in drug metabolism among ethnic
groups. Studies suggest that Asian populations require
lower dosages of psychotropic drugs (Levy, 1993). Other
studies have shown variations in drug metabolism and
interaction with propranolol, isoniazid, and diazepam
among Asians in comparison with those of European
Americans and other ethnic groups (Meyer, 1992).
Although these studies primarily focus on people of
Chinese and Japanese heritage, health-care providers
should be aware and attentive to the possibility of drug
metabolism variations among Korean Americans
(Munoz & Hilgenberg, 2005).
High-Risk Behaviors
Because Koreans place great emphasis on education,
many subject their children to intense pressure to do
well in school. A national survey conducted among
80,000 middle and high school students in South Korea
demonstrated such pressures: 1 out of 20 Korean youths
attempted suicide, and a major reason was their lack of
success in school (The Hankyoreh, 2007). Similar pres-
sures have been seen in the United States, where suicide
has occurred in Korean high school and college students
because of intense pressure to do well in school.
Korea has a high incidence of alcohol consumption,
up from 7.0 liters in 1980 to 8.1 liters per adult per
capita, which is similar to that of the United States and
Ireland at 7.8 liters per adult per capita (World Health
Organization, 2004). Korean business transactions
commonly occur after the decision makers have had
several drinks. Koreans believe that people let their
masks down when they drink and that they truly get
to know someone after they have had a few drinks.
Socioeconomic changes in Korea have resulted in dif-
ferences in alcohol-related social and health problems,
with a change from drinking mild fermented beverages
with meals to drinking distilled liquors without meals.
364 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 2 0 . 2
Laurie, a nurse working at a local clinic, is assessing Young Kim,
who is a high school senior entering college in the coming fall.
Born in South Korea, he was 4 years old when his family emi-
grated from South Korea. His mother accompanied him to the
clinic to get his immunization records cleared for his entrance
to college. All immunization records were adequately docu-
mented in his medical records, but there was an issue related
to his tuberculosis (TB) immunization because his TB skin test
was positive. His mother claimed that he received the Bacille
Calmette Guerin (BCG) vaccination.
1. What might explain Young’s positive TB skin test?
2. Most Korean immigrants have BCG immunization records
and subsequent positive TB skin tests. What are the pros
and cons of BCG vaccination, subsequent positive TB skin
tests, x-rays for verifying TB status, and taking preventive
medications?
3. Besides tuberculosis, what are some other prevalent
infectious diseases among Koreans?
2780_Ch20_357-373 16/07/12 11:55 AM Page 364

In Korea, women drink far less than men. Sons’
drinking patterns are similar to their fathers’ patterns.
A substantial generational difference exists among
females, with daughters abstaining from alcohol less fre-
quently than their mothers and drinking more, and
more often, than their mothers (Weatherspoon, Park, &
Johnson, 2001). In the United States and South Korea,
drinking and vehicular accidents among Koreans and
Korean Americans are a cause for concern.
In a study by Lew and colleagues (2001), about
39 percent of Korean American men and 6 percent of
Korean American women were current smokers. Lee,
Sobal, and Frongillo (2000) also found that bicultural
Korean men were least likely to smoke, whereas accul-
turated and bicultural women were more likely than
traditional women to smoke. In Korea, a few women
do smoke, and for those who do, smoking in public,
such as on the street, is considered taboo.
Cho and Faulkner (1993) studied the cultural con-
ceptions of alcoholism among Korean and American
university students. Students had to decide whether the
person described in a vignette was an “alcoholic” or not
and why. The results showed that American-born
students tended to define alcoholism in terms of social
and interpersonal problems related to drinking, whereas
Korean-born students defined alcoholism in terms of
physical degeneration and physiological addiction. The
authors caution against the misuse of American con-
cepts and diagnostic scales in the cross-cultural arena.
Cultural factors should be examined closely in relation
to the study, diagnosis, and treatment of alcohol prob-
lems. Nakashima and Wong (2000) also reported
alcohol misuse among Korean American adolescents
and concluded that alcohol misuse among Korean
American adolescents is influenced by the social vari-
ables found to affect the use among other ethnic groups,
such as psychological variables (depression, self-esteem),
perceived prejudice, and feeling safe where one lives.
Health-Care Practices
Seat belts are infrequently worn in South Korea,
although seat belts are now mandatory (U.S. Depart-
ment of State, 2010). Korean Americans understand
the legal mandates in the United States and comply
with seat belt and child-restraint laws.
Hobbies such as hiking and golf are enjoyed in South
Korea. Korean Americans do not identify hiking as a
frequent pastime, either because of environmental con-
straints or because of living situations. Golf remains a
significant activity among those Korean Americans who
are financially able to play the sport.
Nutrition
Meaning of Food
Food takes on a significant meaning when one has
been without food. Many Koreans over the age of
60 who lived during the Korean War experienced a
time when their next meal was not guaranteed. Be-
cause of a devastated economy and agricultural base,
barley and kimchee, a spicy pickled cabbage, were
dietary staples during the war. Koreans are taught to
respect and not waste food.
Common Foods and Food Rituals
Korean food is flavorful and spicy. Rice is served with
3 to 5 (and sometimes up to 20) small side dishes of
mostly vegetables and some fish and meats. Season-
ings in Korean cooking include red and black pepper,
garlic, green onion, ginger, soy sauce, and sesame seed
oil. The traditional Korean diet includes steamed rice;
hot soup; kimchee; and side dishes of fish, meat, or
vegetables served in some variation for breakfast,
lunch, and dinner. Breakfast is traditionally consid-
ered the most important meal.
Kimchee is made from a variety of vegetables but
is primarily made from a Chinese, or Napa, cabbage
(Fig. 20-2). Spices and herbs are added to the previ-
ously salted cabbage, which is allowed to ferment over
time and is served with every meal in a variety
of forms. Some common Korean American dishes
include the following:
• Beebimbap is a combination of rice, finely chopped
mixed vegetables, and a fried egg served in a hot
pottery bowl. Hot pepper paste is usually added.
• Bulgolgi is thinly sliced pieces of beef marinated in
soy sauce, sesame oil, green onions, garlic, and
sugar, which is then barbecued.
• Chopchae are clear noodles mixed with lightly
stir-fried vegetables and meats.
Rice is usually served in individual bowls, set to the
left of the diner. Soup is served in another bowl,
placed to the right of the rice. Chopsticks and large
soupspoons are used at all meals. Korean Americans
People of Korean Heritage 365
Figure 20-2 Kimchee, a spicy pickled cabbage that is a staple
of the Korean diet.
2780_Ch20_357-373 16/07/12 11:55 AM Page 365

may use forks and knives, depending on their degree
of assimilation into American culture. Meals are
frequently eaten in silence, using this opportunity
to enjoy the food. When Koreans migrate to the
United States, they increase their consumption of
beef, dairy products, coffee, soda, and bread, as well
as decrease their intake of fish, rice, and other grains.
However, incorporating a larger quantity of Western
foods does not make a less healthy diet. They consume
diets consistent with their traditional Korean food
patterns, with 60 percent of calories coming from
carbohydrates and 16 percent of calories from fat
(Kim, Yu, Chen, Cross, & Kim, 2000). To increase
compliance with dietary prescriptions, health teaching
should be geared to the unique Korean American food
choices and practices.
Understanding the ritual offering of food and drink
to guests is important. Koreans offer a guest a drink
on first arriving at their home. The guest declines
courteously. The host offers the drink again and the
guest again declines. This ritual can occur three to five
times before the guest accepts the offer. This interac-
tion is done out of respect for the hosts and their
generosity to share with their guest and to express an
unwillingness to impose on the hosts. Accepting an
offer when first asked is considered rude and selfish.
Dietary Practices for Health Promotion
Most dietary practices for health promotion apply to
pregnancy, discussed later in this chapter. Someone
suffering from the common cold is served soup made
from bean sprouts. Dried anchovies, garlic, and other
hot spices are added to the hot soup, which assists in
clearing a congested nose.
Nutritional Deficiencies and Food Limitations
Lee, Lee, Kim, and Han (2009) conducted an in-depth
assessment of the nutritional status of 202 Korean
American elderly in a metropolitan city on the East
Coast and reported that the Korean American elderly
consumed more than two regular meals in a day that
were considered part of a Korean food pattern. The
average consumption of nutrients was generally lower
than in Americans reported in the National Health
and Nutrition Examination Survey III, except carbo-
hydrates, vegetable protein, and sodium intake. The
researchers noted inadequate intake of calcium, di-
etary fiber, and folate, and suggested that health-care
providers consider ways to lower sodium intake and
increase fruit and vegetable consumption.
A study by Park, Murphy, Sharma, and Kolonel
(2005) indicated that the proportion of overweight or
obesity was 31.4 percent in U.S.-born Korean women
and 9.4 percent in Korean-born Korean women. They
also reported that U.S.-born Korean women had higher
intakes of total fat and fat as a percentage of energy
and lower intakes of sodium, vitamin C, beta-carotene,
and carbohydrate as a percentage of energy than
Korean-born women. In addition, Cho and Juon (2006)
reported that of 492 Korean American respondents,
38 percent were overweight and 8 percent were obese
according to the World Health Organization for Asian
populations. These findings suggest that acculturation
of Korean immigrants affects dietary intakes in ways
that may alter their risks of several chronic diseases.
Korean Americans, as with most other Asians, are
at a high risk for lactose intolerance. Thus, milk and
other dairy products are not part of the traditional
Korean diet, emphasizing the need to assess them for
calcium deficiencies.
Korean Americans living in or near large metropol-
itan cities have access to Korean markets and restau-
rants. When no Korean stores are available, Chinese
or Japanese markets may contain some of the foods
Koreans enjoy. When no Asian markets are available,
the American grocery store suffices.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
To curtail population growth in Korea, the government
promotes the concept of two children per household.
The government supported the use of contraception
when a 10-year family planning program was adopted
in the early 1960s, resulting in a mass public education
program on contraception. When contraceptive devices
became easily available in Korea, fertility control spread
widely among married women. Contraceptive devices
are covered by the present national health insurance of
Korea. Recently, South Korea’s fertility rate fell to a new
record low in 2007 as more women engaged in economic
activities and got married at older ages (The Korean
Times, 2007). The average number of babies per woman
of childbearing age was 1.19 as of the end of 2006,
which is much lower than the average 2.56 for the UN
member countries (The Korean Times, 2007).
Induced abortion only with legally acceptable ratio-
nales is allowed in South Korea, yet there is an unspoken
acceptance of the practice. The legally acceptable rea-
sons for induced abortion include genetic defects, com-
municable diseases, pregnancy due to rape, pregnancy
by family members or close relatives, and pregnancy that
threatens the mother’s health.
Pritham and Sammons (1993) investigated Korean
women’s attitudes toward pregnancy and prenatal care
with regard to their beliefs and interactions with
health-care providers from the United States. The sur-
vey was conducted with 40 unemployed Korean
women between the ages of 18 and 35 at an American
military medical-care facility in a major metropolitan
area of Korea. Attitudes toward childbearing prac-
tices and relationships with health-care providers were
elicited. The results indicated that these women were
366 Aggregate Data for Cultural-Specific Groups
2780_Ch20_357-373 16/07/12 11:55 AM Page 366

happy about their pregnancies. Only one-third of the
respondents agreed with the traditional preference for
a male child. About 40 percent of the women
reinforced strong food taboos and restrictions and ac-
knowledged the need to avoid certain foods during
pregnancy. Twenty percent disagreed with the use of
prenatal vitamins, and 25 percent indicated needing
only a 10- to 15-pound weight gain in pregnancy. The
women generally had sound health habits in relation
to physical activity and recognized the harm of smok-
ing while pregnant. The study sample was homoge-
neous and small, limiting the ability to generalize
about the findings.
Pregnancy in the Korean culture is traditionally a
highly protected time for women. Both the pregnancy
and the postpartum period have been ritualized by the
culture. A pregnancy begins with the tae-mong, a
dream of the conception of pregnancy. Once a woman
is pregnant, she starts practicing tae-kyo, which liter-
ally means “fetus education.” The objective of tae-kyo
is to promote the health and well-being of the fetus
and the mother by having the mother focus on art and
beautiful objects. Some beliefs include the following:
• If the pregnant woman handles unclean objects or
kills a living creature, a difficult birth can ensue
(Howard & Barbiglia, 1997).
• Some women wear tight abdominal binders begin-
ning at 20 weeks gestation or work physically hard
toward the end of the pregnancy to increase the
chances of having a small baby (Howard &
Barbiglia, 1997).
• In addition, expectant mothers should avoid duck,
chicken, fish with scales, squid, or crab because
eating these foods may affect the child’s appear-
ance. For example, eating duck may cause the
baby to be born with webbed feet (Howard &
Barbiglia, 1997).
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Ludman, Kang, and Lynn’s study (1992) explored the
food beliefs and diets of 200 pregnant Korean American
women. The food items most frequently consumed were
kimchee (82.5 percent), rice or noodles (81.5 percent),
and fresh fruit (79 percent). Foods avoided during
pregnancy included coffee (19.8 percent), spicy foods
(9.9 percent), chicken (6.9 percent), and crab (6.9 per-
cent). A list of 20 food items was then given to the
women, who were asked to respond whether they con-
sumed the food or not and, if not, to indicate their rea-
sons. A number of respondents indicated that they did
not eat rabbit (91.5 percent), sparrow (91.5 percent),
duck (89.5 percent), goat (84 percent), or blemished fruit
(63 percent) because of dislike or lack of availability.
The reason most frequently given for not eating blem-
ished fruit was that it might produce a skin disease on
the infant or cause an unpleasant face. The study
showed that although many Korean American women
were aware of traditionally taboo foods, they did not
avoid consuming them. An awareness of these beliefs
can give health providers a basis for nutritional educa-
tion for Korean American women.
Birthing practices among both Koreans and Korean
Americans are highly influenced by Western methods.
Women commonly labor and deliver in the supine posi-
tion. After the delivery, women are traditionally served
seaweed soup, a rich source of iron, which is believed
to facilitate lactation and to promote healing of the
mother. Bed rest is encouraged after pregnancy for 7 to
90 days. Women are also encouraged to keep warm by
avoiding showers, baths, and cold fluids or foods.
The postpartum period is seen as the time when
women undergo profound physiological, psychologi-
cal, and sociological changes; this period is known as
the Sanhujori belief system. In this dynamic process,
postpartum women should care for their bodies by
augmenting heat and avoiding cold, resting without
working, eating well, protecting the body from harmful
strains, and keeping clean (Howard & Barbiglia, 1997).
In Western society in which they may lack extended
family members from whom to seek assistance, Korean
women may be faced with a cultural dilemma.
Park and Peterson (1991) studied Korean American
women’s health beliefs, practices, and experiences
in relation to childbirth. Using structured questions,
they interviewed in Korean a nonrandom sample of
20 female volunteers. Those interviewed subscribed to
a holistic view, which emphasized both emotional and
physical health. Only one-half of the women inter-
viewed rated themselves healthy. The authors related
this to the stresses of immigration and pregnancy.
Preventive practices were not found among members
of this group. Only one woman regularly received Pap
smears and did breast self-examinations. A common
People of Korean Heritage 367
R E F L E C T I V E E X E R C I S E 2 0 . 3
Alex, a nurse working at a prenatal clinic in a hospital, is assessing
Sook Park, who is 12 weeks pregnant. Sook was raised and edu-
cated in South Korea; recently married Robert Kim, a Korean
American; and moved to the United States early in her preg-
nancy. Alex found that Sook lost 5 pounds since her last visit.
1. From a cultural standpoint, what might explain Sook’s re-
cent loss of weight?
2. Identify Koreans’ cultural beliefs, attitudes, and practices re-
lated to foods during pregnancy.
3. What Korean cultural beliefs, attitudes, and practices re-
lated to foods during pregnancy might explain Sook’s
weight loss?
4. What are some immigration and acculturation issues that
might influence Sook’s nutrition?
2780_Ch20_357-373 16/07/12 11:55 AM Page 367

finding was that most women participated in a signifi-
cant rest period during puerperium. Those who did
not rest lacked help for the home. All the women ate
brown seaweed soup and steamed rice for about
20 days after childbirth to cleanse the blood and to as-
sist in milk production. Because pregnancy is a hot
condition and heat is lost during labor and delivery,
some women avoided cold foods and water after child-
birth to prevent chronic illnesses such as arthritis. The
baby should be wrapped in warm blankets to prevent
harm from cold winds. Herbal medicines are also used
during puerperium to promote healing and health
(Howard & Barbiglia, 1997).
Health-care providers can improve the health
of Korean American women by providing factual
information about Pap smears and teaching breast
self-examination. Pregnant Korean American women
should be asked about their use of herbal medicine
during pregnancy so that harmless practices can be in-
corporated into biomedical care. Recommendations for
improving postpartum care among Korean American
women include (1) developing an assessment tool that
health-care providers can use to identify traditional
beliefs early in a pregnancy, (2) developing a bilingual
dictionary of common foods, (3) developing pam-
phlets with medical terms used in the U.S. health-care
system, and (4) providing time for practicing English
skills (Park & Peterson, 1991).
Death Rituals
Death Rituals and Expectations
Traditionally in Korea, it was important for Koreans
to die at home. Bringing a dead body home if the
person died in the hospital was considered bad luck.
Consequently, viewing of the deceased occurred at
home if the individual died at home and at the hospi-
tal if the person died at the hospital. Several days or
more were set aside for the viewing, depending on the
status of the deceased. The eldest son was expected
to sit by the body of the parent during the viewing
(Martinson, 1998). Friends and relatives paid their re-
spects by bowing to a photograph of the deceased
placed in the same room in which the body rested. The
guests were then offered the favorite foods of the de-
ceased. Today, most Korean Americans are not accus-
tomed to viewing the body of the deceased. More
commonly, relatives and friends come to pay their
respects by viewing photographs of the deceased.
Although Korean Americans view life support more
positively than European Americans, the majority
in one study did not want such technology (Blackhall
et al., 1999). In addition, they were less likely to have
made a prior decision about life support. Older and
more educated Koreans were less likely to favor telling
patients the truth, believing that patients should not be
told that they have a terminal illness.
An ancestral burial ceremony follows, with the
body being placed in the ground facing south or
north. Both the place and the position of the deceased
are important for the future fortune of the living rel-
atives. Koreans believe that if the spirit is content,
good fortune will be awarded to the family. Unlike
Western graves, a mound of dirt covers the gravesite
of the deceased in Korea.
Cremation is an individual and family choice and
is practiced more commonly in Korea for those who
have no family or die at a young age. For example,
when unmarried people die without any children to
perform ancestral ceremonies, they are often cremated
and their ashes scattered over a body of water.
Rice wine is traditionally sprinkled around the
grave. Korean families bow two to four times in re-
spect at the gravesite, and then the men, in descending
order from the eldest to the youngest, drink rice wine.
Some Korean Americans dedicate a corner of their
home to honor their ancestors because they cannot go
to the gravesite.
Circumstances in which “do not resuscitate” orders
are an issue need to be addressed cautiously. Families
trust physicians and may not question other options.
Because death and dying are fairly well accepted in the
Korean culture, prolonging life may not be highly
regarded in the face of modern technology. Korean
hospitals focus on acute care. Families are expected to
stay with family members to assist in feeding and per-
sonal care around the clock. Thus, many Korean
Americans may expect to care for their hospitalized
family members in health-care facilities.
Responses to Death and Grief
Mourning rituals, with crying and open displays of
grief, are commonly practiced and socially accepted at
funerals, and they signify the utmost respect for the
dead. The eldest son or male family member who sits
by the deceased sometimes holds a cane and makes a
moaning noise to display his grief. The cane is a sym-
bol of needing support. Health-care providers may
need to provide a private setting for Korean Americans
to be able to grieve in culturally congruent ways.
Spirituality
Dominant Religion and Use of Prayer
Confucianism was the official religion of Korea from
the 14th to the 20th centuries. Buddhism, Confucian-
ism, Christianity, shamanism, and Chondo-Kyo are
practiced in Korea today. Chondo-Kyo (religion of
the Heavenly Way) is a nationalistic religion founded
in the 19th century that combines Confucianism,
Buddhism, and Daoism. Among Koreans in South
Korea, the most recent estimates of organized reli-
gions include no affiliation, 49 percent; Christianity,
26 percent; Buddhism, 23 percent; and other and
368 Aggregate Data for Cultural-Specific Groups
2780_Ch20_357-373 16/07/12 11:55 AM Page 368

unknown, 2 percent (CIA World Factbook, 2010). In
the United States, the church acts as a powerful
social support group for Korean immigrants (Im &
Yang, 2006). Jo, Maxwell, Yang, and Bastani (2010)
even suggest that Korean churches have a high
potential to serve an important role in the health of
Korean Americans.
Koreans in America might not pray in the same
fashion as Westerners, but for many people, the spirits
demand homage. Korean churches often have prayer
meetings several times a week, some with early-
morning prayers. Buddhist temples have spirit rooms
attached to them. Although Buddhists believe the
spirit enters a new life, the beliefs of the shamans are
so strong that the Buddhist church incorporated an
area of their church for those who believe that ances-
tral spirits need honoring and homage. With such a
variety of spiritual beliefs, caregivers must assess each
Korean patient individually for religious beliefs and
prayer practices.
Meaning of Life and Individual Sources
of Strength
Family and education are central themes that give
meaning to life for Korean Americans. The nuclear and
extended families are primary sources of strength for
Korean Americans in their daily lives. These concepts
were covered earlier under Family Roles and Organiza-
tion and Educational Status and Occupations.
Spiritual Beliefs and Health-Care Practices
Shamanism is a powerful belief in natural spirits. All
parts of nature contain spirits: rivers, animals, and
even inanimate objects. The many religions of Koreans
create numerous ideologies about what happens with
the spirits of the deceased. Christians believe the spirit
goes to heaven; Buddhists believe the spirit starts a
new life as a person or an animal; and shamanists be-
lieve the spirit stays with the family to watch over
them and guide their actions and fortunes. Such a
variety of faith systems provide a great diversity in
beliefs of the Korean people. Given this diversity of
spiritual beliefs among Koreans, each patient needs an
individual assessment with regard to spiritual and
health-care practices.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Beliefs that influence health-care practices include re-
ligious beliefs (see Dominant Religion and Use of
Prayer) and dietary practices (see Nutrition). Health-
care providers need to be aware that the theme domi-
nating these beliefs is a holistic approach, which
emphasizes both emotional and physical health.
Health-care practices among Koreans in America
are primarily focused on curative rather than preventive
measures. Health promotion in Korea is a relatively new
public-health focus. In Korea, education on dental hy-
giene, sanitation, environmental issues, and other pre-
ventive health measures is being encouraged. Visits to
the physician for an annual physical examination, Pap
smears, and mammograms are uncommon. Among
Koreans, traditional patterns of health promotion in-
clude harmony with nature and the universe, activity
and rest, diet, sexual life, covetousness, temperament,
and apprehension (Lee, 1993).
Responsibility for Health Care
One American study reported that only 13.5 percent of
Korean American men and 11.3 percent of Korean
American women had a digital rectal examination
(DRE) for occult blood. Regression analysis indicated
that gender, education, knowledge of the warning signs
of cancer, and length of residence in the United States
were significantly related to having undergone DRE.
The researchers determined that this group of Korean
Americans did not see health-care providers or health
brochures as valuable sources of information, and to
target this group, efforts should be coordinated with
church and community leaders (Jo et al., 2010).
Because of women’s modesty during physical exam-
inations and their preferences that women perform in-
timate examinations, many Korean women defer having
Pap tests or breast cancer screening tests (Lee, Fogg, &
Sadler, 2006). A recent study among Korean immigrant
women reported that 78 percent of the participants had
gotten a mammogram at some point in their lives and
that 38.6 percent had gotten one in the previous year
(Lee et al., 2006). The reluctance for undergoing Pap
tests directly relates to cervical cancer’s rating as the
number one female cancer diagnosed among women
in Korea (Lee, 2000). Modesty has also been associated
with low rates of mammography among Korean
Americans (Lee, Kim, & Han, 2009), as well as limited
knowledge about breast self-examination and causes of
breast cancer (Han, Williams, & Harrison, 2000).
Recent Korean immigrants come from a country
in which universal health insurance was implemented
in the late 1980s. A government mandate established
employer-based health insurance for medium and
large firms. Regional health insurance systems, sub-
sidized by the government, were later established for
small firms, farmers, and the self-employed. Ryu,
Young, and Park (2001) reported that health insur-
ance coverage was the strongest predictor of Korean
Americans’ utilization of health-care services and
that uninsured Korean Americans have less access
regardless of their health-care needs.
The use and availability of over-the-counter medica-
tions vary tremendously between the United States and
Korea. Many prescription drugs in the United States
such as antibiotics, anti-inflammatory and cardiac med-
ications, and certain pain control medications can be
People of Korean Heritage 369
2780_Ch20_357-373 16/07/12 11:55 AM Page 369

purchased over-the-counter in Korea at any yak bang
(pharmacy). For example, when feeling “tired” or
“fatigued,” older people in Korea may perform home
infusions of dextrose and water or albumin.
Self-medication with herbal remedies is also prac-
ticed. Ginseng is a root used for anything from a rem-
edy for the common cold to an aphrodisiac. Seaweed
soup is used as a medicine. Chinese traditional herbs
are used to control the degree of “wind” that may be in
the body. Other herbal medications are taken for pre-
ventive or restorative purposes. Accordingly, health-
care providers should query their patients about their
use of traditional Korean medicine and must be aware
that herbal medicine may be used in conjunction with
Western biomedicine.
Folk and Traditional Practices
Hanyak, traditional herbal medicine used for creating
harmony between oneself and the larger cosmology, is
a healing method for the body and soul. Hanbang, the
traditional Korean medical-care system, works on the
principle of a disturbed state of ki, cosmological vital
energy. Symptoms are often interpreted in terms of a
psychological base. Treatments include acupuncture,
acumassage, acupressure, herbal medicines, and mox-
ibustion therapy. The therapeutic relationship between
hanui (oriental medicine) doctors and their patients is
genuine, spontaneous, and harmonious. Patients who
use both Western and traditional Korean practitioners
may experience conflicts because of the lack of coop-
eration between hanui and biomedical health-care
providers. Even Korean Americans are known to use
both hanui and biomedical health-care providers.
Shamans are used in healing rituals to ward off
restless spirits. Shamans originated with the religious
belief of shamanism, the belief that all things possess
spirits. A shaman, mundang, is usually a woman who
has special abilities for communicating with spirits.
The shaman is used to treat illnesses after other means
of treatment are exhausted. The shaman performs a
kut, a shamanistic ceremony to eliminate the evil spir-
its causing the illness. Such a ceremony may take place
when a young person dies to prevent his or her spirit
from staying tied to the earth. Others believe a shaman
can eliminate evil spirits that may be causing difficulty
with financial transactions. Although shamans have
been around for many years, Koreans consider them
part of the lowest class. Health-care providers need to
determine whether Koreans in America are using folk
therapies and should include nonharmful practices
with biomedical therapies and prescriptions.
Barriers to Health Care
Because many Korean Americans use various options
for healing, Western medical practices may be used in
conjunction with acupressure, acupuncture, and herbal
medicine. Barriers for Koreans in America may result
from the expense of non-Western therapies, because
many insurance companies do not cover alternative
therapies.
As for many other American residents, the lack of
insurance creates barriers to health care. Paying for
health care out-of-pocket is expensive and not feasible
for many Korean American families. Language, mod-
esty, cultural attitudes toward certain illnesses, and
communication problems also serve as impediments
for access to health care.
Cultural Responses to Health and Illness
Perceptions of pain vary widely among Koreans.
Some Koreans are stoic and are slow to express emo-
tional distress from pain. Others are expressive and
discuss their smallest discomforts. Family and friends
are useful resources for learning some of the historical
coping mechanisms of sick individuals. Nonverbal
cues and facial expressions must be monitored for
those who are stoic rather than expressive. Pain assess-
ments should be conducted regularly, and education
may be necessary for stoic individuals.
Mental illness is stigmatized in the Korean culture.
Bernstein (2007) conducted a study of Korean American
women and their reluctance to use mental health
providers in the United States. Her study concluded
that most of the participants acknowledged the need
for mental health services but did not seek professional
help and coped with the stressors of immigrant life by
endurance, patience, and religion. Pang (1990) explored
the cultural construction of hwa-byung among a group
of Korean immigrant women in the United States,
using a convenience sample. Hwa-byung, a traditional
Korean illness, results from the suppression of anger or
other emotions (Donnelly, 2001). Hwa means “fire and
anger,” and byung means “illness.” All the women in the
study knew the meaning of hwa-byung, and 80 percent
370 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 2 0 . 4
Maria, a nurse working in an in-patient oncology unit, is assess-
ing Jong Kim, age 72 years, who was recently diagnosed with
lung cancer. Jong Kim emigrated from South Korea about
40 years ago and has smoked since he was in his early 20s.
Although Jong does not request pain medication, his facial
expressions show that he is obviously in significant pain.
1. What should the nurse do to adequately assess Jong’s
pain level?
2. What are some Korean cultural beliefs, attitudes, and
practices related to cancer?
3. What Korean cultural beliefs, attitudes, and practices re-
lated to cancer might influence Jong’s pain management?
4. What are some Korean cultural beliefs, attitudes, and
practices related to pain and pain medication?
2780_Ch20_357-373 16/07/12 11:55 AM Page 370

reported having experienced it. The emotions they re-
ported suppressing were sadness, depression, worry,
anger, fright, and fear. Most of the emotions described
were related to conflicts with close relatives or family,
such as sons and daughters or significant others. These
were expressed as physical complaints, ranging from
headaches and poor appetites to insomnia and lack of
energy. The complaints were chronic in nature, and a
variety of remedies were used to alleviate the symp-
toms. Most of the women suggested that hwa-byung
was difficult to cure and accepted the symptoms as in-
evitable. For these older Korean women, hwa-byung was
a mode for constructing illness as a personal, social,
and cultural adaptive response (Pang, 1990). These
women expressed life’s hardships by channeling their
emotional illnesses into physical symptoms.
A community study of Korean Americans addressed
the prevalence, clinical significance, and meaning of
hwa-byung (Lin, Lau, Yamamoto, Zheng, & Kim, 1992).
The results indicated a high percentage of Korean
Americans (11.9 percent) who identified themselves as
suffering from hwa-byung. A strong association was
shown between hwa-byung and major depressive disor-
ders. Although hwa-byung is found predominantly
among older Korean women with little education, this
study’s findings did not support this conclusion. The
ability to generalize these findings, however, is limited
because assignment to the study groups was not com-
pletely random and because the sample size was small.
Historically, the area of special education has not
been well studied or researched in Korea. Families
who have children with mental or physical disabilities
often question what they have done wrong to make
their ancestors angry. Families feel stigmatized for
such a misfortune and cannot accept their children’s
disfigurement or low intellect. Korea lacks social sup-
port to assist families in caring for children with men-
tal or physical disabilities. Some families abandon
these children in their desperate need for support with
long-term care and expenses. Other children are kept
from the public eye in the hope of saving the family
from stigmatization.
The estimated rate of students with a disability re-
ceiving special education in South Korea was about
85 percent in 2007, and about 10,000 students with dis-
abilities were neglected in the Korean education system
(Munhwa, 2007). Also, it was estimated in 2007 that
the number of students with a disability in South
Korea was 77,452 and that 65,940 of them attended ei-
ther a specialized or regular school, in either special or
normal education. In other words, 11,512 students
with a disability were not receiving any education at
all. These statistics may reflect negative attitudes to-
ward people with a disability among Koreans, which
may influence the idea of mainstreaming students with
a mild disability in South Korea. Korean Americans
may hold these same views regarding people with
mental and physical disabilities and need special sup-
port in obtaining assistance.
In Korea, once hospitalized people are physically sta-
ble, they are discharged to their homes to be with the
family. Bowel training and physical therapy activities are
not the responsibility of the hospital. The families must
care for family members at home. Long-term care for
chronic problems or for rehabilitation is rare in Korea.
Thus, Korean Americans are familiar with the concept
of family home care. Depending on their adaptation to
the American health-care system, and families’ contact
with American health-care providers, some Korean
Americans adjust their ideologies on the sick role.
Blood Transfusions and Organ Donation
No beliefs held by Korean Americans prevent the ac-
ceptance of blood transfusions. Organ donation and
organ transplantation are rare, reflecting traditional at-
titudes toward integrity and purity. These issues need
to be approached sensitively with Korean Americans
because they may be influenced by the individual’s
religious beliefs.
Health-Care Providers
Traditional Versus Biomedical Providers
In general, no taboos exist that prevent health-care
providers from delivering care to the opposite gender.
Female physicians are definitely preferred for mater-
nity care and female problems because women feel
more comfortable discussing gynecological and ob-
stetric issues with female physicians. However, more
traditional Koreans frequently prefer health-care
providers who speak Korean, are older, and are of the
same gender, although many will seek health care
from others who do not meet these requirements if
their preferred care provider is not available. Miller
(1990) studied the use of traditional health practition-
ers, acupuncturists, and herbalists among a group of
102 Korean immigrants. The findings indicated that
Korean immigrants with higher incomes were more
likely to use traditional Korean practitioners.
The area of social work is new in Korea. The hospi-
tals have no positions for such a role. A few educa-
tional programs exist in Korea for social workers, but
much development is needed in the area of social sup-
port. Because these roles may be new to many Koreans,
health-care providers may need to encourage Korean
Americans to use these services.
Status of Health-Care Providers
Because traditional Korean culture accords high re-
spect to men, older people, and physicians, the ideal
physician is an older man with gray hair. This shows
that he has experience and wisdom and is able to make
the best decisions. With such a high status in Korea,
physicians expect respect from all other health-care
People of Korean Heritage 371
2780_Ch20_357-373 16/07/12 11:55 AM Page 371

providers. Usually, nurses are expected to carry out
physicians’ orders explicitly. This is not to say that the
nurse cannot question orders, but great time and effort
are spent consulting other nurses before questioning
physicians in the most respectful way. However, as
nurses are becoming more educated in Korea, they are
becoming more assertive and more closely mirror
Western practice patterns.
With an emphasis on increasing the educational level
of nurses, they too are gaining stature and respect in
Korean culture. Baccalaureate, masters, and doctoral
programs are available for nurses in Korea, although
exact numbers are not available.
R E F E R E N C E S
Asianinfo. (2010a). General information—Seoul. Retrieved from http://
www.asianinfo.org/asianinfo/seoul/general_information.htm
Asianinfo. (2010b). Korean drama. Retrieved from http://www.
asianinfo.org/asianinfo/korea/about_korea.htm
Bernstein, K.S. (2007). Mental health issues among urban Korean
American immigrants. Journal of Transcultural Nursing, 18(2),
175–180.
Blackhall, L., Frank, G., Murphy, S., Michel, V., Palmer, J., Azen,
S., et al. (1999). Ethnicity and attitudes toward life sustaining
technology. Social Science Medicine, 48(12), 1779–1789.
Cho, J., & Juon, H.S. (2006). Assessing overweight and obesity
risk among Korean Americans in California using World
Health Organization body mass index criteria for Asians.
Prevention of Chronic Disease, 3(3), A79.
Cho, Y.I., & Faulkner, W.R. (1993). Conception of alcoholism
among Koreans and Americans. International Journal of the
Addictions, 28(8), 681–694.
Choi, E. (1995). A contrast of mothering behaviors in women from
Korea and the United States. Journal of Obstetric, Gynecologic,
and Neonatal Nursing, 24(4), 363–369.
CIA World FactBook. (2010). Korea. Retrieved from https://www.
cia.gov/library/publications/the-world-factbook/geos/ks.html
CNN. (2010). Complete coverage on North Korea. Retrieved from
http://topics.cnn.com/topics/north_korea
Donnelly, P.L. (2001). Korean American family experiences of
caregiving for their mentally ill adult children: An interpreta-
tive study. Journal of Transcultural Nursing, 12(4), 292–301.
Han, Y., Williams, R., & Harrison, R. (2000). Breast cancer screen-
ing knowledge, attitudes, and practices among Korean-American
women. Oncology Nursing Forum, 27(10), 1589–1591.
Howard, J., & Barbiglia, V. (1997). Caring for childbearing Korean
women. Journal of Obstetric, Gynecologic, and Neonatal Nursing,
26(6), 665–671.
Im, E.O. (2002). Korean culture. In P.S. St. Hill, J. Lipson, & A.I.
Meleis (Eds.), Caring for women cross-culturally: A portable
guide. Philadelphia: F.A. Davis Company.
Im, E.O., & Meleis, A.I. (2001). Women’s work and symptoms
during menopausal transition: Korean immigrant women.
Women and Health, 33(1/2), 83–103.
Im, E.O., & Yang, K. (2006). Theories on immigrant women’s
health. Health Care Women International, 27(8), 666–681.
Jo, A.M., Maxwell, A.E., Yang, B., & Bastani, R. (2010). Con-
ducting health research in Korean American churches: Per-
spectives from church leaders. Journal of Community Health,
35(2), 156–164.
Johanning, E., Goldberg, M., & Kim, R. (1994). Asbestos hazard
evaluation in South Korean textile production. International
Journal of Health Services, 24(1), 131–144.
Kim, E., Cain, K., & McCubbin, M. (2006). Maternal and pater-
nal parenting, acculturation, and young adolescents’ psycho-
logical adjustment in Korean American families. Journal of
Child Adolescent Psychiatric Nursing, 19(3), 112–129.
Kim, K.E. (2003). Gastric cancer in Korean Americans: Risks and
reductions. Korean American Studies Bulletin, 13(1/2), 84–90.
Kim, H., & Chung, R.H. (2003). Relationship of recalled parenting
style to self-perception in Korean American college students.
Journal of Genetic Psychology, 164(4), 481–492.
Kim, K.K., Yu, E.S., Chen, E.H., Cross, N., & Kim, J. (2000).
Nutritional status of Korean Americans: Implications for
cancer risk. Oncology Nursing Forum, 27(10), 1573–1583.
Kim, Y.G., & Hahn, S.J. (2006). Homosexuality in ancient and
modern Korea. Culture Health and Sex, 8(1), 59–65.
Kimmel, D.C., & Yi, H. (2004). Characteristics of gay, lesbian,
and bisexual Asians, Asian Americans, and immigrants from
Asia to the U.S.A. Journal of Homosexuality, 47(2), 143–172.
Kohls, R.L. (2001). Learning to think Korean. Yarmouth, ME:
Intercultural Press.
Korean Language. (2010). Dialects. Retrieved from http://www.
korean-language.org/korean/dialects.asp
Migration Information Source. (2010). Korean immigrants in the
United States. Retrieved from http://www.migrationinformation.
org/USfocus/display.cfm?ID=793
Lee, Y. (1993). Health promotion: Patterns of traditional health
promotion in Korea. Kanhohak Tamgu, 2(2), 21–36.
Lee, M. (2000). Knowledge, barriers, and motivators related to
cervical cancer screening among Korean-American women. A
focus group approach. Cancer Nursing, 23(3), 168–175.
Lee, E. E., Fogg, L. F., & Sadler, G. R. (2006). Factors of breast can-
cer screening among Korean immigrants in the United States.
Journal of Immigrant and Minority Health, 8(3), 223–233.
Lee, H., Kim, J., & Han, H. R. (2009). Do cultural factors predict
mammography behaviour among Korean immigrants in the
USA? Journal of Advanced Nursing, 65(12), 2574–2584.
Lee, D. C., & Lee, E. H. (1990). Korean immigrant families in
America: Role and value conflicts. In H. C. Kim & E. H. Lee
(Eds.), Koreans in America: Dreams and realities (pp. 165–177).
Seoul: Institute of Korean Studies.
Lee, Y.H., Lee, J., Kim, M. T., & Han, H.R. (2009), In-depth as-
sessment of the nutritional status of Korean American elderly.
Geriatric Nursing, 30(5), 304–311.
Lee, S., Sobal, J., & Frongillo, E. (2000). Acculturation and health
in Korean Americans. Social Science Medicine, 51(2), 159–173.
Levy, R. (1993). Ethnic and racial differences in response to med-
icines: Preserving individualized therapy in managed pharma-
ceutical programmes. Pharmaceutical Medicine, 7, 139–165.
Lew, R., Moskowitz, J.M., Wismer, B.A., Min, K., Kang, S.H.,
Chen, A.M., & Tager, I.B. (2001). Correlates of cigarette smok-
ing among Korean American adults in Alameda County,
California. Asian American Pacific Islander Journal of Health,
9(1), 49–60.
Lin, K., Lau, J.K., Yamamoto, J., Zheng, Y.P., & Kim, K.H. (1992).
Hwa-Byung: A community study of Korean Americans. Journal
of Nervous and Mental Disease, 180(6), 386–391.
Ludman, E.K., Kang, K.J., & Lynn, L.L. (1992). Food beliefs and
diets of pregnant Korean American women. Journal of the
American Dietetic Association, 92(12), 1519–1520.
Martinson, I.M. (1998). Funeral rituals in Taiwan and Korea.
Oncology Nursing Forum, 25(10), 1756–1760.
372 Aggregate Data for Cultural-Specific Groups
2780_Ch20_357-373 16/07/12 11:55 AM Page 372

Meyer, U. (1992). Drugs in special patient groups: Clinical impor-
tance of genetics in drug effects. In M. Melmon & T. Morrelli
(Eds.), Clinical pharmacology: Basic principles in therapeutics
(8th ed., pp. 62–83). New York: Pergamon Press.
Miller, J. (1990). Use of traditional Korean health care by Korean
immigrants to the United States. Sociology and Social Re-
search, 75(1), 38–48.
Munhwa. (2007). About 10,000 disabled students neglected in edu-
cation system. Retrieved from http://www.munhwa.com/news/
view.html?no=20071006010305270970010
Munoz, C., & Hilgenberg, C. (2005). Ethnopharmacology. Amer-
ican Journal of Nursing, 105(8), 40–49.
Nakashima, J., & Wong, M.M. (2000). Characteristics of alcohol
consumption, correlates of alcohol misuse among Korean
American adolescents. Journal of Drug Education, 30(3),
343–359.
Organization for Economic Cooperation and Development
(OECD). (2010). Marriage and divorce rates. Retrieved from
http://www.oecd.org/dataoecd/4/19/40321815
Pang, K.Y. (1990). Hwa-Byung: The construction of a Korean
popular illness among Korean elderly immigrant women in the
United States. Culture, Medicine, and Psychiatry, 14, 495–512.
Park, M.S. (2001). The factors of child physical abuse in Korean
immigrant families. Child Abuse Neglect, 25(7), 945–958.
Park, S.Y., Murphy, S.P., Sharma, S., & Kolonel, L.N. (2005).
Dietary intakes and health-related behaviours of Korean
American women born in the USA and Korea: The multiethnic
cohort study. Public Health Nutrition, 8(7), 904–911.
Park, S., Oh, S., & Lee, M. (1998). Korean Status of alcoholics
and alcohol-related health problems. Alcohol and Clinical
Expression Research, 22(3, Suppl), 170S–172S.
Park, K.Y., & Peterson, L.M. (1991). Beliefs, practices, and expe-
riences of Korean women in relation to childbirth. Health Care
for Women International, 12(2), 261–269.
Pritham, U.A., & Sammons, L.N. (1993). Korean women’s atti-
tudes toward pregnancy and prenatal care. Health Care for
Women International, 14, 145–153.
Ryu, H., Young, W.B., & Park, C. (2001). Korean American health
insurance and health services utilization. Research and Nursing
Health, 24(6), 494–505.
Sorensen, C.W. (1994). Success and education in South Korea.
Comparative Education Review, 38(1), 10–35.
The Hankyoreh. (2007). 1 out of 20 Korean youths attempts suicide:
Study. Retrieved from http://english.hani.co.kr/arti/english_
edition/e_national/199975.html
The Korean Times. (2007). South Korea has 4th lowest birth rate.
Retrieved from http://www.koreantimes.co.kr/www/news/nation/
2007/06/117_5515.html
U.S. Census Bureau. (2006). 2005 American community survey.
Minneapolis, MN: Minnesota Population Center.
U.S. Department of State. (2010). Korea, Republic of Country Spe-
cific Information. Retrieved from http://travel.state.gov/travel/
cis_pa_tw/cis/cis_1018.html#safety
Weatherspoon, A., Park, J., & Johnson, R. (2001). A family study
of homeland Korean alcohol use. Addictive Behavior, 26(1),
101–113.
World Health Organization. (2004). Alcohol consumption among
adults. Retrieved from http://www.nationsencyclopedia.com/
WorldStats/WHO-alcohol-consumption-adults.html
Yi, M., & Jezewski, M. (2000). Korean nurses’ adjustment to hos-
pitals in the United States of America. Journal of Advanced
Nursing, 32(3), 721–729.
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
People of Korean Heritage 373
2780_Ch20_357-373 16/07/12 11:55 AM Page 373

374
Chapter 21
People of Mexican Heritage
Rick Zoucha and Cecilia A. Zamarripa
Overview, Inhabited Localities,
and Topography
Overview
People of Mexican heritage are a very diverse group
geographically, historically, and culturally and are
not easy to describe. Although no specific set of
characteristics can fully describe people of Mexican
heritage, some commonalities distinguish them as an
ethnic group, with many regional variations that re-
flect subcultures in Mexico and in the United States.
A common term used to describe Spanish-speaking
populations in the United States, including people
of Mexican heritage, is Hispanic. However, the term
can be misleading and can encompass many differ-
ent people clustered together owing to a common
heritage and lineage from Spain. Many Hispanic
people prefer to be identified by descriptors more
specific to their cultural heritage, such as Mexican, Mex-
ican American, Latin American, Spanish American,
Chicano, Latino, or Ladino. Therefore, when refer-
ring to Mexican Americans, use that phrase instead
of Hispanic or Latino (Vázquez, 2004). As a broad
ethnic group, people of Mexican heritage often refer
to themselves as la raza, which means “the race.”
The Spanish word for race has a different meaning
than the American interpretation of race. The con-
cept of la raza has brought people together from
separate worlds to make families and is about inclu-
sion (Vázquez, 2000).
Heritage and Residence
Mexico, with an estimated population of 113,724,226
(CIA World Factbook, 2011), is inhabited by white
Spanish, Indians, American Indians, Middle Easterns,
and Africans. Mexican Americans are descendants
of Spanish and other European whites; Aztec,
Mayan, and other Central American Indians; and
Inca and other South American Indians, as well
as people from Africa (Schmal & Madrer, 2007).
Some individuals can trace their heritage to North
American Indian tribes in the southwestern part of
the United States.
Mexico City, one of the largest cities in the world,
has a population of over 20 million. Mexico is under-
going rapid changes in business and health-care prac-
tices. Undoubtedly, these changes have accelerated
and will continue to accelerate since the passage of the
North American Free Trade Agreement as people are
more able to move across the border to seek employ-
ment and educational opportunities.
Historically, for generations, people of Mexican
heritage lived on the land that is now known as the
southwestern United States, long before the first
white settlers came to the territory. By 1853, approx-
imately 80,000 Spanish-speaking settlers lived in the
area lost by Mexico during the Texas Rebellion,
the Mexican War, and the Gadsden Purchase. After
the northern part of Mexico was annexed to the
United States, the settlers were not officially consid-
ered immigrants but were often viewed as foreigners
by incoming white Americans. By 1900, Mexican
Americans numbered approximately 200,000. How-
ever, during the “Great Migration” between 1900
and 1930, an additional 1 million Mexicans entered
the United States. This may have been the greatest
immigration of people in the history of humanity
(Library of Congress, 2005).
Hispanics, the fastest-growing ethnic population in
the United States, include over 44.3 million people
(U.S. Census Bureau, 2008). Sixty-six percent of all
Hispanics are of Mexican heritage (U.S. Census
Bureau, 2010). Mexican Americans reside predomi-
nantly in California, Texas, Illinois, Arizona, Florida,
New Mexico, and Colorado. However, the major
concentration of Mexican Americans, totaling over
19 million, is found in the southern and western por-
tions of the United States (U.S. Census Bureau, 2010).
Ninety percent of Mexican Americans live in urban
areas such as San Diego, Los Angeles, New York City,
Chicago, and Houston, whereas less than 10 percent
reside in rural areas.
2780_Ch21_374-390 16/07/12 11:55 AM Page 374

People of Mexican Heritage 375
Reasons for Migration and Associated
Economic Factors
Historically, many Mexicans left Mexico during the
Mexican Revolution to seek political, religious, and
economic freedoms (Casa Historia, 2011). Following
the Mexican Revolution, strict limits were placed on
the Catholic Church, and, until recently, clerics were
not allowed to wear their church garb in public.
For many, this restricted the expression of faith and
was a minor factor in their immigration north to
the United States (Meyer & Beezley, 2000). Since the
“Great Migration,” the limited employment opportu-
nities in Mexico, especially in rural areas, have en-
couraged Mexicans to migrate to the United States
as sojourners or immigrants or with undocumented
status; the latter are often derogatorily referred to
as wetbacks (majodos) by the white and Mexican
American populations.
Of the undocumented immigrants in the United States,
an estimated 6 million are from Mexico (Van Hook,
Bean, & Passel, 2005). Before the Immigration Reform
and Control Act of 1986, hundreds of thousands
of Mexicans crossed the border, found jobs, and
settled in the United States. Although the numbers
have decreased since 1986, border towns in Texas
and California still experience large influxes of
Mexicans seeking improved employment and educa-
tional opportunities. The tide of illegal immigration
to the United States has decreased from 2008, at which
time it was over 7 million. In 2010, that number
decreased to 6,640,000 (Department of Homeland
Security, 2011). Illegal immigration and what can or
should be done to control it, especially in border states
with Mexico, continue to be hotly debated issues.
Annually, many migrants die trying to illegally emi-
grate. Solutions to U.S. citizens’ concerns are not
forthcoming in the near future. Even though the econ-
omy of Mexico has grown, the buying power of the
peso has decreased, and inflation rates have increased
faster than wages; thus, 47 percent of the population
continues to live in poverty (CIA World Factbook,
2011). Recent Mexican immigrants are more likely
to live in poverty, are more pessimistic about their
future, and are less educated than previous immi-
grants. Many Mexicans are among the very poor, with
little hope of improving their economic status.
Between the years 1999 and 2000 in the United States,
the poverty rate for Hispanics was 33.1 percent (U.S.
Census Bureau, 2009).
Educational Status and Occupations
Many second- and third-generation Mexican Americans
have significant job skills and education. By contrast,
many, especially newer immigrants from rural areas,
have poor educational backgrounds and may place
little value on education because it is not needed to
obtain jobs in Mexico. Once in the United States, they
initially find work similar to that which they did in
their native land, including farming, ranching, mining,
oil production, construction, landscaping, and domes-
tic jobs in homes, restaurants, and hotels and motels.
Economic and educational opportunities in the
United States are attainable, which allows immigrants
to pursue the great American dream of a perceived
better life (Kemp, 2001). Many Mexicans and Mexican
Americans work as seasonal migrant workers and may
relocate several times each year as they “follow the
sun.” Sometimes their unwillingness or inability to learn
English is related to their intent to return to Mexico;
however, this may hinder their ability to obtain better-
paying jobs (Fig. 21-1).
The mean educational level in Mexico is 5 years.
Until 1992, Mexican children were required to attend
school through the sixth grade, but since the Mexican
School Reform Act of 1992, a ninth-grade education
is required. However, great strides have been made in
educational standards in Mexico, which now reports
an 86.1 percent literacy rate among its population
(CIA World Factbook, 2011). A common practice
among parents in poor rural villages is to educate their
children in what they need to know. This group often
finds immigration to the United States to be their
most attractive option. For many Mexicans, high
school and a university education are neither available
nor attainable.
Hispanics are the most undereducated ethnic
group in the United States, with only 45 percent
aged 25 years or older having a high school educa-
tion, compared with 90 percent for non-Hispanic
whites. However, the number of Hispanics who com-
pleted 4 years of college has increased to 7.3 percent
of the total Hispanic population, up from 6.4 percent
in 2000 (U.S. Census Bureau, 2011). As second- and
third-generation Mexican Americans acculturate and
improve their socioeconomic status, these percent-
ages are likely to increase the same as they have for
Figure 21-1 A migrant worker camp on Maryland’s eastern
shore. The Sanchez family (discussed in the case study on
DavisPlus) lives in such a camp, as do many Mexican American
farm workers in the United States.
2780_Ch21_374-390 16/07/12 11:55 AM Page 375

immigrants from European countries in previous
centuries.
Communication
Dominant Language and Dialects
Mexico is one of the largest Spanish-speaking countries
in the world, with over 80 million speaking the language.
The dominant language of Mexicans and Mexican
Americans is Spanish. However, Mexico has 54 indige-
nous languages and more than 500 different dialects
(Spanish Language, 2007). Knowing the region from
which a Mexican American originates may help to iden-
tify the language or dialect the individual speaks. For
example, major indigenous languages besides Spanish
include Nahuatl and Otami, spoken in central Mexico;
Mayan, in the Yucatan peninsula; Maya-Quiche, in the
state of Chiapas; Zapotec and Mixtec, in the valley
of Oaxaca; Tarascan, in the state of Michoacan; and
Totonaco, in the state of Veracruz. Many of the Spanish
dialects spoken by Mexican Americans have similar
word meanings, but the dialects spoken by other groups
may not. Because of the rural isolationist nature of
many ethnic groups and the influence of native Indian
languages, the dialects are so diverse in selected regions
that it may be difficult to understand the language,
regardless of the degree of fluency in Spanish.
Radio and television programs broadcasting in
Spanish in both the United States and Mexico have
helped to standardize Spanish. For the most part,
public broadcast communication is primarily derived
from Castilian Spanish. This standardization reduces
the difficulties experienced by subcultures with multi-
ple dialects. When speaking in a nonnative language,
health-care providers must select words that have
relatively pure meanings in the language and avoid the
use of regional slang.
Contextual speech patterns among Mexican
Americans may include a high-pitched, loud voice
and a rate that seems extremely fast to the untrained
ear. The language uses apocopation, which accounts
for this rapid speech pattern. An apocopation occurs
when one word ends with a vowel and the next word
begins with a vowel. This creates a tendency to drop
the vowel ending of the first word and results in an
abbreviated, rapid-sounding form. For example, in
the Spanish phrase for “How are you?,” ¿Cómo está
usted? may become ¿Comestusted?. The last word,
usted, is frequently dropped. Some may find this fast
speech difficult to understand. However, if one asks
the individual to enunciate slowly, the effect of the
apocopation or truncation is less pronounced.
To help bridge potential communication gaps,
health-care providers need to watch the patient for
cues, paraphrase words with multiple meanings, use
simple sentences, repeat phrases for clarity, avoid the
use of regional idiomatic phrases and expressions, and
ask the patient to repeat instructions to ensure accu-
racy. Approaching the Mexican American patient
with respect and personalismo (behaving like a friend)
and directing questions to the dominant member of a
group (usually the man) may help to facilitate more
open communication. Zoucha and Husted (2002)
found that becoming personal with the patient or
family is essential to building confidence and promot-
ing health. The concept of personalismo may be diffi-
cult for some health-care providers because they
are socialized to form rigid boundaries between the
caregiver and the patient and family.
Cultural Communication Patterns
Whereas some topics, such as income, salary, or in-
vestments, are taboo, Mexican Americans generally
like to express their inner beliefs, feelings, and emo-
tions once they get to know and trust a person.
Meaningful conversations are important, often be-
come loud, and seem disorganized. To the outsider,
the situation may seem stressful or hostile, but this
intense emotion means the conversants are having a
good time and enjoying one another’s company.
Within the context of personalismo and respeto—
respect—health-care providers can encourage open
communication and sharing and develop the
patient’s sense of trust by inquiring about family
members before proceeding with the usual business.
It is important for health-care providers to engage
in “small talk” before addressing the actual health-
care concern with the patient and family (Zoucha &
Reeves, 1999).
Mexican Americans place great value on closeness
and togetherness, including when they are in an in-
patient facility. They frequently touch and embrace
and like to see relatives and significant others. Touch
between men and women, between men, and between
women is acceptable. To demonstrate respect, compas-
sion, and understanding, health-care providers should
greet the Mexican American patient with a hand-
shake. Once rapport is established, providers may
further demonstrate approval and respect through
backslapping, smiling, and affirmatively nodding the
head. Given the diversity of dialects and the nuances
of language, culturally congruent use of humor is dif-
ficult to accomplish and, therefore, should be avoided
unless health-care providers are absolutely sure there
is no chance of misinterpretation. Otherwise, inappro-
priate humor may jeopardize the therapeutic relation-
ship and opportunities for health teaching and health
promotion.
Mexican Americans consider sustained eye contact
when speaking directly to an older person to be rude.
Direct eye contact with teachers or superiors may be
interpreted as insolence. Avoiding direct eye contact
with superiors is a sign of respect. This practice may
or may not be seen with second- or third-generation
376 Aggregate Data for Cultural-Specific Groups
2780_Ch21_374-390 16/07/12 11:55 AM Page 376

People of Mexican Heritage 377
Mexican Americans. Health-care providers must take
cues from the patient and family.
Temporal Relationships
Many Mexican Americans, especially those from
lower socioeconomic groups, are necessarily present
oriented. Many individuals do not consider it impor-
tant or have the income to plan ahead financially. The
trend is to live in the “more important” here and now,
because mañana (tomorrow) cannot be predicted.
With this emphasis on living in the present, preventive
health care and immunizations may not be a priority.
Mañana may or may not really mean tomorrow; it
often means “not today” or “later.”
Some Mexicans and Mexican Americans perceive
time as relative rather than categorically imperative.
Deadlines and commitments are flexible, not firm.
Punctuality is generally relaxed, especially in social sit-
uations. This concept of time is innate in the Spanish
language. For example, one cannot be late for an
appointment; one can only arrive late. In addition,
immigrants from rural environments where adhering
to a strict schedule is not important may not own a
clock or even be able to tell time.
Because of their more relaxed concept of time,
Mexican Americans may arrive late for appointments,
although the current trend is toward greater punctu-
ality. Health-care facilities that use an appointment
system for patients may need to make special provi-
sions to see patients whenever they arrive. Health-care
providers must carefully listen for clues when dis-
cussing appointments. Disagreeing with health-care
providers who set the appointment may be viewed as
rude or impolite. Therefore, some Mexican Americans
will not tell you directly that they cannot make the
appointment. In the context of the discussion, they
may say something like “My husband goes to work at
8:00 a.m., and the children are off to school, and then
I have to do the dishes. . . .” The health-care provider
should ask, “Is 8:30 a.m. on Thursday okay for you?”
The person might say yes, but the health-care provider
must still intently listen to the conversation and then
possibly negotiate a new time for the appointment. In
the conversation, the patient may just give clues
that he or she will not arrive on time, because it is
important to save face and avoid being rude by saying
that outright.
Format for Names
Names in most Spanish-speaking populations seem
complex to those unfamiliar with the culture. A typical
name is La Señorita Olga Gaborra de Rodriguez.
Gaborra is the name of Olga’s father, and Rodriguez
is her mother’s surname. When she marries a man with
the surname Guiterrez, she becomes La Señora (de-
notes a married woman) Olga Guiterrez de Gaborra y
Rodriguez. The word de is used to express possession,
and the father’s name, which is considered more im-
portant than the mother’s, comes first. However, this
full name is rarely used except on formal documents
and for recording the name in the family Bible. Out of
respect, most Mexican Americans are more formal
when addressing nonfamily members. Thus, the best
way to address Olga is not by her first name but rather
as Señora Guiterrez. Titles such as Don and Doña for
older respected members of the community and family
should remain—not all members are respected so not
all would have the title Don or Doña. If using English
while communicating with people older than the nurse
or health-care provider, use titles such as Mr., Ms., Miss,
or Mrs., as a sign of respect.
Health-care providers must understand the role of
older people when providing care to people of Mexican
heritage. To develop confidence and personalismo, an
element of formality must exist between health-care
providers and older people. Becoming overly familiar
by using physical touch or addressing them by first
names may not be appreciated early in a relationship
(Kemp, 2001). As the health-care provider develops
confidence in the relationship, becoming familiar may
be less of a concern. However, using the first name of
an older patient may never be appropriate (Zoucha &
Husted, 2000).
Family Roles and Organization
Head of Household and Gender Roles
The typical family dominance pattern in traditional
Mexican American families is patriarchal, with evidence
of slow change toward a more egalitarian pattern in
recent years (Grothaus, 1996). Change to a more egali-
tarian decision-making pattern is primarily identified
with more educated and higher socioeconomic families.
Machismo in the Mexican culture sees men as having
strength, valor, and self-confidence, which are valued
traits among many. Men are seen as wiser, braver,
stronger, and more knowledgeable regarding sexual
matters. The female takes responsibility for decisions
within the home and for maintaining the family’s health.
Machismo assists in sustaining and maintaining health
not only for the man but also with implications for the
health and well-being of the family (Sobralske, 2006).
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Children are highly valued because they ensure the
continuation of the family and cultural values (Locke,
1998). They are closely protected and not encouraged
to leave home. Even compadres (godparents) are in-
cluded in the care of the young. Each child must have
godparents in case something interferes with the par-
ents’ ability to fulfill their child-rearing responsibilities.
Children are taught at an early age to respect parents
and older family members, especially grandparents.
2780_Ch21_374-390 16/07/12 11:55 AM Page 377

Physical punishment is often used as a way of main-
taining discipline and is sometimes considered child
abuse in the United States. Using children as inter-
preters in the health-care setting is discouraged owing
to the restrictive nature of discussing gender-specific
health assessments.
Family Goals and Priorities
The concept of familism is an all-encompassing value
among Mexicans, for whom the traditional family is still
the foundation of society. Family takes precedence over
work and all other aspects of life. In many Mexican
families, it is often said “God first, then family.” The
dominant Western health-care culture stresses including
both the patient and the family in the plan of care.
Mexicans are strong proponents of this family care con-
cept, which includes the extended family. By including
all family members, health-care providers can build
greater trust and confidence and, in turn, increase ad-
herence to health-care regimens and prescriptions
(Wells, Cagle, & Bradley, 2006).
378 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 2 1 . 1
Mrs. Garcia is a 55-year-old Mexican American woman re-
cently diagnosed with blockages in her coronary vessels, and
as a result, she will undergo a coronary artery bypass graft.
Mrs. Garcia is recently widowed and is grieving for her husband
of 39 years. She has 7 children (3 sons aged 39, 34, and 31;
4 daughters aged 37, 35, 33, and 29) and 20 grandchildren. The
youngest son lives at home with his mother along with his
wife and 5 children. The other children live within 10 blocks.
Mrs. Garcia spends a lot of time helping to care for the grand-
children while her children work. The five youngest members
of the family were born in the United States, and the rest of
the family was born in Oaxaca, Mexico. Mrs. Garcia has never
worked outside of the home and receives survivor benefits
from her husband’s pension. The only job she has ever done is
house cleaning and other domestic help for her husband’s pre-
vious work acquaintances. Mrs. Garcia has one living brother
who lives 8 miles away and a sister who died of heart disease
5 years ago.
The Garcia family members are Catholics. Mrs. Garcia is a
very devout Catholic and attends Mass daily at the church
three blocks away. The children attend Mass with the family on
occasional Sundays. Mrs. Garcia prays the rosary and novenas
so that God will take care of her and her family. Mrs. Garcia is
a good cook and prepares dinner every evening for one of
her sons and his family. The daughter-in-law helps cook the
meals even after a full day of work. Mrs. Garcia and her family
live in a three-bedroom wood frame house. The home is
located in a Mexican American neighborhood 2 miles from
the Mexican border in Reynosa, Texas.
Mrs. Garcia does not have any work experience and is
grateful her husband left a small but substantial life insurance
policy. Mrs. Garcia receives help with shopping and rides to the
doctor from her youngest daughter and many comadres.
One of her comadres is a curandera who has been offering
Mrs. Lopez herbs and teas to help healing. Mrs. Garcia enjoys
making tamales and menudo in her kitchen along with her fam-
ily and comadres. All of the Garcia children and comadres have
committed to help Mrs. Garcia during and after her surgery.
1. When the home health nurse comes to assess Mrs. Garcia’s
incision and teaches about wound care, who should be
included in the teaching and why?
2. Explain the importance of familism to the Garcia family.
3. Mrs. Garcia has been offered herbal tea by the curandera
while the home nurse is making a visit. Should the nurse
intervene to stop this practice? Please provide rationale
for your answer.
4. The nurse is making a visit when the family is praying the
rosary together for the health of Mrs. Garcia. The nurse is
invited to join. What should the nurse do in this situation?
Blended communal families are almost the norm in
lower socioeconomic groups and in migrant-worker
camps. Single, divorced, and never-married male and
female children usually live with their parents or ex-
tended families, regardless of economics. Extended
kinship is common through padrinos: godparents who
may be close friends and are considered the same as
family (Zoucha & Zamarripa, 1997). Thus, the words
brother, sister, aunt, and uncle do not necessarily mean
that they are related by blood. For many men, having
children is evidence of their virility and a sign of
machismo.
When grandparents and older parents are unable
to live on their own, they generally move in with
their children. The extended family structure and the
Mexicans’ obligation to visit sick friends and rela-
tives encourage large numbers to visit hospitalized
family members and friends. This practice may
necessitate that health-care providers relax strict
visiting policies in health-care facilities.
Social status is highly valued among Mexican
Americans, and a person who holds an academic
degree or position with an impressive title commands
great respect and admiration from family, friends, and
the community. Good manners, a family, and family
lineage, as indicated by extensive family names, also
confer high status for Mexicans.
Alternative Lifestyles
Twenty-three percent of Mexican families in the
United States live in poverty, and many are headed by
a single female parent. This percentage is lower than
that for other minority groups in the United States
(U.S. Census Bureau, 2010). Because the Hispanic
cultural norm is for a pregnant woman to marry,
Mexicans are more likely to marry at a young age. Yet,
2780_Ch21_374-390 16/07/12 11:55 AM Page 378

People of Mexican Heritage 379
common-law marriages (unidos) are frequently prac-
ticed and readily accepted, with many couples living
together their entire lives.
Although homosexual behavior occurs in every so-
ciety, The Williams Project reported that five states—
California, Texas, New York, Florida, and Illinois—
have the highest number of same-sex Latino couples,
totaling 100,796, living together in the United States
(Gates, Lau, & Sears, 2006). Newspapers from Houston,
Texas; Washington, DC; and Chicago, Illinois, report
on the efforts of Hispanic lesbian and gay organizations
in the areas of HIV and AIDS (La SIDA in Spanish)
and life partner benefits. In Mexico, homosexuality is
not a crime, but antihate groups raised serious con-
cerns about killings of homosexual men, causing
many to remain closeted (RefWorld, 2011). In Mexico,
machismo plays a large part in the phobic attitudes to-
ward gay behavior. Larger cities in the United States
may have Ellas, a support group for Latina lesbians;
El Hotline of Hola Gay, which provides referrals and
information in Spanish; or Dignity, for gay Catholics.
Health-care providers who wish to refer gay and lesbian
patients to a support group may use such agencies.
Workforce Issues
Culture in the Workplace
In the United States, Hispanics are the most underrep-
resented minority group in the health-care workforce.
Although more than 13 percent of the American
population is of Hispanic origin, only 3.6 percent of
registered nurses are from Hispanic heritage (U.S.
Department of Health and Human Services Health
Resources and Services Administration, 2010). Cultural
differences that influence workforce issues include
values regarding family, pedagogical approach to edu-
cation, emotional sensitivity, views toward status, aes-
thetics, ethics, balance of work and leisure, attitudes
toward direction and delegation, sense of control, views
about competition, and time.
People educated in Mexico are likely to have been
exposed to pedagogical approaches that include rote
memorization and an emphasis on theory with little
practical application taught within a rigid, broad
curriculum. American educational systems usually em-
phasize an analytical approach, practical applications,
and a narrow, in-depth specialization. Thus, additional
R E F L E C T I V E E X E R C I S E 2 1 . 2
Mr. Rodriguez is an 80-year-old Mexican American man who
was recently diagnosed with bladder and prostate cancer.
Mr. Rodriquez has been married for 60 years and has 8 adult
children (3 daughters aged 57, 51, and 40; 5 sons aged 55, 53,
44, 43, and 42), 19 grandchildren, and 4 great-grandchildren.
Mr. Rodriquez’s youngest son and his family live with Mr. and
Mrs. Rodriguez. The other Rodriquez children, except the
second-oldest daughter, live within 3 to 10 miles from their
parents. The second-oldest daughter is a teacher and lives out
of state. All members of the family except for Mr. Rodriquez
were born in the United States. He was born in Guanajuato,
Mexico, and immigrated to the United States at the age of 16 in
order to work and send money back to the family in Mexico.
Mr. Rodriguez has returned to Mexico throughout the years to
visit and has lived in California ever since. Mr. Rodriguez is re-
tired from work as a carpet layer. Mr. Rodriquez has one living
older brother who lives within 15 miles. All members of the
family speak Spanish and English fluently.
The Rodriguez family is Catholic, as evidenced by the reli-
gious items hanging on the wall and prayer books and rosary
on the coffee table. Statues of St. Jude and Our Lady of
Guadalupe are on the living room table. Mr. and Mrs. Rodriguez
have made many mandas (bequests) to pray for the health of
the family, including one to thank God for the healthy birth of
all the children, especially after the doctor had discouraged
them from having any children after the complicated birth of
their first child. The family attends Mass together every Sunday
morning and then meets for breakfast chorizo at a local restau-
rant frequented by many of their church’s other parishioner
families. Mr. Rodriguez believes his health and the health of his
family are in the hands of God.
The Rodriguez family lives in a modest three-bedroom
ranch home they bought 52 years ago. The home is located in
a predominantly Mexican American neighborhood located in
the El Norte section of town. Mr. and Mrs. Rodriguez have
been active in the church and neighborhood community until
recently when Mr. Rodriguez had been experiencing abdomi-
nal pain and difficulty urinating. The Rodriguez home is usually
occupied by many people and has always been the gathering
place for the family.
During his years of employment, Mr. Rodriguez was the
major provider for the family and now receives Social Security
checks and a pension. Mrs. Rodriguez is also retired and re-
ceives a small pension for a short work period as a nurse’s
aide. Mr. and Mrs. Rodriguez count on their nursing student
granddaughter to guide them and advise on their health care.
Mr. Rodriguez visits a curandero for medicinal folk remedies.
Mrs. Rodriguez is the provider of spiritual, physical, and emo-
tional care for the family. In addition, their nursing student
granddaughter is always present during any major surgeries or
procedures. Mrs. Rodriguez, the eldest daughter, and her grand-
daughter (the nursing student) will be caring for Mr. Rodriguez
during his procedure for a TURBT (transurethreal resection of
bladder tumor) as well as radiation therapy.
1. Explain the significance of family and kinship for the
Rodriguez family.
2. Describe the importance of religion and God for the
Rodriguez family.
3. Identify two stereotypes about Mexican Americans that
were dispelled in this case with the Rodriguez family.
4. What is the role of Mrs. Rodriguez in this family?
2780_Ch21_374-390 16/07/12 11:55 AM Page 379

training may be needed for some Mexicans when they
come to the United States.
Because family is a first priority for most Mexicans,
activities that involve family members usually take pri-
ority over work issues. Putting up a tough business
front may be seen as a weakness in the Mexican culture.
Because of this separation of work from emotions in
American culture, most Mexican Americans tend to
shun confrontation for fear of losing face. Many are
very sensitive to differences of opinion, which are per-
ceived as disrupting harmony in the workplace. People
of Mexican heritage find it important to keep peace in
relationships in the workplace.
For many Mexicans, truth is tempered by diplomacy
and tact. When a service is promised for tomorrow,
even when they know the service will not be completed
tomorrow, it is promised to please, not to deceive. Thus,
for many Mexicans, truth is seen as a relative concept,
whereas for most European Americans, truth is an ab-
solute value, and people are expected to give direct yes
and no answers. These conflicting perspectives about
truth can complicate treatment regimens and commit-
ment to the completion of work assignments. Inten-
tions must be clarified and, at times, altered to meet the
needs of the changing and multicultural workforce.
For most Mexicans, work is viewed as a necessity
for survival and may not be highly valued in itself,
whereas money is for enjoying life. Most Mexican
Americans place a higher value on other life activities.
Material objects are usually necessities and not ends
in themselves. The concept of responsibility is based
on values related to attending to the immediate needs
of family and friends rather than on the work ethic.
For most Mexicans, titles and positions may be more
important than money.
Many Mexicans believe that time is relative and
elastic, with flexible deadlines, rather than stressing
punctuality and timeliness. In Mexico, shop hours
may be posted but not rigidly respected. A business
that is supposed to open at 8:00 a.m. opens when the
owner arrives; a posted time of 8:00 a.m. may mean
the business will open at 8:30 a.m., later, or not at all.
The same attitude toward time is evidenced in report-
ing to work and in keeping social engagements and
medical appointments. If people believe that an exact
time is truly important, such as the time an airplane
leaves, then they may keep to a schedule. The real chal-
lenge for employers is to stress the importance and
necessity of work schedules and punctuality in the
American workforce.
Issues Related to Autonomy
Many Mexican Americans respond to direction and del-
egation differently from European Americans. Many
newer immigrants are used to having traditional auto-
cratic managers who assign tasks but not authority, al-
though this practice is beginning to change with more
American-managed companies relocating to Mexico. A
Mexican worker who is not accustomed to responsibility
may have difficulty assuming accountability for deci-
sions. The individual may be sensitive to the American
practice of checking on employees’ work.
Mexicans who were born and educated in the
United States usually have no difficulty communicating
with others in the workplace. When better-educated
Mexican immigrants arrive in the United States, they
usually speak some English. Newer immigrants from
lower socioeconomic groups have the most difficulty
acculturating in the workplace and may have greater
difficulty with the English language.
Biocultural Ecology
Skin Color and Other Biological Variations
Because Mexican Americans draw their heritage
from Spanish and French peoples and various North
American and Central American Indian tribes and
Africans, few physical characteristics give this group a
distinct identity. Some individuals with a predominant
Spanish background might have light-colored skin,
blond hair, and blue eyes, whereas people from indige-
nous Indian backgrounds may have black hair, dark
eyes, and cinnamon-colored skin. Intermarriages
among these groups have created a diverse gene pool
and have not produced a typical-appearing Mexican.
Cyanosis and decreased hemoglobin levels are more
difficult to detect in dark-skinned people, whose skin
appears ashen instead of the bluish color seen in light-
skinned people. To observe for these conditions in dark-
skinned Mexicans, the health-care provider must
examine the sclera, conjunctiva, buccal mucosa, tongue,
lips, nailbeds, palms of the hands, and soles of the feet.
Jaundice, likewise, is more difficult to detect in darker-
skinned people. Thus, the health-care provider needs to
observe the conjunctiva and the buccal mucosa for
patches of bilirubin pigment in dark-skinned Mexicans.
Diseases and Health Conditions
Common health problems most consistently docu-
mented in the literature for both people from Mexico
and Mexican Americans are difficulty in assessing and
utilizing health care, malnutrition, malaria (in some
places), cancer, alcoholism, drug abuse, obesity, hyper-
tension, diabetes, heart disease, adolescent pregnancy,
dental disease, and HIV and AIDS (Kemp, 2001). In
Mexican American migrant-worker populations, infec-
tious, communicable, and parasitic diseases continue to
be major health risks. Substandard housing conditions
and employment in low-paying jobs have perpetuated
higher rates of tuberculosis in Mexican Americans.
Intestinal parasitosis, amoebic dysentery, and bacterial
diarrhea (Shigella) are common among Mexican
immigrants (Kim-Godwin, Alexander, Felton, Mackey,
& Kasakoff, 2006).
380 Aggregate Data for Cultural-Specific Groups
2780_Ch21_374-390 16/07/12 11:55 AM Page 380

People of Mexican Heritage 381
Newer Mexican immigrants from coastal lowland
swamp areas and from some mountainous areas
where mosquitoes are more prevalent may also have a
higher incidence of malaria. People from high moun-
tain terrains may have increased red blood cell counts
on immigration to the United States (Centers for Dis-
ease Control and Prevention [CDC], 2006). Health-
care providers must take these topographic factors into
consideration when performing health screening for
symptoms of anemia, lassitude, failure to thrive, and
weight loss among Mexican immigrants.
Cardiovascular disease is the leading cause of
death and disability in minority populations, includ-
ing Mexican Americans (Kurian & Cardarelli,
2007). However, current research shows that despite
the adverse cardiovascular risk profile, including
the incidence of obesity, diabetes, and untreated
hypertension, Mexican Americans have a lower
rate of coronary heart disease mortality than non-
white Hispanics (Pandey, Labarthe, Goff, Chan, &
Nichaman, 2001). Cardiovascular risk factors are in-
fluenced by behavioral, cultural, and social factors.
Mexican Americans have the highest prevalence
of no leisure time physical activity (Kurian &
Cardarelli, 2007). In addition, poor health, low
social support, lack of educational and occupational
opportunities, low access to health care, and dis-
crimination contribute to the risk factors associated
with cardiovascular disease (Kemp, 2001).
Mexican Americans have five times the rate of dia-
betes mellitus, with an increased incidence of related
complications, as that in European American cohort
groups. In addition, health-care providers working with
Mexican immigrants and Mexican Americans should
offer screening and teach patients preventive measures
regarding pesticides and communicable and infectious
diseases because many of these people work with chem-
icals and live in crowded housing conditions.
Variations in Drug Metabolism
Because of the mixed heritage of many Mexican
Americans, it may be more difficult to determine a
therapeutic dose of selected drugs. Several studies re-
port differences in absorption, distribution, metabo-
lism, and excretion of drugs, including alcohol, in
some Hispanic populations. The mixed heritage of
Mexican Americans makes it more difficult to gener-
alize drug metabolism. Few studies include only one
subgroup of Hispanics; therefore, health-care
providers need to consider some notable differences
when prescribing medications. Hispanics require lower
doses of antidepressants and experience greater side
effects than non-Hispanic whites.
High-Risk Behaviors
Alcohol plays an important part in the Mexican cul-
ture. Many of this group’s colorful lifestyle celebrations
include alcohol consumption. Men overall drink in
greater proportion than women, but this trend is chang-
ing owing to acculturation. Mexican American women
are consuming more alcohol than their mothers or
grandmothers (Stanley Bunting, 2011).
Because of these drinking patterns, alcoholism rep-
resents a crucial health problem for many Mexicans.
More acculturated Hispanics consume more alcoholic
beverages than non-Hispanic whites, possibly expect-
ing alcohol to make them more socially acceptable
and extroverted. Low acculturation and distorted self-
image problems have special implications for nursing
and health care.
Marijuana is the number-two drug used by Mexican
Americans because it is readily available in their na-
tive land and easily accessible from people who work
in farming and ranching occupations. Some adults
who can afford drugs use cocaine and heroin, and
the younger population uses inhalants (Stanley
Bunting, 2011).
The trend toward decreasing cigarette smoking in the
United States is extending to the Mexican American
culture, in which cigarette smoking rates have steadily
declined for both men and women between 1990 and
2009 (CDC, 2011). However, the reported decrease in
cigarette smoking rates for Mexican American men and
women should not promote a sense of complacency for
nurses and health-care providers.
Health-Care Practices
Responsibility for health promotion and safety may be
a major threat for those of Mexican heritage accus-
tomed to depending on the family unit and traditional
means of providing health care. Continuing disparities
in health and health-seeking behaviors have been re-
ported in several studies. Lower socioeconomic condi-
tions and acculturation are responsible for Latina
women being overweight, exhibiting hypertension, ex-
periencing high cholesterol levels, and having increased
smoking behaviors (Kemp, 2001). Latino men are less
likely to have cancer screening or physical examinations
than their non-Latino white counterparts. High-risk
health behaviors such as drinking and driving, cigarette
smoking, sedentary lifestyle, and nonuse of seat belts
increase with fewer years of educational attainment.
Through educational programs and enforcement of
state laws, more Mexicans are beginning to use seat
belts; however, it is still common to see their children
traveling unrestrained in automobiles.
Nutrition
Meaning of Food
As in many other ethnic groups, Mexicans and Mexican
Americans celebrate with food. Mexican foods are rich
in color, flavor, texture, and spiciness. Any occasion—
births, birthdays, Sundays, religious holidays, official
2780_Ch21_374-390 16/07/12 11:55 AM Page 381

and unofficial holidays, and anniversaries of deaths—is
seen as a time to celebrate with food and enjoy the com-
panionship of family and friends. Because food is a pri-
mary form of socialization in the Mexican culture,
Mexican Americans may have difficulty adhering to a
prescribed diet for illnesses such as diabetes mellitus and
cardiovascular disease. Health-care providers must seek
creative alternatives and negotiate types of foods con-
sumed with individuals and families in relation to these
concerns.
Common Foods and Food Rituals
The Mexican American diet is extremely varied and
may depend on the individual’s region of origin in
Mexico. Thus, one needs to ask the individual specifi-
cally about his or her dietary habits. The staples of the
Mexican American diet are rice (arroz), beans, and
tortillas, which are made from corn (maíz) treated with
calcium carbonate. However, in many parts of the
United States, only flour tortillas are available. Even
though the diet is low in calcium derived from milk
and milk products, tortillas treated with calcium car-
bonate provide essential dietary calcium. Popular
Mexican American foods are eggs (huevos), pork
(puerco), chicken (pollo), sausage (chorizo), lard
(lardo), mint (menta), chili peppers (chile), onions
(cebollas), tomatoes (tomates), squash (calabaza),
canned fruit (fruta de lata), mint tea (hierbabuena),
chamomile tea (té de camomile or manzanilla), carbon-
ated beverages (bebidas de gaseosa), beer (cerveza),
cola-flavored soft drinks, sweetened packaged drink
mixes (agua fresa) that are high in sugar (azucar),
sweetened breakfast cereals (cereales de desayuno),
potatoes (papas), bread (pan), corn (maíz), gelatin
(gelatina), custard (flan), and other sweets (dulces).
Other common dishes include chili, enchiladas,
tamales, tostadas, chicken mole, arroz con pollo, re-
fried beans, tacos, tripe soup (Menudo), and other
soups (caldos). Caldos are varied in nature and may
include chicken, beef, and pork with vegetables.
Mealtimes vary among different subgroups of
Mexican Americans. Whereas many individuals
adopt North American schedules and eating habits,
many continue their native practices, especially those
in rural settings and migrant-worker camps. For
these groups, breakfast is usually fruit, perhaps
cheese, or bread alone or in some combination. A
snack may be taken in midmorning before the main
meal of the day, which is eaten from 2 to 3 p.m. and,
in rural areas especially, may last for 2 hours or more.
Mealtime is an occasion for socialization and keep-
ing family members informed about one another.
The evening meal is usually late and is taken between
9 and 9:30 p.m. Health-care providers must consider
Mexican Americans’ mealtimes when teaching pa-
tients about medication and dietary regimens related
to diabetes mellitus and other illnesses.
Dietary Practices for Health Promotion
A dominant health-care practice for Mexicans and
many Mexican Americans is the hot-and-cold theory
of food selection. This theory is a major aspect of
health promotion and illness, and disease prevention
and treatment. According to this theory, illness or
trauma may require adjustments in the hot-and-cold
balance of foods to restore body equilibrium. The hot-
and-cold theory of foods is described under Health-
Care Practices, later in this chapter.
Nutritional Deficiencies and Food Limitations
In lower socioeconomic groups, wide-scale vitamin A
deficiency and iron deficiency anemia exist (Mendoza,
Ventura, Saldivar, Baisden, & Martorell, 1992). Some
Mexican and Mexican Americans have lactose intol-
erance, which may cause problems for schools and
health-care organizations that provide milk in the diet
because of its high calcium content.
Because major Mexican foods and their ingredients
are available throughout the United States, native food
practices may not change much when Mexicans immi-
grate. Of course, Mexican foods are extremely popular
throughout the United States and are eaten by many
Americans because of the strong flavors, spiciness, and
color. Table 21-1 lists the Mexican names of popular
foods, their description, and ingredients. Individual
adaptations to these preparations commonly occur.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Mexican American birth rates were 722,055, or
24.3 percent, live births in 2007; the number of births
has continued to rise every year since 1989 (Martin
et al., 2010). Multiple births are common, especially
in the economically disadvantaged groups. Men view
a large number of children as proof of their virility.
The optimal childbearing age for Mexican women
is between 19 and 24 years. Fertility practices of
Mexican Americans are connected with their pre-
dominantly Catholic religious beliefs and their
tendency to be modest. Some women practice the be-
lief that prolonged infant breastfeeding is a method
of birth control. Abortion in many communities is
considered morally wrong and is practiced (theoret-
ically) only in extreme circumstances to keep the
mother’s life intact. However, legal and illegal abor-
tions are common in some parts of Mexico and the
United States. Despite the strong influence of the
Catholic Church over fertility practices, being Catholic
does not prevent some Mexican American women
from using contraceptives, sterilization, or abortion for
unwanted pregnancies.
Diaphragms, foams, and creams are not commonly
used for birth control practice, mostly because they are
382 Aggregate Data for Cultural-Specific Groups
2780_Ch21_374-390 16/07/12 11:55 AM Page 382

People of Mexican Heritage 383
not approved by Catholic doctrine and partly because
of the belief that women are not supposed to touch
their genitals. Birth control pills are unacceptable be-
cause they are an artificial means of birth control.
Physicians’ offices and clinics that see large numbers of
migrant workers on the Delmarva Peninsula on the
U.S. East Coast report that many younger female
patients are using Norplant (levonorgestrel; a long-term
contraceptive system) for birth control. Men are reluc-
tant to use condoms because they are associated with
prostitutes and because of the belief that they should
be used only for disease control. A woman may reject
the use of a condom and find it offensive because it
means that she is “dirty.” Family planning is one area
in which health-care providers can help the family to
identify more realistic outcomes consistent with current
economic resources and family goals.
Foreign-born Mexicans are less likely to give birth
to low-birth-weight babies than U.S.-born Mexican
women, even though U.S.-born mothers are usually
of higher socioeconomic status and receive more pre-
natal care. Research suggests that better nutritional in-
take and lower prevalence of smoking and alcohol use
are some reasons for these protective outcomes
(American Public Health Association, 2002).
Because pregnancy among Mexican Americans is
viewed as natural and desirable, many women do not
seek prenatal evaluations. In addition, because prena-
tal care is not available to every woman in Mexico,
some women do not know about the need for prenatal
care. With the extended family network and the
woman’s role of maintaining the health status of
family members, many pregnant women seek family
advice before seeking medical care. Thus, familism may
deter and hinder early prenatal checkups. To encour-
age prenatal checkups, health-care providers can
encourage female relatives and husbands to accom-
pany the pregnant woman for health screening and in-
corporate advice from family members into health
teaching and preventive care services. Using videos
with Spanish-speaking Mexican Americans is one cul-
turally effective way for incorporating health educa-
tion, especially for those patients who have a limited
understanding of English. In addition, incorporating
cultural brokers known to the Mexican American fam-
ily may help to empower patients and reduce conflict
for Mexicans and Mexican Americans.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Beliefs related to the hot-and-cold theory of disease pre-
vention and health maintenance influence conception,
pregnancy, and postpartum rituals. For instance, during
pregnancy, a woman is more likely to favor hot foods,
which are believed to provide warmth for the fetus and
enable the baby to be born into a warm and loving
environment (Eggenberger, Grassley, & Restrepo, 2006).
Cold foods and environments are preferred during the
menstrual cycle and in the immediate postdelivery pe-
riod. Many pregnant women sleep on their backs to pro-
tect the infant from harm, keep the vaginal canal well
lubricated by having frequent intercourse to facilitate an
easier birth, and keep active to ensure a smaller baby
and to prevent a decrease in the amount of amniotic
fluid (Burk, Wieser, & Keegan, 1995). An important
activity restriction is that pregnant women should not
walk in the moonlight because it might cause a birth
deformity. To prevent birth deformities, pregnant
women may wear a safety pin, metal key, or some other
metal object on their abdomen (Villarruel & Ortiz de
Montellano, 1992). Other beliefs include avoiding cold
air, not reaching over the head in order to prevent the
❙❙◗ Table 21-1 Mexican Foods
Common Name Description Ingredients
Arroz con pollo Chicken with rice Chicken baked, boiled, or fried and served over boiled or fried rice
Chili Chili Same as the United States but tends to be more spicy
Chili con carne Chili with meat Chili with beef or pork
Chili con salsa Chili with sauce Chili with a sauce that contains no meat
Dulces Sweets Candy and desserts usually high in sugar, lard, and eggs
Enchiladas Enchiladas Tortilla rolled and stuffed with meat or cheese and a spicy sauce
Papas fritas Fried potatoes Potatoes usually fried in lard
Flan Flan Popular dessert made of egg custard; may be filled with fruit or cheese
Gelatina Gelatin Popular dessert made with sugar, eggs, and jelly
Pollo con molé Chicken molé Chicken with a sauce made of hot spices, chocolate, and chili
Salchica or chorizo Sausage Sausage almost always made with pork and spices
Tacos Tacos Tortilla folded around meat or cheese
Tamales Tamales Fried or boiled chopped meat, peppers, cornmeal, and hot spices
Tortilla Tortilla A thin unleavened bread made with cornmeal and treated with lime (calcium carbonate)
Tostadas Tostadas Toast that may have a spicy sauce
2780_Ch21_374-390 16/07/12 11:55 AM Page 383

baby’s cord from wrapping around its neck, and avoiding
lunar eclipses because they may result in deformities.
In more traditional Mexican families, the father is
not included in the delivery experience and should not
see the mother or baby until after both have been
cleaned and dressed. This practice is based on the fear
that harm may come to the mother, baby, or both. In-
tegrating men into the birthing of a child is a process
that requires changing social habits in relation to cul-
tural aspects of life and gender roles. For many, the
presence of men during delivery is considered an un-
invited intrusion into the Mexican culture. Among less
traditional and more acculturated Mexican Americans,
men participate in prenatal classes and assist in the
delivery room. However, based on personal experi-
ences, men who provide support during delivery may
receive friendly gibing from their male counterparts
for taking the role of the wife’s mother (personal com-
munication, Larry Purnell, 2010). In any event,
health-care providers must respect Mexicans’ decision
to not have men in the delivery room.
During labor, traditional Mexican women may be
quite vocal and are taught to avoid breathing air in
through the mouth because it can cause the uterus to
rise up. Immediately after birth, they may place their legs
together to prevent air from entering the womb (Olds,
London, & Ladewig, 2000). Health-care providers can
help the Mexican pregnant woman have a better deliv-
ery by encouraging attendance at prenatal classes.
The postpartum preference for a warm environ-
ment may restrict postpartum women from bathing or
washing their hair for up to 40 days. Although post-
partum women may not take showers or sit in a bath-
tub, this does not mean that they do not bathe. They
take “sitz” baths, wash their hair with a washcloth,
and take sponge baths. Other postpartum practices
include wearing a heavy cotton abdominal binder,
cord, or girdle to prevent air from entering the uterus;
covering one’s ears, head, shoulders, and feet to pre-
vent blindness, mastitis, frigidity, or sterility; and
avoiding acidic foods to protect the baby from harm
(Olds, London, & Ladewig, 2000).
When the baby is born, special attention is given to
the umbilicus; the mother may place a belt around the
umbilicus (ombliguero) to prevent the navel from pop-
ping out when the child cries. Cutting the baby’s nails
in the first 3 months is thought to cause blindness and
deafness.
Health-care providers need to make special provi-
sions to provide culturally congruent health teaching
for lactating women who work with or are exposed to
pesticides, such as dichlorodiphenyldichlorothene
(DDE), the most stable derivative from the pesticide
DDT. High DDE levels among lactating women have
a direct correlation with a decrease in lactation and
increase in breast cancer, especially in women who
have had more than one pregnancy and previous
lactation (Gladen & Rogan, 1995). Education level
and degree of acculturation are key issues when de-
veloping health education and interventions for risk
reduction.
Death Rituals
Death Rituals and Expectations
Mexicans often have a stoic acceptance of the way
things are and view death as a natural part of life and
the will of God (Eggenberger et al., 2006). Death
practices are primarily an adaptation of their religion.
Family members may arrive in large numbers at the
hospital or home in times of illness or an approaching
death. In more traditional families, family members
may take turns sitting vigil over the sick or dying per-
son. Autopsy is acceptable as long as the body is
treated with respect. Burial is the common practice;
cremation is an individual choice.
Responses to Death and Grief
When a person dies, the word travels rapidly, and family
and friends travel from long distances to get to the
funeral. They may gather for a velorio, a festive watch
over the body of the deceased person before burial.
Some Mexican Americans bury the body within
24 hours, which is required by law in Mexico.
More traditional grieving families may engage in
protection of the dying and bereaved, such as small
children who have difficulty dealing with the death
(Andrews & Boyle, 2008). Mexican Americans en-
courage expressions of feeling during the grieving
process. In these cases, health-care providers can assist
the person by providing support and privacy during
the bereavement.
Spirituality
Dominant Religion and Use of Prayer
The predominant religion of most Mexicans and
Mexican Americans is Catholicism. The major religions
in Mexico are Roman Catholic with 76.5 percent;
Protestant with 5.2 percent; Pentecostal with 1.4 percent;
unspecified with 13.1 percent; Jehovah’s Witness,
1.1 percent; other 0.3 percent; and 3.1 percent identified
with no religion. Since the mid-1980s, other reli-
gious groups such as Mormons, Jehovah’s Witnesses,
Seventh Day Adventists, Presbyterians, and Baptists
have been gaining in popularity in Mexico (CIA
World Factbook, 2012). Although many Mexicans
and Mexican Americans may not appear to be prac-
ticing their faith on a daily basis, they may still con-
sider themselves devout Catholics, and their religion
has a major influence on health-care practices and
beliefs. For many, Catholic religious practices are
influenced by indigenous Indian practices.
Newer immigrant Mexican Americans may con-
tinue their traditional practice of having two marriage
384 Aggregate Data for Cultural-Specific Groups
2780_Ch21_374-390 16/07/12 11:55 AM Page 384

People of Mexican Heritage 385
ceremonies, especially in lower socioeconomic groups.
A civil ceremony is performed whenever two people
decide to make a union. When the family gets enough
money for a religious ceremony, they schedule an elab-
orate celebration within the church. Common prac-
tice, especially in rural Mexican villages and some
rural villages in the southwestern United States, is to
post a handwritten sign on the local church announc-
ing the marriage, with an invitation for all to attend.
Frequency of prayer is highly individualized for most
Mexican Americans. Even though some do not attend
church on a regular basis, they may have an altar in
their homes and say prayers several times each day, a
practice more common among rural isolationists.
Meaning of Life and Individual Sources
of Strength
The family is foremost to most Mexicans, and individ-
uals get strength from family ties and relationships.
Individuals may speak in terms of a person’s soul or
spirit (alma or espiritu) when they refer to one’s inner
qualities. These inner qualities represent the person’s
dignity and must be protected at all costs in times of
both wellness and illness. In addition, Mexicans derive
great pride and strength from their nationality, which
embraces a long and rich history of traditions.
Leisure is considered essential for a full life, and work
is a necessity to make money for enjoying life. Mexican
Americans pride themselves on good manners, etiquette,
and grooming as signs of respect. Because the overall
outlook for many Mexicans is one of fatalism, pride
may be taken in stoic acceptance of life’s adversities.
Spiritual Beliefs and Health-Care Practices
Most Mexicans enjoy talking about their soul or spirit,
especially in times of illness, whereas many health-care
providers may feel uncomfortable talking about spiritu-
ality. This tendency may communicate to Mexicans that
the health-care provider has suspect intentions, is insen-
sitive, and is not really interested in them as individuals.
It may be common for a person needing care in the
home or hospital to have a statue of a patron saint or a
candle with a picture of the saint. Rosaries may be pres-
ent, and at times, the family may pray as a group. De-
pending on the confidence maintained with the family
and client, a health-care provider may be asked to join
in the prayer. If time permits, it is very appropriate to
pray with the family, even if only for a few minutes. This
action promotes confidence in the relationship and can
have a positive impact on the health and well-being of
the patient and family (Zoucha, 2007).
Health-Care Practices
Health-Seeking Beliefs and Behaviors
The family is the most credible source of health infor-
mation and the most significant impediment to positive
health-seeking behavior. Mexican Americans’ fatalistic
worldview and external locus of control are closely tied
to health-seeking behaviors. Because expressions of
negative feelings are considered impolite, Mexicans may
be reluctant to complain about health problems or to
place blame on the individual for poor health. If a per-
son becomes seriously ill, that is just the way things are;
all events are acts of God (Eggenberger et al., 2006).
This belief system may impair the dominant view of
communications and hinder health teaching, health
promotion, and disease-prevention practices. Therefore,
it is imperative for health-care providers to plan health-
promoting activities and teaching that are consistent with
this belief but encourage health. For instance, if a person
believes that the illness is due to a punishment from God,
it may be possible to ask to be forgiven by God, thereby
restoring health. This may be an opportune time to call
a priest or minister for official recognition of forgiveness.
Responsibility for Health Care
To many Mexicans, good health may mean the ability
to keep working and have a general feeling of well-
being (Zoucha, 2011). Illness may occur when the per-
son can no longer work or take care of the family.
Therefore, many Mexicans may not seek health care
until they are incapacitated and unable to go about the
activities of daily living. Unfortunately, many people
of Mexican heritage may not know and understand
the occupational dangers inherent in their daily work.
Migrant workers are often unaware of the dangers of
pesticides and the potentially dangerous agricultural
machinery. Health-care providers must serve as
advocates for these people regarding occupational
safety. Often, the companies do not tell the workers of
the dangers of the work, or the workers may not
understand owing to the inability of the company
officials to speak the language of the workers.
The use of over-the-counter medicine may pose a
significant health problem related to self-care for many
Mexican Americans. In part, this is a carryover from
Mexico’s practice of allowing over-the-counter pur-
chases of antibiotics, intramuscular injections, intra-
venous fluids, birth control pills, and other medications
that require a prescription in the United States. Often,
Mexican immigrants bring these medications across the
border and share them with friends. In addition, friends
and relatives in Mexico send drugs through the mail.
To protect patients from contradictory or potentiating
effects of prescribed treatments, health-care providers
need to ask patients about prescription and nonpre-
scription medications they may be taking.
Folk and Traditional Practices
Mexican Americans engage in folk medicine practices
and use a variety of prayers, herbal teas, and poultices
to treat illnesses. Many of these practices are region-
ally specific and vary between and among families.
2780_Ch21_374-390 16/07/12 11:55 AM Page 385

The Mexican Ministerio de Salud Publica y Asistencia
Social (Ministry of Public Health and Social Assis-
tance) publishes an extensive manual on herbal med-
icines that are readily available in Mexico. Lower
socioeconomic groups and well-educated upper- and
middle-socioeconomic Mexicans to some degree
practice traditional and folk medicine. Many of these
practices are harmless, but some may contradict or
potentiate therapeutic interventions. Thus, as with the
use of other prescription and nonprescription drugs dis-
cussed earlier, it is essential for health-care providers to
be aware of these practices and to take them into con-
sideration when providing treatments (Rivera, Anaya,
& Meza, 2003). The provider must ask the Mexican
American patient specifically whether she or he is using
folk medicine.
To provide culturally competent care, health-care
providers must be aware of the hot-and-cold theory
of disease when prescribing treatment modalities and
when providing health teaching. According to this the-
ory, many diseases are caused by a disruption in the
hot-and-cold balance of the body. Thus, eating foods
of the opposite variety may either cure or prevent spe-
cific hot-and-cold illnesses and conditions. Physical or
mental illness may be attributed to an imbalance
between the person and the environment. Influences
include emotional, spiritual, and social state, as well as
physical factors such as humoral imbalance expressed
as either too much hot or cold. As health-care
providers, it is important to understand that if people
of Mexican heritage believe in the hot-and-cold the-
ory, it means that they do not believe or use profes-
sional Western practices (Spector, 2008). Unless a level
of trust and confidence is maintained, Mexicans who
follow these beliefs may not express them to health-
care providers (Zoucha, 2011).
Hot and cold are viewed as specific properties of var-
ious substances and conditions, and sometimes opin-
ions differ about what is hot and what is cold in the
Mexican community. In general, cold diseases or con-
ditions are characterized by vasoconstriction and a
lower metabolic rate. Cold diseases or conditions in-
clude menstrual cramps, frio de la matriz, rhinitis
(coryza), pneumonia, empacho, cancer, malaria, ear-
aches, arthritis, pneumonia and other pulmonary con-
ditions, headaches, and musculoskeletal conditions and
colic. Common hot foods used to treat cold diseases
and conditions include cheeses, liquor, beef, pork, spicy
foods, eggs, grains other than barley, vitamins, tobacco,
and onions (Neff, 2011).
Hot diseases and conditions may be characterized
by vasodilation and a higher metabolic rate. Pregnancy,
hypertension, diabetes, acid indigestion, susto, mal de
ojo (bad eye or evil eye), bilis (imbalance of bile, which
runs into the bloodstream), infection, diarrhea, sore
throats, stomach ulcers, liver conditions, kidney prob-
lems, and fever may be examples of hot conditions.
Common cold foods used to treat hot diseases and
conditions include fresh fruits and vegetables, dairy
products (even though fresh fruits and dairy products
may cause diarrhea), barley water, fish, chicken, goat
meat, and dried fruits (Neff, 2011).
Folk practitioners are consulted for several notable
conditions. Mal de ojo is a folk illness that occurs
when one person (usually older) looks at another
(usually a child) in an admiring fashion. Another ex-
ample of mal de ojo is if a person admires something
about a baby or child, such as beautiful eyes or hair.
Such eye contact can be either voluntary or involun-
tary. Symptoms are numerous, ranging from fever,
anorexia, and vomiting to irritability. The spell can
be broken if the person doing the admiring touches
the person admired while it is happening. Children
are more susceptible to this condition than women,
and women are more susceptible than men. To pre-
vent mal de ojo, the child wears a bracelet with a seed
(ojo de venado) or a bag of seeds pinned to the clothes
(Kemp, 2001).
Another childhood condition often treated by folk
practitioners is caida de la mollera (fallen fontanel).
The condition has numerous causes, which may in-
clude removing the nursing infant too harshly from
the nipple or handling an infant too roughly. Symp-
toms range from irritability to failure to thrive.
To cure the condition, the child is held upside down
by the legs.
Susto (magical fright or soul loss) is associated with
epilepsy, tuberculosis, and other infectious diseases
and is caused by the loss of spirit from the body. The
illness is also believed to be caused by a fright or
by the soul being frightened out of the person. This
culture-bound disorder may be psychological, physi-
cal, or physiological in nature. Symptoms may include
anxiety, depression, loss of appetite, excessive sleep,
bad dreams, feelings of sadness, and lack of motiva-
tion. Treatment sometimes includes elaborate cere-
monies at a crossroads with herbs and holy water to
return the spirit to the body (R. Zamarripa, personal
communication, 2010).
Empacho (blocked intestines) may result from an
incorrect balance of hot and cold foods, causing a
lump of food to stick in the gastrointestinal tract.
To make the diagnosis, the healer may place a fresh
egg on the abdomen. If the egg appears to stick to a
particular area, this confirms the diagnosis. Older
women usually treat the condition in children by
massaging their stomach and back to dislodge the
food bolus and to promote its continued passage
through the body.
Health-care providers are cautioned against diag-
nosing psychiatric illnesses too readily in the Mexican
population. The syndromes mal ojo and susto are
culture-bound and are potential sources of diagnostic
bias. The potential culture-bound mental illness must
386 Aggregate Data for Cultural-Specific Groups
2780_Ch21_374-390 16/07/12 11:55 AM Page 386

People of Mexican Heritage 387
be understood in the context of the culture and the
unique symptoms that accompany each illness.
Barriers to Health Care
Thirty-five percent of Mexican Americans, compared
with 17 percent of the U.S. population in general, do
not have health insurance (CDC, 2011). A number of
factors may account for this high percentage of unin-
sured individuals. First, many Mexican Americans
constitute the working poor and are unable to pur-
chase insurance. Second, many are migratory and do
not qualify for Medicaid. Third, many have an undoc-
umented status and are afraid to apply for health in-
surance. Fourth, even though insurance is available in
their native homeland, it is very expensive and not
part of the culture.
Whereas wealthier Mexican Americans have little dif-
ficulty accessing health care in the United States, lower
socioeconomic groups may experience significant bar-
riers, including inadequate financial resources, lack of
insurance and transportation, limited knowledge re-
garding available services, language difficulties, and the
culture of health-care organizations. Like many other
immigrant groups who lack a primary provider, Mexican
Americans may use emergency rooms for minor ill-
nesses. Health-care providers have the opportunity to
improve the care of Mexican Americans by explaining
the health-care system, incorporating a primary-care
provider whenever possible, using an interpreter of the
same gender, securing a cultural broker, and assisting
patients in locating culturally specific mental health pro-
grams (Zoucha & Husted, 2002).
Cultural Responses to Health and Illness
Good health to many Mexican Americans is to be free
of pain, able to work, and spend time with the family.
In addition, good health is a gift from God and from
living a good life (Zoucha, 2011).
Mexicans and Mexican Americans tend to perceive
pain as a necessary part of life, and enduring the pain is
often viewed as a sign of strength. Men commonly tol-
erate pain until it becomes extreme (Luckmann, 1999).
Often, pain is viewed as the will of God and is tolerated
as long as the person can work and care for the family.
These attitudes toward pain delay seeking treatment;
many hope that the pain will simply go away. Research
has shown that many Mexican Americans experience
more pain than other ethnic groups but that they report
the occurrence of pain less frequently and endure pain
longer (Sobralske & Katz, 2005). Six themes have
emerged that describe culturally specific attributes of
Mexican Americans experiencing pain:
1. Mexicans accept and anticipate pain as a neces-
sary part of life.
2. They are obligated to endure pain in the perform-
ance of duties.
3. The ability to endure pain and to suffer stoically is
valued.
4. The type and amount of pain a person experiences
are divinely predetermined.
5. Pain and suffering are a consequence of immoral
behavior.
6. Methods to alleviate pain are directed toward
maintaining balance within the person and the
surrounding environment (Villarruel & Ortiz de
Montellano, 1992).
By using these themes, health-care providers can
evaluate Mexicans experiencing pain within their
cultural framework and provide culturally specific
interventions.
Because long-term-care facilities in Mexico are rare
and tend to be crowded, understaffed, and expensive,
many Mexican Americans may not consider long-term
care as a viable option for a family member. In addition,
because of the importance of extended family, Mexican
Americans may prefer to care for their family members
with mental illness, physical handicaps, and extended
physical illnesses at home. In Mexican American culture,
someone with a mental illness is not looked on with
scorn or blamed for his or her condition because mental
illness, like physical illness, is viewed as God’s will. It is
common to accept those with mental illness and care for
them in the context of the family until the illness is so
bad that they cannot be managed in the home (Zoucha
& Husted, 2000).
Mexicans can readily enter the sick role without
personal feelings of inadequacy or blame. A person
can enter the sick role with any acceptable excuse and
be relieved of life’s responsibilities. Other family mem-
bers willingly take over the sick person’s obligations
during his or her time of illness.
Blood Transfusions and Organ Donation
Extraordinary means to preserve life are frowned on
in the Mexican and Mexican American culture, and
ordinary means are commonly used to preserve life.
Extraordinary means are defined and determined by
the individual, taking into account such factors as
finances, education, and availability of services.
Blood transfusions are acceptable if the individual
and the family agree that the transfusion is necessary.
Organ donation, although not deemed morally
wrong, is not a common practice and is usually re-
stricted to cadaver donations, because donating an
organ while the person is still alive means that the
body is not whole. Acceptance of organ transplant
as a treatment option is seen primarily among more
educated people. One reason that organ transplant is
unacceptable to some groups is the belief that mal
aire (bad air) enters the body if it is left open too
long during surgery and increases the potential for
the development of cancer.
2780_Ch21_374-390 16/07/12 11:55 AM Page 387

Health-Care Providers
Traditional Versus Biomedical Providers
Educated physicians and nurses are often seen as out-
siders, especially among newer immigrants. However,
health-care providers are viewed as knowledgeable
and respected because of their education (Zoucha &
Husted, 2002). To overcome this initial awkwardness,
health-care providers should attempt to get to know
the patient on a more personal level and gain confi-
dence before initiating treatment regimens. Engaging
in small talk unrelated to the health-care encounter
before obtaining a health history or providing health
education is advised. Health-care providers must re-
spect this cultural practice to achieve an optimal out-
come from the encounter.
Folk practitioners, who are usually well known by
the family, are usually consulted before and during
biomedical treatment. Numerous illnesses and condi-
tions are caused by witchcraft. Specific rituals are car-
ried out to eliminate the evils from the body. Lower
socioeconomic and newer immigrants are more likely
to use folk practitioners, but well-educated upper-
and middle-class people also visit folk practitioners
and brujas (witches) on a regular basis (Torres, 2001).
Although often no contradictions or contraindica-
tions to folk remedies exist, health-care providers must
always consider patients’ use of these practitioners to
prevent conflicting treatment regimens.
Even though the Catholic Church preaches against
some types of folk practitioners, they are common and
meet yearly for several days in Catemaco, Veracruz. Folk
practitioners include the curandero, who may receive her
or his talents from God or serve an apprenticeship with
an established practitioner. The curandero has great re-
spect from the community, accepts no monetary pay-
ment (but may accept gifts), is usually a member of the
extended family, and treats many traditional illnesses.
A curandero does not usually treat illnesses caused by
witchcraft.
The yerbero (also spelled jerbero) is a folk healer
with specialized training in growing herbs, teas, and
roots and who prescribes these remedies for preven-
tion and cure of illnesses. A yerbero may suggest that
the person go to a botanica (herb shop) for specific
herbs. In addition, these folk practitioners frequently
prescribe the use of laxatives.
A sobador subscribes to treatment methods similar
to those of a Western chiropractor. The sobador treats
illnesses, primarily affecting the joints and muscu-
loskeletal system, with massage and manipulation.
Even though Mexicans like closeness and touch
within the context of family, most tend to be modest
in other settings. Women are not supposed to expose
their bodies to men or even to other women. Female
patients may experience embarrassment when it is nec-
essary to touch their genitals or may refuse to have
pelvic examinations as a routine part of a health as-
sessment. Men may have strong feelings about mod-
esty as well, especially in front of women, and may be
reluctant to disrobe completely for an examination.
Mexican Americans often desire that members of the
same gender provide intimate care (C. Zamarripa, per-
sonal communication, 2011). Health-care providers
must keep in mind patients’ need for modesty when
disrobing or being examined. Thus, only the body part
being examined should be exposed, and direct care
should be provided in private. Whenever possible, a
same-gender caregiver should be assigned to Mexican
Americans.
Status of Health-Care Providers
Mexican American patients have great respect for
health-care providers because of their training and ex-
perience. They expect health-care providers to project
a professional image and be well groomed and dressed
in attire that reflects their professional status (Zoucha
& Husted, 2002). Whereas they have great respect for
health-care providers, some Mexican Americans may
distrust them out of fear that they will disclose their
undocumented status. Health-care providers who in-
corporate folk practitioners, the concept of personal-
ismo, and respect into their approaches to care of
Mexican American patients will gain their patients’
confidence and be able to obtain more thorough
assessments.
388 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 2 1 . 3
Vicente Rios is a 25-year-old Mexican man who was recently
diagnosed with a right radial bone fracture after a work-
related injury. An emergency room physician has recom-
mended surgery and physical therapy. Vicente is unmarried
and is a recent immigrant from Mexico City, Mexico.
He is an undocumented worker and has been working for a
construction company doing roofing and bricklaying. Vicente’s
family resides in Mexico. His parents, maternal grandparents,
five sisters, and two brothers live in a small two-bedroom
stone home in the Colonia region of Mexico City. Vicente is
the oldest of the children and has come to the United States
to work and send money back to the family. Vicente’s dad is
being treated for colon cancer and needs money to pay for
health care. Vicente is also trying to earn enough money to
bring his dad to the United States for further cancer treatment.
Vicente speaks mainly Spanish, with limited ability in English.
Vicente is a devout Catholic who attends Mass weekly and
prays the rosary to La Virgen de Guadalupe daily. Vicente often
blesses himself with holy water he brought from San Juan de
Los Lagos. Vicente believes that God will heal him and that his
health is in the hands of God.
Vicente is sharing the rent on a two-bedroom apartment
with three other migrant workers from Mexico. The apartment
2780_Ch21_374-390 16/07/12 11:55 AM Page 388

People of Mexican Heritage 389
Health-care providers can demonstrate respect for
Mexican American patients by greeting the patient
with a handshake, touching the person, or holding the
person’s hand, all of which help to build trust in the
therapeutic relationship. Providing information and
involving the family in decisions regarding health; lis-
tening to the individual’s concerns; and treating the
individual with personalismo, which stresses warmth
and personal relationships, also foster trust.
R E F E R E N C E S
American Public Health Association. (2002). Maternal health risks
of immigrant women from Latin America. Retrieved from
http://www.apha.org
Andrews, M., & Boyle, J. (2008). Transcultural concepts in nursing
care (5th ed.). Philadelphia: Lippincott.
Burk, M.E., Wieser, P.C., & Keegan, L. (1995). Cultural beliefs and
health behaviors of pregnant Mexican-American women: Implica-
tions for primary care. Advances in Nursing Science, 17(4), 37–52.
Casa Historia. (2011, February 23). Mexican revolution and beyond.
Retrieved from http://www.casahistoria.net/mexicorevolution.htm
Centers for Disease Control and Prevention (CDC). (2006). Re-
gional malaria information. Retrieved from http://www.cdc.gov/
travel/regionalmalaria/camerica.htm
Centers for Disease Control and Prevention (CDC). (2011).
Health of Mexican American population. Retrieved from http://
www.cdc.gov/nchs/fastats/mexican_health.htm
CIA World Factbook. (2012). Retrieved from https://www.cia.
gov/library/publications/the-world-factbook/geos/mx.html
URL remains the same even though the date changed.
Department of Homeland Security. (2011). Estimates of the unau-
thorized immigrant population residing in the United States.
Retrieved from http://www.dhs.gov/xlibrary/assets/statistics/
publications/ois_ill_pe_2010
Eggenberger, S.K., Grassley, J., & Restrepo, E. (2006). Culturally
competent nursing care: Listening to the voices of Mexican-
American women. Online Journal of Issues in Nursing, 11(3), 7.
Gates, G., Lau, H., & Sears, B. (2006). Race and ethnicity of same-
sex couples in California: The Williams Project on Sexual Orien-
tation Law and Public Policy UCLA School of Law. Los Angeles,
CA: UCLA.
Gladen, B., & Rogan, W. (1995). DDE and shortened duration of
lactation in a northern Mexican town. American Journal of
Public Health, 85(4), 504–508.
Grothaus, K.L. (1996). Family dynamics and family therapy with
Mexican Americans. Journal of Psychosocial Nursing and Mental
Health Services, 34(2), 31–37.
Kemp, C. (2001). Hispanic health beliefs and practices: Mexican
and Mexican-Americans (clinical notes) [Electronic version].
Retrieved from http://www3.baylor.edu/~Charles_Kemp/
hispanic_health.htm
Kim-Godwin, Y.S., Alexander, J.W., Felton, G., Mackey, M.C., &
Kasakoff, A. (2006). Prerequisites to providing culturally com-
petent care to Mexican migrant farmworkers: A Delphi study.
Journal of Cultural Diversity, 13(1), 27–33.
Kurian, A.K., & Cardarelli, K.M. (2007). Racial and ethnic dif-
ferences in cardiovascular disease risk factors: A systematic
review. Ethnic Diseases, 17(1), 143–152.
Library of Congress. (2005, April, 20). Immigration: Mexican.
Retrieved from http://novaonline.nvcc.edu/eli/evans/his135/
Events/Mexico/Mexico.html
Locke, D. (1998). Increasing multicultural understanding: A com-
prehensive model (2nd ed.). Newbury Park, CA: Sage.
Luckmann, J. (1999). Transcultural communication in nursing.
Albany, NY: Delmar.
Martin, J.A., Hamilton, B.E., Sutton, P.D., Ventura, S.J., Mathews,
T.J., Kirmeyer, & S. Osterman, J.K. (2010). Division of vital
statistics, births: Final data for 2007. National Vital Statistics
Report, 58(4). Retrieved from http://www.cdc.gov/nchs/
data/nvsr/nvsr58/nvsr58_24
Mendoza, F.S., Ventura S., Saldivar L., Baisden K., & Martorell
R. (1992). In A. Furino (Ed.), Health policy and the Hispanic
(pp. 97–115). Boulder, CO: Westview Press.
Meyer, M., & Beezley, W. (2000). The Oxford history of Mexico.
Oxford: Oxford University Press.
Neff, N. (2011). Folk medicine in Hispanics in the southwestern
United States. Retrieved from http://www.rice.edu/projects/
HispanicHealth/Courses/mod7/mod7.html
Olds, S., London, M., & Ladewig, P. (2000). Maternal newborn
nursing: A family-centered approach (5th ed.). Redwood City,
CA: Addison Wesley.
Pandey, D.K., Labarthe, D.R., Goff, D.C., Chan, W., &
Nichaman, M.Z. (2001). Community-wide coronary heart dis-
ease mortality in Mexican Americans equals or exceeds that in
non-Hispanic whites: The Corpus Christi Heart Project. American
Journal of Medicine, 110(2), 81–87.
RefWorld. (2011). Mexico: Treatment of homosexuals and availabil-
ity of state protection. Retrieved from http://www.asylumlaw.
org/docs/sexualminorities/MexicoUNHCRRefworld061507
Rivera, J.O., Anaya, J.P., & Meza, A. (2003). Herbal product use
in Mexican-Americans. American Journal of Health-System
Pharmacy, 60(12), 1281–1282.
is located 15 miles from his job where new homes are being
built outside the city. Vicente usually takes two buses to work.
One of the migrant workers has an uncle who helped secure
the jobs for them. Vicente and his coworkers cook and eat din-
ner together most evenings and enjoy drinking cervezas (beer)
on the weekends.
Vicente has saved money from working over the past
18 months but is worried about health-care coverage. He
usually goes to a local clinic for his health-care needs. His
friends suggested that he should visit a bruja because he might
have had a spell cast upon him. He and his friends believe that
the bruja can rid him of the spell and heal him. Vicente’s friends
are able to help take care of him on weekends only because
of their weekday 12-hour work schedules. Vicente has an uncle
from Mexico who is trying to get money together for a trip up
to help Vicente as he recovers. Vicente will require home phys-
ical therapy and nursing care after his surgery. He will also be
unable to work for 6 to 8 weeks.
1. The home-care case manager, a registered nurse, is
sending a physical therapist to the home. What should
the nurse consider?
2. What does the nurse need to know about what part of
Mexico Vicente and his family are from?
3. Identify potential communication needs of Vicente, his
friends, and his visiting family.
4. Vicente is concerned about letting his boss down because
of his illness. Why is Vicente concerned about this with
his boss?
2780_Ch21_374-390 16/07/12 11:55 AM Page 389

Schmal, J., & Madrer, J. (2007). Ethnic diversity in Mexico [Elec-
tronic version]. Mexico Connect. Retrieved from http://www.
mexconnect.com/mex_/feature/ethnic/ethnicindex.html#imm
Sobralske, M. (2006). Machismo sustains health and illness beliefs
of Mexican American men. Journal of American Academy of
Nurse Practitioners, 18(8), 348–350.
Sobralske, M., & Katz, J. (2005). Culturally competent care of pa-
tients with acute chest pain. Journal of American Academy of
Nurse Practitioners, 17(9), 342–349.
Spanish Language. (2007). Fact, figures and statistics about Spanish.
Retrieved from http://spanish.about.com/library/weekly/
aa070300a.htm
Spector, R. (2008). Cultural diversity in health and illness (7th ed.).
Upper Saddle River, NJ: Pearson.
Stanley Bunting, J. (2011). Chemical dependency within the His-
panic population: Considerations for diagnosis and treatment.
In G. Lawson & A. Lawson (2nd ed.), Alcoholism and substance
abuse in diverse populations (pp. 227–242). Austin, TX: Pro-Ed.
Torres, E. (2001). The folk healer: The Mexican American tradition
of curanderismo. Albuquerque, NM: Nieves Press.
U.S. Census Bureau. (2001). Census 2000 briefs and special reports.
Retrieved from http://www.census.gov/population/www/
cen2000/briefs.html
U.S. Census Bureau. (2008). Population estimates, July 1, 2000, to
July 1, 2006. Retrieved from http://www.census.gov/population/
www/socdemo/hispanic/hispanic_pop_presentation.html
U.S. Census Bureau. (2009). Income, poverty, and health insurance
coverage in the United States. Report P60, n. 238, pp. 62–67.
U.S. Census Bureau. (2010). Facts for features. Retrieved from
http://www.census.gov/newsroom/releases/archives/facts_for_
features_special_editions/cb10-ff08.html
U.S. Department of Health and Human Services Health Re-
sources and Services Administration. (2010, September). The
registered nurse population: Findings from the 2008 national
sample survey of registered nurses. Retrieved from http://bhpr.
hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal
Van Hook, J., Bean, F., & Passel, J. (2005, September). Unautho-
rized migrants living in the United States: A mid-decade por-
trait. Migration Information Source. Retrievedfrom http://www.
migrationinformation.org/Feature/display.cfm?ID=329
Vázquez, R. (2000). Is the phrase “La raza” racist? [Electronic ver-
sion]. Las Culturas. Retrieved from http://www.lasculturas.
com/aa/aa031200a.htm
Vázquez, R. (2004). Hispanic or Latino? [Electronic version]. Las
Culturas. Retrieved from http://www.lasculturas.com/aa/
aa070501a.htm
Villarruel, A.M., & Ortiz de Montellano, B. (1992). Culture
and pain: A Mesoamerican perspective. Advances in Nursing
Science, 15(1), 21–32.
Wells, J.N., Cagle, C.S., & Bradley, P.J. (2006). Building on Mexican-
American cultural values. Nursing, 36(7), 20–21.
Zoucha, R. (2007). Understanding confianza (confidence) in the
nursing relationship with Mexican Americans. Pittsburgh:
Duquesne University School of Nursing.
Zoucha, R. (2011). Understanding the meaning of confianza in
the context of health for Mexicans in an urban community:
A focused ethnography. Pittsburgh: Duquesne University
School of Nursing.
Zoucha, R., & Husted, G.L. (2000). The ethical dimensions of de-
livering culturally congruent nursing and health care. Issues in
Mental Health Nursing, 21(3), 325–340.
Zoucha, R., & Husted, G.L. (2002). The ethical dimensions of de-
livering culturally congruent nursing and health care. Review
Series in Psychiatry, 3, 10–11.
Zoucha, R.D., & Reeves, J. (1999). A view of professional caring
as personal for Mexican Americans. International Journal for
Human Caring, 3(3), 14–20.
Zoucha, R., & Zamarripa, C. (1997). The significance of culture
in the care of the client with an ostomy. Journal of Wound,
Ostomy, and Continence Nursing, 24(5), 270–276.
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
390 Aggregate Data for Cultural-Specific Groups
2780_Ch21_374-390 16/07/12 11:55 AM Page 390

391
Chapter 22
People of Polish Heritage
Larry Purnell
The author would like to thank Henry M. Plawecki, Lawrence H. Plawecki, Judith A. Plawecki, and Martin H. Plawecki
for their contributions to this chapter in the 3rd edition.
Overview, Inhabited Localities,
and Topography
Overview
Almost 9.9 million people in the United States (U.S.
Census Bureau, 2011) and over 8 million people in
Canada identify their ancestry as Polish (Statistics
Canada, 2010). Poland—officially the Republic of
Poland—occupies 120,727 square miles (312,683 square
kilometers), which is slightly smaller than the state of
New Mexico (CIA World Factbook, 2011). The capital
of Poland is Warsaw. Located in Central Europe,
Poland, with a population of about 38,111,000, is the
eighth largest country in Europe. The life expectancy in
Poland 72.1 years for men and 80.25 years for women
(CIA World Factbook, 2011). Poland shares its western
border with Germany, and to the south, it is bordered
by Slovakia and the Czech Republic. Ukraine, Belarus,
Lithuania, and Russia all share eastern and northeast-
ern borders with Poland. The Baltic Sea borders the
majority of the northernmost part of the country.
Poland is an ancient nation that was conceived near
the middle of the 10th century. Its golden age occurred
in the 16th century. During the following century, the
strengthening of the gentry and internal disorders
weakened the nation. In a series of agreements be-
tween 1772 and 1795, Russia, Prussia, and Austria par-
titioned Poland among themselves. Poland regained its
independence in 1918, only to be overrun by Germany
and the Soviet Union in World War II. It became a
Soviet satellite state following the war, but its govern-
ment was comparatively tolerant and progressive.
Labor turmoil in 1980 led to the formation of the first
independent free trade union in Eastern Europe, Soli-
darnosc (Solidarity) that over time became a political
force and by 1990 had swept parliamentary elections
and the presidency. A “shock therapy” program during
the early 1990s enabled the country to transform
its economy into one of the most robust in Central
Europe, but Poland still faces the lingering challenges
of high unemployment, underdeveloped and dilapi-
dated infrastructure, and a poor rural underclass.
Poland joined NATO in 1999 and the European Union
in 2004. With its transformation to a democratic,
market-oriented country largely completed, Poland is
an increasingly active member of Euro-Atlantic organ-
izations (CIA World Factbook, 2011).
In 1947, elections officially brought the Communist
Party to power. The Stalinist model was implemented
until 1956. After Stalin’s death, Polish Communism
vacillated between repression and liberalization until
about 1970. Poland’s resistance to Communist rule
began in 1970 with the emergence of Lech Walesa, the
leader of a strike in the Gdansk shipyards. Walesa
headed Solidarity , which was created because of the
Communists’ violent repression of the workmen of
Radom in 1976 and a second strike at the Gdansk
shipyards in 1980, the result of the government’s
raising food prices (Gdansk, 2008).
The 1978 election of a Polish cardinal, Karol Wojtyla,
as Pope John Paul II led to unprecedented social and
political changes in Poland. The 1980 emergence of
Solidarity and the election of a Polish pope rekindled
a religious rebirth in the Poles, an increased sense
of self, social identity, and the realization of their col-
lective strength. Solidarity became a major social
movement and phenomenon unheard of within the
Soviet bloc’s political system. Despite negotiations,
confrontations, and, ultimately, repressive military op-
erations by the ruling Polish Communist Party, the
Solidarity movement survived as its influential unof-
ficial opposition. Ultimately, the Polish Communist
Party recognized that the people’s massive opposition
reduced their ability to govern. In 1988, formal nego-
tiations between the Polish Communist Party leaders
and the unofficial opposition, called the “Round Table
talks,” resulted in partially free Parliamentary elec-
tions. Solidarity won a landslide victory in the
2780_Ch22_391-406 18/07/12 6:04 PM Page 391

June 1989 elections. In July 1989, the newly elected
Parliament changed the country’s name and constitu-
tion, establishing the Third Republic of Poland and a
democratic system of government (von Geldern &
Siegelbaum, 2003).
Polish immigrants and their descendants who
immigrated to America for many generations have
maintained their ethnic heritage by promoting their
culture, attending Catholic churches, attending pa-
rades and festivals, maintaining ethnic food traditions,
speaking the Polish language, and promoting interest
in their home country through media events as well as
economic and political channels. For newer immigrant
Poles, maintaining ethnic heritage means learning
English and obtaining a good job (Erdmans, 1998).
Newer immigrants are less concerned with raising
consciousness over Polish American issues than they
are with financially helping families who remain in
Poland and raising concerns over the political and
economic climate in their homeland.
Heritage and Residence
The first contribution of the Poles to the development
of American democracy occurred during the American
Revolutionary War. Two prominent Poles who assisted
the colonists in their fight for independence were Count
Kazimierz (Casimir) Pulaski and Tadeusz Kosciusko.
General Pulaski, a valiant cavalryman, led soldiers by
courage and example. His many heroic actions on be-
half of the colonists lead to naming him the “Father of
the American Cavalry” (Polish American Center, 1997).
Many American towns, counties, parks, and other me-
morials bear the names of these Polish heroes.
The Poles’ dedication to the welfare of the
United States was summarized by the motto of the
first Polish American political club, the Kosciuszko
Club, established in 1871, which states, “A good
Pole is a good American citizen” (Jarczak, n.d.).
Immigrants, regardless of their country of origin,
leave their homeland for a variety of reasons that
include avoiding ethnic, religious, and political per-
secution; seeking a better lifestyle; and providing a
means of support for family and relatives who re-
mained in the homeland. Like any other group who
perceives themselves as unaccepted, displaced,
and different, the Polish immigrants established a
geographically and socially segregated area called a
Polonia, the medieval name for Poland. Polonia
allowed members of the immigrant group to expe-
rience social comfort, speak their native language,
and openly practice the customs of their homeland.
The initial migration of about 2000 Polish immi-
grants occurred between 1800 and 1860. This group
consisted of intellectuals and nobles who were moti-
vated by political insurrections. The first substantive
Polish settlement in America was founded in 1854 by
Father Leopold Moczygemba and 100 Polish immigrant
families in Panna Maria, Texas (Panna Maria, 2006).
Even though most Poles preferred living in agrarian
communities, they gravitated to cities where work for
laborers was plentiful.
Between the early 1800s and the beginning of
World War II, over 5 million Polish immigrants came
to the United States. Many of these immigrants per-
ceived America only as a temporary home. This first
major immigrant group was called za chlebem, or “for-
bread” immigrants. These immigrants came to earn
money and then return to Poland. Polish immigration
to America continues today. A new generation of im-
migrants recently freed from foreign domination have
recently been coming to the United States seeking
better lives (Library of Congress, 2004).
At the peak of Polish migration, Chicago was con-
sidered the most well-developed Polish community in
the United States (Pacyga, 2004). The first Polish im-
migrants to Chicago were primarily nobles who fled
Poland after the Polish-Russian war of 1830 to 1831.
They came with plans of establishing a Polonia in Illi-
nois (Pacyga, 2004). Chicago’s Polish community grew
rapidly after 1850. Peter Kiolbassa, who served as a
captain in the Sixth Colored Cavalry during the Civil
War, emerged as a local leader. Kiolbassa organized
the first Polish Society of St. Stanislaus Kostka in
1864. This organization prepared the community for
the development of the city’s first Polish Roman
Catholic parish. Located along the north branch of
the Chicago River, the residents of Polonia initially at-
tended a German parish church. Facing hostility from
some of the Germans, who discouraged their priest
from ministering to the Polish religious needs, the
Polish community established its own Roman Catholic
parish, St. Stanislaus Kostka. The parish was central
to the creation of Polonia, because the establishment
of ethnic Catholic parishes provided the community
with a stable institutional base and served as a status
symbol for the new immigrant colony.
The Polish community’s development allowed them
to actively participate in the labor movement, which,
along with their involvement with fraternal groups, led
to the development of neighborhood organizations. By
1980, Hispanics and African Americans had largely
replaced Poles in the inner-city core neighborhoods.
Polish Chicagoans left the old neighborhoods and
moved to the suburbs. Chicago’s Polonia played a cru-
cial role in the political, religious, educational, busi-
ness, institutional, and cultural life of Chicago.
Polonia was also the name given to Polish commu-
nities found in northeastern and midwestern cities after
1945 (Best, 2004). Members of these communities kept
Polish nationalism alive by speaking their native lan-
guage, preserving customs, and attending the local
Catholic church run by Polish clergy and the Felician
Sisters. Because Poland was partitioned until 1919,
Poles coming to America during the 1800s and early
392 Aggregate Data for Cultural-Specific Groups
2780_Ch22_391-406 18/07/12 6:04 PM Page 392

1900s were unable to report Poland as their emigrat-
ing country, but they tenaciously worked to ensure
the survival of the Polish culture. Over time, the
120-year partition of Poland and its absence from the
world map significantly reduced the number of immi-
grants who could identify Poland as their emigrating
country. Therefore, the partition ultimately led to an
undercount of the actual number of Americans with
Polish ancestry.
For many older Poles, the neighborhood is their
community. Polonias, especially in urban ethnic com-
munities, provide a sense of belonging, reduce alien-
ation, and enhance people’s ability to solve problems
and maintain the motivation to address modern-day
frustrations. Plawecki (2000) states, “The assumption
of voluntary Americanization continues to exist in
spite of the behaviors of past generations who resisted
the assimilation process and have, in fact, reestablished
their pre-immigration cultures in multiple voluntarily
segregated ethnic enclaves/communities” (p. 7). Con-
sequently, the segregated group develops communica-
tion styles, cultural beliefs, and interactive behaviors
that are socially accepted within their community
but are different from those expected by the general
populace (Plawecki, 1992).
Poles are a heterogeneous group. As such, they were
slow to assimilate into multicultural America. Much
of the variation within this ethnic group is due to vari-
ant cultural characteristics (see Chapter 1).
Polish Americans were well represented in the
WWII war effort of the United States. Significant
numbers of Polish Americans, both native and im-
migrant, joined the U.S. military. Even after display-
ing that sense of duty, honor, and patriotism, Polish
Americans often experienced discrimination during
and after the war. Poles were passed over for jobs
because they had difficulties speaking English and
their names were difficult to pronounce or spell.
As a reaction to this discrimination, name changes be-
came common for upwardly mobile Polish Americans.
The shortening and changing of names were in-
tended to decrease discrimination and promote
greater acceptability in the job market as well as in-
crease social acceptance. Many Polish Americans
still experience discrimination and ridicule through
ethnic Polish jokes, which are similar in scope to
those about Irish, Italian, Mexican Americans, and
other ethnic groups.
Reasons for Migration and Associated
Economic Factors
Polish immigration to the United States occurred in
three major waves. The first wave of immigrants, ar-
riving in the early 1800s through 1914, came to Amer-
ica primarily for economic, political, and religious
reasons. Many immigrants were illiterates, peasants,
or unskilled laborers (Grocholska, 1999). They took
low-paying jobs and lived in crowded dwellings just to
make a meager living.
The second major wave of immigration occurred
after World War II. During the war, Poland lost over
6 million of its 35 million people (Brogan, 1990). The
nearly complete destruction of Poland prompted the
post-WWII wave of Polish immigrants to come to
America. This group primarily included political pris-
oners, dissidents, and intellectuals from refugee camps
all over Europe. These immigrants, who were both
educated and had a basic knowledge of English,
assimilated more easily into American culture than
those from the first wave. They consciously separated
from Polonia and aligned themselves with other
middle-class and professional groups in America. The
upwardly mobile and middle-class aspirations of this
group differed from the working-class orientation of
the first- and second-generation descendants of the
first wave (Grocholska, 1999).
The current third wave of immigrants, often called
the Solidarity immigrants, began arriving in 1978
(Grocholska, 1999). These Solidarity immigrants re-
flect the ideologies of the first two waves—that is,
they want to work and to speak freely about political
and intellectual issues. Two types of third-wave im-
migrants came to America. The first came to work
without any initial interest in permanently relocat-
ing. They entered this country on a visitor’s visa and
left their families in Poland. These immigrants fre-
quently lived in low-income housing, shared rooms
with other immigrants, and worked hard to send
money to their families in Poland. Networking with
other Poles was their primary source of job contacts.
They quickly took any job available, particularly
as laborers, domestics, and unskilled farm workers.
Because many of these immigrants were sending
money to their families in Poland, they often over-
stayed their visitor visas.
The second type of third-wave Polish immigrants
chose to come to America for political and economic
reasons. This group typically consists of well-educated
professionals and small-business owners. They con-
sciously decided to leave Poland forever and bring
their families with them. This group epitomizes the
Polish characteristics of hard work, determination,
and frugality. Although many in this group are under-
employed, they actively use English and integrate into
their new country, recognizing that this may be a nec-
essary first step to assimilation.
Many second- and third-wave immigrants avoid
Polish communities because they believe that American
ethnic Polonias are different from those in Poland. The
concerns and issues of political representation and dis-
crimination of established immigrants living in America
are irrelevant to this wave of immigrant Poles. In addi-
tion, many older Polonias are located in diverse, chang-
ing, inner-city neighborhoods, and the upwardly mobile
People of Polish Heritage 393
2780_Ch22_391-406 18/07/12 6:04 PM Page 393

Polish Americans, like other successful groups, have
begun to leave the cities for the suburbs.
Educational Status and Occupations
Educational priorities and their desire to assimilate into
American culture vary widely among Polish immi-
grants. The educational status, socioeconomic levels,
and cultural philosophy often depend on the time frame
when the family emigrated from Poland.
Until the 1950s and 1960s, many Polish families
were slow to recognize the value of education for their
children. Before WWII, most Polish children went to
Catholic schools, where they learned about their cul-
ture, its language, and Catholicism. After WWII, par-
ents felt an acute responsibility to have their children
learn English. Subsequently, the Polish language was
eliminated from the curriculum of many schools, and
its use was restricted to the home.
The second wave of Polish immigrants placed a high
value on education and culture. Educated, cultured
Poles were expected to read widely and speak several
languages. Cultured Poles have great pride and respect
for Poland’s most famous people, such as composer
Frederic Chopin, two-time Nobel laureate scientist
Marie Curie, novelist Joseph Conrad, astronomer
Nicolaus Copernicus, and Karol Wojtyla, better known
as Pope John Paul II. Poles are known for epic works
in prose and poetry. Major themes in Polish literature
are nationality, freedom, exile, and oppression.
After World War II, many Polish Catholics were
blue-collar workers who perceived hard work as hon-
orable. Many feared that education and its resultant
mobility were a threat to their family, religious, and
community life. For women, education was seen as
even less necessary because of the value placed upon
their staying at home and raising their children. Tele-
vision helped change the character of ethnic commu-
nities forever as it brought the outside world into both
the community and the home. The descendants of
immigrants who did go to college valued obedience
and self-control, respected authority, and exhibited
determination (Bukowczyk, 1987).
Communication
Dominant Language and Dialects
The Polish language was influenced by the countries
surrounding Poland and by the Latin of 11th- and
12th-century kings. Depending on the regional and
cultural background of the speaker, Polish may sound
German, Russian, or French. The Polish language has
a lyrical quality that is pleasant to the ear, even if one
has difficulty understanding the words. Poles are an
animated group, and facial expressions generally con-
vey the tone of the conversation.
The dominant language of people living in Poland
is Polish, although there are some regional dialects
and differences. Generally, most Polish-speaking peo-
ple can communicate with one another. Recently, a
resurgence of interest in learning to speak the Polish
language has occurred among Polish Americans. Both
adults and children are learning Polish in church-
affiliated language schools, cultural centers, and col-
leges. Polish radio stations help keep an ongoing
interest in the language, music, and culture.
Cultural Communication Patterns
Poles use touch as a form of personal expression of
caring. Touch is common among family members and
friends, but Poles may be quite formal with strangers
and health-care providers. Handshaking is considered
polite. In fact, failing to shake hands with everyone
present may be considered rude. Most Poles feel com-
fortable with close personal space, but distances
increase when interacting with strangers.
First-generation Poles and other people from East-
ern European countries commonly kiss “Polish
style”—that is, once on each cheek and then once
again. For Poles, kissing the hand is considered appro-
priate if the woman extends it. Two women may walk
together arm in arm, or two men may greet each other
with an embrace, a hug, and a kiss on both cheeks.
To Poles, love is expressed through covert actions
and displayed easily in the form of tenderness to chil-
dren. However, loving phrases are uncommon among
adult Polish Americans. Poles praise others’ deeds and
good works, but they may be reluctant to acknowledge
how they feel about one another. These behavioral
variations may have persevered through generations
of assimilated Poles.
Acknowledging the hostess is important when Poles
visit one another’s homes; bringing flowers or candy
is always in good taste. Normally, guests are discour-
aged from assisting the hostess in the kitchen or with
cleanup after meals. After the event, thank-you letters
and greeting cards should be sent to demonstrate an
appreciation for the host’s hospitality.
Many Polish Americans consider the use of spoken
second-person familiarity rude. Polish people speak in
the third person. For example, they might ask,
“Would Martin like some coffee?” rather than “Would
you like some coffee?” Although the first expression
might sound awkward, the latter expression may be
considered impolite and too informal, especially if the
person being asked is older. Many Polish names are
difficult to pronounce. Even though a name may be
mispronounced, a high value is placed on the attempt
to pronounce it correctly.
When interacting with others, Poles consider age,
gender, and title. For example, when a group is walk-
ing through a door, an unspoken hierarchy requires
the person of lower standing to hold the door for a
woman or those of a higher title. To many Americans,
this behavior may seem excessive, but for Poles, it
394 Aggregate Data for Cultural-Specific Groups
2780_Ch22_391-406 18/07/12 6:04 PM Page 394

shows respect and courtesy. Polish Americans also use
direct eye contact when interacting with others. Many
Americans may feel uncomfortable with this sustained
eye contact and feel it is quite close to staring, but to
Poles, it is considered ordinary.
Most Poles enjoy a robust conversation and have a
keen sense of humor. Polish humor sometimes has an
openness and bawdiness that may be unnerving to
those unaccustomed to it. Cultural nuances may make
it difficult to understand the underlying meaning of
some transactions or exchanges. Because Poles in
Poland have been censored for centuries, they have
raised satire and political savvy to an art form.
Poles, as a group, tend to share thoughts and
ideas freely, particularly as part of their hospitality.
A guest in a Polish home is warmly welcomed and
may be overwhelmed by the outpouring of generos-
ity. Americans talk of sports, whereas Poles speak
of their personal life, their jobs, families, spouse,
aspirations, and misfortunes.
Temporal Relationships
Punctuality is important to Polish Americans. Being
late is a sign of bad manners. Depending on the status
of the person for whom they are waiting, Poles may
be intolerant of lateness. Even in social situations,
people are expected to arrive on time and stay late.
Polish Americans are both past and future oriented.
The past is very much a part of Polish culture, with
the families passing on their memories of WWII,
which still haunt them in some way. A strong work
ethic encourages Poles to plan for the future. Polish
parents very much want their children to have a better
life than the one they have experienced.
Format for Names
Many Polish peasants did not have surnames until the
1600s. The use of surnames appeared in the first half
of the 18th century. After 1850, the practice of creating
surnames was no longer used. Traditional Polish
names are often a description of a person (e.g., John
Wysocki, meaning “John the tailor”), a profession
(e.g., the surname Recznik, meaning “butcher”), a place
(e.g., Sokolowski, meaning “one came from a town
named Sokoly or Sokolka”), or even a thing. Many fac-
tors caused this rather logical process to become some-
what confusing. Historical, linguistic, and political
factors also directly affected the structure of Polish sur-
names. First of all, the partition of Poland for almost
120 years made it impossible for any emigrant at that
time to claim Poland as their homeland. Consequently,
names may have been “adjusted” to sound more like
those of the dominant ethnic group (e.g., Russian,
Prussian, or Austrian) controlling that part of Poland
at the time. Second, changes in surnames may have
been made during the country’s record-keeping process
or during the immigration processing on Ellis Island.
The transfer of information from emigrant to official
records was highly dependent on the pronunciation,
spelling, and writing skills of both the recorder and the
applicant (Generations Network, 2007).
Some examples of common Polish names include
Kowal meaning “blacksmith.” Numerous suffixes,
such as “icz,” “czyk,” “iak,” and “czak,” which mean
“son of,” can be added. The most common suffixes are
“ski” for males and “ska” for females, which originally
were added to many names because they were associ-
ated with nobility. The suffix “cki” became the pho-
netic version of “ski.” Surnames ending in “y,” “ow,”
“owo,” and “owa” are usually derived from names of
places. The “ak” suffix is typical of western Poland,
whereas “uk” is found in the east.
Family Roles and Organization
Head of Household and Gender Roles
Life in the Polish culture centers on family. Each family
member has a certain position, role, and related re-
sponsibilities. All members are expected to work,
make contributions, and strive to enhance the entire
family’s reputation and social and economic position.
People of Polish Heritage 395
R E F L E C T I V E E X E R C I S E 2 2 . 1
Casimir Wronska, a 62-year-old Polish man, has been in the
United States for 19 years. A colleague with whom he works at
a construction site brought him to the Emergency Department
(ED) because he had a severe laceration from a circular saw on
his thigh. In broken English, he described what happened. After
2 hours in the ED, suturing was complete, and he was dis-
charged to home with complex instructions on how to care
for the wound and when he should return for follow-up.
He was also given a prescription for antibiotics and pain pills.
He accepted the prescription for antibiotics but refused the
prescription for pain pills.
Mr. Wronska listened attentively as the nurse gave him his
discharge instructions. He maintained rather intense eye con-
tact and nodded frequently. When the nurse, Mark Babinska,
asked him to repeat the instructions, he folded the instructions
and put them in his pocket, telling Mark that his wife would
take care of him. The nurse asked him to read the instructions
back to him. He told the nurse that he left his glasses at home
and would read the instructions later.
1. What statements by Mr. Wronska indicate that he might
not understand the discharge instructions?
2. What should the nurse do to ensure that Mr. Wronska
understands the instructions?
3. Is maintaining intense eye contact with the nurse culturally
congruent with Polish nonverbal communication?
4. What are some possibilities as to why Mr. Wronska
accepted the prescription for antibiotics but refused the
prescription for pain pills?
2780_Ch22_391-406 18/07/12 6:04 PM Page 395

Individual concerns and personal fulfillment are af-
forded little consideration, and sacrifices for the better-
ment of the family are expected. The family structure
is interwoven with strong beliefs and traditions. In the
United States, the Polish family has maintained itself
as a strong economic unit.
In most Polish families, the father is perceived as the
head of the household. Depending on the degree of as-
similation, the father may rule with absolute authority
in first-, second-, and even third-generation Polish
American families. Depending on circumstances, only
the Church may have greater authority than the father.
For example, if a child wants to leave home and attend
college, the priest may help in convincing the family
that it is an appropriate thing to do. However, among
some third- and fourth-generation Polish Americans
and second- and third-wave immigrants, more egalitar-
ian gender roles are becoming the norm. In addition,
the father, as head of the house, worked as many hours
a day in a mine or a factory as was permitted. He as-
sumed responsibility of finding jobs for both offspring
and newly immigrated friends and relatives.
Historically, large families were expected and com-
monplace among Poles. Polish women who followed the
Church’s teachings had many children, often experienc-
ing between 5 and 10 pregnancies. Although women
were pregnant a good deal of their early married lives,
the wife began the workday well before dawn, and her
responsibilities included cooking, caring for the chil-
dren, laundering the clothes, and cleaning the house. If
necessary, the wife also worked outside the home for
additional income. Although the husband was the final
authority in most matters, it was the woman who ran
the house, disciplined the children, and cared for elderly
family members.
Szaflarski used data from the Polish General Social
Survey to estimate the structural and psychosocial
effects on self-reported health, risk behaviors, and social
participation between the genders. Employment status
was identified as improving the health of men, whereas
marital happiness increased the probability of better
health for women. Marital status was identified to influ-
ence social interactions. Married women were found to
socialize less than unmarried women, whereas marital
status had no effect on men’s socialization. Smoking was
found to decline with the educational level among men
but not among women, whereas excessive drinking in-
creased for unhappily married men. Religiosity was de-
termined to enhance and protect the health of both men
and women (Szaflarski, 2001). The degree of religiosity
may apply to Poles in the United States, especially
among newer immigrants.
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
The most valued behavior for Polish American children
is obedience. Taboo child behaviors include anything
that undermines parental authority. Parents are quite
demonstrative with young children, but they resist
showing much affection toward them once they are
older than toddler age. This is the parents’ way of
teaching children to be strong and resilient. Many par-
ents praise children for self-control and completing
chores. Little sympathy is wasted on failure, but doing
well is openly praised. Children are taught to resist feel-
ings of helplessness, fragility, or dependence.
Family Goals and Priorities
Traditional family values and loyalty are strong in most
Polish households. Children are valued in the Polish
American family. For many first-wave immigrants, mar-
riage is an institution of respect and economic solidarity
and may not necessarily include romance. In the past,
husbands owed their wives loyalty, fidelity, and financial
support, whereas wives owed their husbands fidelity and
obedience. Children owed their parents emotional and
financial support before and after marriage. An impor-
tant family priority for many is to maintain the honor
of the family in the larger society, have a good job, and
be a good Catholic.
The elderly are highly respected in most Polish fam-
ilies. They attend church regularly and carry on Polish
traditions. The Polish ethic of contributing to the
family and enhancing its status extends to the aged as
well. The elderly play an active role in helping grand-
children learn Polish customs and in assisting adult
children in their daily routine with families. For some
families, one of the worst disgraces, as seen through
the eyes of the Polish community, is to put an aged
family member in a nursing home. Third- and fourth-
generation Polish Americans may consider an ex-
tended-care or assisted-living facility because of work
schedules and demands of care, but first-generation
immigrants rarely perceive this as an option. If Polish
people are to assimilate into a nursing home, the use
of the Polish language and rituals may be crucial.
Thus, health-care providers should assist patients
in organizing these types of events for their family
members or should help them select nursing homes
that offer these cultural advantages.
The quality of life for elderly immigrants is an excel-
lent area for research (Berdes & Zych, 2000). Immi-
grants who arrived before the age of 21 adjusted to
aging much better than their elderly counterparts who
arrived in America well into maturity. If the elderly Pole
moved to America and was actively embraced by family
and friends, adjusting to old age in America was less dif-
ficult. However, if the move to America was a forced
choice, the adjustment was more difficult.
Extended family, consisting of aunts, uncles, and
godparents, is very important to Poles. Longtime
friends become aunts or uncles to Polish children. Nu-
merous family rituals surround holidays, and family
gatherings—such as for births, marriages, and name
396 Aggregate Data for Cultural-Specific Groups
2780_Ch22_391-406 18/07/12 6:04 PM Page 396

dates (calendar date of the patron saint for whom
one is named)—are times to socialize and solidify
relationships.
The goals of the family are to work, make economic
contributions, and strive to enhance the position of the
family in the community. The family unit comes to-
gether to help deter behaviors that might cause them
shame or lower prestige in the eyes of the community.
As Poles assimilate into the culture, the American value
of success may prevail. Most Poles expect their children
to have an education and a well-paying job and to pro-
vide for them in their old age.
Alternative Lifestyles
Alternative lifestyles are seen as part of assimilation
into the blended American culture. Same-sex couples
are frowned upon and may even be ostracized, depend-
ing on the level of assimilation. Older second- and
third-generation Poles have one of the lowest divorce
rates of ethnic groups (Lopata, 1994), but patterns are
changing with succeeding generations as they assimilate
into the American lifestyle. Marital problems do exist,
but the Polish value for family solidarity is strong and
divorce is seen as truly a last resort. When divorce does
result, single heads of households are accepted in the
Polish American community.
Workforce Issues
Culture in the Workplace
Most Polish Americans are more socially segregated
than other ethnic groups. In the past, many Poles
never rose above the level of foreman or supervisor.
Polish American immigrants of the 1800s maintained
group solidarity and could always be counted on to
help their families. Because men were semiliterate and
had low-level skills, they gravitated to industrial cities,
such as Chicago, where they could work long hours
as laborers and earn overtime pay. Because Poles
were active in trade unions and maintained a sense of
loyalty to the group, they were strong.
Polish Americans have extensive social networks, and
their strong work ethic enables them to gain employ-
ment and assimilate easily into the workforce. It is still
possible to spend one’s entire life in the same house, be
employed in the same factory, and have the majority of
your social contacts inside the boundaries of Polonia.
Whereas this may have helped immigrants in the past,
it now acts as a deterrent to assimilation. The cultural
tradition of hard work has caused employers to take
advantage of this attitude.
Issues Related to Autonomy
Some Poles entering America are underemployed and
may have difficulty working with authority figures
who are less educated. Poles quietly comment that
they are disrespected for their educational background
and that they must endure decreased status to stay in
America (Lopata, 1994). Poles are usually quick learn-
ers and work hard to do a job well. The Polish char-
acteristic of praising people for their work makes
Poles strong managers, but some lack sensitivity in
their quest to complete tasks.
Even though nursing in Poland is considered a pro-
fession, newer immigrants may be unprepared for the
level of sophistication and autonomy of American
nurses. Only since the 1980s has nursing entered the uni-
versity setting in Poland. Most Polish nursing education
is still completed in 1- to 2-year postsecondary educa-
tion programs. As with many other professionals com-
ing to America, if Polish nurses are willing to complete
the extra courses to become registered or practical
nurses, their employment as a nurse can be continued.
A problem for many foreign nurses is that they may not
receive credit for their work experiences in their home
country. A nurse with 10 years of foreign nursing expe-
rience may have to start with the schedule, salary, and
status of a new graduate. Poland’s nursing students ex-
press fundamental values that are significantly influ-
enced by a society characterized by strong religious
conviction (Wronska, 2002). In the United States, nurs-
ing education’s multireligious attitudes defer any
discussion of religious beliefs.
Because Poles learn deference to authority at home,
in the church, and in parochial schools, some may be
less well suited for the rigors of a highly individualis-
tic, competitive market. For Poles living in a country
with a strong religious tradition, the American work
culture may be very difficult for them to understand.
Nevertheless, the strong Polish work ethic, exhibited
as volunteering for overtime, being punctual, and
rarely taking sick days, is valued by employers.
Native-born Polish Americans have little, if any, dif-
ficulty with the English language. Foreign-born Poles
frequently have some difficulty understanding the sub-
tle nuances of humor. Less-educated Poles tend to
seek jobs as domestics or choose to perform manual
labor because they are reluctant to rely on their Eng-
lish language and communication skills. Recent Polish
immigrants, who had experience working under a
Communist bureaucratic hierarchy, may have some
difficulty with the structure, subtleties, and culture of
the American workplace. New-wave Poles may be very
naive in acclimating to the American work culture
and, therefore, may become frustrated with what is
considered an acceptable work ethic.
Biocultural Ecology
Skin Color and Other Biological Variations
Most Poles are of medium height with a medium to
large bone structure. As a result of foreign invasions
over the centuries, Polish people may be dark and
Mongol-looking or fair with delicate features, blue
People of Polish Heritage 397
2780_Ch22_391-406 18/07/12 6:04 PM Page 397

eyes, and blonde hair. Those with fair complexions are
predisposed to skin cancer and other illnesses related
to exposure to environmental elements. Health-care
providers must be aware of these conditions when as-
sessing Polish patients and providing health teaching.
Diseases and Health Conditions
Poles consider themselves to be a tough people with an
ability to tolerate pain from injuries, illness, and disease.
Poles believe that suffering hardens individuals; there-
fore, they value that experience and perceive it to be
good. In the Polish culture, a common belief is that en-
during pain without complaining or asking for relief
demonstrates virility in men and self-control in women.
Young boys are taught at an early age that they can
control illness, pain, or discomfort without the help of
medicine and, thus, improve their inner strength. An-
other cultural belief is that taking medications weakens
the entire system, which results in the decrease in family
status. Fathers live vicariously through their children,
especially their sons, and any weakness in the child is
believed to reflect directly on them.
Risk factors for newer Polish immigrants are con-
nected with their employment in industries in their
homeland. Heavy industry in Poland produced pro-
longed, significant air pollution and environmental neg-
lect. Living in polluted environments led to an increase
in premature deliveries, low-birth-weight children, dis-
eases of the pulmonary and circulatory systems, and
various forms of cancer. The problem of occupational
lead poisoning from 1970 to 1996 in Poland was
documented by Szeszenia-Dabrowska and Wilczynka
in 1998. Between 1972 and 1976, 8414 cases of lead
poisoning, an occupational disease, were registered.
A diminishing number of occupational lead poisoning
cases were observed in the 1990s (Szeszenia-Dabrowska
& Wilczynka, 1998). Trzcinka-Ochocka, Jakubowski,
and Razniewska (2005) studied occupational exposure
to lead and evaluated the competence of laboratories
responsible for the monitoring and analysis of health
risks in workers exposed to lead. The data indicated
that occupational exposure to lead is still a problem and
that neither the recommendations of 1996, reinforced
by the Minister of Health in 2004, nor the European
Union directive is universally followed. The Minister of
Health mandated accreditation of all laboratories by
January 1, 2008.
In Poland, air pollution remains a serious problem
because of sulfur dioxide emissions from coal-fired
power plants. In addition to the air pollution problems,
Poles have had a long history of excessive smoking.
Zatorski (2003) states, “At the end of the 1980s, Poland
had the highest cigarette consumption in the world”
(p. 97). In 1990, the Cancer Center and Institute, under
the honorary patronage of Lech Walesa and in collab-
oration with the International Union Against Cancer
and the American Cancer Society, hosted the conference
“A Tobacco-Free New Europe.” Public-health leaders
from Eastern Europe were targeted; the participants
heard comprehensive scientific evidence on the magni-
tude of health damage caused by cigarette smoking in
the region. Ultimately, this conference provided the basis
for health-related tobacco control legislation, which
dramatically reduced the consumption of cigarettes
(Zatorski, 2003).
Obviously, miners and workers in heavy industry are
at an increased risk for the development of pulmonary
diseases. Water pollution from industrial and municipal
sources and disposal from industrial waste have also
become environmental problems. Once these industrial
establishments comply with the current European
Union codes, the pollution levels should decrease (CIA
World Factbook, 2011). The factors cited previously
have contributed to the significant incidence of respi-
ratory disease and lung and other cancers.
In 1986, the Chernobyl incident in Russia contam-
inated the land and water systems of eastern Poland.
The full impact of this disaster on the incidence of
cancer in Poland, as well as for Poles emigrating to
other parts of the world, remains unknown.
The long-term effects of hypertension in the Polish
population need to be addressed, and awareness
needs to be increased through patient education
efforts (Niewada, Skowronska, Ryglewicz, Kaminski,
& Czlonkowska, 2006). Zdrojewski and colleagues
(2006) examined high blood pressure, overweight and
obesity, and smoking as risk factors from those
attending the Polish Hygiene Society Congress. The
results were presented to the participants, and the
cumulative results were compared with the nation’s
current epidemiological burden caused by CVD
(Zdrojewski et al., 2006). This strategy appears to be
an effective way of impressing on the leaders the im-
portance of these risk factors and improving the
awareness, education, and lobbying efforts needed to
establish a long-term educational program aimed at
reducing the incidence of CVD risk factors.
Variations in Drug Metabolism
Documentation on the pharmacodynamics of drug
metabolism in Polish individuals is limited. The
health-care literature has yet to report any pharmaco-
logical studies specific to people of Polish descent.
High-Risk Behaviors
Alcohol abuse, with its subsequent physiological, psy-
chological, and sociological effects and its related finan-
cial impact, continues to be an ongoing concern among
Polish Americans. Manwell, Czabala, Ignaczak, and
Munt (2002) found high rates of depression among
heavy drinkers in the primary-care population. In addi-
tion, Cherpitel, Moskalewicz, and Swiatkiewicz (2004)
reported that drinking patterns and subsequent injuries
among males affected the number of emergency services
398 Aggregate Data for Cultural-Specific Groups
2780_Ch22_391-406 18/07/12 6:04 PM Page 398

used, suggesting a high recidivism for alcohol-related in-
juries. These results suggest that the patient’s acknowl-
edgment of the role of alcohol in the injury may be
an important factor used in developing individualized
intervention strategies.
In Poland, a high rate of alcoholic psychosis, cirrhosis
of the liver, and acute alcohol poisoning exists. Other
alcohol-related illnesses include cancer of the gastroin-
testinal tract, peptic ulcers, accidents, and suicide. An
estimated 1 million Poles are dependent on alcohol, and
another 3 million are alcohol abusers. Cumulatively,
4 million of Poland’s estimated 38 million people are
either alcohol-dependent or abusers (Manwell, Ignaczak,
& Czabala, 2002). Alcohol abuse is an important part
of the history of Poland. For some immigrants, alcohol
was a way of relieving boredom, frustrations, and severe
hardships. For other immigrants, alcohol was a way of
mitigating the painful memories of WWII and reducing
depression and the symptoms of post-traumatic stress
syndrome. Alcohol still influences family patterns of
behavior for many Polish immigrants.
Because Poles place a high value on hospitality in
both Poland and America, drinking among Poles is an
accepted part of the culture. Part of being a good host-
ess or host is to have enough alcohol for every guest.
For newer immigrants and older Polish Americans,
vodka is the alcohol of choice. Upper socioeconomic
groups drink wine, whereas beer is consumed by all so-
cioeconomic levels. In a study on drinking patterns of
American and Polish college students, Polish students
drank more than their American counterparts (Eng,
Slawinska, & Hanson, 1991). Wine was the preferred
drink of Polish students, and beer the preferred drink
of American students.
Because alcohol use and cigarette smoking are
prevalent among many Poles, health-care providers
must assess individual patients for abuse and provide
counseling and referral for those who express an in-
terest. Children of immigrants should especially be
targeted for counseling regarding the health effects of
smoking and alcohol consumption.
Health-Care Practices
As with their U.S. counterparts, the behaviors of
the Polish immigrants are directly associated with their
level of education, income, and lifestyle. Those with
higher levels of education are very interested in weight
control, preventive health behaviors, and exercise.
Health-care providers need to include interventions spe-
cific to the individual’s social environment (Stelmach,
Kaczmarczyk-Chalas, Bielecki, & Drygas, 2005).
Health-care providers should carefully screen Polish
immigrants for diseases common in their home coun-
try. Hypertension, CVDs, respiratory conditions, al-
coholism, cancer (particularly leukemia), and thyroid
disorders are endemic diseases of Poland that are also
found in the United States. Culturally congruent
health teaching strategies associated with the risk fac-
tors for these diseases must be implemented when
working with this population.
Nutrition
Meaning of Food
Another rather common depiction of cultural values
is sometimes displayed on a wall hanging in a Polish
home. The wall hanging often features a likeness of
God with the inscription Gosc W Dom, Bog W Dom,
which means “Guest in the House, God in the House.”
Most Poles extend the sharing of food and drink to
guests entering their homes. Eating and/or drinking
with the host is perceived as social acceptance. Three
important considerations influence Poles regarding
food. First, Poland is primarily a land-based country
with short summers and very cold winters. Thus, the
major agricultural products in Poland include pota-
toes, vegetables, wheat, poultry, eggs, pork, and dairy
products (CIA World Factbook, 2011). Second, the
cold weather discourages outdoor activities, while also
creating a craving for hot stews, soups, and foods that
produce a feeling of satiety. Unfortunately, these foods
are high in carbohydrates, fat, and sodium. Meats and
vegetables are cooked for a very long time, resulting
in the destruction of B and other vitamins. Third, the
strong Catholic influence is evidenced by attending
many food-laden celebrations, festivals, and rituals,
each of which has its own traditional high-calorie
foods. Many Poles continue these routine dietary prac-
tices after emigrating. Health-care providers need to
assess how the Polish patients’ dietary habits influence
their weight, blood pressure, and overall health status
and then structure a diet that is culturally acceptable,
promotes healthy food choices, and is sustainable.
Common Foods and Food Rituals
Polish foods and cooking are similar to German,
Russian, and Jewish practices. Staples of the diet are
millet, barley, potatoes, onions, radishes, turnips, beets,
beans, cabbage, carrots, cucumbers, tomatoes, apples,
and wild mushrooms. Common meats are chicken,
beef, and pork. Traditional high-fat entrees include
pigs’ knuckles and organ meats such as liver, tripe, and
tongue. Kapusta (sauerkraut), golabki (stuffed cabbage),
babka (coffee cake), pierogi (dumplings), and chrusciki
(deep-fried bowtie pastries) are common ethnic foods.
As mentioned previously, hot soups and stews are fa-
vored during the bitterly cold winters, and cold soups
are preferred during the summer.
The meal plan for many Poles consists of a hearty
breakfast of coffee, bread, cheese, sausage, and eggs.
A midmorning snack is usually a sandwich and tea or
coffee. The main meal in midafternoon includes soup,
meat, potatoes, a hot vegetable, and dessert. In the
evening, cold cuts, eggs, butter, sour cream, bread, and
People of Polish Heritage 399
2780_Ch22_391-406 18/07/12 6:04 PM Page 399

grains are common. This diet is modified depending
on the availability of the food, the growing season,
and the family’s finances. Dill, paprika, garlic, and
marjoram (used in kielbasa) are common herbs. Many
foods may be pickled or canned for storage, which also
increases their sodium content. Table 22-1 lists a vari-
ety of traditional Polish foods.
Dietary Practices for Health Promotion
The Polish American diet is frequently high in carbo-
hydrates, sodium, and saturated fat. Assessing patients
for increased blood sugar and cholesterol levels and
high blood pressure should be routine. Interventions
that require significant dietary modifications to their
culturally based menus may be difficult.
Like many other economically developing coun-
tries, Poland’s efforts to examine the health status of
its citizens have become increasingly important. One
disease with dramatic long-term consequences is
insulin-dependent diabetes. Over the years, an in-
creased incidence of this disease in Poles has been doc-
umented. Sobel-Maruniak, Grzywa, Oriowska-Florek,
and Staniszewski (2006) compared the long-term
trend in the incidence of insulin-dependent diabetes
over a 20-year period (1980–1999). Their results
showed a significant growth in the incidence of in-
sulin-dependent diabetes among people aged birth to
29 years in the Rzeszow Province. Health-care providers
should be especially alert to the symptoms of diabetes
in younger Polish immigrants.
Nutritional Deficiencies and Food Limitations
Unfortunately, most of the land and water in Poland
contains low levels of iodine. Iodine does not develop
naturally in specific foods unless it is present in the soil
or water. Iodine penetrates the foods that are grown
in the soil, and their ingestion supplies it to the con-
sumer. Ocean water also contains adequate amounts
of iodine; thus, eating fish or other nutrients from the
sea is likely to furnish sufficient amounts. Unfortu-
nately, consuming fish on a regular basis has failed to
become a part of the traditional diet in Poland.
Except for individuals living near the Baltic Sea in
northern Poland, who consume fish regularly, Poles are
in danger of developing nutritional problems related
to the lack of iodine in their diet. Iodine is an essential
component for the thyroid’s hormonal function, and
its deficiency results in the underproduction of thy-
roxine and triiodothyronine. Disorders related to the
inadequate production of these hormones may in-
clude mental retardation, neurological system defects,
goiters (e.g., enlarged thyroid), sluggishness, growth
retardation, reproductive failure, and increased child-
hood mortality. Fortunately, this nutritional problem
is being monitored and addressed.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Because family is very important, most Poles want
children. In an agrarian society, and for early immi-
grants, children were considered important because
they brought happiness and status to the family and
were an economic necessity. In Poland, the Catholic
Church strongly opposes abortion, which is the pre-
vailing attitude of many Poles in America. However,
during the years of war, poverty, and Communist rule,
abortion and child spacing were considered necessi-
ties. For Poles, fertility practices are balanced between
the needs of the family and the laws of the Church.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Pregnant Polish Americans are expected to seek pre-
ventive health care, eat well, and get adequate rest to
ensure a healthy pregnancy and baby. Immigrant
families who have experienced poverty, famine, and
inadequate health care are more likely to pay atten-
tion to prenatal care. The emphasis on food and “eat-
ing for two” is a common philosophy. Health-care
providers must pay special attention to ensure that
pregnant Polish American women restrict their
weight gain during pregnancy.
Because the process of childbirth was poorly un-
derstood by an undereducated society, folk beliefs,
magico-religious explanations, and taboos continue to
surround the process. Many consider it bad luck to
have a baby shower, and even now, many Polish grand-
mothers may be reluctant to give gifts until after the
baby is born. Birthing is typically done in the hospital.
400 Aggregate Data for Cultural-Specific Groups
❙❙◗ Table 22-1 Polish Foods
Common Name Description Ingredients
Babka Coffee cake Yeast bread
Barszcz Beet soup Served plain or
with sour cream
Bigos Hunter’s stew Stew with game,
sausage, sauerkraut
Chrusciki Polish bowties Fried egg dough
Golabki Cabbage rolls Cooked cabbage
stuffed with
chopped meat and
rice in tomato
sauce
Kielbasa Sausage Sausage
Ogorki smietanie Sour cream Sour cream,
cucumbers cucumbers
Pierogi Boiled dumplings Dumplings filled
with potatoes,
cheese, or
sauerkraut
Sledzie Herring Pickled fish
2780_Ch22_391-406 18/07/12 6:04 PM Page 400

Midwives may be used if there is a community feeling
that they are “just as good as the doctor.”
Pregnant women usually follow the physician’s or-
ders carefully. In America, Polish women seek prenatal
clinics when they are unable to afford private fees. The
birthing process is considered the domain of women.
Newer Polish immigrants may feel uncomfortable with
men in the birthing area or with family-centered care.
Women are expected to rest for the first few weeks
after delivery. For many, breastfeeding is important.
Health-care providers may need to provide active lac-
tation counseling and education about appropriate
care during breastfeeding (e.g., proper techniques) and
to help the woman understand the balance among
diet, rest, and exercise after delivery.
Death Rituals
Death Rituals and Expectations
Most Poles have a stoic acceptance of death as part
of the life process and a strong sense of loyalty and
respect for their loved ones. Family and friends stay
with the dying person to negate any feelings of aban-
donment. The Polish ethic of demonstrating caring by
doing something means bringing food to share, caring
for children, and assisting with household chores.
Most Polish women are quick to help with the
physical needs of the dying. Home hospice care is
acceptable to most Poles. Health-care providers may
encounter difficulty in convincing the family that the
dying member may choose to refuse food as a result
of the illness rather than because of stubbornness or
the caretaker’s cooking. Polish women may tend to
hover. Health-care providers need to help families
understand that it is important for the dying person
to conserve energy.
Responses to Death and Grief
In early Poland, individuals were buried within 24 hours
of their deaths. Historically, immigrant Poles continued
the practice of burying the deceased from the home and
having home burial ceremonies, which included a wake
or vigil in which family members prayed and repeated
the rosary over the dead person. Today, Polish American
family members follow a funeral custom of having a
wake for 1 to 3 days, followed by a Mass and religious
burial. Most Poles honor their dead by attending Mass
and making special offerings to the Church on All
Saints’ Day, November 1. Families may continue tend-
ing the gravesite for years.
Spirituality
Dominant Religion and Use of Prayer
The Catholic Church, with its required attendance at
Mass on Sundays and holy days, is an integral part of
the lives of most Polish people. There are holy days
in almost every month of the year, in addition to the
rituals of baptism, confirmation, marriage, sacrament
of the sick, and burial. Christmas and Easter are the
two most important holidays, requiring both special
foods and rituals. On Christmas Eve, depending on
the affluence of the family, up to 13 meatless dishes
are served with the oplatek (similar to a large com-
munion wafer) that everyone shares at the table. On
Christmas Day, the main meal consists of kielbasa,
goose, ham, or turkey. The Easter holiday may begin
with women bringing food to the church on Easter
Saturday to be blessed by the priest. On Easter Sun-
day, lamb or kielbasa and boiled eggs are served. A
table ornament, usually a lamb made of salt or butter,
is often displayed. Like many Americans of various
ethnic backgrounds, Polish Americans have had a re-
newed interest in their ethnic roots. For example, their
attendance at language classes, festivals, and Polish
Catholic churches has become very widespread.
Religious ceremonies are a major part of maintain-
ing Polish culture. Poles are very concerned that
churches continue to act as a vehicle of Polish culture.
Birthdays and name days are important religious and
family events for Poles. One very popular expression
is Sto lat, which conveys wishes that the celebrant live
100 years. Polish weddings are legendary. This is the
time when family and friends get together and two
families unite. One folk practice is to bring chlebem
i sola (bread and salt) as a symbol of hospitality.
Guests always receive plenty of food and drink, listen
to music, and dance. In America, Polish weddings may
last only 1 day, but plenty of food and alcoholic bev-
erages are considered essential to the joyous occasion.
Primary spiritual sources are God and Jesus Christ,
with many Polish immigrants praying to the Virgin
Mary, saints, and angels to ward off evil and danger.
Honor and special attention are paid to the Black
Madonna or Our Lady of Czestachowa (Fig. 22-1).
Czestachowa, a town in central Poland, displays a pic-
ture of the Virgin Mary with two scratch marks on her
darkened face. Every year, many Poles join a walking
pilgrimage to see the Madonna. During times of ill-
ness and serious family concerns, one might hear a
Pole evoking Matka Boska, which literally translated
means “Mother of God.”
Many older Polish people believe in the special
properties of prayer books, rosary beads, medals, and
consecrated objects. Polish Americans commonly ex-
hibit devotions to God, such as crucifixes and pictures
of the Virgin Mary, the Black Madonna, and Pope
John Paul II, in their homes.
Meaning of Life and Individual Sources
of Strength
Most Polish Americans have a strong work ethic and
pride themselves on being fastidious and punctual.
They are loyal to friends and family, have a strong
sense of Catholic ideals, are self-disciplined, and are
People of Polish Heritage 401
2780_Ch22_391-406 18/07/12 6:04 PM Page 401

concerned about respect and honor. Most Polish
Americans enjoy music, such as the works of Chopin
and other classical composers, and dancing, includ-
ing the jovial Polish polka, the waltz, or polonaise.
Liturgical music may be important to older and more
religious Poles.
After years of living under Communist censorship,
newer immigrants value freedom, independence, being
respected for their work, and having status in the com-
munity. Most Polish Americans find meaning in family
loyalty and show great generosity to friends and ex-
tended family. Like all cultural groups, Polish Americans
want to be shown respect.
Spiritual Beliefs and Health-Care Practices
Among the early immigrants, religion had both a folk
tradition and a formal Catholic element. Most be-
lieved in mythological beings, water spirits, and house
ghosts. Killing or any useless slaughter of animals was
condemned. All life had meaning, and if an experience
was unexplainable, mysterious, or magical, folk beliefs
and/or religion provided the answer.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Most Poles put a high value on stoicism and doing
what needs to be done. Many go to health-care
providers only when symptoms interfere with func-
tion; then they may carefully consider the advice pro-
vided before complying. Describing anxiety and
expecting nurturance are uncharacteristic of most
Polish adults and children. Many Poles are reluctant
to discuss their treatment options and concerns with
physicians and routinely accept the proposed care
plan. If Poles believe they are unable to pay the med-
ical bill, they may refuse treatment unless the condi-
tion is life-threatening. Many have a strong fear
of becoming dependent and resist relying on charity.
Because many Poles consider Medicare, Medicaid,
and managed care as forms of social charity, they are
reluctant to apply for them. Any action that lowers
their social status in their community is generally
considered unacceptable. The health-care provider
must describe the intent of these financial programs
carefully, or Poles may perceive them as charity and,
therefore, unacceptable options.
402 Aggregate Data for Cultural-Specific Groups
Figure 22-1 The Black Madonna or Our Lady of Czestachowa
is an object of devotion to millions of native and immigrant
Polish people. (From The Marian Library/International Marian Research
Institute, Dayton, OH; http://www.udayton.edu/mary/resources/blackm/
blackm03.html)
R E F L E C T I V E E X E R C I S E 2 2 . 2
Lorenz and Ludwika Slawinska, ages 49 and 47 years, respec-
tively, came to the United States with their son Christopher
25 years ago shortly after the Chernobyl nuclear accident.
Lorenz is a physicist, and Ludwika is an elementary school
teacher. Christopher is now 27 years old. He had great diffi-
culty in elementary and high school but was able to complete
them. Because he was overweight in school, the other children
made fun of him. For the last 5 years he has successfully held a
job as a janitor in a local factory. He and his fiancée of 3 years
are planning their wedding, which is 3 months away. They both
are only children and want to have a large family. Christopher’s
parents, who are devout Catholics, are not encouraging the
marriage, mostly because they believe he should not have
children.
1. What health problems can result from the Chernobyl
nuclear accident?
2. Are potential health problems greater for adults or
children?
3. Are the Slawinska family’s views on marriage and children
consistent with Polish Catholic ideology?
4. What community resources might the Slawinska family
access for emotional support?
5. Would you support Christopher’s desire to marry and
have a large family? Why? Why not?
2780_Ch22_391-406 18/07/12 6:04 PM Page 402

Poles usually look for a physical cause of disease be-
fore considering a mental disorder. If mental health
problems exist, home visits are preferred. Talk-oriented
interventions and therapies without pharmaceutical or
suitable psychosocial strategies are dismissed unless in-
terventions are action oriented. In addition, Poles con-
sult other family members and the community to assess
the appropriateness of treatments. Polish Americans
often seek self-help groups such as Alcoholics Anony-
mous before seeing a health-care provider. Assimilated
Poles respect the health-care system and tend to seek
specialized care when necessary.
To many immigrant Poles, the U.S. health-care sys-
tem is complex, confusing, and overpriced. They per-
ceive access to health care as difficult, and many people
who can afford to pay higher fees to see a private physi-
cian are unaware of how to gain access. Some Poles re-
turn to Poland to have medical or surgical procedures
performed because these are more understandable,
available, and/or affordable in their homeland.
Responsibility for Health Care
Given the continuation of limited access to care and
the strong work ethic of this cultural group, health
promotion practices are often undervalued by Polish
Americans. In fact, older Polish Americans and
newer immigrants commonly smoke and drink, en-
gage in limited physical exercise outside of work,
and receive poor dental care. Partial and complete
dentures are common in older Poles. A number of
secondary teeth are often found missing in Polish
American immigrant children. This frequently sur-
prises nurses who may be unaware of the limited
number of dentists in Poland.
Attention to health promotion practices among
women may be complicated by Polish American
women’s sense of modesty and religious background.
Breast self-examination and Pap smear tests are
poorly understood by many women. Health promo-
tion practices vary greatly and are dependent on the
woman’s assimilation into American culture.
The Polish ethic of stoicism discourages the use of
over-the-counter medications unless a symptom per-
sists. Most Poles refuse to take time off from work to
see a health-care provider until self-help measures
have proved ineffective. Few Poles use vitamins unless
these are suggested by a physician or a trusted family
member, but even then, their extrinsic value is com-
pared with the cost.
Folk and Traditional Practices
Many Poles continue their established health-related
activities after immigration. For Poles just entering
the United States, obtaining medical benefits has
often been confusing and information facilitating
access to the health-care system limited. This fre-
quently resulted in Polish people treating themselves,
delivering babies at home using a lay midwife, taking
folk medicines and herbal remedies, and even setting
their own broken bones when necessary. In addition,
Polish Americans may use certain remedies to cure
an illness, such as tea with honey and spirits to
“sweat out” a cold. Herbs and rubbing compounds
may also be used for problems associated with aches,
pains, and inflammation from overworked joints and
muscles. Because of individual differences, every pa-
tient must be assessed personally and asked specifi-
cally about his or her use of home remedies and
over-the-counter medications.
The mother’s or grandmother’s responsibility was
to know how to care for the family and their medical
problems. Some additional common cultural prac-
tices included treating the symptoms of colds with
herbs or poultices made from goose grease or fat.
Gunpowder was ingested to promote emesis for an
upset stomach. A boil was healed by soaking the heel
of a loaf of white bread in milk and then placing it
on the boil to draw out the core. Poor circulation or
back pain was relieved by placing heated, alcohol-
swabbed shot glasses, called banki, on the affected
area. The heated banki were placed on the back or
over the painful areas, causing circular, swollen areas
on the skin. The Poles believed that this painless,
raised area increased the circulation and reduced
overall pain. Therefore, the health-care provider ob-
viously needs to individually assess the cultural health
behaviors of their Polish patients.
When a Pole is asked to undress for a physical ex-
amination, the health-care provider should pay special
attention to any medals pinned to the patient’s under-
garments. Most of these medals have special religious
significance to the wearer and should, if possible, re-
main on the garment.
Barriers to Health Care
Being unable to speak and understand English and
the cost of health care and its complexity are the
greatest barriers to health care for Polish immi-
grants. In addition to overcoming the language
barrier, health-care providers need to understand
Polish family values. Health-care providers also
must consider that Poles often filter information
through the extended family and neighborhood
before accepting the recommended health-care reg-
imen. Polish Americans who have learned English
as a second language may have some difficulty with
the nuances of health-care jargon and terminology.
Inadequate or poor communication can result in
tragic consequences for the patient.
Poles are polite to authority figures and avoid of-
fending a health-care worker by disagreeing with
them. Thus, they may be reluctant to ask for clarifi-
cations on questionable issues. In addition, many
Poles are primarily concerned about how a disease
People of Polish Heritage 403
2780_Ch22_391-406 18/07/12 6:04 PM Page 403

affects daily functioning rather than about individual
survival rates.
Cultural Responses to Health and Illness
Owing to their strong sense of stoicism and fear of
being dependent on others, many Polish Americans
use inadequate pain medication and choose distrac-
tion as a means of coping with pain and discomfort.
When asked, many Poles either deny or minimize
their pain or level of discomfort. Poles with chronic
illnesses may have similar attitudes; thus, persevering
with pain is common. The health-care provider should
use a visual analog scale to assess pain, assist patients
with distraction techniques, and help Poles to accept
pain medication when needed.
Premigration stresses (e.g., losses, catastrophic ex-
periences, anxiety, and internment) may be combined
with postmigration stressors (e.g., language difficulty,
loss of relationships, cultural pride, lack of support
systems) to cause mental health problems (Fenta,
Hyman & Noh, 2004). Social and geographic isolation
within one’s own ethnic neighborhood are common,
albeit somewhat restrictive, reactions to this situation.
Many immigrants are able to overcome the initial
shock of moving to a foreign country, but they fail to
have adequate coping skills to get through the stres-
sors of total adjustment. Lack of language skills, feel-
ings of unfamilarity, and fear of the unknown are
some of the reasons given by those who fail to leave
their Polonia. In these self-segregated cultural com-
munities, children often become the go-betweens for
their parents and the larger community. As children
mature, they leave their parents and the Polonia to
start their own families. Thus, the parents’ avoidance
of the acculturation process, even 25 years later,
creates stressors leading to feelings of abandonment,
loneliness, and displacement. These feelings may be-
come significant and lead to major physical and/or
mental illnesses.
Few Poles turn to psychiatrists or mental health
providers for help. Those who seek help from mental
health providers do so as a last resort. Many indi-
viduals choose their priest or seek assistance from a
Polish volunteer-run agency before going to a health
provider for psychiatric help.
Immigration to America failed to change the Pole’s
concerns about the delivery of appropriate health
care. Immigrants are taught from infancy to resist ask-
ing for help or assistance from others but to bear the
burdens of life independently.
Successful adaptation to the new homeland requires
the immigrant to voluntarily progress through the
process of assimilation and acculturation. Assimilation
requires the individual to gradually adopt and incor-
porate the characteristics of the prevailing culture
into their own lives. Acculturation mandates that the
immigrants willingly modify their own culture as an
accommodation to their transition to accepting the
general values and attitudes of their new culture and
homeland. The process of acculturation may affect the
association between migration and health. The bidi-
mensional approach describes acculturation as a
process of adaptation to the mainstream culture while
maintaining the inherited ethnic identity (Ryder, Alden,
& Paulhus, 2000).
Aroian (1992) described three types of social sup-
port needed by Polish immigrants. During the first
3 years, immigrants need help finding housing and
jobs and information about getting through the
system—that is, learning English, buying groceries,
and learning American customs. During the next 3 to
10 years, help is required to secure credit, obtain loans,
and assimilate into American life. Finally, immigrants
who have been in America for more than 10 years
need support in honoring their Polish heritage through
networks of other immigrants while maintaining an
American support system. After immigrants are com-
fortable with resettlement, feelings of grief and loss
begin to be acknowledged. Aroian (1990) states, “The
psychological adaptation to migration and resettle-
ment requires the dual task of mastering resettlement
demands and grieving and removing the losses left in
the homeland” (p. 8).
Blood Transfusions and Organ Donation
The ethic of being useful, independent, and a good
Catholic influences one to refrain from using extraordi-
nary means to keep people alive. The individual or
family determines what means are considered extraor-
dinary. Receiving blood transfusions or undergoing
404 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 2 2 . 3
Mrs. Rutkowski is a 49-year-old second-generation Polish woman
who has lived in a Polonia on Long Island, New York, her entire
life. She has non-insulin-dependent diabetes mellitus and is bor-
derline obese. Currently she has an open wound on her left
ankle, which she has been treating with herbs and a homemade
salve instead of the expensive prescription medicine recom-
mended by her nurse practitioner. The nurse practitioner has
recommended that she lose weight to help control her diabetes
mellitus. The nurse is making a home visit for follow-up care.
1. What is a Polonia?
2. What is the first step in assessing Mrs. Rutkowski’s
nutritional needs?
3. Should the nurse actively discourage Mrs. Rutkowski from
using her traditional treatments and rely solely on the
prescription medications? What might the consequences
be if the nurse does so?
4. Should the nurse recommend the use of a banki? Why?
Why not?
2780_Ch22_391-406 18/07/12 6:04 PM Page 404

organ transplantation is acceptable. However, it is
important for a family to know the extent to which a
patient will be able to function following organ trans-
plantation. Cost is always an important consideration.
Most Poles resist becoming a burden on their family’s
physical or financial resources and may attempt
to convince the family that the procedure is too
costly. Poles do consider it their duty to care for a sick
member at home.
Health-Care Providers
Traditional Versus Biomedical Providers
Immigrant Poles often assess health-care providers by
their demeanor, warmth, and show of respect. Health
advice may be sought from chiropractors and local
pharmacists as well as neighbors and extended family.
Generally, professional biomedical advice is sought
when a symptom persists and interferes with daily life.
Newer immigrants may fail to realize that many pa-
tients are discharged from the hospital before they
have totally healed and are fully recovered. Poles may
assume this practice is related to charity care, disre-
spect, or their financial status. Early discharges should
be explained to the patient and family.
Status of Health-Care Providers
When caring for Polish patients, particularly older
adults, all health-care providers should make every
attempt to address individuals by their surname.
Although this may be difficult, many names can be
phonetically pronounced. Attempting to pronounce
the names demonstrates respect for the patient. As a
group, Poles are fiercely independent, relying on them-
selves or family members for almost every aspect of
their social status, health, and livelihood. Nurses need
to focus on the Polish patient’s background and up-
bringing and take into consideration how health care
becomes accepted or rejected. Illness or being sick is
considered weakness for male family members. Polish
women consider it their role to care for the family
members without asking for help. It is also important
to consider that Polish women are modest and self-
conscious and may refuse health care when asked to
disrobe in front of a male health-care provider. In
some cases, it may be critical to request a female
provider.
When it becomes evident that only professional
help will resolve a problem, the affirmative act of
seeking assistance is a major decision. Communica-
tion, consideration, displaying respect, and demon-
strating cultural sensitivity will help to improve the
Poles’ attitudes toward the health-care provider. The
health-care provider will need to introduce changes
in ways that are appropriate and acceptable and can
be integrated into an established, culturally domi-
nated lifestyle.
Nurses will need to understand their own cultural
values, beliefs, and practices in order to avoid or prevent
alienating the Polish patient and family about the diffi-
culty, complexity, and consequences of any recom-
mended interventions. Using an authoritarian approach
to gain compliance will cause conflict. Based upon their
history, Poles have a tradition of survival, sometimes
through stubbornness, pride, warmth, or genuineness.
Therefore, being perceived as an amiable, respectful, and
knowledgeable provider is integral in teaching health
promotion and wellness; prevention of illness, disease,
and injury; and health restoration. Communicating
through the use of a bilingual family member as a liai-
son and finding agreements on cultural health beliefs
and practices may be the best initial strategy for change
when dealing with older immigrants or more traditional
Polish Americans. However, when assessing intimate
personal health information, an interpreter unknown to
the family should be used.
A person’s culture influences his or her perceptions
of health and illness. How a patient accepts help or al-
lows care to be rendered depends on her or his previous
experiences, understanding, and trust in the provider.
Respect, patience, and acceptance are important com-
ponents of health care. Thus, health-care providers
need to communicate compassionately with their
patients through their professional appearance, words,
actions, gestures, inflections, and postures. Patients of
Polish descent interact with health-care providers,
whom they perceive as authority figures, in very distinc-
tive ways. Polite listening may determine how adherent
a patient may be to the recommended regimen. Often
the tone, how something is said, and the body language
that accompanies it communicate whether the health-
care provider respects the patient. Being culturally sen-
sitive to the Polish American patient will be accepted
as a gift from a stranger and will be reciprocated with
appreciation, genuineness, and respect.
Physicians are held in high regard in Polish com-
munities. Poles typically follow medical orders care-
fully. Poles may change physicians if they believe
their recovery is too slow or if a second opinion is
needed. Educated Poles are more willing than those
less educated to follow medical orders and continue
with prescribed treatment. Poles with less education
tend to change physicians if the disease fails to
subside quickly enough. Poles respect physicians
but need to understand the purpose of the medical
treatment.
Poles expect health-care providers to appear neat
and clean, provide treatments as scheduled, adminis-
ter medications on time, and enjoy their work. Immi-
grant Poles may be unfamiliar with the advanced roles
of the American nurses, who are expected to know
about, plan, and be directly involved in the patients’
care. Thus, many Poles may still want only the physi-
cian to explain all aspects of their care.
People of Polish Heritage 405
2780_Ch22_391-406 18/07/12 6:04 PM Page 405

R E F E R E N C E S
Aroian, K.J. (1990). A model of psychological adaptation to
migration and resettlement. Nursing Research, 39(1), 5–10.
Aroian, K.J. (1992). Sources of social support and conflict for
Polish immigrants. Qualitative Health Research, 2(2), 178–207.
Berdes, C., & Zych, A.A. (2000). Subjective quality of life of Polish,
Polish-immigrant and Polish American elderly. International
Journal of Aging and Human Development, 50(4), 385–395.
Best, W. (2004). Polonia. Retrieved from http://www.encyclopedia.
chicagohistory.org/pages/992.html
Brogan, P. (1990). The captive nations of Eastern Europe: 1945–1990.
New York: Avon Books.
Bukowczyk, J.J. (1987). And my children did not know me: A history
of Polish Americans. Bloomington, IN: Indiana University
Press.
Cherpitel, C.J., Moskalewicz, J., & Swiatkiewicz, G. (2004). Drink-
ing patterns and problems in emergency services in Poland.
Alcohol and Alcoholism, 39(3), 256–261.
CIA World Factbook. (2011). Poland. Retrieved from https://www.
cia.gov/library/publications/the-world-factbook/geos/pl.html
Eng, R., Slawinska, J.B., & Hanson, D.J. (1991). The drinking pat-
terns of American and Polish university students: A cross na-
tional study. Drug and Alcohol Dependence, 27, 167–174.
Erdmans, M.P. (1998). Opposite Poles. University Park, PA:
Pennsylvania State University Press.
Fenta, H., Hyman, I., & Noh, S. (2004). Determinants of depres-
sion among Ethiopian immigrants and refugees in Toronto.
Journal of Nervous and Mental Disease, 192(5), 363–372.
Gdansk. (2008). Freedom broke out in Gdansk: History of August, 1980.
Retrieved from http://www.en.gdansk.gda.pl/about,2,20.html
Generations Network. (2011). Learning: Polish names. Retrieved
from http://freepages.genealogy.rootsweb.com/~atpc/learn/tools/
surname-origins.html
Grocholska, J. (1999). Polish immigration to the US. Retrieved
from www.poloniatoday.com
Jarczak, C.R. (2012). Polish-American contributions to our nation.
Retrieved from http://www.msu.edu/user/jarczakc/polesinus.html
Library of Congress. (2004). Immigration: Polish/Russian: The
Nation of Polonia. Retrieved from http://memory.loc.gov/learn/
features/immig/polish4.html
Lopata, H.Z. (1994) Polish Americans (2nd ed.). New Brunswick,
NJ: Transaction.
Manwell, L.B., Czabala, J.C., Ignaczak, M., & Mundt, M.P.
(2004). Correlates of depression among heavy drinkers in Pol-
ish primary care clinics. International Journal of Psychiatry in
Medicine, 34(2), 165–178.
Manwell, L.B., Ignaczak, M., & Czabala, J.C. (2002). Prevalence
of tobacco and alcohol use disorders in Polish primary care
settings. European Journal of Public Health, 12(2), 139–144.
Niewada, M., Skowronska, M., Ryglewicz, D., Kaminski, B., &
Czlonkowska, A. (2006). Acute ischemic stroke care and out-
come in centers participating in the Polish National Stroke Pre-
vention and Treatment Registry. Stroke, 37, 1837–1843.
Panna Maria, Texas: The oldest permanent Polish settlement in the
USA. (2006). Retrieved from www.pannamariatexas.com
Pacyga, D.A. (2004). Poles. Retrieved from http://www.encyclopedia.
chicagohistory.org/pages/982.html
Plawecki, H.M. (1992). Cultural considerations. Journal of Holis-
tic Nursing, 10(7), 4–5.
Plawecki, H.M. (2000). The elderly immigrant: An isolated expe-
rience. Journal of Gerontological Nursing, 26(2), 6–7.
Polish American Center. (1997). General Casimir Pulaski (1747–
1779). Retrieved from http://www.polishamericancenter.org/
Pulaski.htm
Ryder, A.G., Alden, L.E., & Paulhus, D.L. (2000). Is acculturation
unidimensional or bidimensional? A head-to-head comparison
in the prediction of personality, self-identity and and adjustment.
Journal of Personality and Social Psychology, 79(1), 49–65.
Sobel-Maruniak, A., Grzywa, M., Oriowska-Florek, R., &
Staniszewski, A. (2006). The rising incidence of type 1 diabetes
in south-eastern Poland. A study of the 0–29-year-old age
group, 1980–1999. Endokrynologia Polska, 57(2), 127–130. Re-
trieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16
773587&query_hl=1&itool=pubmed_docsum
Statistics Canada. (2010). Selected ethnic origins for Canada,
provinces and territories. Retrieved from www.statcan.gc.ca
Stelmach, W., Kaczmarczyk-Chalas, K., Bielecki, W., & Drygas,
W. (2005). How education, income, control over life and life
style contribute to risk factors for cardiovascular disease
among adults in a post-communist country. Public Health, 119,
498–508.
Szaflarski, M. (2001). Gender, self-reported health and health-
related lifestyles in Poland. Health Care for Women Interna-
tional, 22, 207–227.
Szeszenia-Dabrowska, N., & Wilczynska, U. (1998). Occupational
lead poisoning in Poland. Medycyna Pracy, 49(23), 217–222.
Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=97
60431&query_hl=4&itool=pubmed_DocSum
Trzcinka-Ochocka, M., Jakubowski, N., & Razniewska, G. (2005).
Assessment of occupational exposure to lead in Poland. Mey-
cyna Pracy, 56(5), 395–404. Retrieved from http://www.ncbi.
nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&do
pt=AbstractPlus&list_uids=16483011&query_hl=2&itool=pub
med_docsum
U.S. Census Bureau. (2011). Population by selected ancestry. Re-
trieved from http://www.census.gov/compendia/statab/2011/
tables/11s0052
von Geldern, J., & Siegelbaum, L. (2003). Solidarity and the Soviet
Union. Retrieved from http://www.soviethistory.org/index.
php?action=L2&SubjectID=1980solidarity&Year=1980
Wronska, I. (2002). The fundamental values of nurses in Poland.
Nursing Ethics, 9(1), 92–100.
Zatorski, W. (2003). Democracy and health: Tobacco control in
Poland. In J. deBeyer & L. Waverley (Eds.), Tobacco control pol-
icy: Strategies, successes & setbacks (pp. 97–120). Washington,
DC: RITC and The World Bank.
Zdrojewski, T., Babinska, Z., Katol, M., Januszko, W., Rutkowski,
M., Bandosz, P., et al. (2006). How to improve cooperation
with political leaders and other decision-makers to improve
prevention of cardiovascular disease: Lessons from Poland.
European Journal of Cardiovascular Prevention and Rehabilita-
tion, 13, 319–324.
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
406 Aggregate Data for Cultural-Specific Groups
2780_Ch22_391-406 18/07/12 6:04 PM Page 406

407
Chapter 23
People of Puerto Rican Heritage
Larry D. Purnell
The author would like to thank Josue Toro Navarro for contributing the Reflective Exercises in this chapter.
Overview, Inhabited Localities,
and Topography
Overview
The island of Puerto Rico, located between the
Caribbean Sea and the North Atlantic Ocean, is an
important location along the Mona Passage, a key
shipping lane to the Panama Canal. The capital, San
Juan, is one of the biggest and best natural harbors in
the Caribbean. The country’s many small rivers and
high central mountains ensure that the land is well wa-
tered, the south coast is relatively dry, and the north
has a fertile coastal plain belt.
Populated for centuries by aboriginal peoples,
Puerto Rico was claimed by the Spanish Crown in
1493 following Columbus’s second voyage to the
Americas. In 1898, after 400 years of colonial rule that
saw the indigenous population nearly exterminated
and African slave labor introduced, Puerto Rico was
ceded to the United States as a result of the Spanish-
American War (CIA World Factbook, 2011a).
Puerto Ricans are the third largest Hispanic cul-
tural subgroup, with over 3 million living in the con-
tinental United States, compared with over 3.9 million
residents in Puerto Rico, of whom 76.2 percent are
white; 6.9 percent are black; and the rest are
Amerindian, Asian, mixed, or other (CIA World Fact-
book, 2011b). Most Puerto Ricans on the mainland
live in metropolitan areas, such as in Connecticut,
Florida, Illinois, and New York. Puerto Ricans have
a unique pride in their country, culture, and music.
They self-identify as Puertorriqueños or Boricuans
(Taíno Indian word for Puerto Rican) or Niuyoricans,
for those born in New York.
In 2010, the mean annual income for Puerto
Ricans was $16,000 (CIA World Factbook, 2011b),
compared with the overall U.S. mean annual income
of $47,400 (CIA World Factbook, 2011a). The per-
centage of Puerto Rican families living below the
poverty level is greater than other Hispanic/Latino
populations in the United States (National Center
for Health Statistics, 2011).
Heritage and Residence
In 1917, Puerto Ricans were granted U.S. citizenship
through the Jones Act; in 1952, Puerto Rico became
a Commonwealth. This Commonwealth “status ques-
tion” is a sensitive topic for most Puerto Ricans. From
the jíbaros (peasants) to educated political leaders, the
perception of many is that the Americanos (European
Americans), their culture, and their politics are a
potential threat to the Puerto Rican culture, language,
and political future.
Reasons for Immigration and Associated
Economic Factors
Puerto Ricans have been migrating to the United States
for decades to seek employment, education, and a
better quality of life. Initially, the Puerto Rican mi-
gration was fostered by a need for manual labor in the
United States. More recently, Puerto Rican physicians,
lawyers, and other professionals have migrated to en-
hance their educational status, social mobility, and
employment opportunities.
Puerto Ricans select geographic areas where they
can preserve their cultural, social, and familial wealth;
enhance their assimilation into the U.S. culture; and
increase their opportunities for employment and social
support. For Puerto Ricans, citizenship status has cre-
ated a controversial Va y Ven (go and come) circular
migration in which individuals and families are often
caught in a reverse cycle of immigration, alternately
living a few months or years in the United States and
then returning to Puerto Rico.
Educational Status and Occupations
Education is greatly respected among Puerto Ricans.
Children are praised and encouraged to become edu-
cated to improve their opportunities for the future.
2780_Ch23_407-425 16/07/12 12:09 PM Page 407

The educational system in Puerto Rico is similar to the
system in the mainland United States for all educa-
tional levels. Nevertheless, when children migrate from
Puerto Rico to the mainland, many educational organ-
izations place them one grade below their previous ac-
ademic year, mainly as a result of language barriers.
The literacy level in Puerto Rico is 94 percent and
is about the same for both men and women (CIA
World Factbook, 2011a). Puerto Rico boasts five well-
developed and sophisticated public and private uni-
versities, plus three medical schools accredited locally
and by the United States. However, on the mainland,
Puerto Ricans have high secondary school dropout
rates (National Center for Education Statistics, 2011).
Historically, many Puerto Ricans have valued private
rather than public education. Many parents make
great financial sacrifices to enable their children to
attend private educational organizations, most often
Catholic schools. Private schools are often referred to
as colegios (colleges), creating confusion with the
American English translation of undergraduate insti-
tutions and the Central American term for college ed-
ucation. Instead of “college,” the term universidad
(university) is most commonly used to refer to 4-year
college institutions in Puerto Rico, where bachelor’s
and master’s degrees equate to those on the mainland.
Many Puerto Ricans who migrated before the
1970s had less than a fifth-grade education. Most were
farmers who worked on rice, sugar cane, and coffee
plantations and in the garment and manufacturing
industries in northeastern and midwestern cities. How-
ever, since the mid-1970s, this pattern has begun to
change as more educated Puerto Ricans migrate to
the United States. After 1970, thousands of Puerto
Ricans lost their jobs, suddenly finding themselves
without the necessary education or training to find
employment. Unemployment resulted in an increase
in alcoholism, drug abuse, street crime, and family
disruption and conflict.
Puerto Rico has one of the most dynamic economies
in the Caribbean region. A diverse industrial sector has
far surpassed agriculture as the primary locus of eco-
nomic activity and income. Encouraged by duty-free
access to the United States and by tax incentives, U.S.
firms have invested heavily in Puerto Rico, where U.S.
minimum wage laws apply, since the 1950s (CIA World
Factbook, 2011b). Sugar production has lost out to
dairy production and other livestock products as the
main source of income in the agricultural sector.
Tourism has traditionally been an important source of
income (CIA World Factbook, 2011a). Even though
many Puerto Ricans value education, high school com-
pletion rates are only 76.6 percent and a college degree
is held by only 16.5 percent (U.S. Census Bureau, 2009).
Modest advances have been made in the educa-
tional status of Puerto Ricans, but the unemployment
status remains a challenge. Among Hispanics, Puerto
Ricans have the highest unemployment rate at 12 per-
cent (CIA World Factbook, 2011b).
Communication
Dominant Language and Dialects
Until recently, Puerto Rico was the only Spanish-
speaking Latin American country in which children,
beginning in kindergarten, learned to read and write
English and Spanish. The issue of two official lan-
guages, English and Spanish, is a sensitive one for some
Puerto Ricans who, after the U.S. occupation in 1898,
were forced to learn English. At that time, many could
not read and write in Spanish. This sensitivity results
from the fear that speaking English would eventually
replace speaking Spanish and affect Puerto Rican cul-
ture, traditions, and practices. For Puerto Ricans, lan-
guage is a political issue. With each government change
since the early 1980s, the official prevailing language
has been disputed and debated. Spanish is spoken at
home, in schools, in businesses, and in the media. How-
ever, people from the metropolitan cities are more
likely to read, write, and speak some English.
Puerto Ricans use the standard form of Spanish,
speaking with no dialects or indigenous languages.
Puerto Ricans frequently use the phrase “!Ay bendito!”
to express astonishment, surprise, lament, or pain.
Some contextual differences occur, mainly in pronun-
ciation by people from rural areas. Rural dwellers may
substitute the sound of e for i and often drop the last
letters of words. For example, después (after) may be
pronounced as dispu, and para donde vas (where are you
going?) may be pronounced as pa’onde vas. In addition,
most Puerto Ricans exchange the letter r for the
letter l; for example, animar (encouragement) may be
pronounced as animal, sounding like “animal.” Some
use a rolling r, a pharyngeal pronunciation that uses
double r, such as arroz (rice) and perro (dog). Puerto
Ricans speak with a melodic, high-pitched, fast rhythm
that may leave non–Puerto Rican health-care providers
confused. This pitch and these inflections are main-
tained when speaking English. Because some Puerto
Ricans feel uncomfortable or even insulted if people
comment on their accent, the health-care provider
should avoid making comments about accent, use cau-
tion when interpreting voice pitch, and seek clarifica-
tion when in doubt about the content and nature of a
conversation that may seem confrontational.
Cultural Communication Patterns
Puerto Ricans are known for their hospitality and
the value placed on interpersonal interaction such as
simpatia, a cultural script in which an individual is
perceived as likeable, attractive, and fun-loving. Puerto
Ricans enjoy conversing with friends and sharing in-
formation about their families, heritage, thoughts, and
feelings. They often expect the health-care provider to
408 Aggregate Data for Cultural-Specific Groups
2780_Ch23_407-425 16/07/12 12:09 PM Page 408

exchange personal information when beginning a
professional relationship. The health-care provider
may wish to set boundaries with discretion and
personalismo, emphasizing personal rather than im-
personal and bureaucratic relationships.
Most Puerto Ricans readily express their physical ail-
ments and discomforts to health-care providers, with the
exception of taboo issues such as sexuality. If confianza
(trust) is established, health-care providers can estab-
lish open communication channels with individuals
and family.
Spatial distancing among Puerto Ricans in the
United States varies with age, gender, generation, and
acculturation. Personal space may be a significant issue
for some older women, particularly those from rural
areas of Puerto Rico, who may prefer to maintain a
greater distance from men. However, Puerto Ricans
born on the mainland may be less self-conscious about
personal space. Young Puerto Rican women may take
offense to verbal and nonverbal communications that
portray women as nonassertive and passive. Thus,
health-care providers must carefully assess each indi-
vidual’s perception of distance and space.
Most Puerto Ricans are very expressive, using
many body movements to convey their messages. Dur-
ing conversations, hand, leg, head, and body gestures
are commonly used to augment messages expressed
by words. Puerto Ricans express feelings and emotions
through touch and are cariñosos (loving and caring)
in verbal and nonverbal ways. Greeting Puerto Ricans
with a friendly handshake is acceptable. Once trust is
established, a patient might greet the health-care
provider with a friendly hug. During conversations,
they are likely to touch with love and affection, includ-
ing a gentle hand stroke on the shoulder. Puerto Rican
women greet one another with a strong familiar hug,
and if among family or close friends, a kiss is included.
Men may greet other men with a strong right hand-
shake and a left hand stroking the greeter’s shoulder.
Nonverbal communication plays a vital role in ac-
quiring informed consent for health-care and research
procedures and when providing health education
and discharge planning. Nonverbal communications
among Puerto Ricans may include an affirmative nod
with an “aha” response, but this does not necessarily
mean agreement or understanding related to the con-
versation. Using a respectful and friendly approach,
health-care providers should seek clarification of the
information provided, ask for language preference in
verbal and written information, and allow time for the
exchange of information with questions and answers
when critical decisions need to be made. Puerto Rican
patients may prefer to read or share sensitive informa-
tion, options, and decisions with close family mem-
bers. Some obtain verbal approval from extended
family or community members who are knowledge-
able in health matters. When consent is needed from
a woman, the health-care provider should ask if ver-
bal approval or consent from the partner should be
obtained first.
Traditional cultural norms discourage an overt
sexual-being image for women, but with family assim-
ilation to the mainland, many of these traditional val-
ues disappear, in particular for younger Puerto Ricans.
When topics such as sex, sexual orientation, sexually
transmitted infections (STIs), or other infectious dis-
eases are discussed, an environment built on confianza
and personalismo must be established if these sensitive
issues are to be effectively addressed. Voice volume
and tone, the degree of eye contact, spatial distancing,
and time are variables that can have an impact on dis-
cussions of sensitive topics with Puerto Ricans.
The meaning and cultural value placed on direct
eye contact has changed over time. Among younger
Puerto Ricans and those born on the mainland, eye
contact is maintained and is often encouraged among
those who believe in a nonsubmissive and assertive
portrayal. However, among more traditional Puerto
Ricans born and raised in rural areas of Puerto Rico,
limited eye contact is preferred as a sign of respect, es-
pecially with older people, who are seen as figures of
respect and great wisdom.
Temporal Relationships
Most Puerto Ricans are present oriented, having a rel-
ativistic and serene view and way of life. This relaxed
attitude often frustrates business people and health-
care providers. Those unaware of this cultural nuance
People of Puerto Rican Heritage 409
R E F L E C T I V E E X E R C I S E 2 3 . 1
Paco and Estrellita Lopez bring their 3-year-old son to the
clinic. They both speak some English and the nurse speaks no
Spanish. The nurse looks at Estrellita holding Pacquito, who is
crying, and asks how she can help them. Estrellita looks at her
husband and speaks to him in Spanish. Paco tells the nurse
that Pacquito ate well until 2 days ago, but now cries while
eating. The nurse continues to look at Estrellita and asks if the
child has any other health problems.
Estrellita looks at her husband while speaking to him in
Spanish, after which the husband tells the nurse that the boy
was born with a heart problem. Again, the nurse asks Estrellita
if she knows what type of heart problem it is.
Paco looks at his wife and speaks in Spanish to her, then
turns to the nurse and says that they can go to La Mirada
Clinic to get help for their son.
1. How is the concept of machismo displayed in this
scenario?
2. How is the concept of marianismo displayed in this
scenario?
3. Why did the parents leave?
2780_Ch23_407-425 16/07/12 12:09 PM Page 409

may misinterpret this view as fatalistic. Health-care
providers should respect this view and assist in iden-
tifying options, choices, and opportunities to empower
individuals to change health-risk behaviors.
Most Puerto Ricans have a relativistic view of time,
which may interfere with being on time for appoint-
ments. This flexible time orientation and relaxed atti-
tude may extend to health-care appointments and
interfere with the ability to provide health services in
a time-limited, cost-containment environment. At the
beginning of an interview, health-care providers
should carefully explain the expectation of being on
time for appointments and the time limits.
Format for Names
Respect for adults, parents, and older people is highly
valued among Puerto Ricans. Respect is reflected in
the way children talk, look, and refer to adults
and older people. Rather than Señora (Mrs.) and
Señor (Mr.), children and adults are expected to use
the terms Doña (Mrs.) and Don (Mr.) for most adults.
Aunts and uncles have their name preceded by tití or
tío (auntie/uncle) and madrina or padrino (godmother
or godfather). These prefixes are symbols of respect
and position in the family. In health-care settings, in-
dividuals expect to be addressed as Sr., Sra., Don, and
Doña. Health-care providers should maintain their re-
spect by using this format for names and by avoiding
calling Puerto Rican patients by their first names or
using terms such as “honey” or “sweetheart.”
Similar to other people of Hispanic heritage,
Puerto Ricans have a complex system for addressing
individuals, specifically women. Single women prefer
to use their father’s and mother’s surnames, in that
order. For example, a single woman may use her name
as follows: Sonia López Mendoza, with López being
her father’s surname and Mendoza her mother’s.
When she is married, the husband’s last name, Pérez,
is added with the word de to reflect that she is married.
This woman’s married name would be Sonia López de
Pérez; the mother’s surname is eliminated. In business
and health-care organizations, Señora López de Pérez
is the correct formal title to use when promoting con-
versation or building a relationship. Younger or more
acculturated women may change their last names to
that of their husbands. The importance and respect
given to these prescriptive name formalities are per-
petuated when friendly verbal and nonverbal gestures
accompany the greeting.
Family Roles and Organization
Head of Household and Gender Roles
Despite many socioeconomic changes and changes in
the position and role of Puerto Rican women, many tra-
ditional patriarchal values still define women in terms
of their reproductive roles. Gender-role expectations are
strikingly different among more acculturated families.
Traditional and newly migrated families may have ex-
pectations and view women as lenient, submissive, and
always wanting to please men. Men demand respect and
obedience from women and the family. Nevertheless,
women play a central role in the family and the commu-
nity, and the Puerto Rican family is moving toward
more egalitarian relationships. Moreover, in Puerto
Rico, women make significant contributions to society
by participating in politics and traditional male-oriented
roles. Many of these changes in family and gender roles
have resulted from the acculturation process and the
increased participation of Puerto Rican women in
the workforce.
Through historical, social, and personal conditions,
a new identity is emerging, and Puerto Rican feminist
voices are calling for changes in family structure, val-
ues, power, and authority. More Puerto Rican families
are sharing the economic and social responsibilities of
the household. However, machismo, a sense of mas-
culinity that stresses virility, courage, and domination
of women, including the need to display physical
strength, bravery, and virility, continues to be the
source of confrontations. Many Puerto Rican women
are negotiating for power to equalize the dynamics of
sexual relationships with Puerto Rican men, who be-
lieve women must be submissive and obedient to men
in all matters. When assessing health risks and rela-
tionships, health-care providers must consider these
issues and assess families for their unique patterns of
relating to identify appropriate interventions.
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Children are the center of Puerto Rican family life.
From childhood through adolescence, children are so-
cialized to have respect for adults, especially the elderly.
Great significance is given to the concept of familism,
and any behavior that shifts from this ideal is discour-
aged and may be perceived as a disgrace to the family.
Families who expect children not to contradict, argue,
or disagree with their parents may have difficulties when
adolescents raised in the Americanized Puerto Rican
culture seek independence and struggle between tradi-
tional and contemporary family values. Many of these
cultural expectations may become a serious threat to
the health and educational future of young Puerto
Rican adolescents. Among others, teen pregnancy, sub-
stance abuse, delinquent behaviors, and depression have
been associated with these issues (National Coalition of
Hispanic Health and Human Services Organizations
[COSSMHO], 1999). Mental health-care providers ad-
dressing family conflict must work within the context of
the family to resolve adolescents’ mental health issues
rather than using individual approaches.
Several prescriptive cultural values surround health
and weight. Many families believe that a healthy child
410 Aggregate Data for Cultural-Specific Groups
2780_Ch23_407-425 16/07/12 12:09 PM Page 410

is one who is gordita or llenito (diminutive for fat or
overweight) and has red cheeks. Massara’s (1989) early
work on weight, body image perceptions, and health
argued that an oversized body image may be perceived
as a mirror of physical and financial wealth, even
among adult women. Young mothers are often encour-
aged to add cereal, eggs, and viandas (see Nutrition) to
their infant’s milk bottles. Nurses are in an excellent
position to educate mothers about these practices and
the health risks for children who are overweight.
Many families socialize male children to be macho,
powerful, and strong with healthy sexual appetites.
This macho behavior encourages dominance over
women; values obtaining social privileges; and empha-
sizes the pursuit of high-paying careers for their finan-
cial advantage. Although many families wish for the
education of their children, a few still want educated
housewives, not necessarily educated professional
working women. Female children are socialized with
a focus on home economics, family dynamics, and
motherhood, which places women in a powerful social
status. Consequently, the value placed on motherhood
may be a precursor to teenage pregnancy among
Puerto Rican adolescents who are seeking power,
support, and cultural recognition (Orshan, 1996).
Some families abide by cultural prescriptions that
encourage the initiation of sexual behaviors before
marriage, extramarital sexual activity, and control by
men over sexual relationships. Girls are socialized to
be modest, sexually ingenuous, respectful, and sub-
servient to men, a cultural script related to marianismo
(Orshan, 1996). Discussions about sexuality are con-
sidered taboo for many families, who use the term
tener relaciones (to have relations) rather than the
word sex. Modesty is highly valued, and issues such
as menstruation, birth control, impotence, STIs, and
infertility are rarely discussed.
Less-educated families and those from rural areas
may have great difficulty educating young women about
sexuality and reproductive issues. Thus, many Puerto
Rican adolescents depend on educational organizations
to learn about menstruation and the reproductive sys-
tem. However, this is often not the case for preadoles-
cents or adolescents, who are exposed to information
through the media, schools, and peers. Cultural respect
for the role of health-care providers as educators places
them in an excellent position to educate the family
about sexuality issues. This respect gains them entrance
into a familiar and trusted family environment that
must be valued for its cultural traditions and practices.
Most families expect their children to stay home
until they get married or pursue a college education.
Families want to care for their young and provide them
with emotional and financial support to the extent that
it is feasible. Children are expected to follow family tra-
ditions and rules. The mother is expected to assume an
active role disciplining, guiding, and advising children.
Most fathers expect to be consulted, but they see them-
selves mainly as financial providers. Puerto Rican
families are often very rigorous with their children’s
discipline. Traditional punishments include making the
child who has told a lie kneel on rice until the truth is
told, washing the mouth vigorously with soap for using
profanity, and spanking the buttocks or lower extrem-
ities with a belt. Puerto Rican mothers tend to be very
protective of their children and may use physical pun-
ishment. Many Puerto Rican mothers use threats of
punishment, guilt, and discipline, which can create
stress and difficulties for adolescents as they struggle
with the more permissive cultural patterns of the
United States, such as dating. Health-care providers
should assess families for these patterns and provide
counseling that promotes stability. The cultural defini-
tion of physical abuse is challenging, and health-care
providers must assess each situation before determining
child abuse.
Family Goals and Priorities
Family roles and priorities among Puerto Ricans are
based on the concept of familism. Puerto Ricans value
the unity of the family. La familia is the nucleus of the
community and the society. The family structure may
be nuclear or extended. Family members include grand-
parents, great-grandparents, married children, aunts,
uncles, cousins, and even divorced children with their
children. Two families may live in the same household.
After marriage, children live away from their par-
ents but are expected to maintain very close ties with
their families, especially the women. Most Puerto
Rican families want a daughter because daughters tra-
ditionally are caretakers when parents reach advanced
ages. In addition, women continue family traditions.
Male children, who are usually more independent, are
valued because they continue the family name.
Because children are the center of the family, close
and extended family members are expected to partici-
pate in the care of children, give support, and encourage
the maintenance of cultural and religious traditions.
Grandparents assume an active role in rearing grand-
children, supporting the family, babysitting, teaching
traditions, disciplining, and enforcing educational activ-
ities. If the woman works outside the home, family
goals and priorities may change, which often results in
social and emotional burdens for women. Health-care
providers can use and encourage older Puerto Ricans to
introduce health-promotion and disease-prevention ed-
ucation within their families.
As women become older, they gain status for their
wisdom. Often, older women have a covert power over
spouses, children, and the family. Dependent older
people are expected to live with their children and
be cared for emotionally and financially. Informal
and formal support systems are considered critical
factors in promoting the health of older Puerto
People of Puerto Rican Heritage 411
2780_Ch23_407-425 16/07/12 12:09 PM Page 411

Ricans, particularly older women. All members of the
family provide support for financial and manpower
efforts needed to keep older people at home. Those who
have higher financial liquidity may take financial re-
sponsibility in exchange for the manpower and physical
efforts of those who cannot provide financially. Place-
ments in nursing homes and extended-care facilities
may be seen as inconsiderate to older people, and fam-
ily members who must use these organizations may
feel guilty and experience depression and distress. Thus,
health-care providers must be sensitive to these issues
by exploring alternatives for care and providing infor-
mation to all family members involved in this decision-
making process. Discharge planning, hospice care, and
other situations can be addressed in a “conference-
style” approach to develop strategies for providing emo-
tional support and assistance to family members.
Friends, neighbors, and close and distant family
members are expected to visit a person during times
of illness, support the family, and take an active role
in family decisions and activities. A family member is
expected to be at the bedside of the sick person.
Health-care providers should ask the name of the
family spokesperson and document it in the patient’s
chart. Nurses may need to set boundaries with
patients’ families about visitation, personal space, and
privacy matters.
Alternative Lifestyles
Since the early 1980s, Puerto Rican families have expe-
rienced an increased incidence of pregnancy among
teenagers and unmarried women. This trend is believed
to be the result of the increased number of women in
the labor force, high divorce rates, poverty, and the in-
creased number of households headed by women. For
health-care services to be effective in identifying appro-
priate interventions, health-care providers must assess
social-support factors and the socioeconomic status of
individuals.
Homosexuality continues to be a taboo topic that
carries a great stigma among Puerto Ricans. Same-
sex behavior is often undisclosed to avoid family
rejection and preserve family links and support.
Unfortunately, the literature does not include infor-
mation about these families and their lifestyles.
When caring for gays and lesbians, health-care
providers must inquire about their “disclosed or
undisclosed status” and act according to patient
preferences and support resources.
Workforce Issues
Culture in the Workplace
In general, Puerto Rican men and women readily as-
similate into the U.S. work environment, which is sim-
ilar to their native work environment in Puerto Rico.
Nurses are among the latest group of Puerto Rican
professionals who have come to the United States
seeking better employment and educational opportu-
nities. They often seek employment opportunities at
federal health facilities such as the Army, Navy, Air
Force, and Veterans Administration.
Despite stereotypical views of Puerto Ricans as
people who do not work and depend solely on the U.S.
welfare system, most Puerto Ricans are hardworking,
like to be competitive, and often make extended efforts
to please their employers. Many Puerto Ricans in the
labor force place a high value on their occupations,
positions, and businesses. They strive for high per-
formance even in the face of oppression; they offer
little resistance and maintain the ability to be happy
even when confronting oppressive situations.
Several cultural differences among Puerto Ricans—
such as education; the value placed on honesty, in-
tegrity, personal relationships; and relativistic views of
time—may have an influence in the workplace. The ed-
ucational system in Puerto Rico emphasizes theoretical
and practical content as well as neatness. Consequently,
whereas most migrant Puerto Ricans are task oriented
and meticulous about the presentation of their work,
some have a relativistic view of time and may not value
regular attendance and punctuality in the workforce.
Most Puerto Ricans are cheerful, have a positive atti-
tude, and value personal relationships at work. Work is
perceived as a place for social and cultural interactions,
which may include listening to background music while
performing job activities. This practice can lead to loud,
cheerful, and noisy conversations that may require the
employer’s attention.
For many women, family responsibilities, pregnancy,
and the health of their children and other family mem-
bers take priority over work. For others, access to the
welfare system becomes more convenient than the pride
of having a secure job. In Puerto Rico, women are given
a lengthy maternity leave because of the emphasis and
value placed on the well-being of working women and
their infants. In the U.S. labor force, many working
Puerto Rican women resent the limited maternity leave
supported by the American culture.
Employers may need to negotiate more lexible work
responsibilities among Puerto Ricans during religious
holiday celebrations such as Easter and Christmas. In
Puerto Rico, schools are closed, and the community
celebrates a spiritual and religious recess from day-to-
day activities and work responsibilities. The great
solemnity and religious commitment among all reli-
gious groups bring Puerto Rican families to a societal
halt for almost 6 weeks. Schools recess from early
December to the middle of January, waiting for the
Epiphany, Los Tres Reyes Magos, on January 6, and the
Octavitas, a post-Epiphany traditional musical and cul-
tural celebration that extends the Christmas celebration
8 more days. Many Puerto Ricans on the mainland
wish to use vacation and unpaid leave to spend time
412 Aggregate Data for Cultural-Specific Groups
2780_Ch23_407-425 16/07/12 12:09 PM Page 412

with their families in Puerto Rico. Traditional music,
food, and folk activities during these celebrations
are used to uphold ethnic pride. Holiday seasons may
challenge employers, who need to manage absenteeism,
increased consumption of alcohol, requests for vaca-
tion, leave without pay, and decreased productivity.
Issues Related to Autonomy
Puerto Rican families have traditionally socialized men
into aggressive, domineering, and outspoken roles.
Thus, many men display confidence at work and as-
sume leadership positions with autonomy. However,
more recent male immigrants who are less educated and
have language difficulties may be reluctant to assume
leadership roles, may be shy and not as outspoken, and
may hesitate to challenge authority and workplace
norms. Changing the conduct of these recent male im-
migrants in the workforce is related to the passivity and
docile behaviors learned in the U.S. and Puerto Rican
educational systems. These immigrants are more likely
to conform to the behavioral norms of the workplace
and avoid personal conflict or confrontations in an
effort to maintain positive relationships.
Women from rural areas and traditional families are
more likely to come from a submissive and noncompet-
itive environment. Thus, they may be perceived as less
determined, less confident, and less outspoken than
other American women in managerial and supervisory
capacities. Some women find themselves in conflict with
traditional values when in a competitive, assertive work
environment. Their ability to succeed in the workforce
may depend on their employers’ support of assertive-
ness and on-the-job training. In addition, women who
wish to climb the career ladder may benefit from an en-
vironment that provides information, promotes confi-
dence, fosters positive interpersonal relationships, and
teaches strategies for resolving conflict.
Although most Puerto Ricans are bilingual, some
may speak broken English, street English, or Puerto
Rican Spanglish such as “I must pay billes [bills]
and find dinero [money].” Younger and urban Puerto
Ricans are usually more fluent in English, a skill that
facilitates integration into the labor market. Older
adults and people who come from a rural background
may have less education, lower literacy levels, de-
creased English proficiency, and increased difficulty
assimilating into the labor force.
Biocultural Ecology
Skin Color and Biological Variations
The heritage of Puerto Ricans is a mixture of Native
Indian, African, and Spanish heritage. Some may have
dark skin; thick, kinky hair; and a wide, flat nose. Oth-
ers are white-skinned with straight, auburn hair and
hazel or black eyes. Certain traits such as skin coloring
require health-care providers to vary their techniques
when assessing individual Puerto Ricans for anemia
and jaundice.
Limited information is available about the biocul-
tural variations among Puerto Ricans. Although no
scientific evidence exists, some posit that diseases such
as hypertension and diabetes mellitus, major illnesses
among Puerto Ricans in Puerto Rico and on the
mainland, are the result of indigenous Indian and
African heritage. Consequently, health-care providers
should assess each person as a unique individual with
awareness that standards developed for the dominant
American population do not necessarily apply to the
Puerto Rican population.
Disease and Health Conditions
The health conditions of Puerto Ricans on the main-
land and in Puerto Rico are similar, with the leading
causes of death being heart disease, malignant neo-
plasms, diabetes mellitus, unintentional injuries, and
AIDS (National Alliance for Hispanic Health, 2011).
Life expectancy for Puerto Ricans females is 82.71 years,
and for men it is 75.31 years (CIA World Factbook,
2011b). Puerto Ricans have decreased mortality rates
for lung, breast, and ovarian cancers and an increased
incidence of stomach, prostate, esophageal, pancreatic,
and cervical cancers. In Puerto Rico, prostate, colon,
and breast cancer, in that order, are the leading causes
of cancer-related deaths, followed by tracheal and lung
cancers (Puerto Rico Department of Health, 2009). Al-
though the overall cancer mortality rate among Puerto
Ricans is lower than that for other groups, health-care
providers should continue to educate Puerto Rican
families about cancer prevention. Smoked, pickled, and
spiced foods should be discouraged, whereas traditional
meals, fruits, and vegetables should be encouraged.
Puerto Ricans on the mainland face a high incidence
of chronic conditions such as mental illness among
younger adults and cardiopulmonary and osteomuscu-
lar diseases among the elderly. Acute conditions among
Puerto Ricans include a disproportionate number of
acute respiratory illnesses, injuries, infectious and par-
asitic diseases, and diseases of the digestive system.
Puerto Rican women in the United States have a
high incidence of being overweight; in particular, this
prevalence increases with age and among women from
lower socioeconomic levels. Obesity and centralized
body fat among these women increase the incidence of,
and mortality from, diabetes, the third leading cause of
death for Puerto Rican women on the mainland. Men
have a lower incidence of obesity than women, and
men from rural areas have lower rates of diabetes than
men from urban areas. Health-care providers need to
develop interventions that are appropriate to gender,
age, and socioeconomic status, while giving considera-
tion to their rural or urban living arrangements.
Dengue fever, a mosquito-transmitted disease
caused by any of the four viral serotypes of the Aedes
People of Puerto Rican Heritage 413
2780_Ch23_407-425 16/07/12 12:09 PM Page 413

aegypti mosquito, is an endemic disease that migrants
may bring to the mainland. Health-care providers
need to advise Puerto Rican patients and families trav-
eling to Puerto Rico to avoid exposure to endemic
areas and to use mosquito repellent and protective
clothing at all times. Health-care providers should be-
come familiar with the signs, symptoms, and current
treatment recommendations for dengue fever.
Puerto Rico has a higher HIV (human immuno –
deficiency virus) infection rate than any state in the
United States. Compared with other ethnic groups in
the United States, Puerto Ricans have the highest in-
cidence of HIV. Among Puerto Ricans with HIV,
20 percent are male-to-male homosexual (compared
with 43 percent overall in the United States), 39 per-
cent are intravenous drug users (compared with
25 percent overall in the United States), 37 percent
are heterosexual (compared with 25 percent overall
in the United States), and 5 percent are other (com-
pared with 6 percent overall in the United States)
(Centers for Disease Control and Prevention, 2006).
Variations in Drug Metabolism
Literature searches reveal no information regarding dif-
ferences in drug metabolism among Puerto Ricans.
Health-care providers must be aware that pharmaceuti-
cal studies conducted with European Americans may
not yield the same results with Puerto Ricans; thus, in-
dividual assessments with accurate documentation of
observations are imperative. Because of the African her-
itage of many Puerto Ricans, drug absorption, metab-
olism, and excretion differences experienced by African
Americans and American Indians may hold true for
black Puerto Ricans. Given that some Puerto Ricans are
short in stature and have higher subscapular and triceps
skin folds, long trunks, and short legs, therapeutic
dosages calculated for the European American popula-
tion may not be appropriate for Puerto Ricans.
High-Risk Behaviors
Puerto Ricans are at high risk for illnesses, with in-
creased mortality and morbidity rates related to al-
coholism, smoking, illicit drug use, physical inactivity,
poor dietary practices, sex-related behaviors, and
underutilization of preventive health-care services.
Alcoholism is the precursor of increased unintentional
injuries, family disruption, spousal abuse, and mental
illness among Puerto Rican families. According to
Centers for Disease Control (2008), 80 percent of
Puerto Rican men and 29 percent of Puerto Rican
women have high rates of alcohol consumption. Alco-
hol consumption among Puerto Ricans is attributed, in
part, to acculturation into the mainstream U.S. culture
and to psychosocial factors (Torres & Villaruel, 1996).
The prevalence of smoking among Puerto Ricans
is lower than that of European Americans but higher
than that for other Hispanic subgroups. Puerto Rican
women have a higher prevalence of smoking than
Cuban and Mexican American women, and when age
is adjusted, Puerto Rican women younger than age 40
have the highest prevalence of smoking among all
women in the United States. Health-care providers
should consider gender and acculturation issues and
build on previous successful intervention programs to
develop specific programs for decreasing smoking
among Puerto Rican populations. Providers must be
aware that Puerto Rican adolescents—in particular
females—are at higher risk of starting and continuing
to smoke than other Hispanic and ethnic subgroups
including African Americans and Asians (Epstein,
Botvin, & Diaz, 1998).
Drug use is a significant public-health problem for
many Puerto Ricans, whose rate of marijuana and co-
caine use is often higher than that of the European
American population. The last research decade clearly
indicates that issues related to acculturation, peer
factors, individual, family, parental, and gender-role
issues are the most important risk factors in need of
early health provider interventions to decrease suscep-
tibility to drug addiction and delinquency. Accultur-
ation, as measured by language use, is significantly
associated with marijuana and cocaine use. Many
studies have shown that the longer one lives in the
United States and the more acculturated one becomes,
the higher the rate of use of marijuana, smoking, and
cocaine. Among Puerto Rican men, social barriers,
family demoralization, and other life problems are sig-
nificant precursors for illicit drug use. However, accul-
turation, family factors, peer domains, language, and
place of birth do not explain these patterns of illicit
drug use in adolescents or men as well as they do for
Puerto Rican women (Torres & Villaruel, 1996). Issues
such as acculturation, self-esteem, self-concept, depres-
sion, hopelessness, and maladaptative coping behav-
iors are significant factors influencing the pattern and
prevalence of Puerto Rican women’s drug use. Health-
care providers should develop programs that promote
early interventions for the use of illicit drugs. Interven-
tions should focus on individual psychological differ-
ences, gender issues, and other contributing factors.
Because many Puerto Ricans support machismo
and submission of women, these roles foster high-risk
behaviors that impede the prevention and increase the
transmission of HIV. In traditional Puerto Rican cul-
ture, most men are given free will over sexual practices,
including the approval and initiation of sex before
marriage and extramarital affairs with other women.
Some men may perceive that sexual intercourse with
men is a sign of virility and sexual power rather than
a homosexual behavior. Puerto Rican women are
often found in a paradoxical position, because they
have to deal with cultural beliefs and health-protective
practices. Knowledge about HIV, beliefs about health
and illness, and beliefs and practices related to condom
414 Aggregate Data for Cultural-Specific Groups
2780_Ch23_407-425 16/07/12 12:09 PM Page 414

use are common concerns encountered by health-care
providers in the prevention and transmission of HIV.
Lack of condom use is perhaps one of the most
significant risk behaviors that need immediate atten-
tion and intervention from health-care providers. Is-
sues such as embarrassment, cost, gender or power
struggles, and abuse are among the barriers encoun-
tered by Puerto Rican women. Some men fear that if
they use condoms, they portray a less macho image,
have decreased sexual satisfaction, or indicate that
they have an STI or HIV. In addition, the Catholic
Church’s opposition to the use of condoms, lower ed-
ucational levels, lower socioeconomic status, and ac-
culturation are significant variables related to the high
rates of AIDS and HIV among Puerto Ricans and
other Hispanics. Health-care providers must be aware
of these barriers, assess individual perceptions of
high-risk behaviors, and intervene with programs de-
signed to meet the particular needs of clients who are
at high risk for HIV infection or other STIs.
Nutrition
Meaning of Food
Puerto Ricans celebrate, mourn, and socialize around
food. Food is used to honor and recognize visitors,
friends, family members, and health-care providers; as
an escape from everyday pressures, problems, and chal-
lenges; and to prevent and treat illnesses. Puerto Rican
patients may bring homemade goods to health-care
providers as an expression of appreciation, respect,
and gratitude for services rendered. Refusing these of-
ferings may be interpreted as a personal rejection.
Some Puerto Ricans believe that being overweight
is a sign of health and wealth. Some eat to excess, be-
lieving that if they eat more, their health will be better,
whereas others pay no attention to weight control or
dietary practices. Many Puerto Ricans perceive that
European Americans are more preoccupied with
how they look than how healthy they are. Efforts by
American health-care providers directed at weight
control may be seen as the Americans’ excessive
preoccupation with a thin body image.
Common Foods and Food Rituals
Traditional Puerto Rican families emphasize having a
complete breakfast that begins with a cup of strong
coffee or café con leche (coffee with milk). Some drink
strong coffees such as espresso with lots of sugar; oth-
ers boil fresh milk (or use condensed milk) and then
add the coffee. Many families introduce children to
coffee as early as 5 or 6 years of age. A traditional
Puerto Rican breakfast includes hot cereal such as
oatmeal; cornmeal; or rice and wheat cereal cooked
with vanilla, cinnamon, sugar, salt, and milk. Although
less common, traditional Puerto Ricans may eat corn
pancakes or fritters for breakfast.
Lunch is served by noon, followed by dinner at
around 5 or 6 p.m. A cup of espresso-like coffee is also
enjoyed at 10:00 a.m. and 3:00 p.m. Rice and stew
habichuelas (beans) are the main dishes among Puerto
Rican families. Rice may be served plain or cooked and
served with as many as 12 side dishes. Rice cooked with
vegetables or meat is considered a complete meal. Arroz
guisado (rice stew) is seasoned with sofrito, a blend of
spices such as cilantro, recao (a type of cilantro), onions,
green peppers, and other nonspicy ingredients. Rice is
cooked with chicken, pork, sausages, codfish, calamari,
or shrimp, as well as corn, several types of beans, and
gandules (green pigeon peas), a Puerto Rican bean rich
in iron and protein. Rice with gandules is a traditional
Christmas holiday dish that is accompanied by pernil
asado (roasted pork) and pasteles, made with root veg-
etables, green plantain, bananas, or condiments and
then filled with meat and wrapped with plantain leaves.
Fritters are also common foods.
Puerto Ricans eat a great variety of pastas, breads,
crackers, vegetables, and fruits. Tostones, fried green or
ripe plantains, are a favorite side dish served with almost
every meal. Puerto Rican families eat a variety of roots
called viandas, vegetables rich in vitamins and starch.
The most common viandas are celery roots, sweet pota-
toes, dasheens, yams, breadfruit, breadnut, green and
ripe plantains, green bananas, tanniers, cassava, and
chayote squash or christophines. A list of common
Puerto Rican meals is presented in Table 23-1. Because
People of Puerto Rican Heritage 415
❙❙◗ Table 23-1 Common Puerto Rican Meals
Puerto Rican Meal English Translation
Alcapurrias Green plantain fritters filled with
meat or crab
Arepas de maíz y queso Cornmeal and cheese fritters
Arroz con pollo Rice with chicken
Arroz con gandules Rice with pigeon peas
Arroz blanco (con aceite) Plain rice (with oil)
Arroz guisado básico Plain stewed rice
Asopao de pollo Soupy rice with chicken
Bacalaitos Codfish fritters
Bocadillo Grilled sandwich
Mondongo Tripe stew
Paella de mariscos Seafood paella
Pastelillos de carne, queso, Turnovers filled with meat,
o pasta de guayaba cheese, or guava paste
Pollo en fricase con papas Stewed chicken with potatoes
Relleno de papa Potato ball filled with meat
Sancocho Viandas and meat stew
Sofrito Condiment
Surullo de queso Cornmeal fritters filled with cheese
2780_Ch23_407-425 16/07/12 12:09 PM Page 415

Puerto Rican meals are flavorful, patients in the health-
care setting may find more traditional American meals
to be flavorless and unattractive. However, more accul-
turated Puerto Ricans are changing their traditional
food practices and often follow mainland U.S. dietary
practices. Health-care providers who work with tradi-
tional Puerto Rican patients should become familiar
with these foods and their nutritional content to assist
families with dietary practices that integrate their tradi-
tional or preferred food selections.
Dietary Practices for Health Promotion
Many Puerto Ricans ascribe to the hot-cold classifi-
cations of foods for nutritional balance and dietary
practices during menstruation, pregnancy, the post-
partum period, infant feeding, lactation, and aging.
Some of the hot-cold classifications are presented in
Table 23-2. Health-care providers should become
familiar with these food practices when planning
culturally congruent dietary alternatives.
416 Aggregate Data for Cultural-Specific Groups
❙❙◗ Table 23-2 Puerto Rican Hot-Cold Classification of Selected Foods, Medications, Herbs,
and Health-Illness Status
Hot-Cold
Classification Health-Illnesses Status Western Medications Traditional Herbs Foods
Hot Gastrointestinal illnesses Syrups Teas Cocoa products
(constipation, diarrhea, Crohn’s
colitis, ulcer, bleeding)
Gynecological issues Dark-colored pills Cinnamon Alcoholic beverages
(pregnancy, menopause)
Skin disorders (rashes, acne) Aspirin Dark-leaf teas Caffeine products
Neurological disorders (headache) Anti-inflammatory agents Teas Hot cereals (wheat, corn)
Heart disease Prednisone Salt
Urological illnesses Antihypertensives Spices and condiments
Castor oil Beans
Cinnamon Nuts and seeds
Vitamins (iron)
Antibiotics
Cold Osteomuscular illnesses (arthritis, Diuretics Orange-lemon Rice
rheumatoid arthritis, multiple chamomile
sclerosis)
Menstruation Bicarbonate of soda Linden Rice and barley water
Respiratory illnesses Antacids Mint Milk
Milk of magnesia Anise Sugar and sugar products
Root vegetables
Avocado
Fruits
Vegetables
White meat
Honey
Onions
Understanding that iron is considered a “hot” food
that is not usually taken during pregnancy can assist
health-care providers to negotiate approval and edu-
cate Puerto Rican women about the importance of
maintaining adherence to daily iron recommendations,
even during pregnancy and lactation. An additional
summary of Puerto Rican cultural food habits, reasons
for practices, and recommendations for health-care
providers during such developmental stages is pre-
sented in Table 23-3.
With the advent of alternatives to hormone replace-
ment therapy (HRT) (Taylor, 1999), many Puerto Rican
women are using a variety of herbal and botanical reme-
dies. Many are using relaxation, massage, acupuncture,
guided imagery, chelation, biofeedback, and therapeutic
touch in addition to or as an alternative to HRT. Black
cohosh, evening primrose, St. John’s wort, gingko, gin-
seng, valerian root, sarsaparilla, chamomile, red clover,
and passion flower are the most common herbs and
botanical alternatives used by Puerto Rican women.
2780_Ch23_407-425 16/07/12 12:09 PM Page 416

People of Puerto Rican Heritage 417
❙❙◗ Table 23-3 Puerto Rican Cultural Nutrition and Health Beliefs and Practices During Particular Stages
Behavioral Dietary and Recommendation for
Period Health Practices Cultural Justification Health-Care Professionals
Menstruation Food taboos: Avoid spices, cold May induce cramps, hemorrhage, Assess individual beliefs and
beverages, acid-citric fruits and clots, and physical imbalance. May acknowledge them.
substances, chocolate, and coffee. produce acne during
menstruation.
Foods encouraged: Plenty of hot Fluids encourage body cleaning of Incorporate traditional beliefs
fluids, such as cinnamon tea, milk impurities. Hot beverages encourage in treatments as required in
with cinnamon and sugar. Teas circulation and reduce nonsteroidal anti-inflammatories
such as chamomile, anise seed, abdominal colic, cramps, and for dysmenorrhea.
linden tea, mint leaves. pain. Teas are soothing to all
body systems.
Health practices: Avoid exercise Exercise may increase pain and Encourage passive exercise.
and practice good hygiene. Do bleeding. Good hygiene is Provide information about the
not walk barefoot. Avoid wind important for health. Walking role of exercise in the reduction
and rain. Stay as warm as possible. barefoot during menstruation may of menstrual discomfort.
cause rheumatoid arthritis and Support other practices.
other inflammatory diseases. Warm
temperatures promote circulation
and the health of the reproductive
system as well as prevent cramps.
Pregnancy Food taboos: Hot food, sauces, May cause excess flatus, acid Encourage healthy food habits.
condiments, chocolate products, indigestion, bulging, and constipation. Provide information about
coffee, beans, pork, fritters, Chocolate and coffee may cause chocolate and coffee myths.
oily foods, and citrus products. darker skin in fetus. Some believe Encourage fruits.
citrus products may be abortive.
Foods encouraged: Milk, beef, Considered healthy and nutritious. Discourage the use of raw eggs
chicken, vegetables, fruits, ponches. Increases hemoglobin, strengthens in beverages because of
and promotes good labor. possibility of Salmonella
poisoning.
Health practices: Rest and get Enhances health and prevents Encourage use of food
plenty of sleep. Eat plenty of problems during birth. Sex may recommended for pregnancy.
food. Follow diet cautiously. cause problems with baby or Provide information about sexual
Many avoid sexual intercourse preterm labor. activity. Encourage a balanced
early in pregnancy. Practice good plan of exercise with emphasis
hygiene and take warm showers. on weight control and health of
the baby.
Lactation Food taboos: Avoid beans, These foods cause stomach Include a dietary plan that is
cabbages, lettuce, seeds, nuts, illnesses for infant and mother, balanced with substitute food
pork, chocolate, coffee, and hot including baby colic, diarrhea, items. Clarify any myths about
food items at all times. and flatus. infant diarrhea, colic, and flatus.
Foods encouraged: Milk, water, Improve health and increase As above with raw eggs.
ponches, chicken soup, chicken, hemoglobin and essential vitamins.
beef, pastas, hot cereals. Protect mother and infant from
illnesses. Fluids and ponches
increase milk supply. Red meats
reduce cravings.
Health practices: Avoid cold Cold temperatures and winds Provide information about
temperatures and wind. A few are believed to cause stroke and reasons for stroke and facial
may avoid showering for several facial paralysis in a new mother. paralysis. Provide time to ask
days during the cuarentena after Showering may cause respiratory questions and reduce anxiety
birth. Great attention is paid to diseases. Mother is believed to during winter season deliveries.
health of the mother. be at risk and fragile.
Infant feeding Food taboos: Beans, too much Believed to cause stomach colic, Provide information about
rice, and uncooked vegetables. flatus, and distended abdomen. Too appropriate dietary patterns for
much rice causes constipation. infant.
Continues on page 418
2780_Ch23_407-425 16/07/12 12:09 PM Page 417

Health-care providers should understand and be able to
discuss the safety and efficacy of the most frequently
used alternatives. The use of HRT alternatives should
be included in routine health assessment among women
in this stage.
An infant is believed to be healthy if it is gordito (a
little fat) and has red cheeks. Consequently, many
mothers add ground root vegetables, eggs, hot cereals,
rice, canned baby foods, and fruits and vegetables to
the infant’s bottle at an early age. Traditionally, when
children are introduced to soft foods and vegetables,
parents boil and grind root vegetables for the infant.
For some, these dietary practices have changed with
the availability of canned baby food. Many mothers
tend to feed whole cow’s milk or canned milk (Carna-
tion) earlier than recommended in Western practice,
believing that canned milk produces healthier babies.
Health-care providers must educate families regarding
the nutritional content of canned milk versus fresh
milk, breastfeeding, and formula.
For older Puerto Ricans, a good diet includes
meats, traditional meals, and vitamin supplements.
Beverages such as fresh-squeezed orange juice, grape
juice, and ponches (punches) are used as additional
nutritional support, particularly for those who are im-
munosuppressed or chronically or terminally ill. If the
older individual is believed to have low blood pressure
and is weak or tired, a small daily portion of brandy
may be added to black coffee to enhance the work of
“an old heart.” If the health-care provider criticizes
these practices, it may deter the client from seeking
follow-up care and decrease trust and confidence in
health-care providers. Health-care providers must
inquire about these practices and should incorporate
harmless or nonconflicting practices into the diet.
During illness, Puerto Ricans pay close attention to
dietary practices. Chicken soups and caldos (broth)
are used as a hot meal to provide essential nutrients.
A mixture of equal amounts of honey, lemon, and
rum is used as an expectorant and antitussive. A malt
drink, malta (grape juice), or milk is often added to
an egg yolk mixed with plenty of sugar to increase the
hemoglobin level and provide strength. Ulcers, acid
indigestion, and stomach illnesses are treated with
warm milk, with or without sugar. Herbal teas are
used to treat illnesses and to promote health. Most
herbal teas do not interfere with medical prescriptions.
Incorporating their use with traditional Western med-
icine may enhance adherence to treatment.
Nutritional Deficiencies and Food Limitations
Most Puerto Ricans moving to the mainland locate in
areas with Puerto Rican or Hispanic communities and
where preferred foods are readily available. Traditional
cooking and food practices do not necessarily change.
Instead, European American foods are quickly inte-
grated into the dietary practices, thereby increasing
food diversity. Fresh fruits and juices are consumed in
large quantities.
Few studies have shown significant data about nu-
tritional deficiencies among Puerto Ricans. Studies
that include small samples of Puerto Ricans show that
Puerto Rican children have nutritional statuses similar
to those of Mexican American and African American
children in terms of malnutrition, obesity, and short
stature. Low-income Puerto Rican children and
418 Aggregate Data for Cultural-Specific Groups
❙❙◗ Table 23-3 Puerto Rican Cultural Nutrition and Health Beliefs and Practices During Particular
Stages Continued from page 417
Behavioral Dietary and Recommendation for
Period Health Practices Cultural Justification Health-Care Professionals
Foods encouraged: Hot cereals, Believed to be nutritious and Instruct about infant diet and
ponches, chicken broth or caldos. healthy and to decrease hunger. timely introduction of food items
Fresh fruits, cooked vegetables, Caldos are fortifying and prevent to diet. Explain consequences of
viandas. Raw eggs, cereals, baby illness. Cooked vegetables are excessive weight in infants.
foods in milk bottle. Fresh fruit healthy and prevent constipation. Discourage food in bottle to
juices. Mint, chamomile, and Bottle food fills the baby. Fresh prevent choking.
anise tea. Sugar and honey juices and fruits refresh the
used for hiccups. stomach. Teas help baby sleep and
cure flatus. Sugar and honey have
curing properties.
Health practices: Keep baby Warm babies eat, chew, and Discourage raw eggs because of
warm while feeding. digest food better, and choking is the risk of Salmonella and egg
decreased. allergies and the use of honey
because of the risk of botulism.
Teas are harmless and provide
additional fluid when used in
moderation without sugar.
Provide information about babies
and choking.
2780_Ch23_407-425 16/07/12 12:09 PM Page 418

adolescents have been found to have anemia and tooth
decay related to consumption of less than the recom-
mended daily allowances of iron, folacin, thiamin,
niacin, and vitamin C. Menstruation is viewed as a
time when women must care for themselves and ad-
here to certain dietary practices to promote health.
From the onset of menstruation, young girls are
encouraged to avoid foods believed to produce flatus,
abdominal cramps, and colic. Hot drinks are encour-
aged to increase circulation and promote the elimination
of metabolic waste.
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Marital status, knowledge, attitudes, beliefs about the
reproductive system, the role of motherhood, sexual-
ity, and contraceptive use are factors that need to be
considered when assessing and implementing cultur-
ally congruent maternal–infant interventions and
educational programs. Compared with 1990 data,
Puerto Rican women are improving their access to
prenatal care (National Center for Health Statistics,
2011). Health-care providers should be aware that so-
cial support has been found to be one of the most sig-
nificant factors related to perinatal outcomes among
Puerto Rican women. Among others, social support
has been found to have significant implications for
stress, health behaviors, and infant health (Landale &
Oropesa, 2001). Among adolescents, culturally im-
posed male behaviors and lack of parental guidance
or supervision have been listed as predictors of
teenage pregnancy (COSSMHO, 1999). The infant
mortality rate for Puerto Rican women is 8.07 percent
(CIA World Factbook, 2011a). Teen pregnancy re-
mains high at 6.9 percent compared with an overall
U.S. rate (all races) at 3.4 percent. Ten percent of
Puerto Rican births are low weight (National Center
for Health Statistics, 2011).
Puerto Rican women do not commonly use birth
control methods such as foams, creams, and di-
aphragms because the Catholic Church, which con-
dones only the rhythm method and sexual abstinence,
sees them as immoral. According to the HHANES
study, in the United States, fertility control methods
used by Puerto Rican women were tubal ligation,
called La Operación (the surgery) with 23 percent,
followed by oral contraceptives with 8.7 percent, hys-
terectomies with 3.5 percent, and oophorectomies
with 3.2 percent (Stroup-Benham & Treviño, 1991).
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Hygiene is highly valued during pregnancy, labor, and
the postpartum period. Pregnancy is a time of indul-
gence for Puerto Rican women. Favors and wishes are
granted to women for their well-being and the health
of their babies. Men are socialized to be tolerant, un-
derstanding, and patient regarding pregnant women
and their preferences. Pregnant Puerto Rican women
are encouraged to rest, consume large quantities of
food, and carefully watch what they eat. Many young
Puerto Rican families prefer to attend birthing classes.
People of Puerto Rican Heritage 419
R E F L E C T I V E E X E R C I S E 2 3 . 2
Rosa Medina, age 33, is 3 days postpartum. She has brought
3-day-old Juanita to the maternal-child clinic because the
baby has been crying continuously.
The nurse greets Mrs. Medina and asks how she and her
family are getting along with Juanita. Mrs. Medina says that
things are “mostly okay” and that her mother and sister help
take care of the other children, while her husband was able to
keep his job after a lot of people at the market were fired.
The nurse asks if the problem is with Mrs. Medina or her
daughter Juanita, and Mrs. Medina says that Juanita has been
crying all day, but nothing seems to help. They don’t have any
chamomile tea to offer the child either.
Nurse: When did she first start crying?
Mrs. Medina: Yesterday morning, right after I gave her the
bottle.
Nurse: Was she taking her bottle okay up to that time?
Mrs. Medina: I am not sure. I have been kind of tired since
the birth, and my mother has been feeding her most of
the time. My mother says that she does not eat as much
as she should. My mother never thinks babies eat enough.
Nurse: Can you help me examine her belly?
Mrs. Medina: Yes, but she cries every time I touch her belly. I
think she has empacho.
Nurse: I notice you have this cloth wrapped around her belly.
Can I take it off?
Mrs. Medina: Oh, of course.
Nurse: You have a coin over Juanita’s belly. What purpose
does it serve?
Mrs. Medina: To keep the bad spirits away and help the cord
heal.
Nurse: And the cloth holds the coin in place?
Mrs. Medina: The cloth keeps her belly button from sticking
out when she cries.
Nurse: Did you do this with your other children?
Mrs. Medina: Yes. Everyone in our family does this, and we all
have flat belly buttons.
Nurse: You know it really is not necessary to put the cloth
on her.
1. How is familism displayed in this scenario?
2. What is the culture-bound syndrome empacho? What is
the equivalent Western concept of empacho?
3. Should the nurse actively discourage Mrs. Medina from
placing the coin on the infant’s umbilicus? Why? Why not?
4. Should the nurse actively discourage Mrs. Medina from
using the abdominal cloth? Why? Why not?
2780_Ch23_407-425 16/07/12 12:09 PM Page 419

Some expect women to “get fat” and place little empha-
sis on weight control. Strenuous physical activity and
exercise are discouraged, and lifting heavy objects is
prohibited. Women are strongly discouraged from con-
suming aspirin, Alka-Seltzer, and malt beverages be-
cause these substances are believed to cause abortion.
Many women refrain from tener relaciones (sexual
intercourse) after the first trimester to avoid hurting
the fetus or causing preterm labor. Some men view
this time as an opportunity for extramarital sexual af-
fairs. Health-care providers should inquire in a non-
confrontational manner about this possibility and
educate men regarding the dangers of STIs and HIV.
Women prefer the bed position for labor, wish to
have their bodies covered, and prefer a limited number
of internal examinations. They welcome their hus-
bands, mothers, or sisters to assist during labor. Men
are expected to be supportive. During labor, women
may be loud and verbally expressive, a culturally ac-
cepted and an encouraged method for coping with
pain and discomfort. Pain medications are welcomed.
Health-care providers should respect these wishes and
explain the necessity of invasive interventions during
labor. Most women oppose having a cesarean section
because it indicates a “weak woman.” The health-care
provider should discuss the possibility of a cesarean
section early in the pregnancy.
Postpartum women receive care from their family
and friends. Their first postpartum meal should be
homemade chicken soup to provide energy and
strength. Women are encouraged to avoid exposure to
wind and cold temperatures, not to lift heavy objects,
and not to do housework for 40 days after delivery
(the cuarentena). Some traditional women do not
wash their hair during this time. Because the mother
is believed to be susceptible to emotional and physical
distress during the postpartum period, family mem-
bers try not to contribute to stress or to give bad news
to the new mother. Fathers may be reluctant to tell the
new mother about a problem with the newborn. How-
ever, most Puerto Rican women want to be told im-
mediately about any problems. This is a critical issue
during the postpartum period, especially with prema-
ture babies, given the belief that a healthy baby is a
“symbol of father’s virility and a time for the woman
to demonstrate her fertility, strength, and success dur-
ing and after birth” (Crouch-Ruiz, 1996).
Some mothers might ask to talk to the pediatrician,
rather than to a nurse, about infant problems. Because
of the value placed on family and children, women
who need to return to work early may experience great
distress when they do not follow some of these cul-
tural values or norms. Health-care providers should
assess for individual perceptions and dissatisfaction
with the working role and birth recuperation. Mothers
who breastfeed are encouraged to drink lots of fluids
such as milk and chicken soup, and if they are feeling
weak or tired, to drink ponches, beverages consisting
of milk or fresh juices mixed with a raw egg yolk and
sugar. Hot foods such as chocolate, beans, lentils, and
coffee are discouraged because they are believed to
cause stomach irritability and flatus for the mother
and colic for the infant.
Early studies on breastfeeding and Puerto Rican
women show that only 10 to 11 percent of Puerto
Rican women breastfeed (Stroup-Benham & Treviño,
1991). However, traditional Puerto Rican mothers
and those from rural areas may prefer to breastfeed
their babies for the first year. Mothers who work out-
side the home may select breastfeeding or formula or
both. However, with the introduction of formula
through U.S. food stamp programs, two generations
of Puerto Rican mothers have been inclined to relin-
quish breastfeeding and adopt formula as the primary
source of infant nutrition. Because some Puerto Rican
women believe that breastfeeding increases their weight,
disfigures the breast, and makes them less sexually at-
tractive, they undervalue the benefits of breastfeeding.
Health-care providers need to provide information
about these beliefs and educate women about breast-
feeding myths and misconceptions. Because maternal
grandmothers have a great influence on practices re-
lated to breastfeeding, they should be included along
with significant others in educational programs that
encourage this practice.
Death Rituals
Death Rituals and Expectations
Death is perceived as a time of crisis in Puerto Rican
families. The body is considered sacred and guarded
with great respect. Death rituals are shaped by reli-
gious beliefs and practices, and family members are
careful to complete the death rituals. News about the
deceased should be given first to the head of the fam-
ily, usually the oldest daughter or son. Because of cul-
tural, physical, and emotional responses to grief,
health-care providers should use a private room to
communicate such news and have a clergy or minister
present when the news is disclosed. Family privacy at
this time is highly valued.
Providers should allow time for family to view,
touch, and stay with the body before it is removed.
Traditionally, some Puerto Rican families keep the
body in their home before burial. Cultural traditions
and financial limitations influence this decision. Con-
sequently, some older adults may wish to follow these
death rituals. For some, funeral homes are viewed as
impersonal, financially unnecessary, and detrimental
to the mourning process because they detract from
family intimacy.
Although the family may prefer to have all death
rituals finished within a reasonable timeframe, it is im-
portant to extend burial rituals until all close family
420 Aggregate Data for Cultural-Specific Groups
2780_Ch23_407-425 16/07/12 12:09 PM Page 420

members can be present. The head of the family is ex-
pected to coordinate the arrival of family members,
which usually creates a delay in death rituals and bur-
ial time and an emotional burden and stress on family
members. Health-care providers should ensure that
members of the family are provided with support, re-
sources, and information regarding differences in U.S.
legal requirements. These requirements are often con-
fusing and are considered insensitive, particularly with
a stillbirth or when an autopsy is necessary. Authori-
zation from several family members might be essen-
tial. Because of the spiritual and religious importance
of burial traditions and rituals during these events,
cremation is rarely practiced among Puerto Ricans.
Among Catholics, the head of the family or other
close family member is expected to organize the reli-
gious ceremonies, such as the praying of the rosary,
the wake (velorio), and the novenas, the 9 days of
rosary following the death of the family member.
Family may meet at the deceased’s home for several
days, sometimes weeks, to support the family and talk
about the deceased. Food is served throughout the day
as a symbol of gratitude for those who come to pay
their respects.
Responses to Death and Grief
It is culturally acceptable for the family of the de-
ceased to freely express themselves through loud cry-
ing and verbal expressions of grief. Some may talk in
a thunderous way to God. Others may express their
grief through a sensitive but continuous crying or sob-
bing. Some believe that not expressing their feelings
could mean a lack of love and respect for the de-
ceased. Similar to the reaction to other crisis events,
some may develop psychosomatic symptoms, and oth-
ers may experience nausea, vomiting, or fainting spells
as a result of a nervousness attack—ataque de nervios.
Health-care providers should be nonjudgmental with
mourners’ psychosomatic or other expressions of
grief by providing a private environment and helping
to minimize interruptions during that period.
Spirituality
Dominant Religion and Use of Prayer
Religious beliefs among Puerto Ricans influence
their approach to health and illness. Most Puerto
Ricans are Catholic (85 percent), and the remainder
are Protestant Evangelical religious affiliations. A
few practice espiritismo, a blend of Native Indian,
African, and Catholic beliefs that deal with rituals
related to spiritual communications with spirits and
evil forces. Espiritistas, individuals capable of com-
municating with spirits, may be consulted to promote
spiritual wellness and treat mental illnesses.
Upon immigration, many Puerto Ricans may feel
out of place and need support resources. Many join
Evangelical churches because these offer a more
personal spiritual approach. These religious groups
provide social support and promote harmony and
spiritual–physical well-being. Health-care providers
should reinforce these spiritual practices, while incor-
porating prescribed medications, health activities, and
the prevention of risk behaviors. Espiritistas treat
patients with mental health conditions and are often
consulted to determine folk remedies compatible with
Western medical treatments. Health-care providers
should be aware that the elderly, those who have
limited access to health care, and those who are dis-
satisfied with or distrust the Western medical system
commonly use spiritual healers.
Among Catholics, candles, rosary beads, or a special
patron or figurine might accompany the patient to the
health-care facility and be used during prayer rituals.
To provide timely and appropriate interventions to
Catholic families, health-care providers should inquire
about the family’s wishes regarding the Sacrament of
the Sick. Special prayers and readings are believed to
be necessary at the moment of death, and families ex-
pect to be present to recite these prayers.
Meaning of Life and Individual Sources
of Strength
Puerto Ricans consider life sacred, something that in-
dividuals should preserve. Many see the quality of life
as a harmonious balance among the mind, the body,
and the spirit. Spirituality helps Puerto Ricans gain
strength to deal with illness, death, and grief and ulti-
mately promotes well-being. Most Puerto Ricans are
very religious, and when confronted with situations re-
lated to health, illness, work, death, or the prognosis
of a terminal illness, they maintain their trust in spir-
itual forces. Spiritual forces assist in controlling and
managing social and economic constraints. Their own
personal actions are perceived as inconsequential or
trivial without the trust and confidence in God’s will,
Si Dios quiere (if God wants). Rather than a fatalistic
approach to life during illness, death, or health pro-
motion, Puerto Ricans use coping mechanisms such
as religious practices that are instrumental in provid-
ing control in their lives. For example, the role of reli-
gion in the lives of Puerto Ricans with chronic
illnesses or with disabled children has been described
as a critical source of support and a mechanism that
allows for appropriate interpretation of health and ill-
ness (Skinner, Correa, Bailey, & Skinner, 2001). God,
who is their highest source of strength, guides life. For
some, scripture readings, praise, and prayer bring
inner spiritual power to the soul, el alma.
Spiritual Beliefs and Health-Care Practices
Spiritual practices influenced by religious groups have
a great impact on the health status of Puerto Ricans
because churches have had a great influence on the
People of Puerto Rican Heritage 421
2780_Ch23_407-425 16/07/12 12:09 PM Page 421

health of individuals by discouraging high-risk behav-
iors and promoting health. Through prayer, church
attendance, and worship, many Puerto Ricans dis-
cover spiritual courage and inner strength to avoid
high-risk behaviors such as smoking and substance
abuse. Clergy and ministers are a resource for spiritual
wisdom and help with a host of spiritual needs.
Although amulets have lost their popularity, some
Puerto Ricans still use them. An azabache (small black
fist) or a rabbit’s foot might be used for good luck, to
drive away bad spirits, and to protect a child’s health.
Rosary beads and patron saint figures may be placed at
the head or side of the bed or on the patient to protect
him or her from outside evil sources. Health-care
providers should ask permission before removing, clean-
ing, or moving these objects. A benediction may be re-
quested before removing amulets or religious objects,
giving the Sacrament of the Sick, or providing spiritual
support. These objects are often used as a means of
dealing with a crisis or as an expression of hope. The
health-care provider should assess individual and family
religious preferences and support spiritual resources
according to the patient’s or family’s request.
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Most Puerto Ricans have a curative view of health.
They tend to underuse health-promotion and preventive
services such as regular dental or physical examinations
and Pap smears (Marks, Garcia, & Solis, 1990). Many
use emergency health-care services rather than preven-
tive health-care services for acute problems. Accultura-
tion, age, access to health care, education, and income
influence health-seeking beliefs and behaviors. Health-
care providers must develop mechanisms to integrate in-
dividual, family, and community resources to encourage
a focus on health promotion and enhance early health
screening and disease prevention. In particular, a great
deal of attention must be provided to improve interper-
sonal processes of care among providers and Puerto
Rican patients. In a study with Puerto Rican women,
Davis and Flannery (2001) reported that women expe-
rienced negative interactions with providers who were
perceived as the “least helpful resource.” Health-care
providers that offer weekend, evening, and late-night
health-care services in community-based settings may
increase the use of preventive services.
Good hygiene is a basic concept for health promo-
tion among Puerto Ricans. Daily showers are essential
for good health and personal appearance. Exceptions
are made during illnesses such as colds, flu, or viral in-
fections. After surgery, some prefer to bathe using a
basin of water instead of taking a shower or tub bath.
Most prefer to shower and wash their hair daily; how-
ever, some women may avoid doing these activities
during menstruation. During hospitalization, some
refrain from having a bowel movement if they have to
use a bedside commode or bedpan. Nurses are in a
unique position to respectfully explore those beliefs
and practices and to provide a private, nonintrusive
environment for the patient.
Responsibility for Health Care
Most Puerto Ricans believe in family care rather than
self-care. Women are seen as the main caregivers and
promoters of family health and are the source of spir-
itual and physical strength. Health-care providers
should incorporate the participation of the family in
the care of the ill.
Natural herbs, teas, and over-the-counter medica-
tions are often used as initial interventions for symp-
toms of illness. Many consult family and friends
before consulting a health-care provider. Moreover,
pharmacists play a vital role in symptom manage-
ment. Although Puerto Rico is subject to U.S. Food
and Drug Administration regulations and practices,
many Puerto Ricans are able to obtain controlled pre-
scriptions from their local pharmacist in Puerto Rico.
When they are on the mainland, they try to obtain the
same kind of services from local pharmacists, creating
distress and frustration for both the patient and the
pharmacist.
Over-the-counter medications and folk remedies
are often used by Puerto Ricans to treat mental health
symptoms, acute illnesses, and chronic diseases.
Health-care providers should inquire about those
practices and encourage patients to bring their
medications to every visit. Engaging in a friendly con-
versation encourages patients to reveal their use of
folk treatments, over-the-counter medications, and
concurrent use of folk healers. Since the early 1980s,
Puerto Ricans have become accustomed to the use of
extended-care facilities and nursing homes. However,
they prefer to keep chronically or terminally ill family
members at home.
Folk and Traditional Practices
Espiritismo and Santería are magico-religious and
folk-healing practices used by some Puerto Ricans.
Espiritistas solve problems by communicating with
spirits. The Santería focuses on health promotion and
personal growth and development. Clients who use
these folk practices visit bótanicas (folk religious
stores) and use natural herbs, aromatic incenses, spe-
cial bathing herbs, prayer books, prayers, and figurines
for treating illness and promoting good health.
Providers must examine their own views about tradi-
tional practices and healers and refrain from making
prejudicial comments that may inhibit collaboration
with folk healers.
Puerto Ricans may use folk practices for shortness
of breath, nausea, and vomiting. Asphyxia or short-
ness of breath is believed to be caused by lack of air
422 Aggregate Data for Cultural-Specific Groups
2780_Ch23_407-425 16/07/12 12:09 PM Page 422

in the body. Fanning the face or blowing into the pa-
tient’s face is believed to provide oxygen and relieve
dyspnea. Some may use tea from an alligator’s tail,
snails, or savila (plant leaves) for illnesses such as
asthma and congestive heart failure.
Nausea and vomiting may be embarrassing and
cause alarm to many Puerto Rican patients. Many be-
lieve that smelling or rubbing isopropyl alcohol (alco-
lado) may help alleviate these symptoms. Some place
a damp cloth on the forehead to refresh the “hot” in-
side the body and relieve nausea. Some put the head
between the legs to stop vomiting. Mint, orange, or
lemon tree leaves are boiled and used as tea to relieve
nausea and vomiting. Rectal suppositories are be-
lieved to induce diarrhea. Health-care providers
should provide clear information about suppositories
and the etiologic cause of symptoms.
Barriers to Health Care
The medically indigent in Puerto Rico receive free
health-care services through the Department of Health.
On the mainland, accessing health-care services is a
complex issue for many Puerto Ricans. A recent analy-
sis of insurance coverage and use of health services
showed that 26 percent of Puerto Ricans are uninsured,
and those who are insured are likely to receive services
through public health insurance coverage (Puerto
Rican Health News, 2007). Lack of access to health
care limits the use of preventive health-care services
such as routine dental and physical examinations, pre-
natal care, postpartum care, and the prevention and
treatment of chronic illnesses such as hypertension, di-
abetes, and cancer. Additional barriers to using health-
care services include poor English-language skills, low
acculturation, poor socioeconomic status, and lack of
transportation and child care.
Cultural Responses to Health and Illness
When a family member is ill, other family members and
friends become a source of support and care. Puerto
Ricans may be loud and outspoken in expressing pain.
Health-care providers should not censure this expres-
sion of pain or judge it as an exaggeration. This expres-
sive behavior is a socially learned mechanism to cope
with pain. Ay! is a common verbal moaning expression
for pain (dolor). Because rural older individuals might
have difficulty interpreting and quantifying pain, the
use of numerical pain-identifying scales may be inap-
propriate. Most people prefer oral or intravenous med-
ications for pain relief rather than intramuscular
injections or rectal medications. In addition, herbal
teas, heat, and prayer are used to manage pain.
Because mental illness carries a stigma, obtaining
information or talking about mental illness with
Puerto Rican families may be difficult. Some might
not disclose the presence or history of mental illnesses,
even in a trusting environment. In addition, Puerto
Ricans may have a different cultural perception about
the etiology, meaning, and treatment of mental ill-
nesses. A mental illness may result from a terrible ex-
perience, a crisis, or the action of evil forces or spirits.
Some perceive that symptoms of mental illness result
from nervios (nerves), having done something wrong,
or breaking God’s commandments. When someone
is anxious or overcome with emotions or problems,
she or he is just nervioso. Similarly, someone who is
experiencing despair, anorexia, bulimia, melancholy,
anxiety, or lack of sleep may be nervioso(a), or suffer-
ing from ataque de nervios rather than being clinically
depressed, manic-depressive, or mentally ill. These
conditions may be used to camouflage mental illness.
Given the high incidence of depression (Munet-
Vilaro, Folkman, & Gregorich, 1999; Oquendo, Ellis,
Greenwald, Malone, Weissman, & Mann, 2001), this
is a critical mental health issue for Puerto Ricans.
Providers must acknowledge the confidentiality of in-
formation when obtaining a history. If trust is devel-
oped, health-care providers may get a more accurate
response to their questions.
Health-care providers must become familiar with
the vocabulary used to describe signs and symptoms
of mental illnesses among this group. Families must be
provided with clear and relevant information about the
diagnosis, treatment, and etiology of mental illnesses
to enhance adherence to treatment and follow-up care.
In addition, health-care providers should be aware of
traditional healing practices and be sensitive to mental
health services for Puerto Rican families. Community-
based settings such as churches, schools, and child care
centers are excellent environments for promoting phys-
ical and mental health among Puerto Ricans.
Genetic or physical defects among Puerto Ricans
may be seen as a result of heredity, suffering, or lack
of care during pregnancy. Less-educated individuals
may place guilt and blame on the mother or father.
Caregivers must provide information about the causes
of genetic defects and reduce stress and guilt for par-
ents. For decades, some Puerto Rican families cared
for impaired family members in a covert environment,
away from the eyes of the community. At present,
families are more open about these family members
and care for the physically and mentally challenged at
home, which is preferred over acute- or long-term-care
facilities. The role of familism is of particular impor-
tance for Puerto Ricans because they provide caregiv-
ing in an interdependent network of extended family
members who provide social support, solidarity, cariño,
and resources for the family. Sociocultural differences
exist in parental beliefs and attitudes when caring for
children with disabilities. Puerto Rican parents de-
velop a sense of interdependence and overprotection
that is expressed through extreme nurturing behaviors
and positive caring behaviors. As a result, conven-
tional test scores for family functioning may not be
People of Puerto Rican Heritage 423
2780_Ch23_407-425 16/07/12 12:09 PM Page 423

appropriate to interpret child development and family
adaptation. Health-care providers should be aware of
these differences and act with caution when interpret-
ing these results (Gannotti, Handwerker, Groce, &
Cruz, 2001). Caregivers’ stress should be a key com-
ponent of the health assessment of these families.
Health-care providers should supply information
about community resources, support groups, and cul-
turally appropriate mental health services.
Blood Transfusions and Organ Donation
For many Puerto Ricans, organ donation is seen as an
act of good will and a gift of life. However, autopsy
may be seen as a violation of the body. When discus-
sions regarding autopsies and organ donations are
necessary, the health-care provider must proceed with
patience and provide precise and simple information.
A clergy or minister may be helpful and may be ex-
pected to be present at the time of death. Although
no proscriptions exist against blood donation and
blood transfusion, many Puerto Ricans may be reluc-
tant to engage in these procedures for fear of contract-
ing HIV. Health-care providers need to carefully
explore these beliefs and dispel myths.
Health-Care Providers
Traditional Versus Biomedical Health-
Care Providers
Many Puerto Ricans use traditional and folk healers
such as espiritistas and Santeros along with Western
health-care providers. Some espiritismo practices are
used to deal with the power of good and evil spirits in
the physical and emotional development of the individ-
ual. Santeros, individuals prepared to practice santería,
are consulted in matters related to the belief of object
intrusion, diseases caused by evil spirits, the loss of the
soul, the insertion of a spirit, or the anger of God.
Modesty is a highly valued quality. An intimate and
unobtrusive environment is preferred for disclosing
health-related concerns. Individuals expect a respect-
ful environment; a soft tone of voice; and time to be
heard, explain concerns, and ask questions when dis-
cussing health matters. Rooms without doors are con-
sidered disrespectful and conspicuous, particularly if
the visit requires the removal of clothing. Some
Puerto Ricans may have a gender or age bias against
health-care providers. Men prefer male physicians for
care and may feel embarrassed and uncomfortable
with a female physician. A few individuals discount
the academic and intellectual competencies of female
physicians and may distrust their judgment and treat-
ment. Some Puerto Rican women feel uncomfortable
with a male physician, whereas a few prefer a male
424 Aggregate Data for Cultural-Specific Groups
R E F L E C T I V E E X E R C I S E 2 3 . 3
Mrs. Martínez, a 37-year-old beauty salon worker from Puerto
Rico, has been visiting her brother, who is a student at Central
University. The following is the conversation that she has with
a nurse at a clinic in her brother’s town:
Nurse: Good afternoon. Why have you come to the clinic?
Mrs. Martínez: Shouldn’t I be here?
Nurse: What is wrong with you that you came here?
Mrs. Martínez: I think that I am having a miscarriage.
Nurse: What is your name?
Mrs. Martínez: Lucero Martínez de Estrada y Rodríguez.
Nurse: That is a very long name.
Mrs. Martínez: Yes, I am from Puerto Rico, and we have
longer names than you do on the mainland.
Nurse: What makes you think you are having a miscarriage?
Mrs. Martínez: I am 3 months pregnant, and I started bleed-
ing this afternoon.
Nurse: How much bleeding are you having?
Mrs. Martínez: Oh, a lot.
Nurse: Well, do you have insurance?
Mrs. Martínez: Yes, I have insurance through my work.
Nurse: I do not know if we take insurance from Puerto Rico.
Mrs. Martínez: I can pay if I need to.
Nurse: Are you married?
Mrs. Martínez: Oh, yes, I am married.
Nurse: Where is your husband?
Mrs. Martínez: Back in Puerto Rico taking care of our daugh-
ter. I am here visiting my brother.
Nurse: Are you taking any medicine?
Mrs. Martínez: (Takes a bottle out of her purse.) Just these
that I got from the pharmacist.
Nurse: I do not recognize these pills. They are in Spanish. You
know you should not be taking any medicine unless it is
prescribed by a doctor.
Mrs. Martínez: He is a pharmacist. And he prescribed these
pills.
Nurse: Since this is not a big emergency, it might be a long
wait to see the doctor.
Mrs. Martínez: I’ll call my brother and tell him where I am.
1. Did the nurse approach Mrs. Martinez with simpatia?
2. In what ways did the nurse display respeto?
3. What evidence in this scenario can be construed as the
nurse not displaying respeto?
4. What might the nurse have done to determine the English
equivalent of the medicine prescribed by the pharmacist?
5. How common is it for pharmacists to prescribe medica-
tions in Puerto Rico?
6. How common is it for pharmacists to prescribe medica-
tions in the United States?
7. Does the mainland United States accept insurance from
Puerto Rico?
2780_Ch23_407-425 16/07/12 12:09 PM Page 424

doctor. Elderly Puerto Ricans may prefer older health-
care providers because they are seen as wise and ma-
ture in matters related to health, life experiences, and
the use of folk practices and remedies. To build the
patient’s confidence, younger and female health-care
providers must demonstrate an overall concern for the
patient and develop respect and understanding by
acknowledging and incorporating traditional healing
practices into treatment regimens.
Status of Health-Care Providers
Puerto Ricans hold health-care providers in high regard
because they are seen as wise authority figures. Distrust
may develop if the health-care provider lacks respect
for issues related to traditional health practices, ignores
personalism in the relationship, does not use advanced
technological assessment tools, and has a physical or
personal image that differs from the traditional “well-
groomed, white-attire” image. Overall, however, Puerto
Ricans are well-educated health consumers and expect
high-quality care blended with traditional practices and
reliable technological approaches.
R E F E R E N C E S
Caraballo, R.S., Yee, S.L., Gfroerer, J., & Mirza, S.A. (2008).
Adult tobacco use among racial and ethnic groups living in the
United States, 2002–2005. Preventing Chronic Disease 5(3). Re-
trieved from http://www.cdc.gov/pcd/issues/2008/jul/07_0116.htm
Centers for Disease Control and Prevention. (2006). HIV among His-
panics. Retrieved from http://www.cdc.gov/hiv/latinos/index.htm
Centers for Disease Control and Prevention. (2008). State-specific
alcohol consumption rates. Retrieved from http://www.cdc.gov/
ncbddd/fasd/monitor_table2008.html
CIA World Factbook. (2011). United States. Retrieved from
https://www.cia.gov/library/publications/the-world-factbook/
geos/rq.html
CIA World Factbook. (2011). Puerto Rico. Retrieved from
https://www.cia.gov/library/publications/the-world-factbook/
geos/rq.html
Crouch-Ruiz, E. (1996). The birth of a premature infant in a
Puerto Rican family. In S. Torres (Ed.), Hispanic voices:
Hispanic health educators speak out (pp. 26–28). New York,
NY: National League for Nursing.
Davis, R.E., & Flannery, D.D. (2001). Designing health informa-
tion delivery systems for Puerto Rican women. Health Educa-
tion and Behavior, 28(6), 680–695.
Epstein, J.A., Botvin, G.J., & Diaz, T. (1998). Ethnic and gender
differences in smoking prevalence among a longitudinal sample
of inner-city adolescents. Journal of Adolescent Health, 23,
160–166.
Gannotti, M.E., Handwerker, W.P., Groce, N.E., & Cruz, C.
(2001). Sociocultural influences on disability status in Puerto
Rican children. Physical Therapy, 81(9), 1512–1523.
Landale, N.S., & Oropesa, R.S. (2001). Migration, social support
and perinatal health: An origin-destination analysis of Puerto
Rican women. Journal of Health and Social Behaviors, 42(2),
166–183.
Marks, G., Garcia, M., & Solis, J. (1990). Health risk behaviors
of Hispanics in the United States: Results from the HHANES
1982–1984. American Journal of Public Health, 80(Suppl.),
20–26.
Massara, E.B. (1989). !Que gordita!: A study of overweight among
Puerto Rican women. New York: AMS Press.
Munet-Vilaro, F., Folkman, S., & Gregorich, S. (1999). Depressive
symptomatology in three Latino groups. Journal of Nursing Re-
search, 21(2), 209–224.
National Alliance for Hispanic Health. (2011). Retrieved from
http://www.hispanichealth.org/
National Center for Education Statistics. (2007). Elementary/
secondary education. Retrieved from http://nces.ed.gov/fastfacts/
National Center for Health Statistics. (2011). Puerto Rico facts.
Retrieved from http://www.cdc.gov/nchs/fastats/popup_pr.htm
National Coalition of Hispanic Health and Human Services Or-
ganizations (COSSMHO). (1999). The state of Hispanic girls.
Washington, DC: COSSMHO Press.
Oquendo, M.A., Ellis, S., Greenwald, S. Malone, K., Weissman,
M.M., & Mann, J. (2001). Ethnic and sex differences in suicide
rates relative to major depression in the United States. American
Journal of Psychiatry, 158(10), 1652–1658.
Orshan, S.A. (1996). Acculturation, perceived social support, and
self-esteem in primigravida Puerto Rican teenagers. Western
Journal of Nursing Research, 18, 460–473.
Puerto Rico Department of Health. (2009). Retrieved from
http://minorityhealth.hhs.gov/templates/content.aspx?ID=8064
&lvl=2&lvlID=6
Puerto Rican Health News. (2007). Health insurance coverage. Re-
trieved from http://health.einnews.com/puertorico/
Skinner, D.G., Correa, V., Bailey, D., & Skinner, M. (2001). Role
of religion in the lives of Latino families with young children
with developmental delays. American Journal of Mental Retar-
dation, 106(4), 297–213.
Stroup-Benham, C.A., & Treviño, F.M. (1991). Reproductive
characteristics of Mexican-American, Puerto Rican and
Cuban-American women. Journal of the American Medical
Association, 265, 222–226.
Taylor, M. (1999). Alternatives to conventional hormonal replace-
ment therapy. Contemporary OB/GYN, 12(3), 23–54.
Torres, S., & Villaruel, A. (1996). Health risk behaviors for His-
panic women. Annual Review of Nursing Research, 5, 293–319.
U.S. Census Bureau. (2009). Educational attainment by race and
Hispanic origin. Retrieved from http://www.census.gov/
compendia/statab/2011/tables/11s0225
For reflective exercises, review questions, and additional
information, go to
http://davisplus.fadavis.com
People of Puerto Rican Heritage 425
2780_Ch23_407-425 16/07/12 12:09 PM Page 425

426
Chapter 24
People of Russian Heritage
Karen J. Aroian, Galina Khatutsky, and Alexandra Dashevskaya
Overview, Inhabited Localities,
and Topography
Overview
Russia, also known as the Russian Federation, was the
largest part of the former Soviet Union before the
Soviet Union collapsed in 1991. Presently, Russia is
the largest country in the world, nearly twice the size of
the United States. It covers 11 time zones. The climate
ranges from temperate and humid to arctic. Ethnically,
80 percent of those living in Russia are Russian, 3.8 per-
cent are Tartars, 2 percent are Ukrainian, and 14.4 per-
cent are other smaller groups. Between 15 and 20 percent
of Russians are Russian Orthodox, 10 to 15 percent
are Muslim, and 2 percent belong to other Christian
groups. Only about 500,000 Russians are Jews. In 2005,
Russian Orthodoxy became the official religion and en-
joys a privileged position with the current government
(Library of Congress, 2010). However, a large number
of Russians are either nonreligious or nonpracticing,
which is the result of over 7 decades of religious
suppression under communist rule. The population of
Russia is about 139 million and is declining, with
1.6 deaths for each birth (CIA World Factbook, 2010).
This high death rate is related to high-risk behaviors such
as smoking, alcoholism, heart disease, traffic accidents,
and low education about sexually transmitted infections.
The average life expectancy is 59 and 73 years for Russian
men and women, respectively. A low fertility rate (1.4 per
women of reproductive age) adds to this population de-
cline (CIA World Factbook, 2010; Library of Congress,
2010; Marquez, 2005). The two largest cities—Moscow,
which is Russia’s capital, and St. Petersburg—have 10 mil-
lion and 4.5 million people, respectively. Although major
cities are heavily populated, 27 percent of Russians live
in very rural areas (CIA World Factbook, 2010; Library
of Congress, 2010).
In 1917, the imperial Czar was overthrown and
Vladimir Lenin took power, replacing imperial rule
with communism. The overthrow, referred to as the
Bolshevik revolution, was due to the discontent that
ensued after the horrific defeat of the Russian armies
during World War I. Josef Stalin took power after
Lenin, further strengthening and unifying communist
rule and infusing it with brutality. During this time,
the Soviet Union was comprised of 15 ethnically and
culturally diverse republics, the largest of which was
the Republic of Russia.
On August 24, 1991, the Soviet Union collapsed and
Russia became an independent country. Each of the
other republics of the former Soviet Union also devel-
oped into independent nations. This collapse led to
Russia adopting a new constitution in 1993 and three
branches of government: the executive, the legislative,
and the judiciary. The 1990s were a period of intense
democratic reform and the development of a market
economy. However, many important democratic re-
forms made in the 1990s have been overturned. Political
bribery and corruption are rampant today.
Russia’s poverty rate is 13.1 percent, with a 6.7 per-
cent inflation rate (CIA World Factbook, 2010). The
number of adults who are unemployed (7.6 percent)
or underemployed is high (CIA World Factbook,
2010). Crime rates are also high. Police have low pay,
low status, and are highly corrupt.
Economically, Russia has some of the most abundant
natural resources, including rich deposits of oil, natural
gas, coal, timber, and minerals such as diamonds, nickel,
aluminum, and platinum. Over 20 percent of the world’s
forests are in Russia (Library of Congress, 2010). How-
ever, water, land, and air pollution is high (Energy
Information Administration [EIA], 2010; Library of
Congress, 2010).
Heritage and Residence
According to the Russian 2002 census, the largest
ethnic group was Russian, accounting for 80 percent
of the total population. Ethnic minority groups
with significant numbers (about 1 million in each
group) include Tartar, Ukrainian, Bashkir, Chuvash,
Chechen, and Armenian. These minority groups are
the result of their homelands being former republics
2780_Ch24_426-440 16/07/12 12:10 PM Page 426

People of Russian Heritage 427
of the Soviet Union. During the period of Soviet
rule (1917 to 1991), Soviet citizens moved, leaving
their own culture and birthplace to work and live in
another republic. Since the fall of the Soviet empire,
non-Russians in Russia have been migrating back
to their homelands, in part because of growing
intolerance in Russia against its ethnic minorities
(Library of Congress, 2010).
International migration includes the United States,
Israel, Canada, and Australia as major destinations
(Vishnevsky & Zayonchkovskaya, 1994). In fact, in
the 1990s, immigrants from the former Soviet Union
were one of the fastest-growing ethnic groups in
the United States, with a 254 percent increase in the
Russian-speaking population (U.S. Department of
Homeland Security, 2005a). Another source of pop-
ulation growth came from adopting Russian children
(U.S. Department of Homeland Security, 2005b).
According to the U.S. Census Bureau, (2000), over
2.6 million Russians live in the United States. However,
in the last decade, the immigration from Russia to the
United States is slowing. From 2001 to 2009, about
14,277 Russian immigrants came to the United States
(U.S. Department of Homeland Security, 2010).
Almost 90 percent of Russian immigrants in
the United States live in urban areas such as
New York City and the Tri-State area (24 percent),
Boston, Philadelphia, Baltimore, Miami, Atlanta,
Cleveland, Chicago, Detroit, Denver, Houston,
Los Angeles, San Diego, San Francisco, Seattle, and
Portland, Oregon (Allied Media Corp., n.d.). Florida
has also become an increasingly popular destination
for Russian immigrants who are close to retirement age
(U.S. Department of Homeland Security, 2005c). In
Canada, Russian-speaking immigrants primarily live in
Toronto, Vancouver, and Montreal (Aroian, 2003).
Classifying Russian immigration is complicated by
several facts. First, until the Soviet Union collapsed,
people from Russia and other former republics of the
Soviet Union were often referred to and classified as
one group regardless of where they were from. Sec-
ond, the definitions vary widely; some are based on
the country of origin, some on primary language,
and some on the ethnic or religious affiliation. Third,
the immigrants from the former Soviet Union are
presently classified as from independent republics,
such as Armenia, Russia, and Azerbaijan. Thus,
when the term Russian immigrant is used in the liter-
ature, it may refer broadly to Russian-speaking im-
migrants of multiple nationalities from the former
Soviet Union (one group under Soviet rule with
Russian as the official language uniting them) or to
people specifically from Russia.
Given the complicated history of Russian immigra-
tion to the United States, this chapter should be read
with an important qualifier in mind. Most of what is
written pertains to immigrants who emigrated in the
latter part of the 20th century. These immigrants were
reared under communism. Later arrivals, those who
came after the Soviet Union collapsed, left a very dif-
ferent homeland. These immigrants were more apt to
be familiar with the English language and a market
economy. In addition, as is the case for most immi-
grant groups, immigrants become more acculturated
over time. This is particularly true for immigrants who
are younger and go to school and/or work in the new
country. Although most of this chapter pertains to a
given wave of migration, generational and cohort dif-
ferences as well as acculturation trends will be noted
when applicable.
Reasons for Migration and Associated
Economic Factors
Migration to the United States from Russia or the
former Soviet Union occurred in four waves (Hobbs,
2002). The first wave of Christian Orthodox Russians
fleeing religious and political persecution was between
1900 and 1914 (Hobbs, 2002). The second wave began
in 1914 and primarily included middle- or upper-class
Russians fleeing the Bolshevik revolution and the
onset of communism. After the Bolshevik revolution
of 1917, thousands of expropriated wealthy Russians
and middle-class professionals and army officers fled
their homeland. About 20,000 Russian refugees, en-
slaved workers, or war prisoners from Germany en-
tered the United States from 1947 to 1952 (Hobbs,
2002). As the first and second waves of Russian im-
migration to the United States, Jews from Ukraine
and other bordering countries were also migrating to
escape the pogroms (Abramson, 1991). The third
wave began in the 1970s, when the United States
granted refugee status to religious and ethnic minori-
ties because of their persecution by the Soviet gov-
ernment (Aroian, 2003). This wave was comprised
primarily of Soviet Jews, but it also included Soviet
Armenians, Pentecostals, and Evangelicals (Aroian,
2003). The fourth wave of immigration started in
1991 with the dissolution of the Soviet Union, which
resulted in much more freedom to immigrate. One
motivation for this fourth wave of immigration in-
cluded harsh economic conditions. When commu-
nism transitioned to a free-market system, economic
conditions were particularly difficult for researchers,
scientists, and physicians. Salaries were fixed and
well below poverty levels, causing a desperate migra-
tion in hopes of improved quality of life. Motivation
for the fourth wave also included family reunifica-
tion, political turmoil, and greater overtly expressed
Russian nationalism and anti-Semitism (Bistrevsky,
2005). Presently, emigration from Russia has slowed
considerably. Only about 3 percent of the Russian pop-
ulation emigrated in 2010 (CIA World Factbook, 2010).
2780_Ch24_426-440 16/07/12 12:10 PM Page 427

Educational Status and Occupations
The average age for U.S. Russian immigrants is 42 years,
and nearly one-fourth of the total U.S. Russian immi-
grant population is 65 years of age or older. Almost
two-thirds (64 percent) of these immigrants are married,
with 1.6 children per couple. Of adults over age 25,
1 million have at least a bachelor’s degree, and over
18 percent have graduate degrees. The average adult
Russian in the United States works in a professional
area, is well educated, and has a better-than-average in-
come (Media Corp, n.d.). However, it is important to
note that more recently arrived Russian-speaking immi-
grants tend to be less well educated and more likely to
pursue technical and service occupations (Minnesota
Department of Employment and Economic Develop-
ment [MDEED], 2006).
Of note is that Russia has a 99.4 percent literacy
rate, which is one of the highest literacy rates in the
world. Men and women are equally literate. Russian-
speaking immigrants highly value education. In the
former Soviet system, education was strongly pro-
moted for both genders, and prestige was tied to
occupational status, which in turn was determined by
education (Aroian, 2003). Given these values, it is not
uncommon in the United States for extended Russian
immigrant families to work additional hours and pool
their financial resources to provide a good education
for their children.
However, the value on education is in transition. By
the mid-1990s, making money by being an entrepreneur
became another venue for self-respect and prestige in
Russia (Library of Congress, 2010). The current focus
on commercialization will likely influence the cultural
values of immigrants from future waves of immigration.
Teaching/learning systems in Russia are rigid com-
pared with U.S. standards. Until recently, learning
English was not a priority. As a result, Russian immi-
grants, especially older people and those who came to
the United States before English became part of the
standard curriculum, are likely to have difficulty with
the English language. Recently, English has grown
more popular in Russia owing to the Internet and
other forms of media, including Western films, music,
and advertising. Thus, younger, more recent immi-
grants are likely to have some English ability.
Some Russian immigrants in the United States re-
ceive public assistance such as Medicaid, Supplemental
Security Income, subsidized housing, or food stamps.
This assistance offsets low income because of disability,
age, and inability to find work commensurate with pre-
migration work experience. Most Russians immigrants
receiving public assistance, including older immigrants,
have a college education (Hobbs, 2002).
Many Russian immigrants, particularly those who
came in the latter third of the 20th century, were
highly trained professionals, employed in fields such
as engineering, math, medicine, biotechnology, com-
puter science, and education. Unfortunately, full-
time and well-paying positions in these fields were
unavailable to many of these professionals due to
language, licensing, and credentialing barriers in the
United States. Language barriers and unfamiliar legal
regulations were also salient for Russian-speaking
immigrants who attempted to start their own small
businesses (Hobbs, 2002). Thus, occupational status
demotion was a common component of the initial im-
migrant experience for Russian immigrants (Aroian &
Norris, 2003). Most Russian immigrants were able to
overcome this initial occupational status demotion,
but this was not the case for Russians who emigrated
at an older age.
Communication
Dominant Language and Dialects
Russian is a living language that is rich and expres-
sive. It is one of the world’s major languages, the most
pervasive of all Slavic languages, and the primary lan-
guage for over 150 million people. It is also one of the
six official languages of the United Nations. As the
official language of the former Soviet Union, it uni-
fied the 15 Soviet republics and Soviet-controlled
satellite nations. Although each republic and Soviet-
controlled satellite nation had its own language
and culture, schoolchildren under Soviet rule were
required to take many years of Russian-language
courses.
According to the U.S. Census Bureau (2007),
850,000 persons over age 5 spoke Russian at home. Of
these, only 43 percent could speak English very well,
29 percent could speak English well, 21 percent could
not speak English well, and 6 percent could not speak
English at all. Even with limited English proficiency,
many Russian-speaking immigrants can read and
write English better than speak it.
Most Russian immigrants, with the exception of
older ones, eventually become proficient in English.
However, large urban centers with a concentrated
number of Russian speakers have their own newspa-
pers and television and radio programming. These are
self-maintained communities with numerous Russian-
language services, including health care. Immigrants in
these communities usually get by despite having very
limited English proficiency, speaking both Russian
and their own native languages (e.g., Ukrainian,
Georgian). This is especially true for older Russians
immigrants who intentionally live in Russian-language
communities even when their adult children move to
outlying areas. Living in a Russian-speaking enclave
allows older Russian immigrants to purchase food and
supplies from Russian retailers and socialize with their
Russian-speaking peers. Such communities provide
little incentive to learn English.
428 Aggregate Data for Cultural-Specific Groups
2780_Ch24_426-440 16/07/12 12:10 PM Page 428

People of Russian Heritage 429
Written Russian uses the Cyrillic alphabet, which is
derived from but not the same as the Greek alphabet.
Russian is considered phonetic and includes five
vowels and numerous consonants that are considered
hard or soft. Interestingly, Russian does not include
articles (e.g., “the”) and is often called a house green
language (“the” and “is” are omitted).
Cultural Communication Patterns
Russians enjoy intellectual conversations that focus on
political, economic, cultural, and social issues. Word of
mouth and advice among Russian speakers are strong
influencing factors for making decisions regarding
health care and major purchases (Aroian, Khatutsky,
Tran, & Balsam, 2001). Russians seek emotional sup-
port from spouses, relatives, and friends, and report not
trusting religious advisors, teachers, social service work-
ers, or community leaders. However, they report a will-
ingness to talk with physicians and other health-care
providers, especially when these workers are able to
speak Russian (Hobbs, 2002).
Russians tend to speak loudly (MDEED, 2006).
They have great insight into their own and others’ feel-
ings and often communicate on an emotional level.
Russians make eye contact, nod their head in a gesture
of affirmation or approval, and are respectful in their
verbal and nonverbal behaviors toward older people
and persons of perceived rank or authority (“Culture
Tips,” 2000; MDEED, 2006).
Russian men shake hands firmly, and this symbol of
agreement is considered more binding than paper doc-
uments. The doorway of a Russian home is considered
the spirit center of the house, and it is a bad omen
to shake hands over the threshold. Shoes are often
removed prior to entering the home (MDEED, 2006).
Behavior in public is formal and respectful. Russians
do not appreciate casual gestures such as standing with
hands inserted into pockets, arms crossed over the
chest or behind the head, slouching posture, and put-
ting feet up on a desk. These behaviors are particularly
insulting if they occur when they are being interviewed
for a job. Shaking a fist shows anger or disagreement,
and pointing with the index finger is considered rude
(Hobbs, 2002; MDEED, 2006).
Russians often require less personal space than Eu-
ropean Americans. Russians freely touch friends and
family members. Greeting close friends by kissing each
cheek is common. Russians are social diplomats and
will “bend” the truth for the sake of politeness or to
soften bad news (Birch, 2006).
Russians have a sense of duty, self-sacrifice, and
genuine caring toward others (“Culture Tips,” 2000).
They perceive themselves as spontaneous and emo-
tional, able to be extremely empathetic toward the suf-
fering of others. They are emotionally strong and have
a long and distinguished history of enduring great
hardship and adversity. Thus, Russians may present a
pervasive attitude of endurance with comments such
as “We have overcome many troubles and we can over-
come these troubles because we are strong; we are
Russians.” They look to others for the same level of
respect and recognition of social order as they give.
Temporal Relationships
Russians who have immigrated to the United States
tend to be both present and future oriented. This is
not the case, however, among nonimmigrants. Russians
living in Russia live in the present, as demonstrated by
a comment the chapter authors and book editor heard
frequently: “Because we have no future.” Russian
immigrants are punctual and value this attribute. For
appointments, Russians will arrive either early or right
on time. However, being punctual is less important for
social occasions. Social occasions typically last late
into the night, so late arrivals are not disruptive.
Format for Names
Russians use titles such as Mr., Mrs., Dr., professor,
aunt, and grandfather to show the appropriate respect
(“Culture Tips,” 2000; Hobbs, 2002). Even when
friendships are established, they often ask to be ad-
dressed by their first name plus their patronymic. The
patronymic is the first name of their father with either
a feminine or a masculine ending, depending on the
person’s gender. An example of a preferred name for-
mat might be Oleg Vasilievich (Oleg, son of Vasily).
Family Roles and Organization
Head of Household and Gender Roles
In Russia, younger adults and youth depend on
the wisdom of their parents and grandparents when-
ever important decisions need to be made. In the
United States, these roles are often reversed because of
an English-language barrier whereby older Russian-
speaking immigrants often have to depend on their
children and grandchildren to guide decision making
(Aroian, Khatutsky, & Dashevskaya, 2006). Role re-
versal may be particularly difficult for older Russians
if they are not living in the United States by choice.
Unlike many other immigrant groups, Russian im-
migrants arrived in the United States in multigenera-
tional family units. This emigration pattern occurred,
in part, because the Soviet regime did not allow families
to emigrate unless they took older family members with
them (Aroian et al., 2006).
Although women are an important part of the
workforce in Russia, the roles of mother and home-
maker are also valued. Russian women pursue educa-
tion and careers, but they often juggle multiple roles,
fulfilling cultural expectations for home and child-care
responsibilities (Aroian, 2003; Aroian, Norris, &
Chiang, 2003; Remennick, 1999).
2780_Ch24_426-440 16/07/12 12:10 PM Page 429

It is important to note that Russians will be reluc-
tant to sign consent forms and other documents with-
out first consulting their family members (Keefe,
2006). Family members will often attend health-care
appointments in order to provide cognitive as well as
affective support (Aroian, 2003).
Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Russian children are taught to obey their parents and
older people, as well as to achieve high grades in school
and complete a university education. Children are ex-
pected to care for family members who are ill and in
need of care (“Culture Tips,” 2000). Older people are
expected to raise their grandchildren, especially if both
parents are employed.
Sexual topics such as contraception and sex educa-
tion are not considered appropriate topics for public
discussion. Sexual activity outside of marriage is not
sanctioned even though the age of sexual consent in
Russia is 16. If teen girls get pregnant, abortion is the
primary intervention (Aroian, 2003). Older Russian
immigrants tend to be more modest, disliking public
displays of affection (Aroian, 2003).
Family Goals and Priorities
Collectivism has been part of Russian society for cen-
turies. Russians view family, group, and communal
needs as more important than individual needs. Ex-
tended family and friends are highly important. Rela-
tionships are very close. Russians depend on and trust
family, neighbors, friends, and colleagues. Love and
support from family and friends are expected and forth-
coming during crises. Spouses consult each other (“Cul-
ture Tips,” 2000). Russians contrast their personal
relationships with Americans’ tendency to reserve close,
intimate ties for immediate family members and are
struck by Americans’ individualism and independence.
Russian young people are expected to do household
chores. Household chores are gender-specific, with
girls doing tasks such as cooking and cleaning and
boys doing more physical labor. Grocery shopping
is an exception; it is a task for both boys and girls.
Although education and a good job are considered
important for Russian women, finding a good hus-
band is even more important. Being an “old maid” is
socially frowned upon (Aroian, 2003).
Domestic violence is a rising concern in Russia.
Because of long-standing distrust of authority figures,
Russian immigrants may not report domestic violence.
Russian women will only rarely admit to and report
being raped. This cultural tendency may also be
operative after immigration. Domestic violence is
often tied to alcohol abuse.
Alternative Lifestyles
Divorce rates in Russia are high, and small families
are typical because of economic hardships. Russian
immigrants also have high divorce rates, perhaps
because of the stress of immigration. For example,
Russian immigrant women grow more independent as
they acculturate, and differential rates of accultura-
tion can cause family problems (Aroian, Spitzer, &
Bell, 1996). On the other hand, Russian women may
wait to reach their new country before ending an
unhappy marriage.
Religion seldom plays a role in the lives of most
Russian immigrants, most likely because of the antire-
ligion dogma of communism. (Exceptions include
Russian Pentecostals and other religious fundamen-
talist groups in Russia.) Therefore, divorce does not
negatively affect social status. Divorced men in Russia
are rarely awarded child custody, and although they
pay child support, they do not often remain active in
their children’s lives (Aroian, 2003). This tendency
may also be noted with Russian immigrants.
Russian women with fertility problems are not con-
sidered desirable spouses (Aroian, 2003). Although
Russian women are expected to marry by age 25 and
have children, they are also expected to continue to
pursue education and career paths. This is possible be-
cause grandmothers become primary caregivers for
young children. Men are seldom expected to fulfill
child-care responsibilities.
The Russian penal code was revised in 1997, and ho-
mosexuality is no longer a crime. In July 1997, the first
gay and lesbian pride festival occurred in Moscow.
Even so, alternative lifestyle choices are still stigmatized
by a large part of the population. Overtly expressed
antigay graffiti is still commonly seen in Russia (“News
About Gay Russia,” n.d.). Given the lack of acceptance
about same-sex relationships, gay and lesbian Russians
in the United States are likely to remain closeted, even
with health-care providers, unless significant trust is de-
veloped. Similarly, same-sex behavior is not typically
disclosed to family members or friends.
Workforce Issues
Culture in the Workplace
When communicating in the workplace, Russians
embrace the value of positive social communication.
Politeness is a key component of positive social com-
munication, as well as saying nice things to connote
acceptance, offer support and empathy, and just to
avoid negative discourse. When negotiating compro-
mise in the workplace, Russians invest time and effort
to provide information that supports their decisions
and requests. Russians expect to be specifically asked
for this kind of information (Bergelson, 2003). This
communication style is in contrast with the more di-
rect communication Russians employ with friends.
Direct communication with friends is considered to
be a sign of sincerity.
Russian-speaking health professionals in the
United States serve a large group of older Russian
430 Aggregate Data for Cultural-Specific Groups
2780_Ch24_426-440 16/07/12 12:10 PM Page 430

immigrants who do not speak English or do not
speak it well. If the health-care professionals were
trained in the former Soviet Union, they are used to
an authoritarian work environment. The training for
nurses in the former Soviet Union has been likened
to that of American licensed practical nurses (LPNs)
(Alaniz, 2001). These nurses are not used to critical
thinking and are used to hierarchical relationships
with physicians, which conflicts with expectations in
the United States for nurses to be part of a health-
care team (Alaniz, 2001). A positive characteristic of
health professionals trained in the former Soviet
Union is that they reflect the Russian emphasis on
holism and holistic health care.
Issues Related to Autonomy
In the United States, nurses and physicians work as a
team. Yet each member maintains independence. In
Russia, the physician makes the decisions and does the
problem solving. Thus, the nursing profession gets
limited status and respect from Russians (Alaniz,
2001). One Russian immigrant explained, “What do
we expect from a nurse? We don’t expect anything; we
only expect something from a doctor. A nurse is just
someone who obeys” (Smith, 1996). Russian immi-
grants in other professions may also be used to hier-
archical work relationships based on authority.
Biocultural Ecology
Skin Color and Other Biological Variations
Ethnic Russians are Caucasian. Stature and skin color
for ethnic Russians are similar to other North Amer-
ican groups, with the exception of high rates of obe-
sity among Russians and Russian immigrants.
Diseases and Health Conditions
Common health disorders seen in Russian immigrants
include hypertension, coronary disease, gastrointestinal
disorders, and diabetes. Common disabilities include
the results of diabetes (e.g., sensory impairment) and
other chronic health disorders, such as hypertension,
psychosocial disorders, arthritis, lung disease, and can-
cer (Keefe, 2006; MDEED, 2006; Shpilko, 2006). There
is also some evidence of a higher than average rate of
colorectal polyps (Vadlamani et al., 2001).
A number of studies suggest that health status is
poorer among Russian immigrants than it is for other
immigrant and nonimmigrant groups. For example,
Russian Jews who immigrated to Israel between 1989
and 1992 reported an average of 3.5 chronic
diseases—a much higher rate than that reported
among immigrants from other countries (Rennert,
Luz, Tamir, & Peterburg, 2002). These findings are
similar to findings from a comparative study of low-
income Russian immigrant and nonimmigrant older
persons in the United States (Aroian & Vander Wal,
2007). In this study, Russian immigrants had more
health problems than their nonimmigrant counter-
parts even though the nonimmigrant group was sig-
nificantly older than the Russian immigrant group.
Older Russian immigrants are also prone to de-
pression, particularly when they live alone and do
not speak English well (Aroian et al., 2001; Shpilko,
2006; Tran, Khatutsky, Aroian, Balsam, & Conway,
2000). In Russia, older people often live with their
adult children and have family responsibilities, such
as caring for grandchildren. In the United States, be-
cause of language barriers, older people are more apt
to live in elder housing with other Russian-speaking
older immigrants rather than with their children and
grandchildren.
Other groups of Russian immigrants at risk for psy-
chological distress include those with less education and
greater immigration demands, such as difficulty with
English (Aroian, Norris, Patsdaughter, & Tran, 1998;
Miller & Chandler, 2002; Miller, Sorokin, Wang,
Feetham, Choi, & Wilbur 2006). Russian immigrants
who feel alienated in the United States or do not possess
resilient personalities also experience more psychologi-
cal distress (Miller et al., 2006). In a longitudinal study
of depression trajectories over time, Russian immigrants
who remained depressed past the initial resettlement pe-
riod were less likely to have family in the area or to have
the highest immigration demands at both time points
(Aroian & Norris, 2003).
There is also some indication that Russian immi-
grant children are at risk. Goodman, Slobodskaya, and
Knyazev (2005) found that emotional and behavioral
disorders were nearly 70 percent higher in Russian im-
migrant children compared to other children in Great
Britain. The most predictive factors in this study were
the child’s school performance, the mother’s mental
health, having a close relative with alcohol addiction,
and witnessing domestic violence.
A number of anecdotal reports and empirical stud-
ies suggest that Russians somaticize psychological
disorders (Belozersky, 1990; Brod & Heurtin Roberts,
1992; Levav, Kohn, Flaherty, Lerner, & Aisenberg,
1990). For example, Russians may present with vague
complaints of skeletal or gastrointestinal problems
when they are suffering from depression. This ten-
dency to somaticize has been attributed to the stigma
of mental illness in Russia, Soviet ideology that recast
psychiatric disorders as neurological, and prior psy-
chiatric abuses by the Soviet regime. However, it is im-
portant to note that Aroian and Norris (1999) found
that somatization was more common among Russian
immigrants who were not highly educated and those
who were older.
Variations in Drug Metabolism
According to Gaikovitch (2003), who investigated
variability in genetic polymorphism and drug metab-
olism, the allele distribution of important metaboliz-
ing enzymes in Russians is not significantly different
People of Russian Heritage 431
2780_Ch24_426-440 16/07/12 12:10 PM Page 431

from that of other Caucasians. In other words, there
are no genetic differences to suggest that medications
are rendered more water-soluble and more readily ex-
creted in urine in Russians. Thus, drug side effects
and efficacy in Russians are likely similar to other
European populations.
The metabolism of alcohol may be the exception.
According to Gabriel (2005), Russians may have
inherited a genetic characteristic from Mongolian
invaders that prevents processing ethanol derived
from fruit or potatoes. Gabriel believes that this
genetic trait makes Russians more susceptible to
alcoholism, especially when the alcoholic beverage
is cognac or vodka.
High-Risk Behaviors
Nutritional issues are a major contributing factor to-
ward the number of chronic diseases experienced by
Russians. According to some studies, over half of
Russian adults have high blood cholesterol, obesity,
or hypertension (Marquez, 2005; Mehler, Scott, Pines,
Gifford, Bigerstaff, & Hiatt; 2001). Nearly half of the
sample in one study (Mehler et al., 2001) had two or
more cardiovascular risk factors. All of these chronic
illnesses are related to Russians’ nutritional habits,
specifically high-salt, carbohydrate, and fat intake
(Keefe, 2006).
Hard liquor, mostly vodka and cognac, are served
routinely at family gatherings and celebrations, and
heavy alcohol consumption is a part of daily life in
Russia. Russian statisticians estimate that over 30 per-
cent of deaths in Russia are directly related to alcohol
(Nemtsov, 2005; Nicholson, Bobak, Murphy, Rose, &
Marmot, 2005). Russian authorities appear indifferent
to these statistics, as they have no official plan to ad-
dress the problem of alcoholism.
Alcoholism is far less prevalent among Russian re-
ligious groups and women (Aroian, 2003). This fact
most likely accounts for lower rates of alcoholism
among Russian immigrants relative to the population
in Russia. A disproportionate number of those who
emigrated from Russia are Jews or Christian funda-
mentalists, and these groups are known to have lower
rates of alcoholism.
Smoking is prevalent in Russia. Russia is one of the
few countries that currently do little or nothing to curb
tobacco use. Nearly 63 percent of Russian men and
15 percent of Russian women smoke, and this number
increases by about 2 percent per year. Although 60 per-
cent of current smokers want to quit, no state-supported
programs exist to help them do so (Parfitt, 2006). This
may explain, in part, why the male life expectancy in
Russia is just above 59.8 years (CIA World Factbook,
2011). Like alcoholism, smoking is less prevalent in
Russia’s ethnic minorities. Russian immigrants, who are
comprised of a disproportionate number of Russian
ethnic minorities, do not demonstrate the same level of
smoking behaviors as their native-born counterparts.
However, more recent Russian immigrants are likely to
engage in these behaviors at higher rates than earlier
Russian immigrants because current migration from
Russia includes fewer ethnic and religious minorities
(Hasin et al., 2002).
Based on high rates of injection drug use in Russia,
there is some evidence that Russian immigrants are at
risk. A preliminary study conducted in New York City
on this topic found that Russian immigrants have
unique drug abuse patterns and behaviors, including
rapid transition to injection drug use (Isralowitz,
Straussner, & Rosenblum, 2006). This study also found
that Russian immigrants are suspicious of traditional
drug treatment approaches.
Russians are reluctant to immunize, and this re-
luctance may also be considered a high-risk behavior.
In Russia, immunizations are available but are of
poor quality. Reports of hepatitis- and HIV-positive–
contaminated immunization needles have created
fear and distrust. Thus, Russian immigrant parents
may not immunize their children unless they receive
sufficient assurances that immunizations are safe.
Another high-risk behavior is the medication be-
havior of many Russian immigrants. These behaviors
include sharing leftover prescriptions with family and
friends, not informing health-care providers that they
are using herbal remedies, and polypharmacy from
augmenting prescriptions with Russian pharmaceuti-
cals (Aroian, 2003). Russian grocery stores in Russian
immigrant communities or people traveling to and
from Russia are both ample sources of Russian phar-
maceuticals and herbs. Adverse health consequences
from polypharmacy are a well-known problem, and
some common herbal remedies interact dangerously
with prescribed medications.
According to one study, high-risk sexual behavior is
increasing among Russia immigrant adolescent girls,
with greater risk among girls who are more acculturated
to American culture (Jeltova, Fish, & Revenson, 2005).
The association between risky behavior in adolescents
and acculturation is not unique to Russian immigrants
or girls. Mostly likely the association between accultur-
ation and greater risky behavior results from the erosion
of traditional family practices as youths acculturate to
the United States.
Nutrition
Meaning of Food
Many Russians grew up with serious food shortages.
Thus, food carries a lot of meaning. When entertain-
ing, Russians can use food as a demonstration of their
love and respect for their visitors, spending days pur-
chasing and preparing food for their guests. Presently,
this practice appears to be limited by time constraints
and increased acculturation to the United States.
432 Aggregate Data for Cultural-Specific Groups
2780_Ch24_426-440 16/07/12 12:10 PM Page 432

Common Foods and Food Rituals
Older Russian immigrants have little interest in
American food. As previously stated, traditional
Russian diets contain high levels of saturated and hy-
drogenated vegetable fats, salt, and carbohydrates
(Keefe, 2006). Typically, Russian immigrants eat three
meals a day, with their largest meal in the middle of
the day. Russians enjoy snacks and tea, water, and
fruit juices without ice. Russian grocery stores and
restaurants were quite popular in Russian immigrant
communities, but these venues are losing business as
Russian immigrants, particularly younger ones, are
acculturating to American diets.
Dietary Practices for Health Promotion
When Russians are ill, they prefer soup and broths,
bland foods, chicken, potatoes, fruit and vegetables,
and yogurt. Tea with honey and milk is considered
medicinal (Hobbs, 2002).
Nutritional Deficiencies and Food Limitations
Russian Jews, if observing kosher dietary restrictions,
do not eat pork or shellfish or combine milk and meat
products (Hobbs, 2002).
Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Marriage and childbearing are acceptable starting at
age 20. Childbearing and child rearing are highly val-
ued. Infertility is perceived by Russians as a health
problem, disappointment, and even punishment for
some feminine wrongdoing (Aroian, 2003).
Russian women are responsible for contraception
and often make contraception decisions without con-
sulting their male partners. These decisions often relate
to access, cost, safety, and partner issues. Contraception
for Russian women is allowed without sanctions or
taboos. Even so, many Russian immigrants are afraid
of birth control pills and refuse to take them. Possible
reasons for this reluctance are the poor quality and high
dosage of oral contraceptives in Russia. To compound
this problem, condoms in Russia were poorly made,
and many jokes have evolved about the routine break-
age of Russian-made condoms. Furthermore, Russian
men believe that condoms hinder sexual pleasure and
many refuse to wear them. Most Russian men also re-
fuse vasectomies (Aroian, 2003).
Abortion was and is one of the most common
forms of birth control in Russia. Russia has one of the
world’s highest abortion rate, with the average woman
having three or more abortions in her lifetime. In 1990,
there were 1972 abortions per 1000 live births. In 2002,
this number dropped to 1276 abortions per 1000 live
births (World Health Organization [WHO], 2005).
Self-induced abortions are not uncommon. Frequent
abortions contribute to the high rate of infertility in
Russian women. Infertility issues may lead to marital
discord and divorce.
Beliefs about menstruation are based on biomedical
principles. Nonetheless, young Russian women are dis-
couraged from strenuous exercise, including swim-
ming, while menstruating (Aroian, 2003). This practice
People of Russian Heritage 433
R E F L E C T I V E E X E R C I S E 2 4 . 1
Inna Scheider is an 87-year-old woman residing in a long-
term-care facility. She has multiple chronic diseases, including
advanced congestive heart failure (CHF) and is very frail. Inna
had balance problems and had multiple falls in the past year,
which resulted in numerous hospitalizations. In addition, she
has moderate dementia. Currently, Inna exhibits some behav-
ioral problems and does not follow directions. Inna does not
speak English and can communicate with her health-care
providers only through an interpreter or when her sons are
present. One of the certified nursing assistants (CNAs) in the
facility is Russian-speaking and often stops by to help calm her
down when her family is not present. Inna has two sons who
live in the area and visit often. Both are very devoted to their
mother and are very involved in her care.
In the past, when Inna lived at home with her children, she
was a great cook and spent a significant amount of time
preparing family meals. Making multicourse meals was a very
important daily family ritual. In the United States, Inna devel-
oped a great fondness for local Russian grocery stores that sell
foods that were not available during severe food shortages in
the Soviet Union.
After several months in the long-term-care facility, Inna de-
veloped weakness and dizziness. Her physician suspects that
she had internal gastrointestinal bleeding. Her physician was
also concerned about risk of aspiration. As a result, Inna was
put on a soft food diet and receives some of her food with
added thickeners. However, the facility staff noticed that her
sons repeatedly brought Inna ready-prepared Russian food
from a local Russian grocery store. One son was observed
trying to feed her pieces of hard salami, herring with black
bread, and a diced beet salad. Inna was choking from her diffi-
culty swallowing some of the items. When confronted by the
staff, the son responded that this was the food that Inna loved
and it would make her feel better.
1. What cultural trait in food attitudes is exhibited by
Inna’s sons?
2. What educational efforts are needed by the health-care
team to educate the family about Inna’s condition and the
need for a special diet?
3. How can Inna’s care plan be integrated to balance her
health-care needs with the need to validate her tastes and
preferences?
2780_Ch24_426-440 16/07/12 12:10 PM Page 433

may have evolved from the former unavailability of
tampons in Russia.
Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Pregnant Russian women do not engage in heavy lift-
ing and often commit to bed rest if it is prescribed.
Russian women who are pregnant receive more re-
spect. When born, boys are dressed in blue and girls
in pink. Breastfeeding is encouraged, and nursing
women are told to drink tea with milk and eat nuts to
improve their milk supply (Aroian, 2003).
Owing to religious beliefs, Russian Jews circumcise
their male infants. Ethnic Russians do not circumcise
their newborn boys.
Death Rituals
Death Rituals and Expectations
Flowers are used to beautify caskets and funeral serv-
ices. Caskets are typically closed, and stones are put
on graves instead of flowers. Food and beverages are
usually served during wakes and funerals. Friends and
family come to pay their respects for 7 days post-
mortem, but the expected total period of official
mourning is 1 full year. A full year is considered the
minimal appropriate time for a surviving spouse to
wait before remarrying. Close relatives of the deceased
dress in black. Russians do not hesitate to cry and sob
at funerals, but overt wailing is often confined to the
home of the deceased (Aroian, 2003).
A family will hold vigil day and night if their loved
one is dying. All relatives and friends are expected to
visit a dying patient and often sit with the person for
hours. Depending on religious affiliation, the placing
of hands on the ill person’s forehead may occur as a
ritual gesture of blessing. Religious symbols may also
be placed at the ill person’s bedside, and a spiritual
advisor may be present when death is impending.
Russian Orthodox families pay vigil to terminally ill
and deceased persons, praying for mercy on their souls
and their entry into heaven (Yehieli, Lutz, & Grey
2005). Spiritual leaders from the Russian Orthodox
religion institute a special prayer vigil, called panikhida,
over the deceased, a vigil that includes chants, prayers,
singing of hymns, and gospel readings (Yehieli et al.,
2005). Regardless of religious affiliation, once a
person dies, his or her mouth and eyes are closed,
and mirrors are covered with black fabric (University
of Washington Medical Center, 2005).
If the patient and family are Russian Orthodox, cre-
mation is unlikely (University of Washington Medical
Center, 2005). Cremation is forbidden in the Jewish tra-
dition. However, some Russian immigrants may choose
cremation so the deceased’s ashes can be shipped back
to “Mother” Russia (Yehieli et al., 2005). Russian Jews
bury the dead within 24 hours except during holidays,
on Saturdays, or if awaiting the arrival of additional
friends and family (University of Washington Medical
Center, 2005).
Responses to Death and Grief
Russians are reluctant to disclose terminal illness or
poor prognosis to patients and believe that talking
about death is a bad omen (Aroian et al., 2006; Birch,
2006; MDEED, 2006; Norman, 1996). Family mem-
bers feel responsible for protecting their loved one
from the psychological turmoil that could result from
disclosing a poor prognosis. They tend to feign cheer-
iness in the presence of a dying person rather than
openly grieve in front of a sick or dying loved one.
This behavior stems from the belief that the stress of
bad news increases morbidity and perhaps even causes
death (Norman, 1996). Two additional explanations
for not disclosing a poor prognosis are that the dying
person would lose hope and succumb to the illness
and the prognosis could be wrong. Therefore, it is
important to carefully and diplomatically talk with
the family first, prior to disclosure of bad news to the
patient (MDEED, 2006).
Consistent with the value on collectivism, Russians
believe that a problem for one family member is a
problem for the entire family. However, discussions
about end of life are better addressed by identifying
a spokesperson from the family. When discussing
end-of-life decisions, it is also important to note that
morphine or other potent analgesics may be perceived
as hopelessness or abandoning the patient (University
of Washington Medical Center, 2005).
Compared with Americans, being in control of de-
cisions at the end of life is less important for Russian
immigrants. Therefore, requests for living wills or
durable powers of attorney, as well as consents for with-
holding or withdrawing treatment, are usually declined
by Russian patients and family members (University of
Washington Medical Center, 2005). One reason for this
is that Russians have great faith in U.S. medical care
and therefore expect that everything possible will be
done to restore health, even when their expectations are
at odds with a grave prognosis (Aroian et al., 2006).
However, evidence suggests that culturally sensitive ed-
ucational efforts can be productive in increasing family
decisions for palliative care of Russian older adults
(Dashevskaya, 2004).
Spirituality
Religious Practices and Use of Prayer
Preferred religious practices for Russian immigrants
vary. Many Russians have no religious affiliation,
which is likely the consequence of antireligious dogma
of the former Soviet Union. Prior to the overthrow of
Czarist Russia, ethnic Russians were predominantly
Russian Orthodox. However, during the Soviet era,
434 Aggregate Data for Cultural-Specific Groups
2780_Ch24_426-440 16/07/12 12:10 PM Page 434

religious practices of all types were condemned, and
people caught practicing their religion risked being
punished severely. With the resurgence of Russian na-
tionalism, the Russian Orthodox Church has resumed
a major role in the life and politics of the Russian peo-
ple. As evidence of this renewed emphasis, Russian
Orthodox Churches are being restored.
Religious practices among ethnic/religious minori-
ties in present-day Russia also vary. Russian Jews may
or may not be religious, but Pentecostals tend to be
devout.
Meaning of Life and Individual Sources
of Strength
Although self-professed atheism has had a dramatic
decline since 1991, religion is still not prominent in
many Russians’ lives. Russians, including Russian im-
migrants, often lead secular lives and tend to gain spir-
itual strength, stability, and meaning through their
associations with family and friends.
Spiritual Beliefs and Health-Care Practices
Seriously ill patients and family members who are re-
ligious consider prayer an essential and powerful tool
toward health and healing (University of Washington
Medical Center, 2005). Members of the Russian Or-
thodox faith believe in the heavenly position of saints
as well as religious miracles.
Health-Care Beliefs and Practices
Russians define health as the absence of disease. Al-
though they embrace biomedical explanations for dis-
ease, their approach to health is holistic. They endorse
the notion that stress, including family and economic
stress, is a causative factor in disease. Additional
causative factors include getting chilled and not hav-
ing fresh air, sunlight, and nutritious food. Given their
holistic perspective, they expect their health-care
providers to holistically diagnose the etiology of
health problems. A common complaint is that West-
ern medicine places too much emphasis on medica-
tions and laboratory results and not enough on
clinical diagnosis and holistic care.
Russians consider health an important resource
and are active in maintaining their health (Aroian
et al., 2001). Russian immigrants generally keep
health-care appointments and adhere to prescribed
treatments (Aroian, 2003). On the other hand, the
general belief is that more professional input is
superior to relying on a single health provider. Thus,
Russians often combine prescribed treatments from
many providers, and providers are often unaware of
multiple treatment plans. In addition, Russians often
supplement prescribed treatments with homeopathic
and herbal remedies.
Mental illnesses are highly stigmatized in Russia.
As a result, Russian immigrants may not provide
truthful answers to questions regarding a family or
personal history of mental illness (University of
Michigan Health System, 2007).
Russians often self-diagnose, seeking out and read-
ing Russian-language health articles related to their
disorders. One important method of receiving health-
care information is through mass media and the
Internet. Rulist.com is a search engine that provides a
kind of Russian yellow pages with information on
health and wellness. Russian immigrants may also
subscribe to the Russian Health Magazine, a magazine
geared toward increasing the medical awareness of
Russian-speaking people in the United States. It is
also noteworthy that a significant portion of Russian
immigrant men and women who emigrated in the lat-
ter part of the 20th century were physicians. Although
some of the older people from this group never prac-
ticed medicine in the United States, they provide in-
formal health information to Russian immigrants.
Russian immigrants have a very different view of
obesity than the dominant U.S. culture. Generally, they
are more accepting of excess weight and obesity, per-
haps because excess weight and obesity are common
due to a high caloric diet and low levels of exercise. For
People of Russian Heritage 435
R E F L E C T I V E E X E R C I S E 2 4 . 2
During the admission to the long-term-care facility, the health-
care team approached Inna and her sons to complete health-
care proxy forms and make some end-of-life decisions. During
the admission interview, it became clear that Inna’s sons do
not fully understand the extent of their mother’s physical and
cognitive impairment and would like the health-care team to
pursue a very aggressive approach in treating her. Inna did not
participate in the discussion fully and deferred all decision
making to her sons. As a result, Inna’s treatment plan included
“full code” instructions to health-care providers. One day
while visiting, one of the sons observed a team treating Inna
during an acute CHF episode. He was distraught by how
much his mother suffered from the brutality of the medical in-
tervention. Afterward, he asked the health-care team to
change “full code” instructions to Do Not Resuscitate (DNR)
but declined Do Not Hospitalize (DNH) instructions, stating
that he did not have the heart to institute this instruction.
1. What attitudes and cultural trends were demonstrated by
Inna’s sons during her admission to the long-term facility?
2. How should the facility admission team have approached
the discussion regarding Inna’s end-of-life wishes?
3. How should the discussion about DNR and DNH have
been framed to demonstrate respect for Inna’s sons’
values and traditions?
4. What type of educational materials would be helpful for
Inna’s sons to help them consider how to address quality
of life and end-of- life goals in her treatment plan?
2780_Ch24_426-440 16/07/12 12:10 PM Page 435

example, Stevens and colleagues (1997) compared
attitudes and behaviors related to body size and other
parameters among black, white, and Russian adoles-
cents. Russian adolescent girls were less likely than
black and white adolescent girls to identify obese and
overweight status as a concern.
Health-Seeking Beliefs and Behaviors
Clinical and anecdotal reports describe Russians as
demanding patients who overuse health care. It is true
that Russians are not passive in voicing their health-
care needs (Aroian, 2003). However, empirical data
about their health care use illustrate that their use is
not always disproportionate to their health needs
(Aroian & Vander Wall 2007). It is also important to
consider that the Russian immigrant community in
the United States is diverse, with much variation in
many of the characteristics that affect health-care use,
such as education, language ability, age, and insurance
coverage. For example, Ivanov and Buck (2002) found
that younger Russian immigrant women only used
health care for emergencies, reportedly because of lack
of time and third party insurance. In contrast, the
older Russian immigrant women in their sample had
much heavier use, presumably because they were re-
tired and covered by Medicaid. There is also geo-
graphic variation in the number of Russian-speaking
health-care providers and transportation barriers for
accessing health care. Geographical differences may
account for why Wei and Spigner (1994) found that
Russian immigrants had lower rates of clinic use than
Southeast Asian refugees in Portland, Oregon, whereas
Aroian and colleagues (2001) found very high health-
care use among Russians in Boston, Massachusetts.
Portland had comparatively fewer language barriers for
Southeast Asians than for Russians, whereas Boston
had almost no language barrier for Russians. Russian-
speaking physicians in Boston also purposefully set up
practices close to dense Russian-speaking communities
so as to minimize transportation barriers.
There are mixed findings about how satisfied Russ-
ian immigrants are with their health-care providers. In
one study, Russian immigrants expressed dissatisfac-
tion with family physicians, perceiving them as lacking
professionalism (Ivanov & Buck, 2002). They were
dissatisfied with the general appearance of health-care
providers and how difficult it is to distinguish between
the nurse and the janitor. In contrast, another study
that compared Russian immigrants with nonimmi-
grants found no differences in satisfaction with
providers, but did find that Russians were less satisfied
with appointment availability and physical access
(Aroian & Vander Wall, 2007). Dissatisfaction with
appointment availability and physical access may be
related to the fact that Russians were used to having
health care readily available in Russia through walk-
in clinics located in convenient settings where people
live and work. Russians were also used to physicians
making home visits in Russia when people are too ill
or frail to travel for health care (Aroian et al., 2001).
Russians perceive male physicians as more skilled
and competent and as having more status than female
physicians (Ivanov & Buck, 2002). Nonetheless, they
are used to having female physicians. Women in Russia
have been practicing medicine in large numbers for
decades.
Responsibility for Health Care
Russians believe that individuals are responsible for
their health and that disabilities and negative health
events result when individuals do not take care of
themselves (Aroian et al., 2001; Aroian & Vander Wal,
2007). Most Russians take an active role in their
health and health care. They use alternative and
homeopathic remedies and commit to self-care.
Even though Russians acknowledge personal re-
sponsibility for their health, they are used to authori-
tarian health encounters. They expect health-care
providers to be directive, telling them exactly what to
do to get or stay well (Aroian et al., 2006; Ivanov &
Buck, 2002). They are unlikely to schedule preventive
screening unless a health-care provider directs them
to do so (Ivanov & Buck, 2002).
Folk and Traditional Practices
Homeopathic and traditional medicines have been
used for centuries in Russia and continue to be used
widely, often simultaneously with those of Western
medical science. Russians, especially older individuals,
use herbal teas, tinctures, mud baths, massage, saunas,
and other alternative medicines and healing practices
(Yehieli et al., 2005). Additional home remedies in-
clude rubbing oils and ointments, enemas, saunas and
whirlpools, mineral water (for soaking as well as
drinking), herbal teas, hot and cold soups, liquors, and
mud plasters (Bistrevsky, 2005). “Cupping,” a tech-
nique whereby the inside of a glass cup is heated and
placed on a person’s back, shoulder, or chest, is used
for respiratory problems such as bronchitis and asthma.
In Russia, physicians and nurses go to patients’ homes
to perform cupping.
Barriers to Health Care
Awareness and Attitudes
Russians expect their health-care providers to look
and act professional. Russian immigrants also expect
health-care providers to be nonjudgmental about
herbal and homeopathic treatments. Russians are very
involved with the care of their family members, which
can conflict with providers who approach care by only
involving the patient, either as a means of promoting
autonomy or protecting the patient’s privacy. Owing
to social and political sanctions against psychiatric
436 Aggregate Data for Cultural-Specific Groups
2780_Ch24_426-440 16/07/12 12:10 PM Page 436

illness in Russia, Russian immigrants may also be re-
luctant to disclose mental health issues and a family
history of mental disorders. Therefore, providers need
to approach the subject carefully and with full assur-
ances of confidentiality.
Russians are unaccustomed to the concept of
managed care. They want direct access to multiple,
sophisticated tests and procedures and to health-care
specialists of their choice. They believe the additional
step of needing a referral by a primary care provider
is not only expensive and wasteful but also detrimen-
tal to their health because it reduces timeliness to
care. Recent Russian immigrants may also be unfa-
miliar with concepts such as defensive health care
and medical malpractice.
Affordability
Russians are egalitarian and believe in an equal distri-
bution of health-care benefits (Culture Tips, 2000). In
the former Soviet Union, health care was free. There-
fore, concepts like private pay, co-pay, and insurance
premiums are difficult for many Russian immigrants
to understand. They may need help to understand
U.S. health-care systems, including Medicaid and
Medicare programs. However, the Russian health sys-
tem underwent significant transformation after the fall
of communism. Therefore, recent immigrants are
more familiar with the notion of paid health care and
the need to have health insurance coverage.
In the United States, about 85 percent of Russian
immigrants carry some kind of health insurance
coverage, including employer-based private insurance
or government plans such as Medicaid, Medicare, or
both (Ethnic Population, 2003). Due to low income, a
lot of older immigrants are dual eligible: enrolled in
Medicare as their primary insurance and also enrolled
in Medicaid to help pay for co-payments and de-
ductibles. In cases of chronic illness and frailty, dual
enrollment provides coverage for home and community-
based services and nursing home care. Even with
coverage, cost can be a major barrier to health care.
Copayments can compete with money needed for food
and other household essentials (Ivanov & Buck, 2002).
Language Proficiency
There are generational differences in language profi-
ciency. Older immigrants have a lesser command of
English than younger immigrants who went to school
in the United States and/or are working for American
employers. Therefore, younger family members often
act as interpreters for the elderly. However, Russian
immigrants who are not proficient in English strongly
prefer Russian-speaking health-care providers and will
actively look for them.
Depending on geographical area, there are a large
number of Russian-speaking health providers and
health services in the United States. For example, some
nursing homes have “Russian units” staffed by Russian-
speaking nurses. It is also noteworthy that Russian
medical and dental associations have been established
in the United States and are a testimony to the lan-
guage- and culture-specific health-care resources that
are available to Russian immigrants who speak only
Russian. The Russian American Medical Association
(RAMA) was founded in 2002 and has a peer-reviewed
journal and a Web site with information relevant to
all Russian-speaking health-care providers (RAMA,
2007). As previously mentioned, there is also a good
amount of Russian-language health literature available
for Russian lay audiences (e.g., the Russian Health
Magazine and Web sites like Rulist.com). There is also
a Web site called RussianDoctor.com, which allows
Russian immigrants to locate Russian-speaking dentists
and physicians by specialty and location (city/state).
Accessibility
For every 1000 people in Russia, there are 4.25 physi-
cians compared with 2.56 physicians in the United States
(WHO, 2006). Although the United States has more
nurses and more nurses in expanded practice roles
than Russia, Russian immigrants perceive that health
care is far less accessible than what they were used to
(Aroian & Vander Wall, 2007; Benisovich & King,
2003). Russian immigrants complain about needing to
wait many weeks or months before getting a health-care
appointment. As mentioned above, Russians were used
to much greater accessibility in the former Soviet Union,
including conveniently located walk-in clinics and home
People of Russian Heritage 437
R E F L E C T I V E E X E R C I S E 2 4 . 3
When Inna was admitted to the long-term-care facility, the
admission staff obtained a list of her prescribed medications
from her primary care provider. During one of the visits by
Inna’s other son, the staff observed that he was giving Inna pills
to take with her meal. In the facility, Inna receives several med-
ications, and they are administered in a crushed form due to her
soft food diet and difficulty swallowing. The staff was worried
and informed Inna’s physician that her son was giving her addi-
tional medications. When the physician called Inna’s son, the son
explained that the pills were “natural,” were recommended by
his alternative health-care provider, and were likely to help his
mother. He takes the same pills to boost his energy level.
However, he does not know what the pills contain.
1. What cultural responses to health and illness are
demonstrated by Inna’s son?
2. What was the missing element in the admission process
in terms of Inna’s medication history?
3. What discussion should have taken place when Inna’s care
team discussed her medication regimen and her treatment
plan with her family?
2780_Ch24_426-440 16/07/12 12:10 PM Page 437

visits by physicians. Transportation is another barrier,
even in geographical settings where Russian-speaking
health-care providers have intentionally set up practices
in Russian-speaking neighborhoods. In addition, in
the Soviet Union, people were hospitalized for minor
illnesses. Therefore, Russian immigrants may be less
used to traveling back and forth for outpatient visits and
multiple appointments in different locations.
Cultural Responses to Health and Illness
Russian immigrants often have unrealistic expectations
of U.S. health-care providers (Aroian et al., 2001). They
expect that a rich country like the United States should
be able to cure disease easily, regardless of disease state.
When one physician is unable to meet expectations, the
patient will likely seek the services of others. Treatments
prescribed by one health-care provider may not be dis-
closed to another, which raises concerns about negative
health effects from polypharmacy (Aroian, 2003). In
addition, Russians are accustomed to health-care
providers placing a greater emphasis on treatment than
prevention. Long in-patient hospitalizations were the
norm in Russia. Thus, Russian immigrants are dis-
mayed by short hospital stays in the United States
(Aroian et al., 2001).
Blood Transfusion and Organ Donation
Owing to contaminated blood supplies in Russia and
the former Soviet Union, health-care providers may
have difficulty convincing Russian immigrants to con-
sent to giving or receiving human blood products.
Health-Care Providers
Traditional Versus Biomedical Care
In Russia, health care was more holistic, with biomed-
ical providers prescribing homeopathic treatments as
supplements to biomedical approaches. As previously
mentioned, Russian immigrants are disappointed by
the lack of holism in American health care.
Status of Health-Care Providers
Physicians are considered to be the most knowledge-
able of all health-care providers and “in charge” of
health care.
R E F E R E N C E S
Abramson, H. (1991). Jewish representation in the independent
Ukraian governments of 1917–1920. Slavic Review, 50(3),
542–550.
Alaniz, J. (2001, September 11). Crossing cultures: Russian nurses
navigate the unfamiliar U.S. health care system, finding career
advantages and obstacles. NurseWeek. Retrieved from
www.nurseweek.com/news/features/01-09/cultures_print.html
Allied Media Corp. (n.d.). Television for Russian Americans
RTVI. (Author). Multicultural communication. Retrieved from
www.allied-media.com/RussianMarket/rtvi.htm
Aroian, K.J. (2003). Russians (former Soviets). In P. St. Hill,
J. Lipson, & A.I. Meleis, (Eds.), Caring for women cross-culturally
(pp. 249–263). Philadelphia: F. A. Davis.
Aroian, K.J., Khatutsky, G., & Dashevskaya, A. (2006). Cross-
cultural health care for older Russian-speaking Americans. In
R.N. Adler & H.K. Kamel (Eds.), Doorway thoughts: Cross-
cultural health care for older Russian-speaking Americans
(Vol. 2, pp. 152–166). Boston, MA: Jones and Bartlett.
Aroian, K.J., Khatutsky, G., Tran, T.V., & Balsam, A.L. (2001).
Health and social service utilization among elderly immigrants
from the former Soviet Union. Journal of Nursing Scholarship,
33(3), 265–271.
Aroian, K.J., & Norris, A.E. (1999). Somatization and depression
among former Soviet immigrants. Journal of Cultural Diversity,
6(3), 93–101.
Aroian, K.J., & Norris, A.E. (2003). Depression trajectories in rel-
atively recent immigrants. Comprehensive Psychiatry, 44(5),
420–427.
Aroian, K.J., Norris, A.E., & Chiang, L. (2003). Gender differ-
ences in psychological distress among immigrants from the
former Soviet Union. Sex Roles, 48(1/2), 39–51.
Aroian, K.J., Norris, A., Patsdaughter, C.A., & Tran, T.V. (1998).
Predicting psychological distress among former Soviet immi-
grants. International Journal of Social Psychiatry, 44(2),
284–294.
Aroian, K.J., Spitzer, A., & Bell, M. (1996). Family support and
conflict among former Soviet immigrants. Western Journal of
Nursing Research, 18(6), 655–674.
Aroian, K.J., & Vander Wal, J.S. (2007). Health service use in
Russian immigrant and nonimmigrant older persons. Family
and Community Health, 30(3), 213–223.
Belozersky, I. (1990). New beginnings, old problems: Psychocul-
tural frame of reference and family dynamics during the ad-
justment period. Journal of Communal Services, 67, 124–130.
Benisovich, S.V., & King, A.C. (2003). Meaning and knowledge of
health among older adult immigrants from Russia: A phenom-
enological study. Health Education Research, 18(2), 135–144.
Bergelson, M.B. (2003). Russian cultural values and workplace com-
munication. III International RCA Conference–2006 “communi-
cation and (re) making social worlds.” Retrieved from http://
www.russcomm.ru/eng/rca_biblio/b/bergelson03_eng.shtml
Birch, D. (2006, August 27). In Russia, the truth is optional [Elec-
tronic version]. The Baltimore Sun, opinion section.
Bistrevsky, T. (2005, Summer). Insight into Spokane’s Russian
families. ABCD and ABCDE Newsletter. Spokane Regional
Health District. Retrieved from www.SRHD.org
Brod, M., & Heurtin Roberts, S. (1992). Older Russian emigres and
medical care. The Western Journal of Medicine, 157, 333–336.
CIA World Factbook. (2011). Russia. Retrieved from www.cia.
gov/library/publications/the-world-factbook/index.html
Culture tips: Understanding the Russian culture and individual.
(2000). Cross Cultural Connection, 5(4), 3–4.
Dashevskaya, A. (2004). Aging well together across cultures. Pre-
sented at a workshop for health providers, Lynn, Massachu-
setts, April 14, 2004.
Energy Information Administration [EIA]. (2010). Russia Energy
Profile. Retrieved from http://www.eia.doe.gov/cfapps/
country/country_energy_data.cfm?fips=RS
Ethnic Population. (2003, July 30). Russian market in USA. Re-
trieved from www.inforeklama.com/market.htm
Gabriel, R. (2005, March). A commentary on pharmacogenomics:
What can it do? Medical Laboratory Observer. Nelson Publish-
ing/Gale Group.
438 Aggregate Data for Cultural-Specific Groups
2780_Ch24_426-440 16/07/12 12:10 PM Page 438

Gaikovitch, E.A. (2003, July 14). Genotyping of the polymorphic
drug metabolizing enzymes cytochrome P450 2D6 and 1A1, and
N-acetyltransferase 2 in a Russian sample. Dissertation, Hum-
bolt University, Berlin, Germany.
Goodman, R., Slobodskaya, H., & Knyazev, G. (2005). Russian
child mental health: A cross-sectional study of prevalence
and risk factors. European Child and Adolescent Psychiatry, 14,
28–33.
Hasin, D., Aharonovich, E., Liu, X., Mamman, Z., Matseoane,
K., Carr, L., & Li, T-K. (2002). Alcohol and ADH2 in Israel:
Ashkenazis, Sephardics, and recent Russian immigrants. American
Journal of Psychiatry, 159(8), 1432–1434.
Hobbs, R. (2002, July 16). Knowledge of immigrant nationalities:
Russia. Retrieved from www.immigrantinfo.org/kin/russia.htm
Isralowitz, R.E., Straussner, S.L., & Rosenblum, A. (2006). Drug
abuse, risks of infectious diseases and service utilization among
former Soviet Union immigrants: A view from New York City.
Journal of Ethnicity and Substance Abuse, 5(1) 91–96.
Ivanov, L.L., & Buck, K. (2002). Health care utilization patterns
of Russian-speaking immigrant women across age groups.
Journal of Immigrant Health, 4(1), 17–27.
Jeltova, I., Fish, M.C., & Revenson, T.A. (2005). Risky sexual be-
haviors in immigrant adolescent girls from the former Soviet
Union: Role of natal and host culture. Journal of School
Psychology, 43(1), 3–22.
Keefe, S. (2006, August 21). Russian-speaking home care nurses
help bridge language and cultural barriers among Brooklyn’s
Russian immigrants. ADVANCE Newsmagazines: Merion
Publications. Retrieved from http://nursing.advanceweb.com/
common/editorial [Requires registration]
Levav, I., Kohn, R., Flaherty, J.A., Lerner, Y., & Aisenberg, E.
(1990). Mental health attitudes and practices of Soviet immi-
grants. Israeli Journal of Psychiatry and Related Sciences, 27,
131–144.
Library of Congress. (2010, July). Country profile: Russia. Library
of Congress—Federal Research Division, Library of Congress
call number: DK510.23. R883 1998. Retrieved from
http://memory.loc.gov/frd/cs/rutoc.html
Marquez, P.V. (2005). Dying too young: Addressing premature mor-
tality and ill health due to non-communicable diseases and in-
juries in the Russian Federation. Washington, DC: World Bank.
Mehler, P.S., Scott, J.Y., Pines, I., Gifford, N., Biggerstaff, S., &
Hiatt, W.R. (2001). Russian immigrant cardiovascular risk as-
sessment. Journal of Health Care for the Poor and Underserved,
12(2), 224–235.
Miller, A.M., & Chandler, P.J. (2002). Acculturation, resilience,
and depression in midlife women from the former Soviet
Union. Nursing Research, 51, 26–32.
Miller, A.M., Sorokin, O., Wang, E., Feetham, S. Choi, M., &
Wilbur, J. (2006). Acculturation, social alienation, and de-
pressed mood in midlife women from the former Soviet Union.
Research in Nursing and Health, 29, 134–146.
Minnesota Department of Employment and Economic Develop-
ment [MDEED]. (2006). Russian immigrants in Minnesota.
Minnesota State Services for the Blind. Retrieved from
www.mnssb.org/rcb/moc/russian.htm
Nemtsov, A. (2005). Russia: Alcohol yesterday and today. Addiction,
100, 146–149.
News about gay Russia. (n.d.). Retrieved from http://russia.bi.org/
news.html
Nicholson, A., Bobak, M., Murphy, M., Rose, R., & Marmot, M.
(2005). Alcohol consumption and increased mortality in Russian
men and women: A cohort study based on the mortality of rela-
tives. Bulletin of the World Health Organization, 83(11), 812–819.
Norman, C. (1996). Breaking bad news: Consultations with ethnic
communities. Australian Family Physician, 25(10), 1583–1587.
Parfitt, T. (2006). Campaigners fight to bring down Russia’s to-
bacco toll. The Lancet, 368, 633–634.
Remennick, L.I. (1999). Women of the “sandwich” generation
and multiple roles: The case of Russian immigrants of the
1990’s in Israel. Sex Roles, 40, 347–378.
Rennert, G., Luz, N., Tamir, A., & Peterburg, Y. (2002). Chronic
disease prevalence in immigrants to Israel from the former
USSR. Journal of Immigrant Health, 4(1), 29–33.
Russian American Medical Association (RAMA). (2007). Re-
trieved from www.russiandoctors.org/
Shpilko, I. (2006). Russian-American health care: Bridging the
communication gap between physicians and patients. Patient
Education and Counseling, 64, 331–341.
Smith, L.S. (1996). New Russian immigrants: Health problems,
practices, and values. Journal of Cultural Diversity, 3(3), 68–73.
Stevens, J., Alexandrov, A.A., Smirnova, S.G., Deev, A.D.,
Gershunskaya, Y.B., Davis, C.E., & Thomas, R. (1997). Com-
parison of attitudes and behaviors related to nutrition, body
size, dieting, and hunger in Russian, black-American, and
white-American adolescents. Obesity Research, 5, 227–236.
Tran, T.V., Khatutsky, G., Aroian, K., Balsam, A., & Conway, K.
(2000). Living arrangements, depression, and health status
among elderly Russian-speaking immigrants. Journal of Geron-
tological Social Work, 33(2), 63–77.
U.S. Census Bureau. (2000). Fact sheet: United States. Census 2000
demographic profile highlights: Selected population group:
Russian (pp. 148–151). Summary file 4(SF4).
U.S. Census Bureau. (2007). Language use in the United States.
Retrieved from http://www.census.gov/hhes/socdemo/
language/data/acs/ACS-12
U.S. Department of Homeland Security. (2005a). Table 3: Legal
permanent resident flow by region and country of birth: Fiscal
years 1995 to 2005. Retrieved from www.uscis.gov/graphics/
shared/statistics/yearbook/LPRO5.htm
U.S. Department of Homeland Security. (2005b). Table 12: Immi-
grant orphans adopted by US citizens by gender, age, and region
and country of birth: Fiscal year 2005. Retrieved from www.
uscis.gov/graphics/shared/statistics/yearbook/LPRO5.htm
U.S. Department of Homeland Security. (2005c). Supplemental
Table 2: Legal permanent resident flow by leading core-based sta-
tistical areas (CBSAs) of residence and region and country
of birth: Fiscal year 2005. Retrieved from www.uscis.gov/
graphics/shared/statistics/yearbook/LPRO5.htm
U.S. Department of Homeland Security. (2010). Yearbook of Im-
migration Statistics: 2009. Retrieved from http://www.uscis.
gov/graphics/shared/statistics/yearbook/LPRO5.htm
University of Michigan Health System. (2007). Cultural compe-
tency. Patient Education. Ann Arbor. Retrieved from
http://www.uofmhealth.org/health-library
University of Washington Medical Center. (2005, April). Commu-
nicating with your Russian patient. Culture clues: Staff Devel-
opment Workgroup, Patient and Family Education Committee.
Seattle.
Vadlamani, A., Maher, J.F., Shaete, M., Smirnoff, A., Cameron,
D.G., Winkelmann, J.C., & Goldberg, S.J. (2001). Colorectal
cancer in Russian-speaking Jewish émigrés: Community-
based screening. American Journal of Gastroenterology, 96(9),
2755–2760.
Vishnevsky, A., & Zayonchkovskaya, Z. (1994). Emigration from
the former Soviet Union: The fourth wave. In H. Fassman &
R. Munz (Eds.), European migration in the late twentieth
century: Historical patterns, actual trends, & social implications
People of Russian Heritage 439
2780_Ch24_426-440 16/07/12 12:10 PM Page 439

(pp. 239–285). Aldershot, UK: Edward Elgar Publishing
Limited.
Wei C., & Spigner, C. (1994). Health status and clinic utilization
among refugees from Southeast Asia and the Former Soviet
Union. Journal of Health Education, 25(3), 266–273.
World Health Organization (WHO). (2005, January 14). Country
profile. WHO Regional Office for Europe. Retrieved from
http://www.who.int/countries/rus/en/
World Health Organization (WHO). (2006). Health workers: A
global profile. The world health report 2006: Working together
for health. Annex table 4, pp. 197–199. Retrieved from
http://www.who.int/whr/2006/en/
Yehieli, M., Lutz, G., & Grey, M. (Eds.). (2005, November). Russians
and other immigrants from the former Soviet Union. Health dis-
parity factsheets. Cedar Falls, IA: Center for Health Disparities,
University of Northern Iowa.
For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com
440 Aggregate Data for Cultural-Specific Groups
2780_Ch24_426-440 16/07/12 12:10 PM Page 440

441
Appendix
Cultural, Ethnic, and Racial Diseases
and Illnesses
Causes are grouped into three categories—genetic,
lifestyle, and environment.
Lifestyle causes include cultural practices and be-
haviors that can generally be controlled—for example,
smoking, diet, and stress.
Environmental causes refer to the external environ-
ment (e.g., air and water pollution) and situations over
which the individual has little or no control (e.g., pres-
ence of malarial mosquitos, exposure to chemicals
and pesticides, access to care, and associated diseases).
Cultural/Racial Group Diseases/Disorders Causes
Black Populations AFRICAN AMERICANS
Sickle cell disease
Hypertension
Systemic lupus erythematosus
Diabetes mellitus
Glaucoma
Cardiovascular disease
Lung, colon, and rectal cancer
Prostate cancer
Lead poisoning
Asthma
HIV/AIDS
Hemoglobin C disease
Hereditary persistence of hemoglobin F
Glucose-6-phosphate dehydrogenase deficiency
�-Thalassemia
HAITIANS
Malaria
Tuberculosis
Diabetes mellitus
Hypertension
SOMALI
Depression, post-traumatic stress disorder
Tuberculosis
Hepatitis B
Helicobacter pylori, intestinal parasites
Malaria
Genetic, environment
Genetic, lifestyle
Genetic with an environmental trigger
Genetic, lifestyle
Genetic
Genetic, environment, lifestyle
Environment and lifestyle
Genetic, environment
Environment
Environment and lifestyle
Lifestyle
Genetic
Genetic
Genetic
Genetic
Environment
Lifestyle, environment
Genetic, environment, lifestyle
Genetic, lifestyle
Environment, lifestyle
Environment, lifestyle
Environment, lifestyle
Environment, lifestyle
Lifestyle
Continues on page 442
2780_Appendix_441-448 16/07/12 12:18 PM Page 441

442 Cultural, Ethnic, and Racial Diseases and Illnesses
Cultural/Racial Group Diseases/Disorders Causes
Hispanics/Latinos
Trichuris trichuria, Enterobius vermicularis, Entamoeba
histolytica, Dientamoeba fragilis, Ascaris lumbricoides,
and Schistosoma mansoni
Lactase deficiency
KENYANS
Nasopharyngeal cancer
Esophageal cancer
ZAIRIANS & UGANDANS
Stomach cancer
Duodenal ulcers
ZIMBABWEANS
Stomach cancer
SUB-SAHARAN AFRICANS
Liver cancer
100 DEGREES NORTH AND SOUTH OF THE EQUATOR
Burkitt lymphoma
BRAZILIANS
Tuberculosis
Dengue fever
Malaria
Trypanosomiasis
Schistosomiasis
Chagas disease
Yellow fever
Intestinal parasites
Cancers
CUBANS
Hypertension
Coronary artery disease
Obesity
Diabetes mellitus
Lung cancer
GUATEMALANS
Lactase deficiency
Gastritis
Malaria
Tuberculosis
Eye disorders
MEXICANS
Lactase deficiency
Diabetes mellitus
Cleft lip/palate
Dental caries
Cardiovascular disease
Tuberculosis
Hypertension
COSTA RICANS
Malignant osteoporosis
PUERTO RICANS
Cardiovascular disease
Hypertension
Dengue fever
Breast cancer
Prostate cancer
Environment, lifestyle
Genetics
Lifestyle
Lifestyle, environment?
Lifestyle
Unknown
Lifestyle
Environment
Environment
Lifestyle, environment
Lifestyle, environment
Lifestyle, environment
Lifestyle, environment
Lifestyle, environment
Lifestyle, environment
Lifestyle, environment
Lifestyle, environment
Lifestyle, genetics
Genetic, lifestyle
Genetic, lifestyle
Environment, lifestyle
Genetic, lifestyle
Lifestyle, environment
Genetic
Environment, lifestyle
Environment, lifestyle
Environment, lifestyle
Lifestyle
Genetic
Genetic, lifestyle
Lifestyle
Lifestyle, environment
Genetic, environment, lifestyle
Environment, lifestyle
Genetic, environment, lifestyle
Environment? Genetic?
Genetic, environment, lifestyle
Genetic, environment, lifestyle
Environment
Genetic, lifestyle
Genetic, environment, lifestyle
2780_Appendix_441-448 16/07/12 12:18 PM Page 442

Cultural, Ethnic, and Racial Diseases and Illnesses 443
Cultural/Racial Group Diseases/Disorders Causes
Arabs/Middle Easterners
Asian/Pacific Islanders
Familial Mediterranean fever
Familial paroxysmal polyserositis
Tuberculosis
Malaria
Trachoma
Typhoid fever
Glucose-6-phosphate dehydrogenase deficiency
Sickle cell disease
Thalassemia
Hepatitis A and B
Schistosomiasis (bilharzia)
Familial hypercholesterolemia
IRANIANS
Dubin-Johnson syndrome
Epilepsy
IRAQIS
Ichthyosis vulgaris
YEMENIS
Phenylketonuria
Glucose-6-phosphate dehydrogenase deficiency
LEBANESE
Dyggve-Melchior-Clausen syndrome
Familial hypercholesterolemia
EGYPTIANS
Schistosomiasis
Trachoma
Typhoid fever
Tuberculosis
�-Thalassemia
SAUDI ARABIANS
Metachromatic leukodystrophy
CHINESE
�-Thalassemia
Glucose-6-phosphate dehydrogenase deficiency
Lactase deficiency
Nasopharyngeal cancer
Liver cancer
Stomach cancer
Cardiovascular disease
Hepatitis B
Tuberculosis
Diabetes mellitus
JAPANESE
Vogt-Koyanagi-Harada syndrome
Cardiovascular disease
Asthma
Takayasu disease
Acatalasemia
Cleft lip/palate
Oguchi disease
Lactase deficiency
Stomach cancer
Hypertension
Genetic
Genetic
Environment, lifestyle
Genetic, environment
Environment, lifestyle
Environment
Genetic
Genetic, environment
Genetic
Environment, lifestyle
Environment, lifestyle
Genetic, lifestyle
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Lifestyle, environment
Environment, lifestyle
Environment
Lifestyle, environment
Genetic
Genetic
Genetic
Genetic
Genetic
Environment, lifestyle
Environment, lifestyle
Unknown, lifestyle and/or environment
Genetic, lifestyle, environment
Genetic, lifestyle, environment
Environment, lifestyle
Genetic, lifestyle, environment
Genetic
Genetic, lifestyle, environment
Lifestyle, environment
Genetic
Genetic
Lifestyle, genetic
Genetic
Environment, lifestyle
Genetic, lifestyle, environment
Genetic, lifestyle, environment
Continues on page 444
2780_Appendix_441-448 16/07/12 12:18 PM Page 443

444 Cultural, Ethnic, and Racial Diseases and Illnesses
Cultural/Racial Group Diseases/Disorders Causes
European American
Ethnic White
Populations
ASIAN INDIANS
Cancer of the cheek
Ichthyosis vulgaris
Tuberculosis
Malaria
Rheumatic heart disease
Cardiovascular disease
Sickle cell disease
FILIPINOS
Diabetes mellitus
Hyperuricemia
Cardiovascular disease
Hypertension
Thalassemia
Glucose-6-phosphate dehydrogenase deficiency
THAILANDERS
Glucose-6-phosphate dehydrogenase deficiency
Thalassemia
Lactase deficiency
VIETNAMESE
Nasopharyngeal cancer
Lactase deficiency
Post-traumatic stress disorder
Tuberculosis
Malaria
Hepatitis B
Melioidosis
Paragonimiasis
Leprosy
HMONGS AND LAOTIANS
Nasopharyngeal cancer
Lactase deficiency
Tuberculosis
Hepatitis B
KOREANS
Stomach cancer
Liver cancer
Hypertension
Schistosomiasis
Hepatitis A and B
Lactase deficiency
Osteoporosis
Peptic ulcer disease
Lactose intolerance
Tuberculosis
Astestosis
Insulin autoimmune deficiency disease
Renal failure
Skin cancer
Appendicitis
Diverticular disease
Colon cancer
Hemorrhoids
Lifestyle
Genetic
Lifestyle, environment
Environment
Environment
Genetic, lifestyle, environment
Genetic
Genetic, environment, lifestyle
Lifestyle
Genetic, lifestyle, environment
Genetic, lifestyle, environment
Genetic
Genetic
Genetic
Genetic
Genetic
Lifestyle, environment
Genetic
Environment
Lifestyle, environment
Environment
Environment, lifestyle
Environment, lifestyle
Environment, lifestyle
Genetic
Lifestyle, environment
Genetic
Environment, lifestyle
Genetic, environment, lifestyle
Lifestyle
Genetic, environment
Genetic, lifestyle, environment
Environment, lifestyle
Environment, lifestyle
Genetic
Genetic, lifestyle
Lifestyle, environment
Genetic
Environment and lifestyle
Environment
Genetic
Lifestyle
Environment, lifestyle
Unknown
Lifestyle, genetic?
Lifestyle, genetic?
Lifestyle, unknown
2780_Appendix_441-448 16/07/12 12:18 PM Page 444

Cultural, Ethnic, and Racial Diseases and Illnesses 445
Cultural/Racial Group Diseases/Disorders Causes
Cardiovascular disease
Varicose veins
Diabetes mellitus
Multiple sclerosis
Obesity
ENGLISH
Cystic fibrosis
Hereditary amyloidosis, type III
Rosacea
ESTONIANS, LATVIANS, LITHUANIANS
Tuberculosis
Alcohol misuse
FRENCH CANADIANS
Sickle cell disease
Osteoporosis
Osteoarthritis
Cardiovascular disease
Lung cancer
Breast cancer
Cystic fibrosis
Phenylketonuria
Tyrosinemia
Morquio syndrome
Familial hypercholesterolemia
Breast and ovarian cancer
Spastic ataxia Charlevoix-Saguenay type
Cytochrome lipase deficiency
Phenylketonuria
GERMANS
Myotonic muscular dystrophy
Hereditary hemochromatosis
Sarcoidosis
Dupuytren’s disease
Peyronie’s disease
Cholelithiasis
Stomach cancer
Cystic fibrosis
Hemophilia
POLISH
Cardiovascular diseases
Diabetes mellitus
Alcohol misuse
Cancer
Pulmondary disorders
GREEKS
Tay-Sachs disease
Cardiovascular disease
Malaria
Tuberculosis
Glucose-6-phosphate dehydrogenase deficiency
Hepatitis A and B
Genetic, lifestyle, environment
Genetic
Genetic, lifestyle
Environment
Lifestyle
Genetic
Genetic
Genetic
Environment, lifestyle
Environment, lifestyle
Genetic, environment
Lifestyle, genetic
Genetic
Genetic, lifestyle, environment
Environment, lifestyle
Genetic, lifestyle
Genetic
Genetic
Genetic
Genetic
Genetic, lifestyle
Genetic, environment
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic, environment
Genetic
Genetic
Genetic, lifestyle
Genetic, lifestyle, environment
Genetic
Genetic
Environment, lifestyle
Genetic, lifestyle
Environment, lifestyle
Environment, lifestyle
Environment, lifestyle
Genetic
Genetic, environment, lifestyle
Environment
Environment, lifestyle
Genetic
Environment, lifestyle
Continues on page 446
2780_Appendix_441-448 16/07/12 12:18 PM Page 445

446 Cultural, Ethnic, and Racial Diseases and Illnesses
Cultural/Racial Group Diseases/Disorders Causes
FINLANDERS
Stomach cancer
Congenital nephrosis
Generalized amyloidosis, type V
Polycystic liver disease
Retinoschisis
Aspartylglycosaminuria
Diastrophic dwarfism
Choroideremia
ITALIANS
Vogt-Koyanagi-Harada syndrome
�-Thalassemia
Recurrent polyserositis
Hypertension
Nasopharyngeal cancer
Stomach cancer
Liver cancer
Familial Mediterranean fever
Glucose-6-phosphate dehydrogenase deficiency
JEWS
Lactase deficiency
Werdnig-Hoffmann disease
Mucolipidosis IV
Phenylketonuria
Kaposi sarcoma
Gaucher disease
Niemann-Pick disease
Tay-Sachs disease
Riley-Day syndrome
Torsion dystonia
Factor XI plasma thromboplastin antecedent (PTA)
deficiency
Cystinuria
Ataxia-telangiectasia
Familial Mediterranean fever
Metachromatic leukodystrophy
Bloom syndrome
Myopia
Polycythemia vera
Hypercholesterolemia
Breast cancer
Diabetes mellitus
POLES
Phenylketonuria
Respiratory diseases
Cardiovascular diseases
APPALACHIANS
Black lung
Emphysema
Tuberculosis
Hypochromic anemia
Cardiovascular disease
Sudden infant death syndrome
Diabetes mellitus
Otitis media
Lifestyle, environment
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Lifestyle, genetic
Lifestyle
Lifestyle
Lifestyle
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic, unknown
Genetic, lifestyle
Genetic, lifestyle
Genetic
Genetic
Environment, lifestyle
Genetic, lifestyle, environment
Environment
Environment, lifestyle
Lifestyle
Environment, lifestyle
Unknown, environment, lifestyle
Genetic, lifestyle, environment
Environment, lifestyle
Genetic, lifestyle
Genetic
Genetic
Lifestyle
2780_Appendix_441-448 16/07/12 12:18 PM Page 446

Cultural, Ethnic, and Racial Diseases and Illnesses 447
Cultural/Racial Group Diseases/Disorders Causes
Native Americans/
Alaskan Natives
SCANDINAVIANS
Cholelithiasis
Sjögren-Larsson syndrome
Krabbe disease
Phenylketonuria
IRISH
Phenylketonuria
Neural tube defects
Cardiovascular disease
Alcoholism
Skin cancer
AMISH
Limb-girdle muscular dystrophy
Ellis–van Creveld syndrome
Dwarfism
Polydactylism
Cartilage hair hypoplasia
Phenylketonuria
Glutaric aciduria
Manic-depressive disorder
Pyruvate kinase deficiency
Hemophilia B
RUSSIANS
Alcoholism
Hypertension
Pulmonary disorders
Hyperlipidemia
Diabetes mellitus
Depression
Gastrointestinal disorders
Diabetes mellitus
Cholelithiasis
Lactase deficiency
Liver disease
Hepatitis B
Nasopharyngeal cancer
Tuberculosis
Alcoholism
NAVAJOS
Ear anomalies
Arthritis
Severe combined immunodeficiency syndrome
Navajo neuropathy
Albinism
Tuberculosis
HOPIS
Tyrosinase-positive albinism
Trachoma
PUEBLOS
Albinism
ZUNIS
Tyrosinase-positive albinism
Genetic, lifestyle
Genetic
Genetic, environment, lifestyle
Genetic
Genetic
Genetic
Genetic
Genetic, environment, lifestyle
Genetic
Genetic
Genetic
Genetic, unknown
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Lifestyle, genetic, environment
Lifestyle, environment
Lifestyle, environment
Lifestyle, genetic
Lifestyle, genetic
Lifestyle, environment
Lifestyle
Genetic, lifestyle, environment
Lifestyle
Genetic
Environment, lifestyle
Environment, lifestyle
Environment, lifestyle
Environment, lifestyle
Lifestyle, genetic
Genetic
Genetic
Genetic
Genetic
Genetic
Environment, lifestyle
Genetic
Environment, lifestyle
Genetic
Genetic
Continues on page 448
2780_Appendix_441-448 16/07/12 12:18 PM Page 447

448 Cultural, Ethnic, and Racial Diseases and Illnesses
Cultural/Racial Group Diseases/Disorders Causes
ESKIMOS
Hereditary amyloidosis
Congenital adrenal hyperplasia
Methemoglobinemia
Lactase deficiency
Pseudocholinesterase deficiency
Haemophilus influenza type B
TURKS
Sickle cell
Goiter
Helminthiasis
Behçet’s disease
Thalassemias
Lactase deficiency
Tuberculosis
Cardiovascular disease
Diabetes mellitus
Genetic
Genetic
Genetic
Genetic
Genetic
Genetic?
Genetic, environment
Genetic, environment
Environment, lifestyle
Genetic
Genetic
Genetic
Environment, lifestyle
Genetic, lifestyle
Genetic, lifestyle
2780_Appendix_441-448 16/07/12 12:18 PM Page 448

449
Abstracts
American Indians
and Alaska Natives
Olivia Hodgins and David Hodgins
The Bureau of Indian Affairs (BIA) recognizes
556 different tribes of American Indians and Alaska Na-
tives (AI/ANs) that extend throughout the United States.
Most live on reservations created on undesirable lands
that European Americans did not view as valuable.
Because of severe economic conditions and high un-
employment rates, significant migration occurs into
and out of the reservations. Many who leave the reser-
vation experience culture shock, and some return due
to lack of social support systems and loss of identity
and self-esteem. In contrast to other cultures, compet-
itiveness is generally discouraged among AI/AN pop-
ulations. Group achievements are more important
than individual achievement.
Health-care providers must be extremely careful
when attempting to speak an AI/AN language because
minor variations in pronunciation may change the en-
tire meaning of a word or phrase. The willingness of
AI/ANs to share their thoughts and feelings varies
from group to group and from individual to individual.
In addition, no set pattern exists regarding their will-
ingness to share tribal ceremonies. However, suspicion
always exists because earlier government and church
groups banned tribal ceremonies and events.
AI/ANs are collectivist cultures with a focus on the
group that promotes reliance and a close bond with
family members, community, and tribe. Older adults are
looked on with clear deference and play an important
role in maintaining rituals and in instructing children
and grandchildren. Elders transmit the ancestral knowl-
edge to the youth of their tribe, the community at large,
and, specifically, their family. Time is not viewed as a
constant or something that one can control, but rather
as something that is always with the individual. Plan-
ning for the future may be viewed as foolish.
A primary social premise is that no person has
the right to speak for another. Parents tend to be
more silent, noninterfering, and permissive in their
child-rearing practices. Children are allowed to make
decisions that other cultures may consider irresponsi-
ble. For example, children may be allowed to decide
whether they want to take their medicine and if they
would like to live with extended family members.
Many AI/ANs remain traditional in their practice
of religious activities, often taking time from work or
school. The needs of the individual must be weighed
against organizational requirements in the develop-
ment of a reasonable solution. IHS is the only organ-
ization allowed to discriminate in hiring practices; it
is required to hire an AI/AN when possible. This law
is referred to as the Indian Preference Law.
Skin color among AI/ANs varies from light to very
dark brown, depending on the tribe. Newborns and
infants commonly have Mongolian spots on the
sacral area.
Historically, most diseases affecting AI/ANs were
infectious such as tuberculosis, smallpox, and in-
fluenza. In the past, contact with settlers who had com-
municable diseases eliminated entire tribes because
they had no acquired immunity. Common diseases re-
lated to living in close contact with others include
upper respiratory illnesses and pneumonia. Diseases
of the heart, malignant neoplasm, unintentional in-
juries, diabetes mellitus, and cerebrovascular disease
are the leading causes of AI/AN deaths.
Other conditions include a high incidence of severe
combined immunodeficiency syndrome (SCIDS), which
results in a failure of the antibody response and cell-
mediated immunity. Thus far, studies indicate that
SCIDS is unique to the Navajo population. Navajo
neuropathy has been researched since 1974, and in 2006
it was discovered to be the result of a mutation of the
MPV17 gene. Characteristics of this disease include
poor weight gain, short stature, sexual infantilism,
serious systemic infections, and liver derangement.
Manifestations include weakness, hypotonia, areflexia,
2780_Abstract01_449-451 16/07/12 12:11 PM Page 449

loss of sensation in the extremities, corneal ulcerations,
acral mutilation, and painless fractures. Individuals who
survive have many complications and are ventilator
dependent; none have survived past 24 years old.
Most AI/AN tribes exhibit high-risk behaviors re-
lated to alcohol misuse, with its subsequent morbidity
and mortality. Many accidents are attributed to driv-
ing while under the influence of alcohol. Although al-
cohol is illegal on most reservations, many purchase
it off the reservation, and bootleggers make money
selling it on reservations at grossly inflated prices.
Spousal abuse is frequently related to alcohol use. The
wife is the usual recipient of the abuse, but occasion-
ally, the husband is abused.
Food has major significance beyond nourishment
in AI/AN populations. Food is offered to family and
friends or may be burned to feed higher powers and
those who have died. Life events, dances, healing,
and religious ceremonies evolve around food. Corn
is an important staple in the diet of American Indians
and is used in many rituals.
AI/AN diets may be deficient in vitamin D because
many members suffer from lactose intolerance or do
not drink milk. Isolated tribes lack electricity for re-
frigeration. Therefore, they have difficulty storing
fresh vegetables or milk. Distances from settlements
or villages to larger off-reservation towns limit the
availability of fresh food items because of shipping
and storage issues.
The definitive goal for a woman in AI/AN societies
is being a mother and rearing a healthy family. Tradi-
tional AI/ANs do not practice birth control and often
do not limit family size.
Death rituals vary among tribes, maintaining and
adapting them to their regional environments. Most
AI/AN tribes believe that the souls of the dead pass
into a spirit world and become part of the spiritual
forces that influence every aspect of their lives.
Some tribes maintain their traditional practices but
use a mortuary or the IHS morgue to prepare their
dead. The Pueblo tribes prepare their own dead,
and only certain family members are allowed to pre-
pare the body. Hopis bury their dead before the next
setting of the sun and bury them in upright sitting
positions. After the Zuni burial ceremony, the mem-
bers must take off 3 days from work for a cleansing
ceremony.
The individual’s source of strength comes from the
inner self and depends on being in harmony with
one’s surroundings. Spirituality cannot be separated
from the healing process in ceremonies. Illnesses, es-
pecially mental illnesses, result from not being in har-
mony with nature, from the spirits of evil persons
such as a witch, or through violation of taboos.
Healing ceremonies restore an individual’s balance
mentally, physically, and spiritually. The following
are core concepts to traditional Indian medicine:
• AI/ANs believe in a Supreme Creator.
• Each person is a threefold being composed of
mind, body, and spirit.
• All physical things, living and nonliving, are a part
of the spiritual world.
• The spirit existed before it came into the body and
it will exist after it leaves the body.
• Illness affects the mind and the spirit as well as the
body.
• Wellness is harmony with nature and spirits
• Natural unwellness is caused by violation of a
taboo.
• Unnatural wellness is caused by witchcraft.
• Each of us is responsible for our own health.
Through existing treaties, the federal government as-
sumed responsibility for the health-care needs of
AI/ANs. However, with the Indian Self-Determination
Act, many tribes have contracted for this money to op-
erate their own health-care systems. Few tribal members
have traditional health insurance.
Since the early 1980s, an increase has occurred in
wellness-promotion activities and a return to past tra-
ditions such as running for health, avoiding alcohol,
and using purification ceremonies. Mental-health pro-
grams are not well funded and are understaffed in
IHS. Physicians are oriented to traditional healing
practices, but if patients perceive reluctance to accept
these practices, they do not reveal their use. This is es-
pecially true among older people who seek hospital or
clinic treatments only when their conditions become
life-threatening. Younger generations seek treatment
sooner and use the health-care system more readily
than do older people. However, if their parents are tra-
ditional, they may combine native traditional medi-
cine with Western medicine.
Medicine men, diagnosticians, crystal gazers, and
shamans tell them how to restore harmony. The med-
icine man is expected to diagnose the problem and
prescribe necessary treatments for regaining health.
AI/ANs receiving care within the context of Western
medicine are concerned about obtaining adequate
pain control. Frequently, pain control is ineffective be-
cause the intensity of their pain is not obvious to the
health-care provider because patients do not request
pain medication. Older adult AI/AN’s view pain as
something that is to be endured and may not ask for
analgesics or may not understand that pain medica-
tion is available. At other times, herbal medicines are
preferred and used without the knowledge of the
health-care provider.
AI/AN healers are divided primarily into three cat-
egories: those working with the power of good, those
450 American Indians and Alaska Natives
2780_Abstract01_449-451 16/07/12 12:11 PM Page 450

working with the power of evil, or both. Generally,
medicine people are from specific clans and promote
activities that encourage self-discipline and self-
control and involve acute body awareness. Within
these three categories are several types of practition-
ers. Some are endowed with supernatural powers,
whereas others have knowledge of herbs and specific
manipulations to “suck” out the evil spirits.
Treatment regimens prescribed by a medicine man
not only cure the body but also restore the mind. Ac-
ceptance of Western medicine is variable, with a
blending of traditional health-care beliefs. Experi-
enced IHS providers understand the concepts of ho-
listic health for AI/ANs, and behavioral health
specialists are beginning to make referrals to the
medicine man.
American Indians and Alaska Natives 451
2780_Abstract01_449-451 16/07/12 12:11 PM Page 451

452
Abstracts
People of Baltic Heritage: Estonians,
Latvians, and Lithuanians
Rauda Gelazis
The Baltic countries today are democratic, growing
economically, and successful when compared with
many other former Soviet Union countries where
poverty and dictatorships have been predominant. All
three Baltic countries have established strong ties to
Western democratic countries and have been accepted
into the North Atlantic Treaty Organization (NATO)
and the European Union. Since the mid-1990s, the
Baltic countries have experienced a “brain drain” to
some extent, because many of their highly educated
people have emigrated to the United States and Europe.
People of Baltic descent share thoughts and feel-
ings readily. The stereotype of quiet, stoic individuals
is not borne out by observation or research. Older in-
dividuals from these cultural groups are generally
first-generation Americans or immigrants who came
to the United States after World War II. Many indi-
viduals are not as acculturated as younger people and
often prefer to speak their own languages. Health-
care providers need to be sure that any instructions
given to these patients are well understood. The
father or father figure is the head of the household in
the typical family of Baltic heritage, although both
men and women in the family may have jobs and
discuss major decisions. Health-care and other major
decisions are often made jointly by both spouses.
Because both spouses tend to work, child care may
be shared by grandparents and should be included in
health teaching.
People of Baltic descent adapt readily to American
values of timeliness in the workplace. Most have no
difficulty maintaining their sense of autonomy and
readily assume work roles and responsibility for deci-
sion making. They usually do not like to directly con-
front those in authority and find ways to deal with
difficult situations or people through the use of humor
or deference. Recent immigrants who have lived under
the Soviet regime may not be accustomed to making
decisions for themselves or acting autonomously, and
this must be considered when they are hired.
Recent immigrants from Estonia, Latvia, and
Lithuania may be at risk for cancer because of the cur-
rent industrial pollution, including radiation exposure
resulting from the Chernobyl nuclear disaster in 1988.
Some immigrants are survivors of political torture,
having spent years in prison labor camps in Siberia.
When performing health assessments, health-care
providers need to be alert to ill health resulting from
the conditions that immigrants endured because of
the political situations in their countries of origin.
Americans of Baltic descent are health conscious
and believe that a well-balanced lifestyle maintains
health and well-being. For example, well-being among
Lithuanian Americans is typically described as a ho-
listic concept—that is, a state of being in which the
person’s physical, spiritual, psychological, and social
health are in balance. Moderation is perceived as de-
sirable for living a healthy life. Natural foods are pre-
ferred, and whenever possible, vegetables and fruits
are homegrown.
Americans of Baltic descent use modern Western
medicine practices, are likely to obtain early prenatal
medical care, and are likely to be receptive to health
teaching for prenatal and postnatal care. Because they
prefer natural processes, some women and families
prefer natural childbirth and breastfeeding.
Grief is expressed by sadness, crying, and talking
about the deceased with fondness and respect. Emo-
tions are readily expressed but not in highly dra-
matic ways. Decorum is maintained in public and
with strangers. Estonian Americans and Latvian
Americans are predominantly Lutherans but include
some Catholics. Lithuanian Americans are predom-
inantly Roman Catholic. Most Americans of Baltic
descent consider prayer an individual expression of
their faith. The nurse or health-care provider should
2780_Abstract02_452-453 16/07/12 12:12 PM Page 452

allow the patient and family to take the lead with
regard to prayer. Because prayer is individualized,
some patients welcome time for individual or shared
prayer, whereas others do not wish to pray. Many
have been sustained through hardships by their strong
religious faith and continue to have strong religious
needs. Patients find considerable comfort in speaking
with the clergy in times of crises and serious illness.
Some stigma is attached to mental illness, but med-
ical care is sought. The family encourages adherence
to prescription medications and treatments. Most
people of Baltic descent accept physical handicaps,
mental illness, and mental retardation. The family
usually cares for the individual at home. The commu-
nity is also supportive. Americans of Baltic descent
do not enjoy the sick role and avoid it when possible.
People of Baltic descent are used to both men and
women giving direct physical care. Physicians in the
Baltic countries may be female. Health-care providers
need to provide for privacy and consider the modesty
needs of female and male patients of these cultures
as they would for any patient.
People of Baltic Heritage: Estonians, Latvians, and Lithuanians 453
2780_Abstract02_452-453 16/07/12 12:12 PM Page 453

454
Abstracts
People of Brazilian Heritage
Marga Simon Coler and Maria Adriana Felix Coler
Brazilians are a mixture of Portuguese, French,
Dutch, German, Italian, Japanese, Chinese, African,
Arab, and native Brazilian Indians. Information about
Brazilian culture is unidentifiable in the professional
health-care literature, which tends to incorporate
Brazilians into aggregate data on Hispanics. Most
Brazilians in the United States are concentrated in
communities around Boston; New York; Newark,
New Jersey; and Miami.
Portuguese is the official language of Brazil and
continues to dominate the Brazilian communities in
the United States. Brazilians, in general, are not punc-
tual, arriving late—from minutes to hours—especially
for social occasions. However, those in professional
circles are punctual. Health-care providers may need
to carefully explain the necessity of showing up on
time for health appointments.
Gender roles vary according to socioeconomic class
and education. Brazilian society is one of machismo,
with the middle and upper classes being patriarchal in
structure. As women assert their equality, more egali-
tarian relationships are becoming evident. However,
lower-socioeconomic households tend to be more
matriarchal in nature. Godparents are a very impor-
tant family extension to Brazilians. Poor families fre-
quently ask their patron or patrona (employer and his
wife) to be godparents to their child. Godparent re-
sponsibilities include clothing, schooling, and caring
for the child if the parents die. Health-care providers
need to be nonjudgmental regarding Brazilian family
decision-making patterns.
Brazilians value diplomacy over honesty, as shown
in their tendency to promise to attend to something the
next day, knowing that it will be impossible. This is due
in part to their fatalistic beliefs and in part to the need
to save face. Most Brazilians in the workforce show up
for work on time and generally respect authority. They
are more comfortable in employment situations in
which rules and job specifications are well defined.
Brazilians often have a lesser sense of responsibility
than is seen in the dominant American culture. When
educated people believe that they can do something
more efficiently, they are apt not to ask permission
from their supervisor to do what they believe is re-
quired to complete the job.
Specific diseases related to the regional topography
and climate of Brazil include dengue fever, meningitis,
rabies, and yellow fever. In addition, Chagas disease,
schistosomiasis, typhoid fever, Hansen’s disease, hep-
atitis, and tuberculosis are present in various parts of
Brazil. Because intestinal worms are common in
Brazilian immigrants, parasitic diseases should be
considered during health assessments.
The undocumented status of Brazilian immigrants
places them at a high risk for nonassimilation into
the culture of the community in which they live.
Brazilians in America have become vitamin and
health food conscious. The preference, especially
among young Brazilian women, is to rely on vitamins
instead of a heavy diet to help them remain thin.
Undocumented Brazilians who are here to earn fast
money may experience malnutrition.
Brazilian immigrants generally practice birth con-
trol so that pregnancy will not interfere with their
reason for leaving Brazil. At times, single women
become pregnant to facilitate their chance of remain-
ing permanently in their new country. This opportu-
nity is greatly enhanced if the child is born in the
United States and has been able to attend school.
Many restrictions are related to pregnancy. Women
are encouraged not to do heavy work or swim. Taboos
also warn against having sexual relations during preg-
nancy. During pregnancy, some foods are to be
avoided and other specific foods are recommended.
The meaning of life is found in religion, economy,
fatalism, and reality. The greatest source of strength
for Brazilians is their immediate and extended fami-
lies. Tradition and folk religion are other sources of
strength.
Most Brazilians do not talk about their illnesses un-
less these are very serious. Generally, illness is dis-
cussed only within the family. Many Brazilians feel
that talking about an illness such as cancer negatively
influences their condition. Because many Brazilians
2780_Abstract03_454-455 16/07/12 12:12 PM Page 454

tend to shun hospitals, when they are hospitalized,
their families accompany them and stay around the
clock. Brazilian families are eager to participate in pa-
tient care and, thus, can be taught various procedures
and care activities.
Responses to death and grief depend on the family.
To a poor family, a continuously suffering person is
rescued. The fatalistic expression “It was God’s will”
helps the grieving among the rich and the poor. Older
people wear black for various lengths of time, de-
pending on the relationship of the family member.
Frequently, the final portrait is hung in the family
chapel or near the family altar, and prayers are
recited. An eternal light burns.
The Brazilian culture is rich in folk practices that
depend on geographic region, ethnic background, so-
cioeconomic factors, and generation. Traditional and
homeopathic pharmacies are supplemented by reme-
dios populares (folk medicines) and remedios caseiros
(home medicines). Health-care providers need to
specifically ask about their use. Brazilians generally do
not like to talk about pain. However, once the emo-
tional barrier is removed, they feel relieved to be able
to discuss their discomfort. Many pain-relieving med-
icines are available without a prescription in Brazil.
Frequently, a person requiring these on a regular basis
will request that friends or friends of friends bring a
supply from Brazil.
The folk health field has many types of health-care
practitioners for Brazilians. Curandeiros are divinely
gifted; rezadeiras (praying women) help exorcise an
illness; card readers can predict fortunes; espiritual-
istas are able to summon souls and spirits; consel-
heiros are counselors or advisors; and catimbozeiros
are sorcerers. All have the power to heal their believ-
ers. Health-care providers need to specifically ask
Brazilian patients about their use of folk healers and
the treatments prescribed.
People of Brazilian Heritage 455
2780_Abstract03_454-455 16/07/12 12:12 PM Page 455

456
Abstracts
People of Egyptian Heritage
Afaf Ibrahim Meleis and Mahmoud Hanafi Meleis
Egypt is considered part of 22 Arabic-speaking
countries in North Africa and as a Middle Eastern
country. Scholarly literature about Egyptians in the
United States is limited. Most Egyptians Americans
are Sunni Muslims but are diverse in many ways. How-
ever, only the most common patterns of responses and
experiences of Egyptian Americans with regard to
health and illness are presented in this chapter. An in-
fluential part of modern Egyptian history is the Arab-
Israeli conflict. The conflict between Egypt and Israel
ended in 1979 when the two countries signed the Camp
David Accords. Another important turning point for
Egyptians, as well as Egyptian Americans, in their
identity and connection to their cultural heritage is
the February 2011 revolution that ousted President
Hosni Mubarak. Egyptians have immigrated to the
United States to escape economic stagnation, for edu-
cational opportunities, for career options, and for eco-
nomic incentives that reward hard-working individuals.
The terrorist attacks in New York, Pennsylvania,
and Washington, DC, and the tragic consequences of
September 11, 2001, have rendered many newly immi-
grated Egyptian Americans vulnerable to profiling
and stereotyping in the United States of America.
Therefore, a newly acquired sense of stigma tends to
influence their patterns of responses in ways that were
not manifested previously.
The dominant language of Egyptians is Arabic.
The written Arabic language is the same in all Arab
countries, but spoken Arabic is dialectal and does not
necessarily follow proper Arabic grammar. A number
of Arabic dialects are spoken in Egypt. Despite these
different dialects and their distinct vocabularies, neither
Egyptians nor Egyptian Americans have any noticeable
communication barriers among themselves.
Several values govern interaction patterns among
Egyptians. The first is respect, ihteram, which is ex-
pected when speaking with those who are older and
those in higher social positions. A second important
value, politeness, adab, is related to what is appropri-
ate, expected, and socially sanctioned. Truth and re-
ality may be sacrificed for what is appropriate and
polite. Politeness results in a preference for more indi-
rect modes of communication. Sharing negative news
directly or asking for things directly is not polite.
Therefore, a poor prognosis of an illness is not
immediately shared; calamities should be slowly and
deliberately introduced and shared in stages.
Egyptian Americans tend to be in touch with their
inner feelings and are highly expressive of them; how-
ever, this expression is governed by external orienta-
tion, spontaneity, and the differences between private
and public spheres. Because their personal space
boundaries tend to be small, they stand and sit very
close to one another. Most speak with expressive
words and facial expressions, gesticulating with hands
and using body movements. Devout Muslim men and
women do not touch each other; even a handshake is
not practiced.
Respect for individuals is demonstrated in the
use of certain titles: inta (you) for those in equal or
lower positions, and hadretak (you) for those in
higher-ranking positions or for older people. Older
people should never be called by their first names
without an adjective or title attached to the name. The
man is formally considered the head of the household;
however, the demands of life on immigrants and nu-
clear families force couples to share responsibilities
and decision making. Egyptian American family roles
change considerably after immigration.
Children are treasured and viewed as security for
their parents’ future. During their early years, they are
expected to be studious and goal oriented, respectful,
and loyal to the family. When they become adults, they
are expected to take care of their parents. However,
second-generation Egyptians tend to blend with other
Americans. The greatest calamity that may happen in
a Christian or Muslim Egyptian American household
is to have a daughter lose her virginity prematurely.
This fear stems from a potential lack of marriageabil-
ity of the daughter, loss of face for the father, and
gossip within the Egyptian American community.
Although Egyptians in their own country have
extended families, Egyptian American families tend
2780_Abstract04_456-458 16/07/12 12:13 PM Page 456

to be more nuclear. They also prefer family gatherings
to adult gatherings where they often include extended
family and their new networks of friends.
Egyptian immigrants tend to be team players and
effective contributors to the society at large. They are
usually punctual and follow work rules and proce-
dures. Being well assimilated, they create a close
network of colleagues.
Pap smears for unmarried women are discouraged
and considered totally unacceptable because of the
expectations for preserving virginity until marriage.
Gynecological examinations are given only to mar-
ried women, usually during the checkup for a first
pregnancy.
Egyptians entertain lavishly and enjoy good food,
which represents nurturing. The more food one pro-
vides, the more love is portrayed. Egyptians develop
trust in one another by having a meal together. The
more food a person eats, the greater the potential for
being healthy. Thus, children tend to be overfed. Food
is associated with generosity and giving. To offer food
and to accept food are indications of friendship. Meal-
time is for eating and for socializing but not for con-
ducting business or discussing issues.
Most devout Muslims do not consume pork or
drink alcohol. Egyptian Copts may consume both in
moderation. Ramadan calls for a month of fasting to
experience the plight of the poor and the underprivi-
leged. Fasting precludes taking anything by mouth or
intravenously and abstaining from sexual activities.
Even Egyptian Americans who do not follow and
abide by the teachings of Islam during the year con-
sider this month holy, and they become more devout
during Ramadan.
Women are advised to curtail physical activities
during pregnancy for fear of miscarriage. Women are
also advised to eat more because they are feeding two.
Some Egyptian American women have strong cravings
for certain foods. They believe if these foods are not
consumed, babies may be marked with the shape of
the foods that were craved.
Egyptians react vigorously and dramatically to the
loss of a family member, expressing their grief out-
wardly. Wailing and public crying occur when first
learning of death. This public reaction is an expected
demonstration of their grief; otherwise, the community
may regard them as lacking affection for the deceased.
Among Muslims, the burial ritual includes cleaning the
body and wrapping it in a white cotton cloth.
Prayers, even for the nondevout Muslim or
Christian, are significant during times of illness.
Egyptian Americans may bring the Qur’an or the
Bible to their hospital beds and usually put it under
the pillow or on the bedside table. Prayers may be
recited by the individual or in groups.
Whereas Egyptian Americans are usually well ed-
ucated, their views are colored by beliefs about the
influence of imbalances, the evil eye, and Islamic be-
liefs about the role God plays in their illness. How-
ever, they are firm believers in Western medicine’s
miraculous ability to treat and cure illnesses.
Cleanliness and hygiene are integral to practicing
Muslims. A number of elaborate prayer rituals are also
related to health care and prevention of illness. For ex-
ample, before praying, Muslims must engage in a purifi-
cation ritual, which consists of washing every exposed
body part. Prayer, required five times daily, consists of
elaborate bending and kneeling movements in system-
atic ways, increasing a person’s range of movements,
limbering stretches, and meditative poses.
Typically, Egyptian Americans experiencing a
health problem consult family members and friends
before visiting a trusted health-care provider. Once in
the health-care system, they prefer immediate, person-
alized attention. They value tests and prescriptions for
their illnesses and follow medical regimens and pre-
scriptions carefully, particularly if they consist of oral
medications, injections, or both. Egyptian Americans
tend to share medications freely and use Western med-
ications and home remedies such as herbs, hot com-
presses, and hot fluids and foods. They also believe
that vitamins given intramuscularly and intravenously
are more effective than vitamins taken in pills.
Egyptians believe the evil eye is responsible for per-
sonal calamities. The evil eye is cast by those who have
blue eyes, by those who tend to speak of an admired
person or object in a boastful manner, or by the mere
description of beauty, wealth, or health without say-
ing some verses from the Qur’an or Bible. These verses
protect the person from losing whatever good they
possess. Some use blue beads or religious verses in-
scribed on charms to protect them or their children
from the evil eye. Children are particularly at risk for
the evil eye and need more protection than adults.
Egyptians avoid pain at all costs by seeking prompt
interventions. They tend to be verbally and nonver-
bally expressive about pain; moaning, groaning, sigh-
ing, and holding the painful body part tightly are
common expressions of pain. Although they tend to
be more constrained in front of health-care providers
or other “strangers,” they are quite expressive in front
of family members. Egyptian descriptions of pain may
not be as specific as the Western health-care system
prefers. Egyptians present a more generalized descrip-
tion of pain, regardless of whether it is localized. They
usually describe general weakness, dizziness, or overall
tension and stress associated with pain. They also use
metaphors reflecting humoral medicine such as earth,
rocks, fire, heat, and cold to describe their pain.
Mental and emotional issues tend to be expressed
somatically; psychosomatic interventions are more ef-
fective than psychologically based interventions. They
also do not like to call treatments “psychotherapy” or
“analysis” but prefer to call it “counseling.” Disabilities
People of Egyptian Heritage 457
2780_Abstract04_456-458 16/07/12 12:13 PM Page 457

are usually hidden from public view. Whereas there are
public sympathy and acceptance of people with dis-
abilities, families still tend to be protective and shield
them from public display.
Egyptian Americans have no taboos against blood
transfusions or organ transplants. All measures
needed to heal, cure, or prolong life are welcomed.
Accustomed to Egyptian physicians whose clinical
judgments and skills have been developed within a sys-
tem that lacks adequate resources for meticulous diag-
noses, some may misperceive an American physician’s
thoroughness as a lack of experience or appropriate
knowledge. Therefore, they may shop for physicians
whose clinical judgments are congruent with their cul-
tural expectations of a prompt and firm diagnosis.
Sharing the intimate details of their health history
is enhanced if the health-care provider is the same
gender. Egyptian Americans may also view older fe-
male physicians as more experienced and, therefore,
more trustworthy than younger female physicians. The
physician’s age, years of experience, and position in
the organization may indicate better qualifications.
458 People of Egyptian Heritage
2780_Abstract04_456-458 16/07/12 12:13 PM Page 458

459
Abstracts
People of French Canadian Heritage
Myriam Gauthier and Ginette Lazure
Canada, with a population of 34 million and an area
of more than 3,800,000 square miles, is larger than the
entire United States but has only one-ninth the popu-
lation. One-quarter of the population uses French as
their mother tongue, and the rest speak French as a
second language. The Métis, descendants of Native
Americans and Europeans, are mainly, though not en-
tirely, French-speaking. Some regard the Métis as a
historically and culturally distinct people in their own
right. Another major portion of Canada’s French-
speaking population is the Acadians, descendants of
the early French colonists. Canadians whose first
language is French are called Francophones.
Canada has two official languages, French and
English. Regional differences exist in accent, vocabu-
lary, and degree of Anglicization. Oral communica-
tion, in particular, has undergone assimilation. Indian
words have been added, and English words are incor-
porated into a syntax and grammar that is essentially
French, resulting in a dialect, Joual in Québec and
Chiac in New Brunswick.
Among French Canadians, a conversation may be
conducted with high voice crescendos that do not nec-
essarily mean anger or violence. Volume can increase
with the importance and the emotional charge in-
vested in the content of the message. Nonverbal com-
munication patterns for French Canadians encourage
sharing thoughts and feelings. Acadians are more re-
served, quieter, shy, even self-effacing, and are less
likely to share their thoughts and feelings than people
from Québec. The use of hand gestures for emphasis
when speaking is common.
When in the intimacy zone, people may touch fre-
quently and converse in close physical space; however,
they tend to avoid physical contact in public. When
greeting another person, men usually shake hands, an
approach recommended for health-care providers. Eye
contact is an important way for the health practitioner
to acknowledge whether the person has understood
or is following what is being said.
Under Québec law, a woman keeps her maiden
name throughout her lifetime, although in other parts
of Canada, the husband and wife decide what name
the wife will use. A Québécois family of two spouses
and two children may well include four different sur-
name combinations: One child may have the father’s
surname or the mother’s surname alone or a hyphen-
ated or nonhyphenated surname composed of those
of the father and mother. For a second child, the sur-
names are the same, but in reverse order. The decision
for using surnames rests entirely with the parents and
must appear on the birth certificate.
Traditionally, the Catholic Church dictated the pa-
rameters of sexual behavior, with a high priority
placed on marriage and the begetting and raising of
children. In the years before 1960, abstinence from
premarital sex was encouraged, and a sexual double-
standard existed, whereas the 1970s and 1980s wit-
nessed a liberalization of sexual norms and the
establishment of more egalitarian relationships be-
tween young men and women. In 1996, the Canadian
government extended health, relocation, and other job
benefits to same-sex partners of federal employees.
During the same year, the Ontario Court of Appeals
ruled that same-sex couples must be treated as
common-law couples under the Family Leave Act.
Canada is one of the few countries in the world where
same-sex marriage is legalized.
The primary causes of death among the Québec
population are cancer, with an increase in lung cancer
in women, and cardiovascular diseases. Prostate can-
cer is high among the Francophone population of
Québec. Genetic susceptibility to breast and ovarian
cancer is high among French Canadians. The suicide
rate in Québec is higher than in any other province
and occurs more often in rural areas than in urban
areas. Few countries surpass the Québec mortality rate
by suicide. Eighty percent of all suicides reported in
1991 involved men. The population’s osteoarthritic
disorders and the prevalence of multiple sclerosis are
among the highest in the world.
A number of hereditary and genetic diseases are
more common among Québécois, including spastic
ataxia Charlevoix-Saguenay type, cystic fibrosis,
2780_Abstract05_459-461 16/07/12 12:13 PM Page 459

tyrosinaemia, and cytochrome lipase deficiency (COX),
to name a few. Familial chylomicronemia resulting
from the lipoprotein lipase (LPL) deficiency, hyper-
lipoproteinemia type I, is the highest frequency world-
wide. A rare genetic disease among French Canadian
newborns is phenylketonuria (PKU). In addition, in-
creased incidences of cystic fibrosis and muscular dys-
trophy occur among French-speaking Canadians.
The French population has a long-standing appre-
ciation of alcohol, with wine being their beverage of
choice. Alcohol consumption has increased since the
early 1990s, particularly among men; drinking and
driving among young men has reached a summit de-
spite the legal implications. Impaired driving is still
the leading cause of fatalities on Québec roads.
Good health practices are more prevalent among
Canadian men under the age of 25 years and over the
age of 65 than among men in their middle adult years.
In contrast to men, the prevalence of good health
practices among Canadian women increases until the
age of 65 and then decreases. These practices were
positively correlated with levels of education in both
sexes, adequate income for women, and managerial or
professional occupations for men.
Food is associated with hospitality and warmth and
is part of all meetings and celebrations. Common veg-
etables enjoyed by French Canadians include pota-
toes, turnips, carrots, asparagus, cabbage, lettuce,
cucumbers, and tomatoes. Apart from citrus fruits, all
other edible fruits, particularly apples and berries
grown in gardens or in the wild, are prepared and pre-
served by French Canadians for the winter. Meat
choices are mainly beef, pork, and poultry. Lately,
however, lamb has gained popularity. In Acadia,
owing to the proximity of the coastal areas, fresh fish
and seafood are part of the diet.
Until the middle of the 20th century, French
Canadians maintained high fertility rates, which is
uncommon for a population living in an industrialized
country. The “overfertility” of French Canadians ap-
pears to be a response to socialization that is distin-
guished by the prevalence of extended family ties.
However, as education increases, the fertility rate
within the Francophone group decreases, whereas the
contrary is observed within the English group, mean-
ing that as education level increases, so does the fer-
tility rate. For many years, French Canadian fertility
practices have been closely tied to the Catholic reli-
gion. The number of children per family started to de-
cline from 3.1 in 1965 to 1.5 in 1990, with a current
record of 1.1 children per family.
Midwives have officially been accepted by the gov-
ernment, but the use of midwives and maternity cen-
ters is far from being customary, mostly because of a
fear of problematical labor. More women are talking
about the desire to deliver at home, but the actual use
of a midwife throughout labor and delivery at home
is quite low. Fathers are encouraged to be present in
the delivery room. They are invited to assume an ac-
tive role by assisting the mother and the physician, re-
ceiving the baby, cutting the cord, and “kangaroo’s
father care”—placing the infant in direct skin-to-skin
contact. With the advent of birthing rooms, more
women are delivering their babies in half-sitting or
side-lying positions.
Rooming-in of the mother and child is a relatively
new practice. Breastfeeding has regained importance
after years of bottle-feeding. The mother’s general
hesitation to breastfeed relates to not having sufficient
milk, experiencing sore nipples, losing breast firmness,
and muscle wasting after the breastfeeding period. In
practice, once the mother has made a decision regard-
ing breastfeeding, the father’s support and encourage-
ment are key for a successful outcome.
French Canadians’ issues related to death and death
rituals are closely related to Christian religious practices.
If death is expected, part of the preparation is the vigil,
where a family member will stay with the dying person.
During this time, in devout families, people will usually
recite prayers, and a priest is often called in to deliver
the Sacrament of the Sick. During the viewing, if the
person was religious, a relative might be designated to
say the rosary. Religious services are either full funeral
masses held in the deceased’s parish church or a more
intimate service at the funeral home. Graveside rites are
generally brief and include a few prayers and a blessing.
Traditionally, French Canadians buried their dead
according to Roman Catholic rites. Over the last few
decades, however, cremation has become a common
alternative to burial. Ashes are usually buried in the
cemetery or placed in a mausoleum. Grief is usually
expressed with “restrained sincerity.” Genuine grief
is viewed with compassion, but displays of keening
and wailing are usually seen as unsincere and overly
dramatic.
Whereas most French Canadians identify them-
selves as Roman Catholic and are baptized at birth,
they may or may not remain active church members.
A growing number of births are registered through
civil channels rather than through the traditional
Catholic registry and baptism. Despite the sharp de-
cline in actively practicing Catholics, most people
from all socioeconomic levels turn to their church for
important life events such as marriage and funerals.
Older adults are more inclined to use prayers for
finding strength and for adapting to difficult physical,
psychological, and social health problems. In times of
illness and tragedy, many French-speaking Canadians
use prayer to help recovery. The younger generation is
not strongly influenced by religious values, beliefs, and
faith practices. They tend to turn to spirituality rather
than religion. Renewed interest in spirituality across
Canada is being recognized as a source of physical
and psychological health.
460 People of French Canadian Heritage
2780_Abstract05_459-461 16/07/12 12:13 PM Page 460

The health beliefs, values, and practices of the
French Canadian population are very similar to those
of other Canadians. Being healthy is described as hav-
ing reached balance in one’s life, taking into considera-
tion the relationship among the physical, mental, social,
and spiritual aspects of the person. Health-seeking
behaviors span the gamut of diet, exercise, sleep,
home remedies, a belief in a spiritual being, and con-
sulting health-care providers. Canada’s government-
administered health system ensures free, universal
health coverage at any point of entry into the system.
However, many people in the upper socioeconomic
classes call on their family physicians instead of the
local community service centers. Among the lower-
socioeconomic classes of Québec and the Maritimes,
many do not seek health care until their health becomes
a crisis situation. French Canadians have no official
proscription against receiving blood or blood products.
Those who are members of a religious group that pro-
hibits the acceptance of a blood transfusion are rare in
Canada. The decision to donate or receive an organ or
a tissue is an individual decision.
Health-care providers hold a favorable status in the
eyes of French Canadians, especially among older
people. Today, folk and traditional practitioners are
almost nonexistent.
People of French Canadian Heritage 461
2780_Abstract05_459-461 16/07/12 12:13 PM Page 461

462
Abstracts
People of Greek Ancestry
Irena Papadopoulos and Larry D. Purnell
The Greek and Greek Cypriot diaspora is of consid-
erable size and is spread to all continents and numer-
ous countries. The largest Greek community outside
Greece is in America, whereas the largest Greek
Cypriot community outside Greece is in Britain. The
characteristics of Greek and Greek Cypriot commu-
nities vary considerably according to the time of im-
migration; rural, island, or urban residence; and other
variant cultural characteristics.
Despite considerable temporal and geographic vari-
ation, several core themes are common to people who
retain affiliation with a Greek community: emphasis
on family, honor, religion, education, and Greek her-
itage. The core values of honor, respect, and shame
are key when considering the experience of Greeks
and Greek Cypriots. Because Greeks and Greek
Cypriots value warmth, expressiveness, and spontane-
ity, northern Europeans are often viewed as “cold”
and lacking compassion. Eye contact is generally di-
rect, and speaking and sitting distances are closer than
those of other European Americans. Whereas inner-
most feelings such as anxiety or depression are often
shielded from outsiders, anger is expressed freely,
sometimes to the discomfort of those from less-
expressive groups. Thus, health-care providers must
not take personal offense with verbal and nonverbal
communication practices that are different from theirs.
Greek children are included in most family social ac-
tivities and tend not to be left with babysitters. The child
may be disciplined through teasing, which is thought to
“toughen” children and make them highly conscious of
public opinion. Providers must interpret these child-
rearing practices within their cultural context.
Treatment of older people reflects the themes of
closeness and respect within the family. Grandparents
tend to participate fully in family activities. Families
feel responsible to care for their parents in old age, and
children are expected to take in widowed parents. Fail-
ure to do so results in a sense of dishonor for the son
and guilt for the daughter. Health-care providers need
to thoroughly assess the family beliefs when consider-
ing long-term care.
In regard to the workforce, probably no single char-
acteristic applies so completely to members of the
Greek and Greek Cypriot communities as the empha-
sis on self-reliance within a family context. Greeks and
Greek Cypriots in North America, Britain, Australia,
and Sweden stress this trait, seen as reluctance to be
told what to do and given as a major reason for their
pattern of establishing their own businesses as soon
as possible.
Two important genetic conditions, thalassemia and
glucose-6-phosphate dehydrogenase (G-6-PD), are
seen in relatively high proportions among Greek pop-
ulations. Drugs such as aspirin, primaquine, quini-
dine, thiazolsulfone, dapsone, furzolidone, nitrofural,
naphthalene, toluidine blue, phenylhydrazine, and
chloramphenicol can induce a hemolytic crisis. This
threat is sufficiently severe that the World Health
Organization recommends that all hospital popula-
tions in areas with high proportions of Greeks and
Greek Cypriots be screened for G-6-PD deficiency
before drug therapy is offered.
Fasting is an integral part of the Greek Orthodox re-
ligion. General fast days are Wednesdays and Fridays;
nowadays, these are observed only by some older peo-
ple. Greek Orthodox wishing to take Holy Communion
observe at least 3 days of fasting. However, people with
health conditions and small children are exempt from
fasting. The prevalence of lactose maldigestion among
Greek adults is about 75 percent; however, milk intol-
erance is rarely seen in children. Health-care providers
should use this knowledge when counseling clients with
these conditions.
If a pregnant woman remarks that a food smells
good, or if she has a craving for a particular food, it
should be offered to her; otherwise, the child may be
“marked.” This is the usual explanation for birthmarks.
After a death in the Greek community, pictures and
mirrors may be turned over. During a wake, women
may sing dirges or chant. In some regions, people
practice “screaming the dead,” in which they cry a
lament, the miroloyi. This ritual may involve scream-
ing, lamenting, and sobbing by female kin. After
2780_Abstract06_462-463 16/07/12 12:14 PM Page 462

death, family and close relatives, who stay at home,
mourn for 40 days. Close male relatives do not shave,
as a mark of respect.
The Greek Orthodox religion emphasizes faith
rather than specific tenets. Easter is considered the
most important of holy days, and nearly all Greeks
and Greek Cypriots in America and Britain attempt
to honor the day. Women often consider faith an im-
portant factor in regaining health. Family members
may make “bargains” with saints, such as promises to
fast, be faithful, or make church donations if the saint
acts on behalf of an ill family member.
Three traditional folk healing practices are particu-
larly notable: those related to matiasma (bad eye or the
evil eye), practika (herbal remedies), and vendouses (cup-
ping). Matiasma results from the envy or admiration of
others. Whereas the evil eye can harm a wide variety of
things, including inanimate objects, children are partic-
ularly susceptible to attack. Common symptoms of
matiasma include headache, chills, irritability, restless-
ness, and lethargy; in extreme cases, matiasma has re-
sulted in death.
Ponos (pain) is the cardinal symptom of ill health
and an evil that needs eradication. The person in pain
is not expected to suffer quietly or stoically in the pres-
ence of family. The family is relied on to find resources
to relieve the pain or, failing that, to share in the ex-
perience of suffering. However, in the presence of out-
siders, the lack of restraint in pain expression suggests
lack of self-control. Although the experience of phys-
ical pain is acknowledged publicly, emotional pain is
hidden within the privacy of the family.
Many Greeks and Greek Cypriots display a general
distrust of all professionals and may “shop around”
for physicians and other health-care providers to ob-
tain additional opinions. The use of several physicians
simultaneously may result in untoward drug interac-
tions from conflicting multiple drug use.
People of Greek Ancestry 463
2780_Abstract06_462-463 16/07/12 12:14 PM Page 463

464
Abstracts
People of Guatemalan Heritage
Tina A. Ellis and Larry D. Purnell
People of Guatemalan heritage compose a growing
number of Hispanic/Latino populations in the
United States. Whereas some Guatemalans may share
a common Spanish language with other Hispanic eth-
nic groups, they are, nonetheless, a unique cultural
group. Guatemala continues to be plagued by “ab-
ject” poverty, resulting in more than 600,000 legal
and undocumented Guatemalan immigrants in the
United States. Most Guatemalans are a mixture of
Spanish and Mayan Indian heritage. A small group
of black Guatemalans have an ancestry from the
Caribbean and Africa. This accounts for variations
in skin color, facial features, hair, body structure, and
other biological variations.
Although many Guatemalans speak Spanish, many
speak one of 23 Amerindian languages, including
Quiche, Cakchiquel, Kekchi, Mam, Garifuna, and
Xinca. Each Mayan ethnic group speaks one dialect
as their primary language. Most Guatemalan people
tend to value the past and live in the present, being
more concerned with today than the future because
the future is uncertain for many.
Because work is such a priority in the life of many
Guatemalans, they seek health care only when their
illness has progressed to the point of preventing them
from working or carrying out their duties or roles
within the family. Taking time to go to the doctor
means time lost from work and loss of pay.
Guatemalans who have a Hispanic heritage use the
Spanish format for names. At birth, a child is given a
first name (Ovidio), followed by the surname of his
father (Garcia), and then the surname of his mother
(Salvador), resulting in Ovidio Garcia Salvador. When
referring to him as Mr. (señor), it would be appropri-
ate to use Señor Garcia. Men’s names remain the same
through their lifetime. However, when a woman
named Jovita Garcia Salvador marries Francisco
Vasquez Gutierrez, she then becomes Jovita Garcia de
Vasquez or simply Jovita Garcia Vasquez. She should
be addressed as Mrs. (señora) Vasquez.
To convey respect, health-care providers should ad-
dress Guatemalans in a formal manner unless otherwise
requested by the patient. Male children and adults are
referred to as Mr. (señor). Females are referred to as
Ms. or Miss (señorita) or Mrs. (señora). Highly respected
persons in the community are often referred to as Don
(male) or Doña (female), followed by the person’s first
name. For example, one respected gentleman is referred
to as Don Martin and a respected nurse is referred to as
Doña Alma. Guatemalans are customarily greeted with
a handshake.
In rural areas, people shake hands softly. A firm
handshake indicates aggressive behavior. Guatemalans
avoid direct eye contact with others, including health-
care providers, which is a way of demonstrating respect
and should not be misinterpreted as avoidance, low
self-esteem, or disinterest. They speak softly in public.
Speaking loud is considered rude. Many Guatemalan
families follow traditional roles for husbands, wives,
and children, although this is changing for some, espe-
cially in the United States.
Guatemalans place a high value on the family
and the extended family. Most families are nuclear—
comprising a father, mother, and children. Extended
family is important to Guatemalans and may include
grandparents, aunts, uncles, and cousins. Children are
taught to be obedient and demonstrate respect for
older people.
Most Guatemalans in the United States work in
agriculture, housekeeping, or the restaurant business.
Guatemalans may miss work owing to an illness of a
loved one, a need for transportation to an appointment,
or a lack of child care. Because punctuality is not val-
ued in Guatemala, the Guatemalan employee in the
United States may arrive for work late. Some may not
wear a watch, be able to tell time, or understand the im-
portance of punctuality in the United States.
Guatemalans tend to respect persons in positions
of authority. Those of lower socioeconomic status
and/or with formal education and English-language
skills usually acquire positions with responsibility but
little authority.
Men who immigrate to the United States from
Guatemala for work may find themselves drinking
2780_Abstract07_464-465 16/07/12 12:14 PM Page 464

alcohol excessively, even if they did not prior to mi-
gration. This may be due to such factors as the stress
of living in another country illegally; being away from
family, friends, and support systems; fears of inade-
quate work and deportation; and illness and being vic-
tims of violence and injury. They may live with other
men they hardly know.
Food to Guatemalans signifies physical, spiritual, and
cultural wellness. Foods vary among Guatemalans based
on cultural traditions and accessibility. Guatemalans
value corn because it brings good health. Corn is eaten
at every meal, most often in the form of tortillas. The
Mayan diet primarily consists of maize, black beans, rice,
chicken, squash, tomatoes, carrots, chilies, beets, cauli-
flower, lettuce, cabbage, chard, leeks, onions, and garlic.
Guatemalans value life beginning from concep-
tion; a baby is a gift from God. For religious reasons,
most do not believe in contraception or abortion.
Mayan women do not believe in lying down to give
birth or delivering in a hospital. Following delivery,
the placenta has to be burned, not buried, because it
is disrespectful to the earth to do so. Guatemalan
women may continue breastfeeding until the child
reaches the age of 5 years. Moreover, they may be
breastfeeding a new baby while continuing to breastfeed
a toddler.
Some Guatemalans relate their illness to “punish-
ment” or impending death to “God’s will” and refuse
an intervention or heroic measures to reverse the out-
come. Guatemalans believe in burial; they do not
practice cremation. Yellow is the color of mourning.
When a Guatemalan dies in the United States, the
family may request repatriation, because it is impor-
tant for the final resting place to be the home country.
Often, immediate and extended family will pool their
resources to send the body home.
Most Guatemalans are Roman Catholic. Many in-
tegrate aspects of Catholicism into their lives, while
continuing to believe in the spirituality of their ances-
tors in private. Family provides Guatemalans with
meaning in their lives. Life revolves around the nuclear
and extended family. Whether Catholic, Protestant, or
traditional Maya, many believe that life’s events hap-
pen for a reason. The reason may be attributed to
favor from God or the gods when positive experiences
occur and to punishment or disfavor from God or the
gods when negative events occur. Some feel nothing
can be done to change the outcome of these experi-
ences. This belief is referred to as fatalism.
The preferred mode of treatment among Guatemalans
is medication administered by hypodermic injection. For
example, if an infant has a cold, Guatemalans believe an
injection is necessary to treat it effectively. If someone
has the flu, an IV infusion is preferred. Intramuscular
medications are preferred to those taken orally.
Health-care seeking among Guatemalans generally
occurs by first seeking advice from a mother, grand-
mother, or other respected elder. If this approach is un-
successful, then the family usually seeks health care
from folk healers. Many are fearful of hospitals. In
Guatemala, when hospital care is necessary, patients
are often seriously ill, resulting in death, which perpet-
uates the belief that “hospitals are places where patients
go to die.”
Guatemalans tend to view health and illness in re-
lation to their ability to perform duties associated with
their roles. As long as women are functioning in their
role of caring for the home and family, and men are
functioning in their job, then they feel “healthy.”
When an illness prevents normal functioning required
for their roles, then Guatemalans view it seriously.
The cause of debilitating illness or disease may be
viewed as punishment from God rather than lack of
prevention or early detection. Sometimes early warn-
ing signs of illness or disease are ignored in hopes they
will go away on their own. When symptoms persist,
fear may keep the Guatemalan patient from seeking
medical attention. Some Guatemalans fear venipunc-
ture because taking blood leaves the body without
enough blood to keep them strong and healthy.
Guatemalans have great respect and admiration for
health-care providers, who are viewed as authority
figures with clinical expertise. Guatemalans expect
their health-care provider to have the appearance and
manners of a professional. When this is not the case,
Guatemalans may lose confidence in the provider.
Guatemalans are very private and are not accustomed
to discussing issues and concerns openly. It may take
a while to develop the necessary trust in and rapport
with the provider for them to share. They fear disclo-
sure may result in deportation or rejection. Patients
also fear confidentiality will not be maintained in the
health-care setting.
Guatemalan women are usually very modest. They
may refuse to discuss personal issues or receive an ex-
amination by a male health-care provider. Likewise, a
male Guatemalan patient may refuse a female health-
care provider. Because Guatemalans dislike conflict,
they may not actually refuse care, but they may with-
hold personal information owing to discomfort with
the health-care provider. Incorporating these prefer-
ences into the encounter with Guatemalan patients en-
hances the development of relationships that result in
effective and meaningful care.
People of Guatemalan Heritage 465
2780_Abstract07_464-465 16/07/12 12:14 PM Page 465

466
Abstracts
People of Iranian Heritage
Homeyra Hafizi and Hydeh Hafizi
Iran is a geographically and ethnically diverse, non–
Arabic-speaking Muslim country. Iran’s 1979 Revolu-
tion generated a steady wave of immigration to North
America, Europe, and Australia. Since the 1979 Rev-
olution, Iran’s socioeconomic and political instability
and the most recent power shifts in the Middle East
have spurred emigration. Many Iranian immigrants
face considerable ethnic bias in the United States, with
an intensity directly linked to the ongoing events in
the Middle East. Over 400,000 Iranians live in the
United States, although unofficially the estimate may
be over 1 million. The political climate discourages
some Iranian immigrants from disclosing their native
origin; hence, they self-identify as “other” or “white.”
Farsi is the national language of Iran; however, nearly
half the country’s population speaks different lan-
guages and dialects, such as Turkish, Kurdish, Armenian,
or Baluchi.
Even though the focus of this chapter is on cul-
tural commonalities and aggregate data, health-care
providers must recognize that Iranians are a highly
diverse population. Overemphasis on culture, reli-
gion, and ethnicity as the defining factors in the ex-
pression of health and illness, treatment-seeking
behaviors, and health-maintenance practices can lead
to stereotyping.
A central tenet of the Iranian social life and per-
sonal development is the boundary between inside/
private (baten) and outside/public (zaher). The most
private and true self is always kept for intimate spaces
and trusted relations. “Inside” and “outside” define
both individuals and families, in which honor and so-
cial shame play powerful roles. Challenges particular
to the older population of Iranian immigrants have
been learning the language, adapting to the new
culture and lifestyle, and redefining the relationship
between parent and child.
Iranians greatly value education and expect their
children to do well. Iranian immigrants strive to main-
tain a social façade of affluence and upper-class status
because family judgment and social shame weigh
heavy on their decision making. Many immigrants
who held white-collar positions in Iran are unable to
find comparable work in the United States.
Not verbalizing one’s thoughts is viewed as a cus-
tomary and useful defensive behavior. This form of
communication, also known as ta’arof, can effectively
hinder open exchange of feelings with the health-care
provider.
More traditional married couples do not publicly
display outward affections to each other; however,
most are vocal in expression of love for their children.
Greeting is often accompanied by a kiss on each cheek
(maybe three kisses) and/or a handshake. A slight bow
or nod while shaking hands shows respect. Crossing
one’s legs when sitting is acceptable, but slouching in
a chair or stretching one’s legs toward another person
is considered offensive. Nonverbal beckoning is done
by waving the fingers with the palm mostly up. Tilting
the head up quickly means no and down means yes.
Extending the thumb (like thumbs-up) is considered
a vulgar sign.
As in other Mediterranean cultures, personal dis-
tance is generally closer than that of Americans or
Northern Europeans. The strength of the relationship
affects how freely participants touch one another.
Iranians maintain intense eye contact between inti-
mates and equals of the same gender. This behavior
may be observed less in traditional Iranians.
Time orientation is a combination of emphasis on
the present and on the future. The ideal is to maintain
a balance between enjoying life to the fullest and
ensuring a comfortable future.
Iranians refrain from calling older people and those
in higher status by their first names. Traditional, and
many nontraditional, women do not take the surname
of their husbands. Iranians give their name with the
given name (first name) first followed by their surname
(last name).
Consistent with traditional collectivistic cultures,
Iranian families value harmony within an established
patriarchal hierarchy. Also valued are avoidance of
open conflict, unconditional respect for parents, and
indirect and figurative communication to maintain
2780_Abstract08_466-468 16/07/12 12:15 PM Page 466

social hierarchy and group harmony. In the father’s
absence, the oldest son has authority.
Young women are expected to remain sexually in-
active until they marry, but sexual activity by men out-
side marriage is tolerated. Dating is not allowed in the
most traditional Iranian families but is tolerated in
more acculturated families. Many Iranian adolescents
in the United States resemble their American counter-
parts in dress and outward behavior; they often be-
have more respectfully toward family members,
particularly older people and other highly respected
individuals and members of the family.
Religious women living outside Iran may avoid
bright colors, cover their arms and legs, and conceal
their heads with head covers or scarves (hijab). In
Iran, wearing the hijab is mandatory because of the
ruling Islamic Republic.
Although homosexuality undoubtedly occurs in
Iranians as frequently as in any other group, it is
highly stigmatized. Iranian gays and lesbians do not
easily disclose their sexual orientation because they
would be against both a religious and a cultural norm.
The punishment is death if the participants are con-
senting adults of sound mind. In contrast to the older
generation, younger Iranians in the United States are
increasingly tolerant of alternative lifestyles.
Iranians may perceive and actually experience a
degree of bias at work. There is a general lack of
understanding that the countries of the Middle East
and their people are very different in ethnic identity
and culture. More acculturated immigrant profession-
als respond flexibly in the workplace. Efficiency
and efficacy supersede personal communication and
human connection.
In the United States, many Iranians experience
stress-related health problems from cultural conflict
and loss, homesickness, and the previous conditions of
war. Iranians’ high-risk health behaviors are similar to
those in the general population. Among both men and
women, smoking is more prevalent in Iran than in the
immigrant population residing in the United States.
Alcohol is prohibited by the Qur’an, the Holy Book of
the Islamic faith. However, Iranians who are not de-
voutly religious drink socially, only in private places,
and sometimes to excess.
Iranian food is flavorful, with a lengthy preparation
time. Presentation is important. At any given table, a
pleasing mixture of foods of different colors and in-
gredients, composed of a balance of garm (hot) and
sard (cold). Islam has a strict set of dietary prescrip-
tions, halal, and proscriptions, haram. Slaughter of
poultry, beef, and lamb must be done in a ritual man-
ner to make the meat halal. Strict Muslims avoid pork
and alcoholic beverages; a few avoid shellfish. Histor-
ically, pork was prohibited for hygienic reasons. Com-
pliance with proscriptive food and beverage items is
seen less frequently among the younger generations.
Based on humoral theory, Iranians classify foods
into one of two categories: garm (hot) and sard (cold).
The categories sometimes correspond to high- and
low-calorie foods. The key to humoral theory is
balance and moderation. The belief is that too much
of any one category can cause symptoms of being
“overheated” or “chilled.”
Food cravings during pregnancy are believed to re-
sult from the needs of the fetus; thus, cravings must
be satisfied. Special attention is given to the balance
of hot and cold food items. Heavy work is believed to
cause miscarriage.
During the birthing process, in the more traditional
families, the father is usually not present. The post-
partum period can be as long as 30 to 40 days. Some
families believe in keeping an infant home for the first
10 to 15 days, after which time the infant is strong
enough to handle environmental pathogens.
Family members and friends gather to support
the dying person and one another. Among devote
Muslims, the deathbed, or at least the patient’s face, is
turned to face Mecca. Withdrawal of life support may
be considered as “playing God.” This is not to say that
Iranians absolutely defy withdrawal of life support.
There may be no objection to beginning life support,
viewing it as a gift of medical technology. Cremation
is not practiced in Iran. It is unlikely for Iranians in
other countries to practice cremation, but cases of
personal choice have been documented.
Grieving may be expressed outwardly and loud.
Black is the customary color for clothing. On the an-
niversary of the death, the family gathers again.
During the month of Ramadan, devout Muslims
fast from sunrise to sunset, although certain individ-
uals are exempt from fasting, such as those whose
health is in jeopardy. Prayer is observed five times per
day by those who have a strong faith.
The sacred traditions include beliefs in the evil eye
and jinns as evil spirits. Healing is reached through elim-
inating impurities from the body or by prayers. Galenic
medicine is a way of life, a daily practice in health pro-
motion and wellness, illness, disease, and injury preven-
tion; and health promotion and wellness. Modern
medicine is viewed more curative in nature. Biomedi-
cine and humoral medicine complement each other.
Among Iranians, narahati is a general term used to
express a wide range of undifferentiated, unpleasant
emotional or physical feelings such as feeling de-
pressed, uneasy, nervous, disappointed, or, generally
speaking, not well. Iranians may use somatization to
communicate emotional distress in a way that is
culturally sanctioned and socially understood. In
some instances, a sudden ailment may be attributed to
the evil eye, cheshm-i-bad, the belief that negative
thoughts and jealousy can cause illness. Cheshm-i-bad
can be the result of an intentional or unintentional
projection of a thought. Acculturated immigrants use
People of Iranian Heritage 467
2780_Abstract08_466-468 16/07/12 12:15 PM Page 467

the terminology in everyday speech and encounters;
however, most do not fully believe in the concept.
Self-medication is common, with prescription med-
ications, over-the-counter remedies, and homemade
herbal preparations used simultaneously. When ill,
Iranians rely heavily on family members for support
and assistance. The patient may behave passively while
the family appears persuasive in medical encounters.
If a patient is hospitalized, visiting is frequent, some-
times excessive according to U.S. standards.
Most Iranians are expressive about their pain.
Some justify suffering in the light of rewards in the
afterlife. Blood transfusions, organ donations, and
organ transplants are widely accepted among Irani-
ans. In Iran, donation of organs has become a busi-
ness transaction: if a kidney is needed, it can be
purchased.
Iranians appreciate state-of-the-art facilities, high-
technological equipment, and skilled professionals.
Many Iranian clients expect to receive a definitive di-
agnosis and a clear road map for treatment, including
prescriptions and therapies. They may not ask too
many questions or inquire about different modalities,
believing that the provider knows best. The most
respected health-care provider is an educated and
experienced physician.
468 People of Iranian Heritage
2780_Abstract08_466-468 16/07/12 12:15 PM Page 468

469
Abstracts
People of Irish Heritage
Sarah A. Wilson
The history of the Irish in America has not been har-
monious. Early immigrants were subjected to reli-
gious persecution and economic discrimination. Irish
Americans are a diverse group, and health-care
providers must be careful to avoid generalizations or
assumptions, such as the Irish being superstitious,
heavy drinkers, and practical jokers, because these do
not apply to all Irish. Religious persecution and de-
plorable economic conditions were primary reasons
for early immigration to America. Ireland had a pop-
ulation of 8.5 million until the Great Potato Famine
of 1846 to 1848, when the population decreased to
3.4 million. During the famine, thousands of Irish
died from malnutrition, typhus epidemics, dysentery,
and scurvy, and millions immigrated to America.
The Irish use low-context English, in which many
words are used to express a thought. This low-
contextual use of the language has its roots in the
Celtic folk tradition of storytelling. Humility and
emotional reserve are considered virtues. Displays of
emotion and affection in public are avoided and often
difficult in private. They often rely on humor and teas-
ing as expressions of affection and may use this form
of humor with health-care providers.
Kinship and sibling loyalty are important to the Irish.
Irish families emphasize independence and self-reliance
in children. Boys are allowed and expected to be more
aggressive than girls. Girls are raised to be respectable,
responsible, and resilient. Children are expected to have
self-restraint, self-discipline, and respect and obedience
for their parents and older people. Over time, the Irish
have made a place for themselves in the workforce in the
United States or wherever they have migrated and are
represented in all occupations and professional roles.
Most Irish are either dark-haired and fair-skinned
or have red hair, rosy cheeks, and fair skin. However,
as with other ethnic groups, variations in hair and skin
color exist. The fair complexion of the Irish places
them at risk for skin cancer. The major cause of infant
mortality in Ireland is congenital abnormalities. Other
conditions with a high incidence among the Irish are
phenylketonuria (PKU), neural tube defects, and
alcoholism. Most states require screening all new-
borns for PKU; health-care providers may need to en-
courage women who give birth at home to seek PKU
screening for their infants.
Alcohol problems in Ireland are among the highest
internationally. In their multinational review of the lit-
erature on alcohol use, Purnell and Foster reported
that the percentage of people in the United States,
Ireland, and England who drink is the same; however,
behavior problems are greater among the Irish.
Because drinking may be a way of coping with prob-
lems, the health professional needs to assist Irish
American clients to explore more effective coping
strategies and caution them against the dangers of
mixing alcohol with medications.
The Irish believe that not eating a well-balanced
diet or not eating the right kinds of food may cause
the newborn to be deformed. In addition, the Irish
share the belief common to many other ethnic groups
that the mother should not reach over her head during
pregnancy because the baby’s cord may wrap around
its neck. A taboo behavior in the past, which some
women still respect, is that if the pregnant woman sees
or experiences a tragedy during pregnancy, a congenital
anomaly may occur.
The Irish reaction to death is a combination of
their pagan past and current Christian beliefs. The
Celts denied death and ridiculed it with humor. The
Irish are fatalists and acknowledge the inevitability of
death. The American emphasis on technology and
dying in the hospital may be incongruent with the
Irish American belief that family members should stay
with the dying person. The Irish wake continues as an
important phenomenon in contemporary Irish fami-
lies and is a time of melancholy, rejoicing, pain, and
hopefulness.
The predominant religion of most Irish is Catholi-
cism, and the church is a source of strength and solace
for many Irish Americans. In times of illness, Irish
Catholics receive the Sacrament of the Sick, which in-
cludes Anointing, Communion, and a blessing by the
priest. Prayer is an individual and private matter. In
2780_Abstract09_469-470 16/07/12 12:15 PM Page 469

the health-care setting, patients should be given pri-
vacy for prayer, whether or not a clergy member is
present. Some Irish Americans wear religious medals
to maintain health. These emblems provide them with
solace and should not be removed by the health-care
provider.
The Irish’s fatalistic outlook and external locus of
control influence health-seeking behaviors. Irish
Americans use denial as a way of coping with phys-
ical and psychological problems. Many Irish limit
and understate symptoms when ill. For some Irish
Americans, illness behavior does little to relieve
suffering and perpetuates a self-fulfilling prophecy.
Illness or injury may be linked to guilt and the result
of having done something morally wrong. The be-
havioral response of the Irish to pain is stoic, usually
ignoring or minimizing it.
In most Irish families, nuclear family members are
consulted first about health problems. Mothers and
older women are usually the family members who pos-
sess the knowledge of folk practices to alleviate com-
mon problems such as colds. When home remedies are
not effective, the Irish seek the care of biomedical
health-care providers.
470 People of Irish Heritage
2780_Abstract09_469-470 16/07/12 12:15 PM Page 470

471
Abstracts
People of Italian Heritage
Sandra M. Hillman
This chapter describes the beliefs and practices of
Italian Americans from the mainland of Italy, although
some of these characteristics may be shared by Italian
Americans with a heritage from Sicily and Sardinia.
The willingness to share thoughts and feelings
among family members is a major distinguishing char-
acteristic of the Italian American family. Many times,
a fluctuating emotional climate exists within the
family, with expressions of affection erupting briefly
into what appears to an outsider as anger or hostility.
Italians are sentimental and not afraid to express their
feelings, and this extends into the health-care environ-
ment. Even though traditional roles remain strong in
Italian American families, a trend toward more egali-
tarian relationships is evolving. Families maintain
close relationships: daughters have close ties with both
parents, particularly as they approach old age.
Most Italians believe strongly in the work ethic, are
punctual, and rarely miss work commitments owing
to a cold, headache, or minor illnesses. If completing
their work requires staying later, they do so. Although
the family is of utmost importance to Italians, work
takes priority over family unless serious family situa-
tions arise. This cultural predisposition parallels the
North American work ethic.
People of Italian ancestry have some notable ge-
netic diseases, such as familial Mediterranean fever,
Mediterranean-type glucose-6-phosphate dehydroge-
nase (G-6-PD) deficiency, and β-thalassemia. Thus,
administration of sulfonamides, antimalarial agents,
salicylates, and naphthaquinolones should be avoided.
A recommendation is to screen all people of Italian
heritage for these conditions before administering
medications.
A close association between food and mothering
results in some predictable problems. Many Italians
believe that bigger babies are healthier. The size of the
baby is perceived as an index of the successful main-
tenance of maternal and wifely responsibilities. The
belief that a mother does not conceive while nursing
continues to be held by many Italian women. Among
traditional Italians, a postpartum woman is not
allowed to wash her hair, take a shower, or resume her
domestic chores for at least 2 or 3 weeks after birth so
she can rest. New mothers are expected to breastfeed,
restoring the health of the reproductive organs and
keeping the mother and baby free of infections.
In the Italian American family, death is a great
social loss and brings an immediate response from the
community. Sending food and flowers (chrysanthe-
mums), giving money, and congregating at the home
of the deceased are expected. The funeral procession
to the cemetery is a symbol of family status. There is
great pride in the size of the event, which is deter-
mined by the number of cars in the procession.
Although there is a tendency today to decrease the
elaborateness of the funeral, it remains very much a
family and community event.
Emotional outpourings can be profuse. Women
may mourn dramatically, even histrionically, for the
whole family. They do not merely weep; they may rage
against death for the harm it has done to the family.
Family members may moan and scream for the de-
ceased throughout the church. Screaming is an effort
to ensure that Jesus, Mary, and the saints hear what
the bereaved are thinking and feeling.
Their predominant religion, Roman Catholicism,
includes folk religious practices. Most Italians pray to
the Virgin Mary and the saints in addition to God.
Many traditional first-generation and newer Italian
American families display shrines to the Blessed Vir-
gin in their backyards. God is an all-understanding,
compassionate, and forgiving being. Prayer and hav-
ing faith in God and the saints help Italian Americans
through illnesses. The health-care provider may
need to help the client obtain the basic rites of the
Sacrament of the Sick, which includes Anointing,
Communion, and if possible, a blessing by the priest.
The concept of family, the most dominant influence
on the individual, is the most credible source of
health-care practices. Italians believe that the most sig-
nificant moments of life should take place under their
own roofs. The extended family is the front-line re-
source for intensive advice on emotional problems.
2780_Abstract10_471-472 16/07/12 12:16 PM Page 471

Mental health providers are frequently perceived as
inappropriate agents for meeting problems that are be-
yond the expertise of the family and local community.
Individuals can protect themselves from the evil eye
by using magical symbols and by learning the rituals
of the maghi, which means “witch.” Amulets are worn
on necklaces or bracelets, held in a pocket, or sewn
into clothing. Cornicelli, “little red horns,” can still be
purchased as good luck charms. These should not be
removed from patients’ bedsides or from their clothing
because they provide significant solace for some.
Both age and gender mediate ethnic differences in
the expression of pain for Italian Americans. Older
Italian Americans, especially women, are more likely
to report pain experiences, express symptoms to the
fullest extent, and expect immediate treatment. Ital-
ians tend to be more verbally expressive with chronic
pain. The sick role for many Italian Americans is one
not entered into without personal feelings of guilt;
thus, they may keep sickness a secret from family and
friends and are not inclined to describe the details be-
cause they blame themselves for the health problem.
472 People of Italian Heritage
2780_Abstract10_471-472 16/07/12 12:16 PM Page 472

473
Abstracts
People of Somali Heritage
Richard Adair and Yurub Jama
Somali people are united by a common language,
Somali; religion, Sunni Muslim; and culture that are in-
fluenced by their Arabic neighbors. Although minority
languages exist in Somalia, the majority of the inhabi-
tants speak Somali.
After the collapse of the Somali government in
1991, at least 1 million Somali people fled to neighbor-
ing counties. Many of these refugees have now resettled
in the United States, Canada, Europe, Australia, and
New Zealand. Others are still living in refugee camps,
especially in one large camp on the outskirts of
Nairobi, under difficult and somewhat unsafe condi-
tions. Some children and adolescents have spent most
of their lives in these camps.
Children are encouraged to speak Somali at home,
but it is recognized that learning English is important.
Somalis are polite and appreciate full introductions of
everyone in the room, including interpreters and fam-
ily members. Somalis follow Muslim traditions regard-
ing social touching. Somali women typically greet one
another with a hug and a kiss on the cheek.
Voice volumes are not noticeably different from
American cultural norms. Many use their hands to
make gestures when speaking. Women and men are
not shy about the process of obtaining medical care,
and often they will ask detailed/direct questions until
they are satisfied. Although the use of family members
is not recommended, most Somali prefer close family
member to interpret. They may want to use an inter-
preter who is of the same gender, especially in issues
such as sex or genital exam visits.
A man or woman may not touch a person of the
opposite gender except for spouses or close relatives.
This includes handshaking with the opposite gender.
However, in the exam room, it is understood that
touching is permitted because there is a specific
medical reason. Maintaining eye contact in consid-
ered polite when speaking with someone. Punctual-
ity is not expected in a social context, but Somali
people are generally quick to adapt to new cultures
and learn that they are expected to be on time for
appointments.
Somalis do not have surnames in the Western sense.
To identify a Somali, three names must be used: a
given name, followed by the father’s given name, and
then the grandfather’s name. Women, therefore, do
not change their names at marriage.
A Somali nuclear family is considered to include
father, mother, children, and grandchildren. The
father is the head of the family and the final decision
maker in family affairs. Family relations are based on
hierarchical respect, as the Qur’an expects children
to be unconditionally obedient to their parents.
Children are also expected to care for their parents
when they are in need, especially in times of sickness,
aging, or financial hardship.
For all Somalis, the family is the ultimate source of
personal security and identity. When Somalis meet
one another, they don’t ask “Where are you from?”
but “Whom are you from?” Most Somalis in the
United States help support their family members in
Somalia or in refugee camps in neighboring countries.
Same-sex relationships are hidden and not discussed.
Marrying and producing children are expected.
Somali people tend to have thinner frames, lighter
skin, and more Arabic-looking faces than West
Africans, the ancestors of the majority of today’s
African Americans. Men are quite lean, and women
less so.
Many Somali immigrants have significant depres-
sion or post-traumatic stress disorder related to war,
family disruption, and long years in refugee camps.
Many patients are uncomfortable with the word
“depression” and respond better to simpler explana-
tions like too much stress, not enough sleep, or a
reaction to the past.
Tuberculosis is by far the most important infectious
disease in Somali immigrants; extrapulmonary tuber-
culosis, especially in lymph nodes, is more common
than pulmonary tuberculosis and often presents with
fever alone or with vague other symptoms. Other com-
mon infectious diseases are hepatitis B, Helicobacter
pylori, intestinal parasites, and malaria. Remember
that most arrivals are coming from refugee camps in
2780_Abstract11_473-474 16/07/12 12:16 PM Page 473

countries other than Somalia, especially Kenya and
Ethiopia.
Lactase deficiency occurs in adulthood but is not a
common cause of symptoms. Rates of obesity and di-
abetes among Somalis have increased dramatically, es-
pecially among women adjusting to the availability of
food in Western countries and decreased physical ac-
tivity due to being in cold climates or fear of going
outdoors in high-crime neighborhoods.
Common foods are rice, pasta, bread, potatoes,
corn, beans, and sugar. Meat products include goat,
lamb, beef, camel, and fish. Fruits include banana,
mango, papaya, grapefruit, oranges, lemons, grapes,
and dates. Beverages include milk from goats, cows,
and camels; tea and coffee; and soda.
A typical breakfast includes angelo, a flour product
resembling crepes, to which oil with sugar can be added,
and tea. At midday, curry rice or pasta with sauce is con-
sumed and often includes vegetables such as onions and
potatoes. For dinner, meat is usually not consumed, but
a mixture of beans and corn called ambulo is consumed
with added sugar and oil. Pork of any kind is forbidden.
Somali families tend to be large by American and
European standards. Children and pregnancy are in-
variably considered a precious gift. Abortion is pro-
hibited. Expectant and newly delivered mothers
benefit from a strong network of women within So-
mali culture. During pregnancy, women are expected
to eat well and avoid heavy exertion or lifting.
After childbirth, a period of 40 days is observed
where the woman stays home, eats well, is assisted by
her family and neighbors, and abstains from sexual in-
tercourse. During this time, the mother wears earrings
made from string placed through a clove of garlic, and
the baby wears a bracelet made from string and the
herb malmal in order to ward away the evil eye. In-
cense (myrrh) is burned twice a day in order to protect
the baby from the ordinary smells of the world, which
are felt to have the potential to make him or her sick.
Breastfeeding for as long as possible, usually up to
2 years, is a religious obligation. Newborn care includes
warm water baths, sesame oil massages, and passive
stretching of the baby’s limbs. Malmal is applied to the
umbilicus for the first 7 days of life. Malmal is available
in the United States in some Asian markets.
When a person is dying, a religious person such as
the imam from the local mosque may visit the person
in the hospital, offer prayers, and help mobilize com-
munity support. As faithful Muslims, Somalis believe
that Allah will determine how long a person will live.
For this reason, discussing end-of-life care or advance
directives is taboo and may be misunderstood.
In Somalia there are no confidentiality laws, and the
family is informed instead of the patient. The family
may feel distrustful of health-care providers if they are
not informed of their family member’s prognosis.
Somalis feel it is important to tell the immediate family
first if there is a poor prognosis so they can be prepared
to work together and comfort the patient. After death,
the funeral home cooperates with the mosque in prepar-
ing the body, washing it, wrapping it in white cloth, and
delivering it to the mosque for a prayer service.
Essentially all Somalis are devout Sunni Muslims.
Prayers (Salat) are performed five times daily, in any
location, facing Mecca. These specified prayers take
about 3 minutes apiece and involve kneeling and
touching the forehead to the ground.
Strict fasting occurs during the lunar month of
Ramadan. During this time, all people age 15 years
and older refrain from taking food or drink from sun-
rise to sunset. Sometimes this is interpreted to include
medication, including insulin. Exceptions can be made
in the event of illness, travel, menstruation, pregnancy,
and so forth. Many Somalis will give January 1 of the
year they were born when asked by immigration
authorities or Western medical records systems.
Traditional Somali healing practices include ritual
reading or reciting of verses from the Qur’an; creating
superficial skin burns on the abdomen, chest, or head;
superficial cutting of the skin (especially used for jaun-
dice in children from hepatitis A); Mingis (or Saar),
which consists of ceremonial drumming, singing, and
dancing around the sick person; and herbs that may
be consumed or used as a poultice. Such practices are
guided by a traditional healer. Some traditional heal-
ers specialize in setting fractures or trephine proce-
dures for subdural bleeding.
In Somalia, prepubertal girls are circumcised by re-
moving the clitoris, labia minora, and labia majora.
The vaginal orifice is then narrowed by sutures, leaving
room for menstruation. At the time of marriage, these
sutures are removed. In another variation of this prac-
tice, only the clitoris is removed. While these practices
seem extreme to Western medical providers, they are
accepted as normal by many Somali women who
value chastity and tradition. In the United States, this
practice is illegal. In response, some families arrange
for their children to travel to Africa for circumcision.
There are no restrictions on accepting blood prod-
ucts when needed. Organ donation at the time of
death is traditionally not practiced in Somalia. Tradi-
tionally, Somalis believe the body should be buried in-
tact. Donating an organ while still alive or receiving a
transplanted organ may be considered more accept-
able. Since there are no specific codes on transplant
and organ donation in Islamic law, there are different
approaches to treatment.
Somali people sometimes seek healing from tradi-
tional and religious healers first. But they do not hes-
itate to go to the physician when symptoms persist or
are alarming.
A Somali traditional healer, usually an older man,
is called an alaqad. Traditional healing may include
participation by a large group of people. Respect for
medical education and expertise is the rule; physicians
and nurses are valued as professionals.
474 People of Somali Heritage
2780_Abstract11_473-474 16/07/12 12:16 PM Page 474

475
Abstracts
People of Thai Heritage
Ratchneewan Ross and Jeffrey Ross
Siam, the land of the musical The King and I, is the
former name of Thailand and is the only Southeast
Asian country that has never been colonized by
Westerners. Thailand began a tradition of emulating
Western political, economic, and cultural ideas in
the late 19th century. Over 150,000 Thais live in
the United States, with most living in Los Angeles,
California. The first two Thai immigrants in the
United States were Eng and Chang Bunker, the
famous Siamese twins who captured the world’s atten-
tion because of their conjoined chests and whose
career was a public exhibition.
The standard Thai dialect, which is a fixed tonal
language with five tones, is the official language in
Thailand. Thus, the same phonetic sound can have
different meanings depending on the tone. The written
alphabet is a complicated system of 44 letters with
over 33 vowels or vowel combinations. The north,
northeast, and southern regions of Thailand have
their own unique dialects.
A Thai female uses the word “Kah,” and a Thai
male uses “Kraab” at the end of a sentence to add
politeness in a conversation. Looking in a person’s eyes
and conversing quietly reflect respect and politeness. A
distance of 1½ to 2 feet between two speakers is prefer-
able. Thais usually greet each other with the “Wai”
motion—putting the palms of both hands together in
a prayer-like gesture and bowing the head slightly. This
gesture is used by both men and women of all age
groups. Respect for older people, an important aspect
of Thai culture, is always signaled by a younger person
gesturing with the “Wai” to the older person first.
Traditional Thai families are nuclear in nature.
When older people in a Thai family are unable to care
for themselves, younger members are morally required
to care for them. Most Thais have long first and long
last names. A Thai is usually referred to by his or her
first name, even in an official setting like school or
work. In general, when a woman marries, she usually
takes her husband’s last name. A couple’s children also
take their father’s last name. When Thai names are
transcribed in English, the spelling is merely a kind of
phonetic translation from its spelling in the Thai
alphabet. Because Thai is a tonal language, however,
the correct pronunciation of names cannot be ascer-
tained from their spelling in English. Importantly,
almost all Thais have a short nickname used by their
family and close friends and often by colleagues at
work. Nicknames normally have no relationship with
first names. They are often humorous to Thais them-
selves. Nicknames are usually either Thai or English
words. They might be derived from names of colors,
body types, fruits, or any number of other things.
A man is the head of the household in a traditional
Thai family, usually being the breadwinner and man-
aging important tasks. In most Thai families, respon-
sibilities involving household chores and taking care
of children belong to a woman. However, more Thai
families today have begun to divide household chores
between men and women. Thai female adolescents
have traditionally been expected to protect their vir-
ginity until marriage. Dating with a chaperone present
is preferable to parents. However, more and more Thai
adolescents date on their own today.
Children are the center of the family for Thais.
Many Thai children sleep with their parents from
birth until some point in time before they reach ado-
lescence. Often, children are spoon-fed by adults until
they are 6 to 7 years old.
Most Thais try to avoid personal conflicts at work
and are hard workers. Although the family is deemed
very important for Thais, in many circumstances, es-
pecially for economic reasons, work comes before
family. Thai Americans respect their supervisors be-
cause seniority is strongly valued in their culture. Thus,
they might not be assertive at work. Therefore, super-
visors may be wise to provide open discussions and ex-
pression of opportunities for their Thai American
colleagues. English proficiency among some Thais is
low. Therefore, with Thai Americans who are learning
English as their second language, the language used
in the workplace should be clear. Slang expressions
should be avoided. If used, slang expressions need to
be clarified.
2780_Abstract12_475-476 16/07/12 12:16 PM Page 475

Glucose-6-phosphate dehydrogenase deficiency
(G6PD) and thalassemia are common genetic disor-
ders among Thais. Some recent literature reports some
variations in drug metabolism between Thais and
non-Thais associated with antiretroviral medications.
In general, an individual portion of a Thai dish is
about one-third to one-fifth of a typical U.S. dish in
terms of volume. As a result, most Thais are slim owing
to these smaller portions and also the types of food they
eat. Thais believe that foods containing adequate essen-
tial nutrients help to maintain life and growth and delay
illness later in life. A Thai balanced diet usually includes
low-fat/low-meat dishes with a large percentage of veg-
etable and legumes. Rice and fish are main staples. Over-
all, pork or chicken is eaten more than beef. All meats
are consumed more sparingly in proportion to vegeta-
bles when compared with a Western diet.
Communal eating is an essential part of the Thai
culture. Friends and families eat seated together either
on the floor or at a table. Either way, when rice is part
of the meal, Thais will begin with a large amount of
rice on their plates and reach to central communal
plates of combined meat and vegetable recipes to add
to their rice. Hot or warm foods or drinks are consid-
ered healthier than cold ones. This idea is based in
part on a belief in “cold and hot” or “Yin and Yang.”
Some herbs are considered a panacea. Therefore, Thai
dishes usually contain some kind of herbs, particu-
larly garlic and hot chilies.
Thai women view pregnancy as a special time in their
lives when they need extra care physically and emotion-
ally. Ideally, the age of 20 years is the optimal time for
pregnancy owing to the women’s physical and emo-
tional maturity. Owing to modesty, especially during a
vaginal examination, Thai women prefer female health-
care providers over their male counterparts. In general,
Thai pregnant women are discouraged from visiting a
hospitalized person (regardless of the kind of sickness),
attending a funeral ceremony, or visiting a house where
there has been a death. Some new mothers might be ad-
vised to not eat eggs, chicken, or buffalo meat, believing
that the new mother’s perineum may not heal. Eggs are
avoided by some mothers, believing that they could
cause a big scar on the perineum.
Thai Buddhists believe that after a person dies, the
person will be reborn somewhere else based on that
person’s Karma. “Karma means ‘action’ and . . . refers
to the process by which a person’s moral behavior or
actions have consequences for the person’s future, ei-
ther in the present or later life.” Most Thai Buddhists
follow the custom of cremation. Many people believe
that if the deceased is not given a proper burial or if a
sanctified tombstone is not placed on the grave, then
the soul of the deceased will wander to the four cor-
ners of the world and weep and wail and sometimes
even return to disturb the relatives.
During the funeral ceremony, the family gets to-
gether. The sons of the deceased are expected to be
ordained for a short period of time, ranging from
1 week to 3 months. The ordination is believed to help
the dead go to heaven. Female relatives normally wail
quietly. The family members pray quietly to the dead
before the cremation to ask for forgiveness and wish
the dead to be reborn in a happy and peaceful home.
Most Thais are Buddhist, and the rest are Muslim,
Christian, Hindu, or other. Buddhism is an exception-
ally tolerant religion with its roots in Hinduism. Family
support along with Buddhism is a crucial source of
strength. The ultimate goal for a Buddhist Thai is to
reach Nirvana. This is the end of reincarnation or the
cycle of rebirths. When there is no rebirth, there is no
suffering. They are either happy or suffering. “Peace”
is the ultimate goal.
Many Thais believe that unwholesome Karma from
their past life has caused them to become ill in the pres-
ent life. They believe that the illness can be improved
by following the Five Precepts, similar to the Christian
Ten Commandments, which stress abstinence from
killing, stealing, lying, sexual misconduct, and illicit
drugs and alcohol consumption. Meditation and
prayer are ways for many Thais to cope with an illness.
Health promotion and disease prevention among
the Thais are very limited. Many Thais believe that
bad Karma and/or negative supernatural power causes
mental illness. Therefore, folk therapies from tradi-
tional healers are the first resource for many. Folk
therapies may include healing ceremonies, using
shamans (as a mediator) to converse with supernatu-
ral beings (such as black magic, evil beings, and/or
ancient/natural spirits) and negotiating with them to
release the sick person from his or her illness. Stigma-
tization attached to mental illness and beliefs in ani-
mism and Karma tend to prevent some Thais from
seeking professional help when mental health prob-
lems arise. Some may not seek assistance from health-
care providers until they realize that traditional
healers, shamans, cannot help them.
Many Thais may appear stoic in trying to withhold
expressions of pain or suffering from their illness. No
religious beliefs against blood transfusion exist for
Thais. Although donating and receiving organs are ac-
ceptable among many Thais, belief in their rebirth
might prevent some from donating their organs, for
fear they might not have the organ in the next life.
476 People of Thai Heritage
2780_Abstract12_475-476 16/07/12 12:16 PM Page 476

477
Abstracts
People of Turkish Heritage
Marshelle Thobaben and Sema Kuguoglu
The 202,000 people of Turkish descent in the United
States live in 42 states, with over half living in New York,
California, New Jersey, and Florida. Just over half of
the individuals in this group were born outside the
United States, and most arrived since 1980. Most Turks
practice Islam and come from a collectivist culture in
which an individual’s behavior is expected to conform
to the norms or traditions of the group, which has im-
portant implications for health-care providers advocat-
ing health promotion and wellness; illness, disease, and
injury prevention; and health-maintenance restoration.
Modern Turkish women tend to be more Western-
ized than some of their Middle Eastern or Muslim
counterparts, resulting in more egalitarian decision
making. Older people in Turkish culture are attributed
authority and respect until they become weak or re-
tired, at which time their authoritative roles diminish.
However, respect always remains a factor. Individuals
are socialized to take care of older parents, regarding
it as normal rather than an added burden. Grandpar-
ents play a significant role in raising their grandchil-
dren, especially if they live in the same home.
Turkey is known for its high-power distance (the
psychological and emotional distance between supe-
riors and subordinates), respect for authority, central-
ized administration, and authoritarian leadership
style. In Turkish culture, a manager’s authoritative
control is often more important than the achievement
of organizational goals; thus, the U.S. workforce
culture must be explained to ensure satisfactory work
relationships.
Helminthiasis (intestinal worms), hepatitis, tuber-
culosis, and malaria have not been fully eradicated in
Turkey. Endemic goiter associated with iodine defi-
ciency is a major health problem among Turks. Turkey
also has some of the highest rates of occupational dis-
eases and work accidents in Europe. Thus, health-care
providers may need to provide education regarding
safety issues in occupational health and assess newer
Turkish immigrants for intestinal parasites, tubercu-
losis, malaria, and other health conditions found in
Turkey.
Turkish cuisine is influenced by the many civiliza-
tions encountered by nomadic Turks over the cen-
turies, as well as by a mixture of delicacies from
different regions of the vast Ottoman Empire. There-
fore, food choices are varied and tend to provide a
healthy, balanced diet. Food is a highly valued symbol
of hospitality and communicates love and respect to
those for whom it is prepared. The Islamic tradition
of Ramazan is a month of fasting observed by
practicing Muslims throughout the world. During
Ramazan, one is not allowed to eat or drink anything
from sunrise to sunset, necessitating adjustments in
medication administration. Generally, pregnant and
postpartum women, travelers, and those who are ill
are excused from fasting.
Motherhood, and therefore pregnancy, is accorded
great respect, and pregnant women are usually made
comfortable in any way possible, including satisfying
their cravings. Pregnant women may continue their daily
activities or work as long as they are comfortable. In tra-
ditional Turkish culture, one of the most important de-
sires of a married woman is to have a child. A woman
who has not had a child is faced with social pressure and
accusations and, thus, may try to use some traditional
practices to increase fertility. Newborns are treated as
cherished gifts. A small blue bead, nazar boncuk, pro-
tects the child from the “evil eye” and is usually placed
on the child’s left shoulder. This practice protects the
child from the evil angel whispering in the left ear, often
portrayed in Christian religious art.
Traditional rituals after death are closing the eyes
of the deceased, tying the chin, turning the head
toward Mecca, putting the feet next to each other, put-
ting the hands together on the abdomen, and remov-
ing clothing. After the burial, the deceased is honored
with a meal that signifies moving the deceased into the
afterlife, emphasizing the need to eat and drink, and
filling the void that will occur in the community. If
these rituals are not completed, the spirit of the
deceased will be left behind.
Turks who emigrate to the West tend to be very
moderate Muslims. Traditional prayer is practiced five
2780_Abstract13_477-478 16/07/12 12:17 PM Page 477

times each day and can take place anywhere as long
as one is facing the holy city of Mecca. A special small
rug is used for praying. Health-care providers may
need to assist patients to prepare for prayers.
Most Turks rely on Western medicine and highly
trained professionals for health and curative care. How-
ever, remnants of traditional beliefs have an impact on
health-care practices. A common explanation for the
cause of illness is an imbalance of hot and cold. For ex-
ample, diarrhea is thought to come from too much cold
or heat; pneumonia results from extreme cold.
Terminally ill patients are generally not told the
severity of their conditions. Informing a patient of a
terminal illness may take away the hope, motivation,
and energy that should be directed toward healing, or
it may cause the patient additional anxiety related to
the fear of dying and concern about those being left
behind. Thus, the health-care provider should discuss
a terminal illness with the family spokesperson before
informing the patient.
Depression is a major public health problem in
Turkey; high-risk groups include women, individuals in
middle adulthood, and those in nuclear rather than ex-
tended families. Such groups may well describe a large
portion of Turkish immigrants in the United States, re-
quiring careful assessments. Physicians, and to a lesser
extent nurses and midwives, have historically been held
in very high esteem. Moreover, health-care providers
should ask about a same-gender health-care provider
for those who practice Islam.
478 People of Turkish Heritage
2780_Abstract13_477-478 16/07/12 12:17 PM Page 478

479
Abstracts
People of Vietnamese Heritage
Susan Mattson
Well over 1 million Vietnamese live in the United States.
Vietnamese immigrants confront a unique set of prob-
lems, including dissimilarity of culture, lack of family
or relatives to offer initial support, and a negative
identification with the unpopular Vietnam War. Many
Vietnamese are involuntary immigrants. Their expatri-
ation was unexpected and unplanned, and their depar-
tures were often precipitous and tragic. Escape attempts
were long, harrowing, and, for many, fatal. Survivors
were often placed in squalid refugee camps for years.
Whenever confronted with a direct but delicate
question, many Vietnamese cannot easily give a blunt
“no” as an answer, because such an answer may create
disharmony. Self-control, another traditional value,
encourages keeping to oneself, whereas expressions of
disagreement that may irritate or offend another per-
son are avoided. Expressing emotions is considered a
weakness and interferes with self-control. At times of
distress or loss, they often complain of physical dis-
comforts, such as headaches, backaches, or insomnia.
A person’s age is calculated roughly from the time
of conception; most children are considered to already
be a year old at birth and gain a year each Tet, the
Asian Lunar New Year. A child born just before Tet
could be regarded as 2 years old when only a few days
old by American standards. Because the practice of
determining age is so different in Vietnam, many im-
migrants may have difficulty determining their exact
birth date and are often given January 1 as a date of
birth for official records.
The traditional Vietnamese family is strictly patri-
archal and is almost always an extended family struc-
ture, with the man having the duty of carrying on the
family name through his progeny. Young people are
expected to respect their elders and to avoid behavior
that might dishonor the family. As a result of the
effects of their exposure to Western cultures, a dis-
proportionate share of young people have difficulty
adapting to this expectation. A conflict often devel-
ops between the traditional notion of filial piety,
with its requisite subordination of self and unques-
tioning obedience to parental authority, and the
pressures and needs associated with adaptation to
American life.
Most Vietnamese respect authority figures with
impressive titles, achievement, education, and a har-
monious work environment. They may be less con-
cerned about such factors as punctuality, adherence
to deadlines, and competition. Other traditions in-
clude a willingness to work hard, sacrificing current
comforts, and saving for the future to ensure that
they assimilate well into the workforce. Because
many fear losing their jobs if they speak out about
inequities, they are likely to be taken advantage of
by some more unscrupulous employers.
The Vietnamese family may try various home reme-
dies, allowing the condition to become serious before
seeking professional assistance. Once a physician or
nurse has been consulted, the Vietnamese are usually
quite cooperative and respect the wisdom and experi-
ence of health-care providers. Hospitalization is viewed
as a last resort and is acceptable only in case of emer-
gency, when everything else has failed. With respect to
mental health, Vietnamese do not easily trust authority
figures, including treatment staff, because of their
refugee experiences.
A predominant aspect of the traditional Asian sys-
tem of health maintenance is the principle of balance
between two opposing natural forces, known as am
and duong in Vietnamese. These forces are represented
by foods that are considered hot (duong) or cold (am).
Illness or trauma may require therapeutic adjustment
of hot-and-cold balance to restore equilibrium. The
am-and-duong balance of forces continues during
pregnancy and postpartum. Because body heat is lost
during delivery, Vietnamese women avoid cold foods
and beverages and increase consumption of hot foods
to replace and strengthen their blood. Ice water and
other cold drinks are usually not welcome, and most
raw vegetables, fruits, and sour items are taken in
lesser amounts.
Most Vietnamese have an aversion to hospitals and
prefer to die at home. Some believe that a person who
dies outside the home becomes a wandering soul with
2780_Abstract14_479-480 16/07/12 12:17 PM Page 479

no place to rest. Family members think that they can
provide more comfort to the dying person at home.
Vietnamese families may wish to gather around the
body of a recently deceased relative and express great
emotion. Traditional mourning practices include the
wearing of white clothes for 14 days, the subsequent
wearing of black armbands by men and white head-
bands by women, and the yearly celebration of the an-
niversary of a person’s death.
Vietnamese religious practices are influenced by the
Eastern philosophies of Buddhism, Confucianism,
and Taoism. Confucianism stresses harmony through
maintenance of the proper order of social hierarchies,
ethics, worship of ancestors, and the virtues of chastity
and faithfulness. Taoism teaches harmony, allowing
events to follow a natural course that one should not
attempt to change. These beliefs have contributed
to an attitude characterized by maintenance of self-
control, acceptance of one’s destiny, and fatalism
toward illness and death that may be perceived as
passive by Westerners.
Good health is achieved by having harmony and
balance with the two basic opposing forces, am (cold,
dark, female) and duong (hot, light, male). An excess
of either force may lead to discomfort or illness. The
belief that life is predetermined is a deterrent to seek-
ing health care. For many Vietnamese, diagnostic tests
are baffling, inconvenient, and often unnecessary.
Common treatments practiced in Vietnam and con-
tinued, to some degree, in the United States are cao
gio, giac, be bao, xong, moxibustion, and acupuncture.
Fatalistic attitudes and the belief that problems are
punishment may reduce the degree of complaining
and expression of pain among the Vietnamese, who
view endurance as an indicator of strong character.
One accepts pain as part of life and attempts to main-
tain self-control as a means of relief.
Traditional Asian male practitioners do not usually
touch the bodies of females and sometimes use a doll
to point out the nature of a problem. Young and un-
married women are more comfortable with female
health-care providers.
480 People of Vietnamese Heritage
2780_Abstract14_479-480 16/07/12 12:17 PM Page 480

481
Glossary
A
aagwachse Amish folk illness, re-
ferred to in English as livergrown,
with symptoms of abdominal dis-
tress believed to be caused by too
much jostling, especially occurring
in infants during buggy rides.
abnemme Amish folk illness charac-
terized by “wasting away”; usually
affects infants or young children
who seem to be too lean and not
active.
abwaarde Amish term for minister-
ing to someone by being present
and serving when someone is sick
in bed.
Acadia Part of the Canadian
Maritime Provinces.
Acadian Early French settler of
Acadia; a French dialect spoken
by people in Acadia.
acculturate To modify or give up
traits from the culture of origin as
a result of contact with another
culture.
achegewe Amish term for warm
hands.
adab Egyptian term for politeness.
afatanbah Somali term for after
childbirth.
alaqad Somali traditional healer.
Allah Greatest and most inclusive of
the names of God. Arabic word
used to describe the God
worshipped by Muslims,
Christians, and Jews.
am Pervasive force in Vietnamese
traditional medicine, associated
with cold conditions and things
that are dark, negative, feminine,
and empty.
Anabaptist Adherent of the radical
wing of the Protestant Reforma-
tion who espouses baptism of
adult believers.
Anatolia Geographic and historical
term denoting the westernmost
protrusion of Asia, comprising the
majority of the Republic of
Turkey.
antyesti Hindu equivalent of
last rites.
apocopation Dropping the first vowel
when one word ends with a vowel
and the next word begins with a
vowel.
Arabic Semitic language of the
Arabs.
arwah Egyptian term for spirits.
Ashkenazi Descended from Eastern
Europe and Russia.
assimilate To gradually adopt and in-
corporate the characteristics of the
prevailing culture.
attitude State of mind or feeling with
regard to some matter of a culture.
!Ay bendito! Frequently used Puerto
Rican phrase expressing astonish-
ment, surprise, lament, or pain.
Ayurveda Traditional Asian Indian
medicine.
B
barrenillos Spanish term for
obsessions.
baten Iranian term for inner self.
be bao or bat gio Vietnamese folk
practice in which the skin is
pinched in order to produce ecchy-
mosis and petechiae; practiced
to relieve sore throats and
headaches.
boat people Haitian or Cuban
immigrants who arrive in small
boats; usually of undocumented
status.
Boricua Puerto Rican term used with
great pride; name given to Puerto
Rico by the Taino Indians.
botanica Traditional Cuban or other
Spanish store selling a variety of
herbs, ointments, oils, powders, in-
censes, and religious figurines used
in Santería.
brauche Folk healing art common
among Pennsylvania Germans.
braucher Amish practitioner of
brauche, a folk healer.
bris or brit milah Ritual circumcision
of a male Jewish child.
Bureau of Indian Affairs (BIA)
Federal agency responsible for
ensuring services to Native
Americans, Alaskan Indians, and
Eskimo tribes.
C
caida de la mollera Condition of
fallen fontanelle, believed to occur
because the infant was withdrawn
too harshly from the nipple;
common among some Spanish-
speaking populations.
Cami Turkish word for mosque.
cao gio Vietnamese practice of plac-
ing ointments or hot balm oil
across the chest, back, or shoul-
ders and rubbing with a coin; used
to treat colds, sore throats, flu, and
sinusitis.
carı̆noso(a) Hispanic term for caring,
in both verbal and nonverbal com-
munications.
2780_Glossary_481-488 16/07/12 12:19 PM Page 481

catimbozeiros Portuguese word for
sorcerer; can be a folk practitioner.
Celtic Belonging to a group of Indo-
European languages: Irish, Welsh,
or Breton.
Chasidic (or Hasidic) Ultra-
Orthodox Jewish sect.
cheshm-i-bad Iranian term for
evil eye.
Chiac or ciac French dialect used in
New Brunswick.
cho Haitian word for cold.
Chondo-Kyo Korean naturalistic reli-
gion that combines Confucianism,
Buddhism, and Daoism.
choteo Cuban term for a lighthearted
attitude, involving teasing, banter-
ing, and exaggeration.
collectivism Moral, political, or
social outlook that stresses human
interdependence.
comadre Portuguese term for
godmother.
community Group of people having a
common interest or identity; goes
beyond the physical environment
to include the physical, social, and
symbolic characteristics that cause
people to connect.
compadrazgo Spanish term for a sys-
tem of personal relationships in
which friends or relatives are
considered part of the family
whether or not there is a blood
relationship.
compadre Portuguese term for
godfather.
confianza Hispanic term for trust
developed between individuals;
essential for effective communica-
tion and interpersonal interactions
in health-care settings.
Conservative Jewish term for the reli-
gious group between Reform and
Orthodox in terms of religious
practice.
contadini Italian term for peasants.
cornicelli Italian charm with little red
horns worn for good luck.
Creole Rich and expressive language
derived from two other languages,
such as French and Fon, an
African tongue.
cultural awareness Appreciation of
the external signs of diversity such
as the arts, music, dress, and physi-
cal characteristics.
cultural competence Having the
knowledge, abilities, and skills to
deliver care congruent with the pa-
tient’s cultural beliefs and prac-
tices. (See Chapter 1 for a more
extensive definition.)
cultural humility Focuses on the
process of intercultural exchange,
paying explicit attention to clarify-
ing the professional’s values and
beliefs through self-reflexion.
cultural imperialism Practice of ex-
tending the policies and practices
of one organization (usually the
dominant one) to disenfranchised
and minority groups.
cultural imposition Intrusive applica-
tion of the majority cultural view
onto individuals and families.
cultural leverage A process whereby
the principles of cultural compe-
tence are deliberately invoked to
develop interventions.
cultural relativism Belief that the be-
haviors and practices of people
should be judged only from the
context of their cultural system.
cultural safety Expresses the diversity
that exists within cultural groups
and include the social determi-
nants of health, religion, and
gender in addition to ethnicity.
cultural sensitivity Having to do with
personal attitudes and not saying
things that may be offensive to
someone from a cultural or ethnic
background different from the
health-care provider’s background.
culture Totality of socially transmit-
ted behavior patterns, arts, beliefs,
values, customs, lifeways, and all
other products of human work
and thought characteristics of a
population of people that guides
their worldview and decision mak-
ing. Patterns may be explicit or
implicit, are primarily learned and
transmitted within the family, and
are shared by the majority of the
culture.
curandeiro Portuguese folk practi-
tioner whose healing powers are
divinely given.
curandero Traditional folk practi-
tioner common in Spanish-
speaking communities; treats
traditional illness not caused by
witchcraft.
D
daadihaus Amish grandparents’
cottage adjacent to farmhouse.
dan wei Functional unit of Chinese
society; work unit or neighbor-
hood unit responsible to and
for the Chinese people’s way
of life.
dao Balance between yin and yang.
dayah Arab midwife.
decensos Spanish term for fainting
spells.
demut German term for humility, a
priority value for the Amish, the
effects of which may be seen in
details such as the height of the
crown of an Amish man’s hat, as
well as in very general features
such as the modest and unassum-
ing bearing and demeanor usually
shown by Amish in public. This
behavior is reinforced by frequent
verbal warnings against its oppo-
site, hochmut, pride or arrogance,
which is to be avoided.
Deitsch/Duetsch Pennsylvania
German (sometimes incorrectly
anglicized as Pennsylvania Dutch);
American dialect derived from
several uplands and Alemanic
German dialects, with an admix-
ture of American English
vocabulary.
docte fey Haitian word for leaf
doctor.
docte zo Haitian word for bonesetter.
doule Haitian word for pain.
dulse Iodine-rich edible seaweed used
in clarifying beer and wine and as
a suspension medium in some
medicines; also known as
Irish moss.
duong Vietnamese force used in tra-
ditional health practice, associated
482 Glossary
2780_Glossary_481-488 16/07/12 12:19 PM Page 482

with things positive, masculine,
light, and full.
E
Eid Arabic, Iranian, and Somali
term for celebration of a feast—
for example, Eid Gorgan
(day/feast ending pilgrimage
to Mecca); Eid Fetr (last day of
the month of Ramadan).
Eire Gaelic name for Ireland.
el ataque/ataque de nervios Hyperki-
netic spasmodic activity common
in Spanish-speaking groups. The
purpose is to release strong feel-
ings or emotions. The person re-
quires no treatment, and the
condition subsides spontaneously.
It is an expression of deep anger
or depression.
empacho Condition common among
some Spanish-speaking popula-
tions; believed to be caused by a
bolus of food stuck in the gas-
trointestinal tract. Massage of the
abdomen is believed to relieve the
condition.
enculturation A natural conscious and
unconscious conditioning process
of learning accepted cultural
norms, values, and roles in society.
endropi Greek term for shame.
espiritista (espiritualista) Spanish or
Portuguese folk practitioners who
receive their talent from “God”;
treat conditions believed to be
caused by witchcraft.
estampitas Spanish for little statues
of saints.
ethic of neutrality Avoiding aggres-
sion and assertiveness, not inter-
fering with others’ lives unless
asked to do so, avoiding domi-
nance over others, and avoiding ar-
guments and seeking agreement.
ethnic group Group of people who
have had experiences different
from those of the dominant cul-
ture in status, background, resi-
dence, religion, education, or other
factors that functionally unify the
group and act collectively on one
another. Pertains to a religious,
racial, national, or cultural group.
ethnocentrism Universal tendency for
human beings to think that our
own ways of thinking, acting, and
believing are the only right,
proper, and natural ones and to
believe that those who differ
greatly are strange, bizarre, or un-
enlightened.
F
familism Social pattern in which
family solidarity and tradition
assume a superior position over
individual rights and interests.
Falasha Black Jews originating from
Africa.
fam saj Haitian Creole word for lay
midwife.
Farsi The national language of Iran.
fatalism Acceptance that occurrences
in life are predetermined by fate
and cannot be changed by human
beings.
Francophone People living in Canada
using French as their first
language.
freindschaft Amish three-generational
extended family network of
relationships.
fret Haitian word for cold.
G
Gaelic The language spoken in
Ireland.
garm Iranian term for hot.
garmie Iranian digestive problem
caused from eating too much hot
food.
gelassenheit Amish term for submis-
sion, yielding, surrender of self
and ego to the higher will of the
group or deity.
Gemeinschaft German word for
community.
generalization Reducing numerous
characteristics of an individual or
group of people to a general form
that renders them indistinguish-
able. Generalizations have to be
validated by the individual.
giac Vietnamese dermabrasive
procedure performed with cup
suctioning.
giagia Greek term for grandma.
Global society Seeing the world as
one large community as people
travel and interact.
Great Eid Islamic feast of 4 days.
guanxi Chinese term defining how
relatives are expected to help one
another through connections, used
by Chinese society in a manner
similar to the use of money in
other cultures.
Gullah Creole language spoken by
African Americans who reside on
or near the islands off the coasts
of Georgia and the Carolinas.
H
Hasidic (or Chasidic) Ultra-
Orthodox Jewish sect.
hadith Oral tradition of the Prophet
Muhammad; collection of words
and deeds that form the basis of
Muslim law.
Hajji (Hajj an haji) Annual
pilgrimage to Mecca.
halal The lawful—that which is per-
mitted by Allah; also, the term
used to describe ritual slaughter
of meat.
hanbang Traditional Korean
medical-care system.
hanui Korean word for oriental
medicine doctor.
hanyak Korean traditional herbal
medicine used to create harmony
between oneself and the larger
cosmology; a healing method for
body and soul.
haram The unlawful—that which is
prohibited by Allah; anyone who
engages in what is prohibited is
liable to incur punishment in
the hereafter (as well as legal
punishment in countries that
incorporate Islamic law into
legal codes).
Hasidic Jewish ultra-Orthodox sect.
Hebrew Language of Israel and of
Jewish prayer.
hejab Iranian term for any behavior
that expresses modesty in public—
for example, in women, modest
attire (loose dress or head scarf)
Glossary 483
2780_Glossary_481-488 16/07/12 12:19 PM Page 483

or shy, self-limiting behavior in
relating to the other gender.
hijab Modest covering of a Muslim
woman; conceals the head and the
body, except for the hands and
face, with loosely fitting, nontrans-
parent clothing.
hilot Filipino folk healer and
massage therapist.
Hindi Primary language of India.
Hispanic American of Spanish or
Latin American origin.
Hochmut Amish term for pride and
arrogance.
hogan Earth-covered Navajo
dwelling.
honor Spanish term for goodness or
virtue; can be diminished or lost
by an immoral or unworthy act.
hot-and-cold theory Hispanic concept
that illness is caused when the
body is exposed to an imbalance
of hot and cold; foods are also
classified as hot or cold.
hwa-byung Korean traditional illness
that occurs from repressing anger
or other strong emotions.
hwangap Significant celebration in
Korean society—at the age of 60,
a person starts the calendar cycle
over again.
I
ideology Thoughts and beliefs that
reflect the social needs and aspira-
tions of an individual or an
ethnocultural group.
Ihteram Egyptian Arabic word for
respect.
il mal occhio Italian term for the
evil eye.
imam Muslim leader of the prayer;
usually the most learned member
of the local Islamic community.
Indian Health Service Federal agency
that has the responsibility for pro-
viding health services to Native
Americans.
Indids Asian Indians who have a
light brown skin color.
individualism Term used to describe
a moral, political, or social
outlook that stresses human
independence and the importance
of individual self-reliance, and
freedom.
individuality The sense that each
person has a separate and equal
place in the community and where
individuals who are considered
“eccentrics or local characters”
are tolerated.
Indochinese Individuals originating
from Vietnam, Cambodia, or
Laos.
Insallah or Insh’Allah Arabic and
Turkish word for “if God wills.”
Islam Monotheistic religion in which
the supreme deity is Allah; accord-
ing to Muslim belief, God im-
parted his final revelations—the
Holy Qur’an—through his last
prophet, Mohammed, thereby
completing Judaism and
Christianity.
issei First-generation Japanese
immigrant.
itami Japanese term for pain.
itheram Egyptian term for respect.
J
jenn Egyptian term for the devil.
jerbero Spanish folk practitioner who
specializes in treating health con-
ditions through the use of herbal
therapy.
Jinn Arabic term for demons.
Joual French dialect incorporating
English words into a syntax and
grammar that is essentially French.
Judaism Refers to a religion, people,
and a culture.
K
kaddish Jewish prayer said for the
dead.
kampo Japanese term for East Asian
or Chinese medical practices and
botanical therapies.
karma Hindu term for actions
performed in the present life
and the accumulated effects from
past lives.
kashrut or kashrus Jewish laws that
dictate which foods are permissible
under religious law.
ki Korean term for the energy that
flows through living creatures.
Koran See Qur’an.
kosher Kashrut laws in the Jewish re-
ligion.
koumbari Greek term for coparents.
kut Korean shamanistic ceremony to
eliminate the evil spirits causing an
illness.
L
la gente de la raza Phrase denoting a
genetic determination to which all
Spanish-speaking people belong,
regardless of class differences or
place of birth.
lace curtain Irish Name given to Irish
in America who left inner-city en-
claves and moved to the suburbs.
Latino(a) Person from Latin
America.
laub Hmong dish made with raw
pork and vegetables and spices.
laying on of hands Spiritual practice
of placing one’s hands on an indi-
vidual for the purpose of healing.
lien Vietnamese concept that repre-
sents control over and responsibil-
ity for moral character.
M
maalesh Arabic term meaning never
mind, it doesn’t matter; substantial
efforts are directed at maintaining
pleasant relationships and preserv-
ing dignity and honor; hostility in
response to perceived wrongdoing
is warded off by an attitude of
maalesh.
machismo Sense of masculinity that
stresses virility, courage, and domi-
nation of women; includes the
need to display physical strength,
bravery, and virility.
madichon Haitian term used when
children are disrespectful; it means
that their future will be marred by
misfortune.
maghi Italian word for witch.
magissa Greek folk healer.
mal ojo Spanish term for the evil eye,
a hex condition with unspecific
signs and symptoms believed to be
caused by an older person admir-
ing a younger person; condition
can be reversed if the person doing
484 Glossary
2780_Glossary_481-488 16/07/12 12:19 PM Page 484

the admiring touches the person
being admired.
Marielitos Cuban immigrants who
arrived in 1980 on a massive
boatlift from Muriel Harbor,
Cuba, to Key West, Florida.
masallah Turkish term for God bless
and protect.
matiasma Greek term for the
evil eye.
Métis People of mixed Native
American and European,
especially French Canadian,
heritage.
mestizo(a) Person of mixed
Spanish and Native American
heritage.
mezuzah Container with biblical
writings; placed on the doorpost
of homes or hung around the neck
on a necklace.
mien Vietnamese concept based on
wealth and power.
Mohammed Prophet of God and
founder of Islam.
mohel Ritual circumciser in the Jew-
ish faith.
moreno Portuguese Brazilian individ-
ual who has black or brown hair
and dark eyes.
morita therapy Indigenous Japanese
school of psychotherapy.
Moslem See Muslim.
mosque Muslim place of worship.
moxibustion Vietnamese health-care
practice in which pulverized
wormwood is heated and
placed directly on the skin at
specified meridians to counter
conditions associated with
excess cold.
mukrah Arabic term for undesirable
but not forbidden.
Mulatto Person of mixed European
and African heritage.
mundang Korean folk healer who
has special abilities for communi-
cating with the spirits and in
treating illnesses after all other
means of treatment are
exhausted.
Muslim Person who follows the
Islamic faith, the world’s
second-largest religion.
N
naharati Iranian term for generalized
distress.
Naikan therapy Japanese indigenous
psychotherapy of reflection on
how much goodness and love are
received from others.
Navajo neuropathy Neurological
condition confined to Navajo
Indians; characterized by a com-
plete absence of myelinated fibers
resulting in short stature, sexual
infantilism, systemic infection, hy-
potonia, areflexia, loss of sensa-
tion in the extremities, corneal
ulcerations, acral mutilation, and
painless fractures.
nazar Turkish term for envy.
nazar boncuk Small blue bead used
among Turkish people to protect a
child from the evil eye.
nervioso(a) Hispanic term used to
describe signs and symptoms of
nervousness, anxiety, sadness,
and grief.
nevra Greek folk illness.
Niuyoricans Puerto Ricans born in
New York.
Nihon/Nippon Japanese name for
Japan.
Nihonjin Japanese term that denotes
a strong sense of nationalism and
pride in ethnic purity.
nisei Japanese term for the second
generation of an immigrant family.
O
Old Order Amish Most conservative
and traditionalist group among
the followers of Jacob Ammann;
today simply called Amish, but
technically known as Old Order
Amish Mennonite to distinguish
them from other related Amish
and Mennonite groups.
oppression Haitian ailment related
to asthma; describes a state of
anxiety and hyperventilation.
ordnung Codified rules and regula-
tions that govern the behavior of a
local Amish church district, or
congregation; local consensus
of faith and practice; also the
German term for order.
orishas Gods or spirits in Santería.
Orthodox Traditional Judaism.
P
Padrone or capo di famiglia Italian
word for master, head of the
family.
Paj ntaub (pan dow) Form of embroi-
dery that Hmong women do to
decorate their clothing and make
historical story cloths.
pappous Greek word for grandfather.
parve Jewish term used for foods that
are neutral and can be eaten with
meat or milk products.
Pasah Dai Dialect in southern
Thailand.
Pasah Isaan Dialect in northeastern
Thailand.
Pasah Nua Dialect in northern
Thailand.
personalismo Spanish word for
emphasis on intimate, personal
relationships as more important
than impersonal, bureaucratic
relationships.
philptimo Greek term for respect.
phylacto Greek amulet worn to ward
off envy.
pidgin Simplified language used for
communicating between speakers
of different languages.
pikirist Haitian word for
injectionist.
pogrom Organized persecution or
massacre of a minority group.
Polonia Communities heavily occu-
pied by Polish immigrants and de-
scendants of Polish nationals. Also
the medieval name for Poland.
Ponos Greek word for pain.
practika Greek herbal remedies.
pseudofamilies Vietnamese house-
holds made up of close and dis-
tant relatives and friends that
share accommodations, finances,
and fellowship.
pu tong hua Recognized language of
China.
Q
qi One of five substances or
elements of traditional Chinese
Glossary 485
2780_Glossary_481-488 16/07/12 12:19 PM Page 485

medicine; encompasses the founda-
tion of the energy of the body, envi-
ronment, and universe; includes all
sources and expenditures of energy.
quinceñera A Hispanic/Latino girl’s
15th birthday that celebrates her
passage into womanhood.
Qur’an or Koran Muslim holy book;
believed by Muslims to contain
God’s final revelations to
humankind.
R
rabbi Jewish religious leader.
Ramadan or Ramazan The 9th
month of the Islamic year during
which Muslims are required to fast
during daylight hours for 30 days.
Reconstructionism Mosaic of the
three main branches of Judaism; is
an evolving religion of the Jewish
people; seeks to adapt Jewish be-
liefs and practices to the needs of
the contemporary world.
Reform Liberal or Progressive
Judaism.
remedios caserios Portuguese
(Brazilian) home medicine or
remedy.
remedios populares Portuguese
(Brazilian) folk medicine practices.
respeto Hispanic term denoting re-
spect; refers to the qualities devel-
oped toward others such as
parents, the elderly, and educated
people who are expected to be
honored, admired, and respected.
restavec Haitian term to denote
children who are sent to live with
a nonparent family for the pur-
poses of improving their lives
economically.
Rezadeiras Brazilian spiritual
leaders.
S
Sabra Jew who was born in Israel.
sansei Japanese term for the third
generation of an immigrant family.
Santería 300-year-old Afro-Cuban
religion that syncretizes Roman
Catholic elements with ancient
Yoruba tribal beliefs and practices.
santero Practitioner of Santería.
sard Iranian term for cold.
sardie Iranian digestive problem;
occurs from eating too much
cold food.
sensei Japanese term for master; used
to address teachers, physicians, or
those in seniority in a corporate
setting.
Sephardic Jewish term for being de-
scended from Spain, Portugal, the
Mediterranean, Africa, or Central
or South America.
severe combined immune deficiency
syndrome Immune deficiency syn-
drome (unrelated to AIDS), char-
acterized by a failure of antibody
response and cell-mediated
immunity.
shanty Irish Term for Irish who lived
in urban Irish ethnic enclaves.
sheikhs The most learned individuals
in an Islamic community.
Shinryo Naika Japanese indigenous
therapy focusing on bodily
illnesses that are emotionally
induced.
Shinto Indigenous religion of Japan.
simpatia Spanish term for smooth in-
terpersonal relationships; charac-
terized by courtesy, respect, and
the absence of harsh criticism or
confrontation.
Small Eid Islamic holy feast of
3 days.
sobador Spanish folk practitioner,
similar to a chiropractor, who
treats illnesses and conditions
affecting the joints and
musculoskeletal system.
Solidarnosc “Solidarity” Union of
interests, purposes, and sympa-
thies promoting fellowship with
Polish nationals.
Spanglish Sentence structure that in-
cludes both English and Spanish
words.
stereotyping Oversimplified concep-
tion, opinion, or belief about some
aspect of an individual or group
of people.
sto lat Polish phrase meaning that
the celebrant should live a
hundred years.
subculture Group of people who
have had experiences different
from those of the dominant cul-
ture in status, ethnic background,
residence, religion, education, or
other factors that functionally
unify the group and act collec-
tively on one another.
susto “Magical fright,” a condition
believed to be caused by witch-
craft; symptoms can be quite var-
ied and include both mental and
physical concerns.
Synagogue, temple, or shul Jewish
house of worship.
T
T’ai chi Chinese system of exercise
for mind and body control.
ta’arof Iranian ritual expressing
courtesy.
tae-kyo Korean term, literally fetus
education, with the objective being
health and well-being of the fetus
and the mother through art,
beautiful objects, and a serene
environment.
tae-mong Korean term signifying the
beginning of pregnancy; the preg-
nant woman dreams of conception
of the fetus.
Tagalog Filipino national language.
Tesbih Turkish small beads tradi-
tionally used for praying, now take
a more secular meaning and are
often referred to as worry beads.
Tet Asian Lunar New Year; cele-
brated in January or February.
Torah Five books of Moses; referred
to in the Jewish faith.
treyf Jewish term for forbidden or
unclean.
tribe Native American social organi-
zation comprising several local vil-
lages, bands, districts, lineages, or
other groups who share a common
ancestry, language, and culture.
Tridosha Theory that the body is
made up of five elements: fire, air,
space, water, and earth.
tu txiv neeb Hmong shaman who is a
religious leader and health healer.
tudo bom Portuguese word for great,
often said in a stoical sense.
486 Glossary
2780_Glossary_481-488 16/07/12 12:19 PM Page 486

two spirit Term to used among
AI/AN populations to connote di-
verse gender and sexual identities.
V
variant cultural characteristics Deter-
mine a person’s adherence to
beliefs and values of his or her
dominant culture. Includes nation-
ality, race, color, gender, age,
religious affiliation, educational
status, socioeconomic status, occu-
pation, military experience, politi-
cal beliefs, urban or rural
residence, enclave identity, marital
status, parental status, physical
characteristics, sexual orientation,
gender issues, and reason for
migration (sojourner, immigrant,
or undocumented status).
velorio Spanish term for a wake; a
festive occasion following the
burial of a person.
vendouses Greek practice of cupping.
verguenza Spanish term for a con-
sciousness of public opinion and
the judgment of the entire
community.
via nuova Italian for new way.
via vecchia Italian for old way.
Viddui Jewish personal confession re-
cited when death is imminent.
visiting High-frequency custom of
family-to-family home visits that
help to maintain kinship and
church ties and the flow of
information within the Amish
community.
voudou or voodoo Vibrant religion
born from slavery and revolt; the
term means sacred in the African
language of Fon.
W
wake Watch over a deceased person
before burial; usually accompa-
nied by a celebration, which may
include feasting.
warm hands Healing art related to
therapeutic touch; regarded by
Amish as a gift to be applied for
the good of others in need of
healing; a form of brauche.
worldview Way an individual or
group of people look upon
their universe to form values
about their life and the world
around them.
Y
yang In Chinese belief system, one
of two opposing principles of the
balance of life; can be either a sin-
gle phenomenon or a state of
being of a phenomenon. See yin.
yarmulke Jewish head covering worn
by men.
yerbero See jerbero.
Yiddish Language often spoken by
elderly Jews.
yin In Chinese belief system, one of
two opposing principles of the
balance of life; can be either a sin-
gle phenomenon or a state of
being of a phenomenon. See yang.
Z
zaher Iranian term for public
persona.
zar Egyptian transmeditative
ceremony.
Zhong guo The Chinese name for
China and means “middle
kingdom.”
zong Vietnamese herbal preparation;
relieves motion sickness or cold-
related problems.
Glossary 487
2780_Glossary_481-488 16/07/12 12:19 PM Page 487

2780_Glossary_481-488 16/07/12 12:19 PM Page 488

489
A
Aagwachse, 91
Abnemme, 91
Abortion viewpoint
African Americans and, 67
Amish people and, 105
Arab people and, 121
Chinese and, 137
Egyptians and, 168
Filipinos and, 187–188
Guatemalan people and, 153
Haitians and, 241
Japanese and, 269
Jewish people and, 286
Koreans and, 302
Mexicans and, 326
Polish and, 348
Russians and, 332
Abwaarde, 90
Acadians, 197
Acceptability, health care, 48
Accessibility, health care, 48
Accountability, health care, 48
Acculturation, 8, 24, 352
Achtgewwe, 90
Acupuncture, 140
Acute-care services, 47
Adaptability, health care, 48
Adolescent behavior. See Children and
adolescent behavior
Advanced directives, 47
Affordability, health care, 48. See also
Health-care barriers
African American English (AAE), 58
African American heritage
alternative lifestyles and, 60
asthma and, 63
autonomy and, 61
biocultural ecology and, 61–65
biological variations and, 61–62
blood transfusions and, 71
cancer incidence and, 63
cardiovascular disease and, 62–63
childbearing practices and, 67
children and adolescent behaviors and,
59–60
common foods and food rituals and, 66
cultural communication patterns and,
58–59
cultural responses to health and illness
and, 71
death rituals and, 67–68
diabetes and, 63
dietary practices for health promotion
and, 66
diseases and health conditions and,
62–64
dominant languages and dialects
and, 58
dominant religion and, 68–69
drug metabolism and, 64–65
educational status and occupations and,
57–58
family goals and priorities and, 60
family roles and organization and,
59–60
fertility practices and, 67
folk and traditional practices and, 70
formats for names and, 59
gender roles and, 59
head of households and, 59
health-care barriers and, 70–71
health-care practices and, 65, 70–71
health-care practitioners and, 71–72
health care responsibility and, 70
health-seeking beliefs and behaviors
and, 70
healthcare disparities and, 3
heart disease and, 62
heritage and residence and, 56–57
high-risk behaviors and, 65
HIV/AIDS and, 64
hypertension and, 62
meaning of food and, 66
meaning of life and, 69
migration and associated economic
factors and, 57
nutrition and, 65–67
nutritional deficiencies and food
limitations and, 66–67
organ donation and, 71
overview of, 56
pregnancy practices and, 67
psychiatric disorders and, 65
reasons for migration and, 57
responses to death and grief and, 68
sickle cell disease and, 63
skin color and, 61–62
sources of strength and, 69
spiritual beliefs and health care
practices and, 69
spirituality and, 68–69
teen pregnancy and, 60
temporal relationships and, 59
use of prayer and, 68–69
views toward pregnancy and, 67
workforce issues and, 60–61
workplace culture and, 60–61
African American Vernacular English
(AAVE), 58
Agency for Healthcare Research and
Quality (AHRQ), 3
AIDS. See HIV/AIDS
Air pollution, 38
Alaskan natives
diseases and disorders, 378–379
healthcare disparities and, 4
Alcohol consumption, 39–40, 39t
Amish and, 84
French Canadians and, 204
Germans and, 221
Guatemalans and, 151
Haitians and, 239
Iranians and, 253–254
Irish and, 391
Japanese and, 267
Jewish people and, 283
Koreans and, 300
Mexicans and, 315
Polish people and, 346
Russians and, 330
Thais and, 362
Alternative lifestyles, 32–33
African Americans and, 60
Amish and, 81
Appalachian people and, 101
Arabs and, 117
Chinese and, 134–135
Egyptians and, 164
Filipinos and, 182–183
French Canadians and, 201–202
Germans and, 219
Guatemalans and, 148
Haitians and, 236
Iranians and, 252
Japanese and, 265
Jewish people and, 281
Koreans and, 299
Mexicans and, 313
Polish people and, 344
Russians and, 329
Thais and, 358–359
Amal, 171
American Indians, healthcare disparities
and, 4
American Pain Foundation, 50
Amish heritage
alcohol and drug abuse and, 84
alternative lifestyles and, 81
autonomy issues and, 82
biocultural ecology and, 82–84
biological variations and, 82
blood transfusions and, 92
childbearing practices and, 86–87
children and adolescent behaviors
and, 80
common foods and, 85
communication and, 77–80
cultural communication patterns and,
78–79
cultural responses to health and illness,
92
death rituals and, 88
diseases and health conditions and,
82–84
dominant languages and dialects and,
77–78
drug metabolism and, 84
educational status and occupations and,
76–77
Ellis-van Creveld syndrome and, 83
family goals and priorities and, 80–81
family roles and organization and, 80–81
Index
Note: Page numbers followed by f refer to figures; those followed by t refer to tables.
2780_Index_489-506 16/07/12 12:19 PM Page 489

490 Index
farms, 77f
fertility practices and, 86
folk and traditional practices and, 90–91
food rituals and, 85–86
format for names and, 79–80
gender roles and, 80
head of households and, 80
health-care barriers and, 91–92
health-care practices and, 84–85, 89–92
health-care practitioners and, 92–93
health-care responsibility and, 89–90
hemophilia B and, 83
herbal medications and, 91
hereditary defects and, 82–83
heritage and residence and, 75–76
high-risk behaviors and, 84–85
manic depressive illness and, 83–84
meaning of food and, 85
meaning of life and, 88–89
migration and associated economic
factors and, 76
nutrition and, 84, 85–86
organ donation and, 92
overview of, 75
pregnancy and childbearing practices
and, 86–87
responses to death and grief and, 88
schoolhouses, 77f
skin color and, 82
sources of strength and, 88–89
spirituality and, 88–89
temporal relationships and, 79
views toward pregnancy and, 86
workforce issues and, 81–82
Amor propio (personal affront), 178
Anabaptist movement, 76
Ancestor worship, Chinese and, 138
Apocopation, 311
Appalachian heritage
alternative lifestyles and, 101
autonomy and, 101
behaviors of children and adolescents
and, 100
biocultural ecology and, 101–102
biological variations and, 101
blood transfusions and, 111
cancer rates and, 102
common foods and food rituals and,
104
communication and, 97–98
cultural communication patterns and,
98–99
cultural responses to health care illnesses
and, 111
death rituals and, 105–106
dietary practices and, 104
diseases and health conditions and,
101–102
dominant languages and dialects and,
97–98
dominant religion and, 106
drug abuse and, 102–103
drug metabolism and, 102
educational status and occupations
and, 97
family goals and priorities and, 100–101
family roles and organization and,
100–101
fertility practices and, 104–105
folk and traditional practices and,
107–110, 108t–110t
food limitations and, 104
format for names and, 99
gender roles and, 100
head of household and, 100
health-care barriers and, 110–111
health-care practices and, 103, 107–111
health-care responsibility and, 107
health-seeking beliefs and behaviors
and, 107
heritage and residence and, 96
high-risk behaviors and, 102–103
isolation of, 96f
meaning of food and, 103
meaning of life and, 106
methamphetamine laboratories and,
102–103
migration and associated economic
factors and, 96–97
nutrition and, 103–104
nutritional deficiencies and, 104
organ donation and, 111
poor housing conditions and, 101–102
pregnancy practices and, 104–105
responses to death and grief and,
105–106
skin color and, 101
sources of strength and, 106
spirituality and, 106
temporal relationships and, 99
use of prayer and, 106
views toward pregnancy and, 104–105
workforce issues and, 101
workplace culture and, 101
Appointments, expectations and, 29
Approachability, health care and, 48
Appropriateness, health care and, 48
Arab heritage
alcohol and pork prohibitions and,
120–121
alternative lifestyles and, 117
autonomy and, 117–118
barriers to health care and, 125
biocultural ecology and, 118–119
biological variations and, 118
blood transfusions and, 126
breastfeeding and, 121–122
cardiovascular diseases and, 119
childbearing practices and, 121–122
children and adolescent behaviors and,
116–117
common foods and food rituals and,
120
communication and, 114–115
cultural communication patterns and,
114–115
cultural responses to health care and,
125–126
death rituals and, 122
dietary practices and, 120
diseases and disorders and, 374–375
diseases and health conditions and, 118
diversity among, 113
dominant languages and dialects and,
114–115
drug metabolism and, 119
educational status and occupations and,
114
ethnic identity and, 113
family goals and priorities and, 117
family roles and organization and,
116–117
fertility practices and, 121
folk practices and, 124–125
food limitations and, 120–121
format for names and, 116
gender roles and, 116
head of households and, 116
health-care practices and, 119–120,
123–126
health-care practitioners and, 126–127
health-care responsibility and, 124
health-seeking beliefs and behaviors
and, 123–124
heritage and residence and, 114
high-risk behaviors and, 119–120
meaning of life and, 123
migration and associated economic
factors and, 114
modesty and Arab women, 119
nutrition and, 120–121
nutritional deficiencies and, 120–121
organ donation and, 126
overview of, 113
pregnancy and childbearing practices
and, 121–122
Ramadan and, 120
religious practices and, 122–123
responses to death and grief and, 122
responses to illness and, 123
skin color and, 118
smoking rates and, 119
sources of strength and, 123
spirituality and, 122–123
temporal relationships and, 115
use of prayer and, 122–123
workforce issues and, 117–118
workplace culture and, 117
Arabic, 159
Arabic-speaking Iranians, 249
Arwah, 171
Ashkenazi Jewish people, 279
Asians
diseases and disorders, 375–376
healthcare disparities and, 3–4
population in United States, 3
Assimilation, 8, 24, 352
Attitudes, health care, 48
Autonomy issues, workplace, 34–35
African Americans and, 61
Amish and, 82
Appalachian people and, 101
Arabs and, 117–118
Chinese and, 135
Egyptians and, 164–165
Filipinos and, 184
French Canadians and, 203
Germans and, 220
Guatemalans and, 149
Haitians and, 237–238
Iranians and, 253
Japanese and, 266
Jewish people and, 282
Koreans and, 299
2780_Index_489-506 16/07/12 12:19 PM Page 490

Index 491
Mexicans and, 314
Polish people and, 344–345
Russians and, 329
Thais and, 359
Autopsy. See Death rituals and
expectations
Availability, health care, 48
Awareness, health care, 48
Ayerveda, 390
B
Baby boomers, 36
Bahala na, 184
Baltic heritage, 381–382
Baptists, 106
Baten, 251
Beliefs, defined, 6
Bereavement time, 45
Besprechung, 216
Best evidence, 12–15. See also Evidence-
based practice
Biocultural ecology, 36–38. See also
Diseases and health conditions
African Americans and, 61–62
Amish and, 82–84
Appalachian people and, 101–102
Arabs and, 118–119
Chinese and, 135–136
Egyptians and, 165–166
Filipinos and, 184–185
French Canadians and, 203–204
Germans and, 220–221
Guatemalans and, 149–151
Haitians and, 238–239
Iranians and, 253
Japanese and, 266–267
Jewish people and, 282–283
Koreans and, 300–301
Mexicans and, 314–315
Polish people and, 345–346
Russians and, 314–315
Thais and, 359–360
Biological variations, 36–37
African Americans and, 61–62
Amish and, 82
Appalachian people and, 101
Arabs and, 118
Chinese and, 135–136
Egyptians and, 165
Filipinos and, 184–185
French Canadians and, 203
Germans and, 220
Guatemalans and, 149
Haitians and, 238
Iranians and, 253
Japanese and, 266
Jewish people and, 282
Mexicans and, 314
Polish people and, 345
Russians and, 329–330
Thais and, 359
Black/African American populations in
United States, 3
Black English, 58
Black Madonna, 350f
Black populations, diseases and disorders,
373–374
Black Vernacular English (BVE), 58
Blood transfusions, 51
African Americans and, 71
Amish and, 92
Appalachian people and, 111
Arabs and, 126
Chinese and, 143
Egyptians and, 173
Filipinos and, 193
French Canadians and, 210
Germans and, 229
Guatemalans and, 156
Haitians and, 246
Iranians and, 258
Japanese and, 275
Jewish people and, 291
Koreans and, 307
Mexicans and, 322
Polish people and, 352
Russians and, 335
Thais and, 369
Boat people, 233
Body habitus, variations in, 36–37
Body language, 28–29
Bone density, 37
Boston Cancer Pain Education Center, 50
Brauche, 91
Braucher, 92
Brazilian heritage, 383–384
Brown v. Board of Education of Topeka, 57
Buddhism, 272, 366–368, 366f
Burakumin, 265
C
Cancer incidence
African Americans and, 62, 63
Appalachian people and, 102
Chinese and, 136
Filipinos and, 185
French Canadians and, 203
Germans and, 221
Haitians and, 238
Jewish people and, 283
Koreans and, 300
Polish people and, 346
Russians and, 330
Catholic Church, 208, 349, 392
Census 2000, 2
Cheshm-i-bad, 257
Chiac, 198
Chicanos, 309. See also Mexican heritage
Child rearing. See Children and adolescent
behavior/discipline
Childbearing age. See Fertility practices
Childbearing practices, family, 43–44
African Americans and, 67
Amish and, 86–87
Appalachian people and, 104–105
Arabs and, 121–122
Chinese and, 137–138
Egyptians, 168–169
Filipinos and, 187–188, 189t
French Canadians and, 206–207
Germans and, 223–224
Guatemalans and, 152–153
Haitians and, 241–242
Iranians and, 255
Japanese and, 269–270
Jewish people and, 285–286
Koreans and, 302–303
Mexicans and, 316–318
Polish people and, 348–349
Russians and, 331–332
Thais, 364–366
Children and adolescent behavior/
discipline
African Americans and, 59–60
Amish and, 80
Appalachian people and, 100
Arabs and, 116–117
Chinese and, 133–134
Egyptians and, 162
Filipinos and, 181
French Canadians and, 201
Germans and, 218
Guatemalans and, 148
Haitians and, 236
Iranians and, 251–252
Japanese and, 264
Jewish people, 280–281
Koreans and, 297–298
Mexicans and, 312
Polish people and, 343–344
Russians and, 328
Thais and, 358
Children of Israel, 278
Chinese heritage
alternative lifestyles and, 134–135
ancestor worship and, 138
autonomy and, 135
biocultural ecology and, 135–136
biological variations and, 135–136
blood transfusions and, 143
cancer incidence and, 136
children and adolescent behavior and,
133–134
common foods and food rituals and,
136–137
communication and, 130–132
cultural barriers and, 141–142
cultural communication patterns and,
132
cultural responses to health care,
142–143
death rituals and expectations and,
138–139
dietary practices and, 137
diseases and health conditions and, 136
dominant religions and, 139
drug metabolism and, 136
educational status and occupations
and, 130
extended families and, 134
family goals and priorities and, 134
family roles and organization and,
132–135
fertility practices and, 137
format for names, 132
frequently used words and phrases, 131t
gender roles and, 132–133
head of household and, 132–133
health-care barriers and, 141–142
health-care practices and, 139–141
health-care practitioners and, 143–144
health-care responsibility and, 140
2780_Index_489-506 16/07/12 12:19 PM Page 491

492 Index
health-seeking beliefs and behaviors
and, 139–140
heritage and residence and, 129–130
high-risk behaviors and, 136
language barriers and, 141
meaning of food and, 136
meaning of life and, 139
migration and associated economic
factors and, 130
nutrition and, 136–137
nutritional deficiencies and food
limitations and, 137
organ donation and, 143
overview of, 129
pregnancy and childbearing practices
and, 137–138
privacy concept and, 134
responses to death and grief and, 139
skin color and, 135–136
smoking incidence and, 136
socioeconomic barriers and, 142
sources of strength and, 139
spirituality and, 139
traditional Chinese medicine, 140–141,
140t
use of prayer and, 139
veneration of older people and, 134
views toward pregnancy and, 137
workforce issues and, 135
workplace culture and, 135
Chondo-Kyo, 304
Christian Scientists, 47
Circumcision, 286
Classism, 32
Clinical context, evidence-based practice
and, 15
Clinical encounters, individual cultural
competence and, 10
Clinical expertise, evidence-based practice
and, 15
Collectivist societies, 8
Commission on Graduates of Foreign
Nursing Schools, 35
Common foods, 41–42
African Americans and, 66
Amish and, 85–86
Appalachian people and, 104
Arabs and, 120
Chinese and, 136–137
Egyptians and, 167–168
Filipinos and, 186–187
French Canadians and, 205
Germans and, 222
Guatemalans and, 152
Haitians and, 240, 240t
Iranians and, 254
Japanese and, 268–269
Jewish people and, 284–285
Koreans and, 301
Mexicans and, 316
Polish people and, 347, 347t
Russians and, 331
Thais and, 363–364, 363f
Communication, 25–30
African Americans and, 58–59
Amish and, 77–80
Appalachian people and, 97–98
Arabs and, 114
Chinese and, 130–132
Egyptians and, 159–161
Filipinos and, 177–180
French Canadians and, 198–200
Germans and, 215–217
Guatemalans and, 146
Haitians and, 234–235
Iranians and, 250–251
Japanese and, 261–262
Jewish people and, 279–280
Koreans and, 295–296
Mexicans and, 311–312
Polish people and, 342–343
Russians and, 327–328
Thais and, 357–358
Community, defined, 21–22
Confucianism, 272, 304
Conservative Amish Mennonites, 76
Conservative Judaism, 278
Constitution of the United States, 23
Contagious magic, 70
Continuing education, 16
Contraceptive use, 43. See also Fertility
practices
Creole, 232
Cross-cultural, defined, 8
Cuban heritage, 387–388
Cultural awareness, defined, 6
Cultural communication patterns,
27–29
African Americans and, 58–59
Amish and, 78–79
Appalachian people and, 98–99
Arabs and, 114
Chinese and, 132–133
Egyptians and, 159–160
Filipinos, 178–179
French Canadians, 199–200
Germans and, 216–217
Haitians and, 234–235
Iranians and, 250–251
Japanese and, 261–262
Jewish people and, 279–280
Koreans and, 295–296
Mexicans and, 311
Polish people and, 342
Russians and, 327–328
Thais and, 357
Cultural competence, defined, 6
Cultural imperialism, 9
Cultural imposition, 9
Cultural leverage, 9
Cultural patterns, 27–29
Cultural/racial disease and illness, 373–379
Arabs/Middle Easterners, 374–375
Asian/Pacific islanders, 375–376
black populations, 373–374
European American ethnic white
populations, 376–378
Hispanics, 374
Native Americans/Alaskan natives,
378–379
Cultural relativism, 9
Cultural responses to health/illness,
321–322
African Americans and, 71
Amish and, 92
Appalachian people and, 111
Arabs and, 125–126
Chinese and, 142–143
Egyptians and, 172–173
Filipinos and, 193
French Canadians and, 209–210
Germans and, 228–229
Guatemalans and, 155–156
Haitians and, 245–246
Iranians and, 257–258
Japanese and, 274–275
Jewish people and, 291
Koreans and, 306–307
Mexicans and, 321–322
Polish people and, 351–352
Russians and, 335
Thais and, 369
Cultural sensitivity, defined, 6
Cultures
defined, 5
ethics across, 8–10
primary and secondary characteristics
of, 7–8
D
Daadihaus, 81
Dan wei, 135, 141
Dao, 140
Death, responses to, 45
African Americans and, 68
Amish and, 88
Appalachian people and, 105–106
Arabs and, 122
Chinese and, 139
Egyptians and, 169
Filipinos and, 189–190
French Canadians and, 207
Germans and, 224–225
Guatemalans and, 154
Haitians and, 243
Iranians and, 256
Japanese and, 272
Jewish people and, 288
Koreans and, 304
Mexicans and, 318
Polish people and, 349
Russians and, 332–333
Thais and, 366
Death rituals/expectations, 44–45
African Americans and, 67–68
Amish and, 88
Appalachian people and, 105–106
Arabs and, 122
Chinese and, 138–139
Egyptians and, 169
Filipinos and, 188–189
French Canadians and, 207
Germans and, 224–225
Guatemalans and, 153–154
Haitians and, 243
Iranians and, 255–256
Japanese and, 271–272
Jewish people and, 287–288
Koreans and, 304
Mexicans and, 318
Polish people and, 349
Russians and, 332
Thais and, 366
2780_Index_489-506 16/07/12 12:19 PM Page 492

Index 493
Defensive charting, 34
Deitsch, 77–78
Demut, 79
Diabetes mellitus (DM), 37
Dialect-shifting, 58
Dialects, 26–27. See also Dominant
languages
African Americans and, 58
Amish and, 77–78
Appalachian people and, 97–98
Arabs and, 114
Chinese and, 130–131
Egyptians and, 159–160
French Canadians and, 198–199
Germans and, 215–216
Guatemalans and, 146
Haitians and, 234
Iranians and, 250
Japanese and, 261
Jewish people and, 279
Koreans and, 295
Mexicans and, 311
Polish people and, 342
Russians and, 326–327
Thais and, 357
Dietary counseling, 41–42
Dietary practices for health promotion,
41–42
African Americans and, 66
Appalachian people and, 104
Arabs and, 120
Chinese and, 137
Egyptians and, 168
Filipinos and, 187
French Canadians and, 205
Germans and, 222
Guatemalans and, 152
Haitians and, 240–241
Iranians and, 254
Japanese and, 269
Jewish people and, 285
Koreans and, 301
Mexicans and, 316
Polish people and, 348
Russians and, 331
Thais and, 364
Disabled and handicapped, 35
Arab attitudes and, 125–126
Chinese attitudes and, 143
Egyptians attitudes and, 173
Iranian attitudes and, 258
Japanese attitudes and, 275
Korean attitudes and, 306–307
Russian attitudes and, 329
Diseases and health conditions, 37–38
African Americans and, 62–64
Amish and, 82–84
Appalachian people and, 101–102
Arabs and, 118
Chinese and, 136
Egyptians and, 165
Filipinos and, 185
French Canadians and, 203–204
Germans and, 220–221
Guatemalans and, 149–151
Haitians and, 238–239
Iranians and, 253
Japanese and, 266
Jewish people and, 282–283
Koreans and, 300
Mexicans and, 314–315
Polish people and, 345–346
Russians and, 330
Thais and, 360
Diseases/disorders, cultural and racial
listing, 373–379
Diskutieren, 216
Divorce. See Alternative lifestyles
Domestic partnerships, 32–33
Dominant languages, 26–27. See also
Dialects
African Americans and, 58
Amish and, 77–78
Appalachian people and, 97–98
Arabs and, 114
Chinese and, 131–132
French Canadians and, 198–199
Germans and, 215–216
Guatemalans and, 146
Haitians and, 234
Iranians and, 250
Japanese and, 261
Jewish people and, 279
Koreans and, 295
Mexicans and, 311
Polish people and, 342
Russians and, 326–327
Thais and, 357
Drug metabolism, 38
African Americans and, 64–65
Amish and, 84
Appalachian people and, 102
Arabs and, 119
Chinese and, 136
Egyptians and, 165
Filipinos and, 185
French Canadians and, 204
Germans and, 221
Guatemalans and, 151
Haitians and, 239
Japanese and, 267
Jewish people and, 283
Koreans and, 300
Mexicans and, 315
Russians and, 330
Thais and, 360
Düütsch, 78
E
Ebonics, 58
Education and orientation, organizational
cultural competence and, 11–12
Educational level, practitioner respect
and, 52
Educational preparation, health-care
profession, 34
Educational status, 25
African Americans and, 57–58
Amish and, 76–77
Appalachian people and, 97
Arabs and, 114
Chinese and, 130
Egyptians and, 159
Filipinos and, 176–177
French Canadians and, 198
Germans and, 214–215
Guatemalans and, 146
Haitians and, 233–234
Iranians and, 250
Japanese and, 261–262
Jewish people and, 279
Koreans, 294–295
Mexicans and, 310
Polish people and, 341–342
Russians and, 326–327
Thais and, 356–357, 357f
Egalitarianism, 32
Egyptian heritage
alternative lifestyles and, 164
autonomy issues and, 164–165
biocultural ecology and, 165–166
biological variations and, 165
blood transfusions and, 173
cardiovascular diseases and, 166
children and adolescent behaviors and,
162
common foods and food rituals and,
167–168
communication and, 159–161
cultural communication patterns and,
159–160
cultural responses to health care and,
172–173
death rituals and, 169
dietary practices for health promotion
and, 167
disabilities and, 173
diseases and health conditions and, 165
dominant religion and, 169–170
drug metabolism and, 165
educational status and occupations
and, 159
family goals and priorities and, 162–164
family roles and organization and,
161–164
fertility practices and, 168
folk and traditional practices and, 171
format for names and, 161
gender roles and, 161–162
head of household and, 161–162
health-care barriers and, 171–172
health-care practices and, 166–167,
170–173
health-care practitioners and, 173–174
health-care responsibility and,
170–171
health-seeking beliefs and behaviors
and, 170
heritage and residence and, 158
high-risk behaviors and, 166–167
meaning of food and, 167
meaning of life and, 170
mental illness and, 172–173
migration and associated economic
factors and, 158–159
nonverbal communication patterns
and, 160
nutrition and, 167–168
nutritional deficiencies and food limita-
tions and, 167
organ donation and, 173
overview of, 157–158
parasitic diseases and, 165
2780_Index_489-506 16/07/12 12:19 PM Page 493

494 Index
pregnancy and childbearing practices
and, 168–169
responses to death and grief and, 169
skin color and, 165
sources of strength and, 170
spiritual beliefs and health-care practices
and, 170
spirituality and, 169–170
temporal relationships and, 160–161
tobacco use and, 166
use of prayer and, 169–170
views toward pregnancy and, 168
workforce issues and, 164–165
workplace culture and, 164
Eid feast celebrations, 163
Eid Norouz, 249
Elderly. See Older adults
Enzyme deficiencies, 42
Equal opportunity, 32
Equal Treatment Framework Directive, 35
Estonians, 381–382
Ethics
across cultures, 8–10
universal, 9
Ethnic diseases and illnesses. See Cultural/
racial diseases and illness
Ethnic disparities in health care, 3–4
Ethnocentrism, defined, 6
European American white populations,
diseases and disorders, 376–378
European settlement, 23
Euthanasia, 287
Evidence-based practice (EBP), 12–17
best evidence and, 12–15
clinical context and, 15–16
clinical expertise and judgment and, 15
components of, 13f
facilitating shift toward, 16–17
information access and, 16–17
leadership commitment and, 16
patient values and, 15
process of, 13t–14t
pyramid of evidence, 14f–15f
skill set development and, 16
Evil spirits (arwah), 171
Extended family concept, 32
Extramarital relationships. See Alternative
lifestyles
Eye contact, 28
F
Facial expressions, 28
Family, defined, 22
Family goals and priorities, 31–32
African American families and, 60
Amish and, 80–81
Appalachian people and, 100–101
Arabs and, 117
Chinese and, 134
Egyptians and, 162–164
Filipinos and, 181–182
French Canadians and, 201, 201f
Germans, 218–219
Guatemalans and, 148
Haitians and, 236
Iranians and, 252
Japanese and, 265
Jewish people and, 281
Koreans and, 298–299
Mexicans and, 312–313
Polish people and, 344
Russians and, 328
Thais and, 358
Family planning. See Fertility practices
Family roles and organization, 30–33
African Americans and, 59–60
Amish and, 80–81
Appalachian people and, 100–101
Arabs and, 116–117
Chinese and, 132–135
Egyptians and, 161–164
Filipinos and, 180–183
French Canadians and, 200–202
Germans and, 217–219
Guatemalans and, 147–148
Haitians and, 235–237
Iranians and, 251–252
Japanese and, 263–265
Jewish people and, 280–281
Koreans and, 296–299
Mexicans and, 312–313
Polish people and, 343–344
Russians and, 328–329
Thais and, 358
Farsi (Persian), 250
Female circumcision, 8
Fertility practices, 43
African Americans and, 67
Amish and, 86
Appalachian people and, 104–105
Arabs and, 121
Chinese and, 137
Egyptians and, 168
Filipinos and, 187–188
French Canadians and, 206
Germans and, 223–224
Guatemalans and, 153
Haitians and, 241–242
Iranians and, 255
Japanese and, 269–270
Jewish people and, 285–286
Koreans and, 302–303
Mexicans and, 316–318
Polish people and, 348–349
Russians and, 332
Thais and, 364
Filipino heritage
alternative lifestyles, 182–183
autonomy issues and, 184
biocultural ecology and, 184–185
biological variations and, 184–185
blood transfusions and, 193
cancer rates and, 185
children and adolescent behaviors
and, 181
common foods and food rituals and,
186–187
communication and, 177–180
cultural communication patterns and,
178–179
cultural responses to health care and, 193
death rituals and, 188–190
depression and, 185
dietary practices for health promotion
and, 187
diseases and health conditions and, 185
dominant languages and dialects and,
177–178
dominant religion and, 190
drug metabolism and, 185
educational status and occupations and,
176–177
family goals and priorities and, 181–182
family roles and organization and,
180–183
fertility practices and, 187–188
folk and traditional practices and, 192
format for names and, 180
gender roles and, 180–181
head of household and, 180–181
health-care barriers and, 192–193
health-care practices and, 186, 191–193
health-care responsibility and, 191–192
health-seeking beliefs and behaviors
and, 191
herbal medications and, 192t
heritage and residence and, 175–176,
176f
high-risk behaviors and, 185–186
hypertension and, 185
meaning of food and, 186
meaning of life and, 190
migration and associated economic
factors and, 176
nutrition and, 186–187
nutritional deficiencies and food
limitations and, 187
organ donation and, 193
overview and, 175
pregnancy and childbearing practices
and, 187–188, 189t
responses to death and grief and,
189–190
skin color and, 184–185
sources of strength and, 190
spiritual beliefs and health-care practices
and, 190
spirituality and, 190
temporal relationships and, 180
use of prayer and, 190
views toward pregnancy and, 187–188
workforce issues and, 183–184
workplace culture and, 183–184
Finger pointing, 29
Five Precepts, 367
Folk-healing. See Folk remedies
Folk remedies, 40, 48
African Americans and, 70
Amish and, 90–91
Appalachian people and, 107–110,
108t–110t
Arabs and, 124–125
Chinese and, 140–141
Egyptians and, 171
Filipinos and, 192
French Canadians and, 209
Germans and, 228, 228t
Haitians and, 244–245
Iranians and, 257
Japanese and, 274
Jewish people and, 291
Koreans and, 305–306
Mexicans and, 320–321
2780_Index_489-506 16/07/12 12:19 PM Page 494

Index 495
Polish people and, 351
Russians and, 334
Thais and, 368–369
Food. See also Common foods; Food
limitations; Food rituals; Meaning of
food; Nutrition
Food limitations, 42
African Americans and, 66–67
Appalachian people and, 104
Arabs and, 120–121
Chinese and, 137
Egyptians and, 168
Filipinos and, 187
French Canadians and, 205
Germans and, 222
Guatemalans and, 152
Haitians and, 241
Iranians and, 255
Japanese and, 269
Jewish people and, 285
Koreans and, 300–301
Mexicans and, 316
Polish people and, 348
Russians and, 331
Thais and, 364
Food pyramid, 41
Food rituals, 40–42
African Americans and, 66
Amish and, 85–86
Appalachian people and, 104
Chinese and, 136–137
Egyptians and, 167–168
Filipinos and, 186–187
French Canadians and, 205
Germans and, 222
Guatemalans and, 152
Haitians and, 240
Iranians and, 254
Japanese and, 268–269
Jewish people and, 284–285
Koreans and, 301
Mexicans and, 316
Polish people and, 347
Russians and, 331
Thais and, 363–364, 363f
Formality, cultural differences and, 32
Four Noble Truths, 367
Francophones, 197
Freindschaft, 81
French Canadian heritage
alcohol consumption and, 204
alternative lifestyles and, 201–202
autonomy issues and, 203
biocultural ecology and, 203–204
biological variations and, 203
blood transfusions and, 210
cancer incidence and, 203
children and adolescent behaviors
and, 201
common foods and food rituals and,
205
communication and, 198–200
cultural communication patterns and,
199–200
cultural responses to healthcare and,
209–210
cystic fibrosis and, 204
death rituals and, 207
dietary practices for health promotion
and, 205
diseases and health conditions and,
203–204
dominant languages and dialects and,
198–199
drug metabolism and, 204
educational status and occupations and,
198
environmental diseases and, 203–204
family goals and priorities and, 201,
201f
family roles and organization and,
200–202
fertility practices and, 206
folk and traditional practices and, 208
format for names and, 200
gender roles and, 200
head of household and, 200
health-care barriers and, 208
health-care practices and, 208
health-care practitioners and, 210
health care responsibility and, 208–209
heredity and genetic diseases and, 204
heritage and residence and, 197–198
high-risk behaviors and, 204–205
meaning of food and, 205
meaning of life and, 208
mental illness and, 210
migration and associated economic
factors and, 198
nutrition and, 205
nutritional deficiencies and food limita-
tions and, 205
organ donation and, 210
overview of, 196–197
pregnancy and childbearing practices
and, 206–207
responses to death and grief and, 207
skin color and, 203
sources of strength and, 208
spiritual beliefs and health-care practices
and, 208
spirituality and, 208
suicide rates and, 203
temporal relationships and, 199–200
tobacco use and, 204
views toward pregnancy and, 206
workforce issues and, 202–203
workplace culture and, 202–203
G
Galenic (humoral) medicine, 256
Garm/sard balance, 254
Gay and Lesbian Medical Association, 4
Gays and lesbians. See also Homosexual
behavior
healthcare disparities and, 4
social attitudes and, 32–33
Geisha, 265
Gelassenheit, 79
Gemeinschaft, 217
Gender, disparity in nursing, 53
Gender roles, 30
African Americans and, 59
Amish and, 80
Appalachian people and, 100
Arabs and, 116
Chinese and, 132–133
Egyptians and, 161–162
Filipinos and, 180–181
French Canadians and, 200
Germans and, 217–218
Guatemalans and, 147
Haitians and, 235
Iranians and, 251
Japanese and, 263–264
Jewish people and, 280
Koreans and, 297
Mexicans and, 312
Polish people and, 343
Russians and, 328
Thais and, 358
Generalizations, defined, 7
Generation X, 36
Generational differences, in workforce,
35–36
Genetic testing, 9
German heritage
alcohol consumption and, 221
alternative lifestyles and, 219
autonomy issues and, 220
biocultural ecology and, 220–221
biological variations and, 220
blood transfusions and, 229
cancer risk and, 221
children and adolescent behaviors and,
218
common foods and food rituals and,
222, 223t
communication and, 215–217
cultural communication patterns and,
216–217
cultural responses to health care and,
228–229
cystic fibrosis and, 221
death rituals and, 224–225
dietary practices for health promotion
and, 222
diseases and health conditions and,
220–221
dominant languages and dialects and,
215–216
dominant religion and, 225
drug metabolism and, 221
Dupuytren’s disease and, 220
educational status and occupations and,
214–215
family goals and priorities and, 218–219
family roles and organization and,
217–219
fertility practices and, 223–224
folk and traditional practices and, 228,
228t
format for names and, 217
gallbladder disease and, 220–221
gender roles and, 217–218
genetic diseases and, 220
head of household and, 217–218
health-care barriers and, 228
health-care practices and, 221, 225–229
health-care practitioners and, 229
health-care responsibility and, 225–226
health-seeking beliefs and behaviors
and, 225
2780_Index_489-506 16/07/12 12:19 PM Page 495

496 Index
hemophilia and, 221
heritage and residence and, 213–214
high-risk behaviors and, 221
meaning of food and, 221–222
meaning of life and, 225
migration and associated economic
factors and, 214
nutrition and, 221–223
nutritional deficiencies and food limita-
tions and, 222
organ donation and, 229
overview of, 213
pregnancy and childbearing practices
and, 223–224
responses to death and grief and,
224–225
sarcoidosis and, 220
skin color and, 220
sources of strength and, 225
spiritual beliefs and health-care
practices, 225
spirituality and, 225
temporal relationships and, 217
topography and, 213
use of prayer and, 225
views toward pregnancy and, 223–224
workforce issues and, 219–220
workplace culture and, 219–220
Gespräch, 216
Global society, defined, 20
Globalization, of health-care services, 8–10
Governance, organizational cultural
competence and, 11
Great Eid feast, 167
Greek ancestry, 385–386
Greetings, preferred, 28–29
Grieving, 45
African Americans and, 68
Amish and, 88
Appalachian people and, 105–106
Arabs and, 122
Chinese and, 139
Egyptians and, 169
Filipinos and, 189–190
French Canadians and, 207
Germans and, 224–225
Guatemalans and, 154
Haitians and, 243
Iranians and, 256
Japanese and, 272
Jewish people and, 288
Koreans and, 304
Mexicans and, 318
Polish people and, 349
Russians and, 332–333
Thais and, 366
Guanxi, 134, 135
Guatemalan heritage
alcohol consumption and, 151
alternative lifestyles and, 148
autonomy and, 149
barriers to health care and, 155
biocultural ecology and, 149–151
biological variations and, 149
blood transfusion and, 156
children and adolescent behavior and,
148
common foods and food rituals and, 152
communication and, 146
cough and upper respiratory symptoms
and, 150
cultural responses to health and illness
and, 155–156
death rituals and, 153–154
diarrhea and, 151
dietary practices for health promotion
and, 152
diseases and health conditions and,
149–151
dominant language and dialects
and, 146
drug metabolism and, 151
educational status and occupations
and, 146
eye disorders and, 151
family goals and priorities and, 148
family roles and organization and,
147–148
fertility practices and, 153
format of names and, 147
gender roles and, 147
head of household and, 147
headaches and, 150
health-care practices and, 151–152,
154–156
health-care responsibility and, 155
health-seeking beliefs and behaviors
and, 154–155
heritage and residence and, 145
high-risk behaviors and, 151–152
meaning of food and, 152
meaning of life and, 154
migration and associated economic
factors and, 145–146
musculoskeletal pain and, 149–150
nutrition and, 152
nutritional deficiencies and food limita-
tions and, 152
organ donation and, 156
overview of, 145
pregnancy and childbearing practices
and, 152–153
responses to death and grief and, 154
skin color and, 149
skin lesions and, 150–151
sources of strength and, 154
spiritual beliefs and, 154
spirituality and, 154
temporal relationships and, 147
views toward pregnancy and, 153
workforce issues and, 148–149
workplace culture and, 148–149
Guidelines for non-English speaking
clients, 26–27
H
Hadith, 123
Haitian heritage
alternative lifestyles and, 236–237
attention deficit/hyperactivity disorder
and, 239
autonomy issues and, 237–238
biocultural ecology and, 238–239
biological variations and, 238
blood transfusions and, 246
cancer incidence and, 238
children and adolescent behaviors
and, 236
common foods and food rituals and,
240, 240t
communication and, 234–235
cultural communication patterns and,
234–235
cultural responses to health care and,
245–246
death rituals and, 243
diabetes and, 238
dietary practices for health promotion
and, 240–241
diseases and health conditions and,
238–239
dominant languages and dialects and,
234
dominant religion and, 243
drug metabolism and, 239
educational status and occupations and,
233–234
family goals and priorities and, 236
family roles and organization and,
235–237
fertility practices and, 241–242
folk and traditional practices and,
244–245
food classifications and, 241t
format for names and, 235
gender roles and, 235
head of household and, 235
health-care barriers and, 245
health-care practices and, 240, 244–246
health-care practitioners and, 246
health-care responsibility and, 244
health-seeking beliefs and behaviors
and, 244
heritage and, 231–232
high-risk behaviors and, 239–240
hypertension and, 238
infectious diseases and, 238
meaning of food and, 240
meaning of life and, 243–244
migration and associated economic
factors and, 232–233
nutrition and, 240–241
nutritional deficiencies and food limita-
tions and, 241
organ donation and, 246
overview and, 271
pregnancy and childbearing practices
and, 241–242
residence and, 231–232
responses to death and grief and, 243
skin color and, 238
sources of strength and, 243–244
spiritual beliefs and health-care practices
and, 244
spirituality and, 243–244
temporal relationships and, 235
topography and, 231
use of prayer and, 243
views toward pregnancy and, 241–242
workforce issues and, 237–238
workplace culture and, 237
Halal, 120, 254
Hanbang, 305
2780_Index_489-506 16/07/12 12:19 PM Page 496

Index 497
Handicapped. See Disabled and
handicapped
Hanui, 306
Hanyak, 305
Haram, 121, 254
Hasidic Jewish people, 280, 289
Head of household, 30
African Americans and, 59
Amish and, 80
Appalachian people and, 100
Arabs and, 116
Chinese and, 132–133
Egyptians and, 161–162
Filipinos and, 180–181
French Canadians and, 200
Germans and, 217–218
Guatemalans and, 147
Haitians and, 235
Iranians and, 251
Japanese and, 263–264
Jewish people and, 280
Koreans and, 297
Mexicans and, 312
Polish people and, 343
Russians and, 328
Thais and, 358
Health, defined, 22
Health-care barriers, 48–49
African Americans and, 70–71
Amish and, 91–92
Appalachian people and, 110–111
Arabs and, 125
Chinese and, 141–142
Egyptians and, 171–172
Filipinos and, 192–193
French Canadians and, 209
Germans and, 228
Guatemalans and, 155
Haitians and, 245
Iranians and, 257
Jewish people and, 291
Koreans and, 306
Mexicans and, 321
Polish people and, 351
Russians and, 334
Thais and, 369
Health-care practices, 47–51
African Americans and, 65, 70–71
Amish and, 84–85, 89–92
Appalachian people and, 103,
107–111
Arabs and, 119–120
Chinese and, 139–141
Egyptians and, 166–167, 170–173
Filipinos and, 186, 191–193
French Canadians and, 208–210
Germans and, 221, 225–229
Guatemalans and, 151–152,
154–156
Haitians and, 240, 244–246
Iranians and, 254, 256–258
Japanese and, 268
Jewish people and, 290–291
Koreans and, 301, 305–307
Mexicans and, 315, 319–322
Polish people and, 347, 350–352
Russians and, 331, 333–335
Thais and, 360, 368–369
Health-care practitioner status, 52–53,
126–127
African Americans and, 71
Amish and, 92–93
Appalachian region and, 111–112
Chinese and, 143–144
Egyptians and, 173–174
Filipinos and, 194
French Canadians and, 210
Germans and, 229
Guatemalans and, 156
Haitians and, 246
Iranians and, 258
Japanese and, 275–276
Jewish people and, 291
Koreans and, 307
Mexicans and, 322–323
Polish people and, 352
Russians and, 335
Thais and, 369
Health-care responsibility, 47–48, 170–171
African Americans and, 70
Amish and, 89–90
Appalachian people and, 107
Arabs and, 124
Chinese and, 140
Egyptians and, 170–171
Filipinos and, 191–192
French Canadians and, 208–209
Germans and, 225–226
Guatemalans and, 155
Haitians and, 244
Iranians and, 257
Japanese and, 273–274
Jewish people and, 290–291
Koreans and, 305
Mexicans and, 320
Polish people and, 351
Russians and, 334
Thais and, 368
Health insurance coverage, 47–48
Health issues. See Diseases and health issues
Health-seeking beliefs/behaviors, 47
African Americans and, 70
Amish and, 89
Appalachian people and, 107
Arabs and, 123–124
Chinese and, 139–140
Egyptians and, 170
Filipinos and, 191
French Canadians and, 208
Germans and, 225
Guatemalans and, 154–155
Haitians and, 244
Iranians and, 256–257
Japanese and, 273
Jewish people and, 290
Koreans and, 305
Mexicans and, 320
Polish people and, 350–351
Russians and, 333–334
Thais and, 368
Healthy People 2010, 3
Hebrew, 278
Herbal remedies. See also Folk remedies
Amish and, 91
Appalachian people and, 107–110
Chinese and, 141
Filipinos and, 192t
Iranians and, 257
Koreans and, 305
Russians and, 333
Heritage, 23–24
African Americans, 56–57
Amish, 75–76
Appalachians and, 96
Arabs and, 114
Chinese and, 129–130
Egyptians and, 158
Filipinos and, 175–176, 176f
French Canadians and, 197–198
Germans and, 213–214
Guatemalans and, 145
Haitians and, 231–232
Iranians and, 249
Japanese and, 260
Jewish people and, 278
Koreans and, 293–294
Polish people and, 338–340
Russians and, 326
Thais and, 356
Hex, 246
High blood, 66
High-risk behaviors, 38–40
African Americans and, 65
Amish and, 84–85
Appalachian people and, 102–103
Arabs and, 119–120
Chinese and, 136
Egyptians and, 166–167
Filipinos and, 185–186
Germans, 221
Guatemalans and, 151–152
Haitians and, 239–240
Iranians and, 253–254
Japanese and, 267–268
Jewish people and, 283
Koreans and, 300
Mexicans and, 315
Polish people and, 346–347
Russians and, 330–331
Thais and, 360–362
Hijab, 116
Hindi ibang tao (insiders), 178
Hindu heritage, 389–390
Hinduism, 389–390
Hispanic/Latino populations in
United States, 3
Hispanics, diseases and disorders, 374
HIV/AIDS, 37
African Americans and, 64
Arabs and, 119
Filipinos and, 183, 186
Germans and, 220
Haitians and, 239
Japanese and, 268
Thais and, 360–361
Hiya (shame), 178
Hochdeitsch, 78
Hochmut, 79
Holocaust, 281, 286
Homecare services. See Health-care
responsibility
Homosexual behavior
African American attitudes and, 60
Amish attitudes and, 81
2780_Index_489-506 16/07/12 12:19 PM Page 497

498 Index
Arab attitudes and, 117
Chinese attitudes and, 134
Egyptian attitudes and, 164
Filipino attitudes and, 182–183
French Canadian attitudes and, 202
German attitudes and, 219
Guatemalan attitudes and, 148
Haitian attitudes and, 236–237
Iranian attitudes and, 252
Jewish attitudes and, 281
Korean attitudes and, 299
Mexican attitudes and, 313
Russian attitudes and, 329
social attitudes and, 32–33
Thai attitudes and, 358–350
“Hot” diseases and conditions, 321
Human Genome Project, 6
Human immunodeficiency virus. See
HIV/AIDS
Human Resource Institute, 35
Humanism, 8
Hwa-byung, 306
Hwangap, 298
Hyperpigmentation, 61–62
I
Ibang tao (outsiders), 178
Ideology, defined, 6
Imam, 122, 169
Imitative magic, 70
Immigration. See also Migration
associated economic factors, 24
job skills and, 25
patterns to United States, 3
reasons for, 24
status, worldview and, 8
Immunization, preventative, 47
Inclusion, workplace issues and, 35
Individual cultural competence, 10–11
clinical encounters and, 10
cultural general approaches and, 10
language and, 10–11
Individualism, 34
Informality, Americans and, 32
Information access, evidence-based
practice and, 16–17
Inhabited localities. See Residence/
inhabited localities
Inshallah, 115
Intercultural, defined, 8
International Organization for
Migration, 2
Interpretation, 15, 21, 24t, 28
Interpreters, 26–27
Iranian heritage
alternative lifestyles and, 252
autonomy issues and, 253
biocultural ecology and, 253
biological variations and, 253
blood transfusions and, 258
children and adolescent behavior and,
251–252
common foods and food rituals
and, 254
communication and, 250–251
cultural communication patterns and,
250–251
cultural responses to health and illness
and, 257–258
death rituals and, 255–256
dietary practices for health promotion
and, 254
diseases and health conditions
and, 253
dominant language and dialects
and, 250
dominant religion and, 256
educational status and occupations
and, 250
ethnic bias and, 248
family goals and priorities and, 252
family roles and organization and,
251–252
fertility practices and, 255
folk and traditional practices and, 257
format for names and, 251
gender roles and, 251
head of household and, 251
health-care barriers and, 257
health-care practices and, 255,
256–258
health-care practitioners and, 258
health-care responsibility and, 257
health-seeking beliefs and behaviors
and, 256–257
heritage and residence and, 249
heroin and opium addiction and,
253–254
high-risk behaviors and, 253–254
infectious diseases and, 253
inhabited localities and, 248–249
ischemic heart disease and, 253
meaning of food and, 254
meaning of life and, 256
migration and associated economic
factors and, 250
nutrition and, 254–255
nutritional deficiencies and food limita-
tions and, 255
organ donation and, 258
overview of, 248–249
pregnancy and childbearing practices
and, 255
psychological illnesses and, 253
responses to death and grief and, 256
skin color and, 253
socioeconomic and political instability
and, 248
sources of strength and, 256
spiritual beliefs and health-care practices
and, 256
spirituality and, 256
stress-related health problems
and, 253
temporal relationships and, 251
topography and, 249
use of prayer and, 256
workforce issues and, 252–253
workplace culture and, 252–253
Iranian Turks, 249
Irish heritage, 391–392
Isaan dance, 360f
Islam, 249
Islamic law, 122–123
Islamic (sacred) medicine, 256
Issei, 261
Italian heritage, 393–394
J
Japanese heritage
alternative lifestyles and, 265
autonomy issues and, 266
biocultural ecology and, 266–267
biological variations and, 266
blood transfusions and, 275
children and adolescent behaviors and,
264
common foods and food rituals and,
268–269
communication and, 261–262
cultural communication patterns and,
261–262
cultural responses to health care and,
274–275
death rituals and, 271–272
dietary practices for health promotion
and, 269
diseases and health conditions and, 266
dominant languages and dialects and,
261
drug metabolism and, 267
educational status and occupations and,
261
family goals and priorities and, 265
family roles and organization and,
263–265
fertility practices and, 269–270
folk and traditional practices and, 274
format for names and, 262
gender roles and, 263–264
head of household and, 263–264
health-care practices and, 268, 273–275
health-care practitioners and, 275–276
health-care responsibility and, 273–274
health-seeking beliefs and behaviors
and, 273
heritage and, 260
high-risk behaviors and, 267–268
illicit drug use and, 267–268
meaning of food and, 268
meaning of life and, 272
migration and associated economic
factors and, 260–261
nutrition and, 268–269
nutritional deficiencies and food limita-
tions and, 269
organ donations and, 275
overview of, 260
pregnancy and childbearing practices
and, 269–270
residence and, 260
responses to death and grief and, 272
saving face and, 262
skin color and, 266
sources of strength and, 272
spiritual beliefs and health-care practices
and, 272–273
spirituality and, 272–273
temporal relationships and, 262
topography and, 260
workforce issues and, 265–266
workplace culture and, 265–266
2780_Index_489-506 16/07/12 12:19 PM Page 498

Index 499
Jenn (Devil), 171
Jewish heritage
alternative lifestyles and, 281
autonomy issues and, 282
biocultural ecology and, 282–283
biological variations and, 282
blood transfusions and, 291
Bloom syndrome and, 283
Canavan’s disease and, 282–283
cancer rates and, 283
children and adolescent behaviors and,
280–281
circumcision and, 286
common foods and food rituals and,
284–285
communication and, 279–280
cultural communication patterns and,
279–280
cultural responses to health and illness
and, 291
death rituals and, 287–288
dietary practices for health promotion
and, 285
diseases and health conditions and,
282–283
dominant language and dialects
and, 279
dominant religion and, 288–289
drug metabolism and, 283
educational status and occupations and,
279
euthanasia and, 287
family goals and priorities and, 281
family roles and organization and,
280–281
fertility practices and, 285–286
folk and traditional practices and, 291
format for names and, 280
Gaucher’s disease and, 282
gender roles and, 280
head of household and, 280
health-care barriers and, 291
health-care practices and, 283, 290–291
health-care practitioners and, 291
health-care responsibility and, 290–291
health-seeking beliefs and behaviors
and, 290
heritage and residence and, 278
high-risk behaviors and, 283
holidays, 290t
kosher meals and, 284–285
meaning of food and, 283–284
meaning of life and, 289
migration and associated economic
factors and, 279
nutrition and, 283–285
nutritional deficiencies and food
limitations and, 285
organ donation and, 291
overview of, 278
pregnancy and childbearing practices
and, 285–286
responses to death and grief and, 288
Riley-Day syndrome and, 283
skin color and, 282
sources of strength and, 289
spiritual beliefs and health-care practices
and, 290
spirituality and, 288–290
Tay-Sachs disease and, 282
temporal relationships and, 280
use of prayer and, 288–289
workforce issues and, 281–282
workplace culture and, 282
Jinaan, 124
Jinn, 124
Job skills, immigration and, 25
Joual, 198
Judaism, 288–289. See also Jewish heritage
K
Kabsa, 168
Kaddish, 285
Kapwa (shared identity), 178, 182
Karma, 367
Kashrut, 284
Khwan ceremony, 368–369
Ki, 305
Kimchee, 301, 301f
Korean Christian churches, 289
Korean heritage
alternative lifestyles and, 299
autonomy issues and, 299
biocultural ecology and, 300–301
blood transfusions and, 307
cancer prevalence and, 300
children and adolescent behaviors and,
297–298
common foods and food rituals and, 301
communication and, 295–296
cultural communication patterns and,
295–296
cultural responses to health and illness
and, 306–307
death rituals and, 304
depression and, 306
dietary practices for health promotion
and, 301
diseases and health conditions and, 300
dominant languages and dialects and,
295
dominant religion and, 304
drug metabolism and, 300
educational status and occupations and,
294–295
family goals and priorities and, 298–299
family roles and organization and,
296–299
fertility practices and, 302–303
folk and traditional practices and, 305
format for names and, 296
gender roles and, 297
head of household and, 297
health-care barriers and, 306
health-care practices and, 301, 305–307
health-care practitioners and, 307
health-care responsibility and, 305
health-seeking beliefs and behaviors
and, 305
heritage and residence and, 293–294
high-risk behaviors and, 300
hwa-byung and, 306
meaning of life and, 305
migration and associated economic
factors and, 294
nutrition and, 301–302
nutritional deficiencies and food limita-
tions and, 300–301
obesity and, 302
organ donation and, 307
overview of, 293
parasitic diseases and, 300
pregnancy and childbearing practices
and, 302–303
responses to death and grief and, 304
sources of strength and, 305
spiritual beliefs and health-care practices
and, 305
spirituality and, 304–305
temporal relationships and, 296
topography and, 293
use of prayer and, 304
workforce issues and, 299
workplace culture and, 299
Kosher meals, 284–285
Kurds, 249
Kut, 306
L
La raza, 309
Ladino, 327
Language barriers. See Health-care
barriers
Languages. See also Dialects; Dominant
languages
individual cultural competence and,
10–11
most popular, 2
organizational cultural competence
and, 12
Latinos, 309. See also Mexican heritage
Latvians, 381–382
Leadership commitment, evidence-based
practice and, 16
Life expectancy, worldwide, 2
Lithuanians, 381–382
Living wills, 47
Location. See also Migration
“Low” blood, 66
M
Maalesh, 115
Machismo, 312
Madichon, 236
Magicoreligous practices, 40, 48
Mandarin, 131
Marriage. See Family goals and priorities
Meals on Wheels, 41
Meaning of food
African Americans and, 66
Amish and, 85
Appalachian people and, 103
Arabs and, 120
Chinese and, 136
Egyptians and, 167
Filipinos and, 186
French Canadians and, 205
Germans and, 221–222
Guatemalans and, 152
Haitians and, 240
Iranians and, 254
Japanese and, 268
2780_Index_489-506 16/07/12 12:19 PM Page 499

500 Index
Jewish people and, 283–284
Koreans and, 301
Mexicans and, 315–316
Polish people and, 347–348
Russians and, 331
Thais and, 362–363
Meaning of life, 46
African Americans and, 68–69
Amish and, 88–89
Appalachian people and, 106
Arabs and, 123
Chinese and, 139
Egyptians and, 169–170
Filipinos and, 190
French Canadians and, 208
Germans and, 225
Guatemalans and, 154
Haitians and, 243–244
Iranians and, 256
Japanese and, 272
Jewish people and, 289
Koreans and, 305
Mexicans and, 318–319
Polish people and, 350
Russians and, 333
Thais and, 367
Medications, sale of, 48
Mennonites, 76
Mental illness. See Psychological illness
Mentally challenged. See Disabled and
handicapped
Métis, 197
Mexican heritage
alcohol consumption and, 315
alternative lifestyles and, 313
autonomy issues and, 314
biocultural ecology and, 314–315
biological variations and, 314
blood transfusion and, 322
cardiovascular disease and, 315
children and adolescent behaviors
and, 312
common foods and food rituals and,
316
communication and, 311–312
cultural communication patterns
and, 311
cultural responses to health and illness
and, 321–322
death rituals and, 318
diabetes mellitus and, 315
dietary practices for health promotion
and, 316
diseases and health concerns and,
314–315
dominant languages and dialects and,
311
dominant religion and, 318
drug metabolism and, 315
educational status and occupations and,
310
family goals and priorities and, 312–313
family roles and organization and,
312–313
fertility practices and, 316–317
folk and traditional practices and,
320–321
format for names and, 312
gender roles and, 312
head of household and, 312
health-care barriers and, 321
health-care practices and, 315, 319–322
health-care practitioners and, 322–323
health-care responsibility and, 320
health-seeking beliefs and behaviors
and, 320
heritage and residence and, 309–310
high-risk behaviors and, 315
malaria and, 315
meaning of food and, 315–316
meaning of life and, 318–319
migration and associated economic
factors and, 310
nutrition and, 315–316
nutritional deficiencies and food limita-
tions and, 316
organ donation and, 322
overview of, 309
pregnancy and childbearing practices
and, 316–318
responses to death and grief and, 318
skin color and, 314
smoking prevalence and, 315
sources of strength and, 318–319
spiritual beliefs and health-care prac-
tices and, 319
spirituality and, 318–319
temporal relationships and, 311–312
use of prayer and, 318
views toward pregnancy and, 316–317
workforce issues and, 313–314
workplace culture and, 313–314
Middle Easterners, diseases and disorders,
374–375
Middle Way, 367
Midwives. See Pregnancy practices and
views
Migration, 2–3. See also Location
African Americans and, 57
Amish, 76
Appalachian people and, 96–97
Arabs and, 114
Chinese and, 130
Egyptians and, 158–159
Filipinos and, 176
French Canadians and, 198
Germans and, 214–215
Guatemalans and, 145–146
Haitians and, 232–233
Iranians and, 250
Japanese and, 260–261
Jewish people and, 279
Koreans and, 294
Mexicans and, 310
Polish people and, 340–341
Russians and, 326–327
Thais and, 356
Millennials, 36
Minority groups in health-care
profession, 34
Modesty, Arab women and, 119
Morita therapy, 274
Morning-after pill, 43
Mosques, 120
Mosquito-infested areas, 38
Mourning activities. See Death rituals
Moxibustion, 140
Mulatto, 232
Multiculturalism, 8
Mundang, 306
Musculoskeletal variations, 37
Muslims, 249, 325
N
Naikan therapy, 274
Name formats, 29–30
African Americans and, 59
Amish and, 79–80
Appalachian people and, 99
Arabs and, 116
Chinese and, 132, 147
Egyptians and, 161
Filipinos and, 180
French Canadians and, 200
Germans and, 217
Haitians and, 235
Iranians and, 251
Japanese and, 262
Jewish people and, 280
Koreans and, 296
Mexicans and, 312
Polish people and, 343
Russians and, 328
Thais and, 357–358
National Healthcare Disparities Report, 61
Native American/Alaskan Native popula-
tion, in United States, 3
Native Americans, diseases and disorders,
378–379
Native Hawaiian/Pacific Islander popula-
tion in United States, 3
Natural childbirth. See Pregnancy practices
and views
Navajo Indians, 397–398
New diseases, outbreaks of, 38
New Order Amish, 76
Nihonjin, 260
Nippon. See Japanese heritage
Nirvana, 367
Nisei, 261
Non-English speaking clients, guidelines
for, 26–27
Nonverbal communication, 28–29
Egyptians and, 160
Filipinos and, 179
Germans and, 217
Haitians and, 234–235
Japanese and, 262
Koreans and, 295–296
Mexicans and, 311
Russians and, 327–328
Northern dialects, Russian, 327
Nursing. See also Health-care provider
status; Workforce issues
gender disparity in, 53
respect and, 52
workforce shortages, 34
Nutrition, 40–42. See also Dietary prac-
tices for health promotion; Nutritional
deficiencies
African Americans and, 65–67
Amish and, 84, 85–86
Appalachian people and, 103–104
2780_Index_489-506 16/07/12 12:19 PM Page 500

Index 501
Arabs and, 120–121
Chinese and, 136–137
Egyptians and, 167–168
Filipinos and, 186–187
French Canadians and, 205
Germans and, 221–223
Guatemalans and, 152
Haitians and, 240–241
Iranians and, 254–255
Japanese and, 268–269
Jewish people and, 283–285
Koreans and, 301–302
Mexicans and, 315–316
Polish people and, 347–348
Russians and, 331
Thais and, 362–364
Nutritional deficiencies
African Americans and, 66–67
Appalachian people and, 104
Arabs and, 120–121
Chinese and, 137
Egyptians and, 168
Filipinos and, 187
French Canadians and, 205
Germans and, 222
Guatemalans and, 152
Haitians and, 241
Iranians and, 255
Japanese and, 269
Jewish people and, 285
Koreans and, 300–301
Mexicans and, 316
Polish people and, 348
Russians and, 331
Thais and, 364
O
Obesity, 40
Occupational health services, 50–51
Occupations, 25
African Americans and, 57–58
Amish and, 76–77
Appalachian people and, 97
Arabs and, 114
Chinese and, 130
Egyptians and, 159
Filipinos and, 176–177
French Canadians and, 198
Germans and, 213–214
Guatemalans and, 146
Haitians and, 233–234
Iranians and, 250
Japanese and, 261–262
Jewish people and, 279
Koreans and, 294–295
Mexicans and, 310
Polish people and, 341–342
Russians and, 326–327
Thais and, 356–357
Office of Minority Health, 10
Old Order Amish, 76
Older adults. See also Family goals
and priorities; Family roles and
organization
balanced meals and, 41
reverence for, 32
Ordnung, 87, 217
Organ donation, 51
African Americans and, 71
Amish and, 92
Appalachian people and, 111
Arabs and, 126
Chinese and, 143
Egyptians and, 173
Filipinos and, 193
French Canadians and, 210
Germans and, 229
Guatemalans and, 156
Haitians and, 246
Iranians and, 258
Japanese and, 275
Jewish people and, 291
Koreans and, 307
Mexicans and, 322
Polish people and, 352
Russians and, 335
Thais and, 369
Organizational cultural competence,
11–12
education and orientation, 11–12
governance and administration, 11
language, 12
Orthodox Judaism, 278
OUCHER Pain scale, 50
Our Lady of Czestachowa, 350f
Outbreaks, new or re-emerging diseases, 38
P
Pacific islanders, diseases and disorders,
375–376
Pain beliefs, 49–50
Pain response. See Cultural responses to
health and illness
Pakakikipagkapwa, 178
Pakikisama, 178
Pakiramdam (shared perception), 182
Patient autonomy, 47
Patient-intervention-comparison-outcome
(PICO) format, 16
Patient values, evidence-based practice
and, 15
Pennsylvania German, 77–78
Persians, 249
Person, defined, 22
Personal space, 28
Personalismo, 387
Physical disabilities. See Disability
Physically handicapped, 50
Pogroms, 279
Polish heritage
alcohol consumption and, 346
alternative lifestyles and, 344
autonomy issues and, 344–345
biocultural ecology and, 345–346
biological variations and, 345
blood transfusions and, 352
cancer incidence and, 346
cardiovascular diseases and, 346
children and adolescent behaviors and,
343–344
common foods and food rituals and,
347, 347t
communication and, 342–343
cultural communication patterns and, 342
cultural responses to health and illness
and, 351–352
death rituals and, 349
dietary practices for health promotion
and, 348
diseases and health conditions and,
345–346
dominant languages and dialects and,
342
dominant religion and, 349–350
educational status and occupations and,
341–342
family goals and priorities and, 344
family roles and organization and,
343–344
fertility practices and, 348
folk and traditional practices and, 351
format for names and, 343
gender roles and, 343
head of household and, 343
health-care barriers and, 351
health-care practices and, 347, 350–352
health-care practitioners and, 352–353
health-care responsibility and, 351
health-seeking beliefs and behaviors
and, 350–351
heritage and residence and, 338–340
high-risk behaviors and, 346
lead exposure and, 345
meaning of food and, 347
meaning of life and, 350
migration and associated economic
factors and, 340–341
nutrition and, 347–348
nutritional deficiencies and food limita-
tions and, 348
organ donation and, 352
overview and, 337–338
pollution levels and, 345–346
pregnancy and childbearing practices
and, 348–349
responses to death and grief and, 349
skin color and, 345
sources of strength and, 350
spirituality and, 349–350
temporal relationships and, 342
topography and, 337
use of prayer and, 349–350
views toward pregnancy and, 348
workforce issues and, 344–345
workplace culture and, 344
Polonia, 338
Population and census data, 2–3
Positive politeness, 329
Post-modernism, 8
Pra poom, 366–367
Prayer. See Religious practices and prayer;
Spirituality
Pregnancy outside marriage. See Alterna-
tive lifestyles
Pregnancy practices/views, 43–44
African Americans and, 67
Amish and, 86–87
Appalachian people and, 104–105
Arabs and, 121–122
Chinese and, 137–138
Egyptians, 168–169
Filipinos and, 187–188, 189t
2780_Index_489-506 16/07/12 12:19 PM Page 501

502 Index
French Canadians and, 206–207
Germans and, 223–224
Guatemalans and, 152–153
Haitians and, 241–242
Iranians and, 255
Japanese and, 269–270
Jewish people and, 285–286
Koreans and, 302–303
Mexicans and, 316–318
Polish people and, 348–349
Russians and, 331–332
Thais and, 364–366
Prenatal care. See Pregnancy practices
Prescriptive behaviors (children/
adolescents), 30–31
African Americans and, 59–60
Amish and, 80
Appalachian people and, 100
Arabs and, 116–117
Chinese and, 133–134
Egyptians and, 162
Filipinos and, 181
French Canadians and, 201
Germans, 218
Guatemalans and, 148
Haitians and, 236
Iranians and, 251–252
Japanese and, 264
Jewish people and, 280–281
Koreans and, 297
Mexicans, 312
Polish people and, 343–344
Russians and, 328
Thais and, 358
Prescriptive childbearing practices, 43–44
African Americans and, 67
Amish and, 86–87
Appalachian people and, 105
Arabs and, 121–122
Chinese and, 137–138
Egyptians and, 169
Filipinos and, 188
French Canadians and, 206–207
Germans and, 224
Haitians and, 242
Iranians and, 255
Japanese and, 269–270
Jewish people and, 286
Koreans and, 303
Mexicans and, 317–318
Polish people and, 349
Russians and, 332
Thais and, 364–366
Preventative immunization, 47
Primary characteristics, of culture, 7–8
Privacy. See Cultural communication
patterns
Protestant religions, views on health-care
practices, 226t–227t
Pseudofolliculitis barbae, 62
Psychological illness, 50
African Americans and, 65
Amish and, 83–84
Arabs and, 125
Egyptians and, 172–173
French Canadians and, 208, 210
Germans and, 228–229
Iranians and, 253, 258
Mexican and, 322
Polish people and, 352
Pu tong hua, 131
Puerto Rican heritage, 395–396
Punctuality. See also Temporal
relationships
expectations for, 29
multicultural workforce and, 33–34
Punishment, children and adolescents. See
Children and adolescent behavior/
discipline
Purnell Model for Cultural Competence
assumptions and, 20
biocultural ecology and, 36–38
communication and, 25–30
death rituals and, 44–45
educational status and occupations
and, 25
family roles and organization and, 30–33
health-care practices and, 47–51
health-care practitioners and, 52–53
heritage and residence and, 23–24
high-risk behaviors and, 38–40
illustration of, 21f
inhabited localities and, 22–25
macro aspects of model, 20–22
micro aspects of model, 22
migration and associated economic
factors and, 24
nutrition and, 40–42
pregnancy and childbearing practices
and, 43–44
purposes of, 19
spirituality and, 45–46
topography and, 22–25
workforce issues and, 33–36
Pyramid of evidence, 14f–15f
Q
Qi, 141
Qur’an, 167, 253
R
Rabbis, 288
Race, defined, 6
Racial diseases and illness. See
Cultural/racial diseases and illness
Racial disparities in health care, 3–4
Racial tensions in workplace, 60–61
Racism, 6–7
Ramadan, 120, 163, 168, 256
Re-emerging diseases, outbreaks of, 38
Rebellion, adolescent. See Children and
adolescent behavior/discipline
Reconstructionism, 278, 289
Recreational drug use, 40
Reform Judaism, 278
Rehabilitation, 50–51
Reincarnation, 366
Religious discrimination in employment, 35
Religious practices and prayer, 45–46. See
also Spirituality
African Americans and, 68–69
Amish and, 88
Appalachian people and, 106
Arabs and, 122–123
Chinese and, 139
Egyptians and, 169–170
Filipinos and, 190
French Canadians and, 208
Germans and, 225
Guatemalans and, 154
Haitians and, 243
Iranians and, 256
Japanese and, 270
Jewish people and, 288–289
Koreans and, 304
Mexicans and, 318
Polish people and, 349–350
Russians and, 333
Thais and, 366–367
Residence/inhabited localities, 23–24
African Americans, 56–57
Amish, 75–76
Appalachian people and, 96
Arabs and, 114
Chinese and, 129–130
Egyptians and, 158
Filipinos and, 175–176
French Canadians and, 197–198
Germans and, 213–214
Guatemalans and, 145
Haitians and, 231–232
Iranians and, 249
Japanese and, 260
Jewish people and, 278
Koreans and, 293–294
Polish people and, 338–340
Russians and, 326
Thais and, 356
Respeto, 311
Responsibility for health-care. See
Health-care responsibility
Restrictive behaviors (children/
adolescents), 30–31
African Americans and, 59–60
Amish and, 80
Appalachian people and, 100
Arabs and, 116–117
Chinese and, 133–134
Egyptians and, 162
Filipinos and, 181
French Canadians and, 201
Germans and, 218
Guatemalans and, 148
Haitians and, 236
Iranians and, 251–252
Japanese and, 264
Jewish people and, 280–281
Koreans and, 297
Mexicans and, 312
Polish people and, 343–344
Russians and, 328
Thais and, 358
Restrictive childbearing practices, 43–44
African American families and, 67
Amish and, 86–87
Appalachian people and, 105
Arabs and, 121–122
Chinese and, 137–138
Egyptians and, 169
Filipinos and, 188
French Canadians and, 206–207
Germans and, 224
Haitians and, 242
2780_Index_489-506 16/07/12 12:19 PM Page 502

Index 503
Iranians and, 255
Japanese and, 269–270
Jewish people and, 286
Koreans and, 303
Mexicans and, 317–318
Polish people and, 349
Russians and, 332
Thais and, 364–366
Roman Catholic church, views on
health-care practices, 226t–227t
Roman Catholicism, 393–394
Root-work system, 245
Ruhezeit, 221
Russian heritage
alcohol consumption and, 330
alternative lifestyles and, 329
autonomy issues and, 329
biocultural ecology and, 329–330
biological variations and, 329–330
blood transfusion and, 335
cancer incidence and, 330
children and adolescent behavior
and, 328
common foods and food rituals and, 331
communications and, 327–328
cultural communication patterns and,
327–328
cultural responses to health and illness
and, 335
depression and, 330
dietary practices for health promotion
and, 331
diseases and health conditions and, 330
domestic violence and, 328
dominant languages and dialects and,
326–327
drug metabolism and, 330
family goals and priorities and, 328
family roles and organization and,
328–329
fertility practices and, 332
folk and traditional practices and, 334
format for names and, 328
gender roles and, 328
head of household and, 328
health-care barriers and, 334
health-care practices and, 331, 333–335
health-care practitioners and, 335
health-care responsibility and, 334
health-seeking beliefs and behaviors
and, 333–334
heritage and residence and, 326
high-risk behaviors and, 330–331
meaning of food and, 331
meaning of life and, 333
migration and associated economic
factors and, 326–327
nutrition and, 331
nutritional deficiencies and food
limitations and, 331
organ donation and, 335
overview of, 325
pregnancy and childbearing practices
and, 331–332
religious practices and, 333
responses to death and grief and, 332–333
skin color and, 329–330
smoking prevalence and, 330–331
sources of strength and, 333
spirituality and, 333
temporal relationships and, 328
use of prayer and, 333
workforce issues and, 329
workplace culture and, 329
Russian Orthodox, 325
S
Safety issues. See High-risk behaviors
Sandwich generation, 36
Sansei, 261
Santeria, 243f
Saving face, 262
Secondary characteristics, of culture, 7–8
Segregation, 57–58
Self-awareness, health professionals
and, 4–5
Self-care, overreliance on, 40
Self-exploration, 5
Self-medication, 48. See also Health-care
practices
Senior citizens. See Older adults
Sephardic Jewish people, 279
September 11 terrorist attacks, 24
Sexual behavior. See Alternative
lifestyles
Sexually transmitted diseases, 37
Shamanism, 306
Shariah, 122
Sheiks, 122
Shiite Arabs, 249
Shinkei shitsu, 274
Shinryo Naika, 274
Shinto, 272
Shiva, 288
Sick role behaviors, 51
Simpatia, 387
Single parenting. See Alternative
lifestyles
Skill set development, evidence-based
practice and, 16
Skin coloration, 36–37
African Americans and, 61–62
Amish and, 82
Appalachian people and, 101
Arabs and, 118
Chinese and, 135–136
Egyptians and, 265
Filipinos and, 184–185
French Canadians and, 203
Germans and, 220
Guatemalans and, 149
Haitians and, 238
Iranians and, 253
Japanese and, 266
Jewish people and, 282
Koreans and, 300
Mexicans and, 314
Polish people and, 345
Russians and, 329–330
Thais and, 359
Small Eid feast, 167
Smoking prevalence, 38–39
Arabs and, 119
Chinese and, 136
Egyptians and, 166
French Canadians and, 204
Haitians and, 239
Japanese and, 267
Koreans and, 300
Mexicans and, 315
Russians and, 330–331
Thais and, 362
Social exchanges, 27
Socioeconomic status, food selections
and, 41
Soul food, 66
Sources of strength, 46
African Americans and, 68–69
Amish and, 88–89
Appalachian people and, 106
Arabs and, 123
Chinese and, 139
Egyptians and, 170
Filipinos and, 190
French Canadians and, 208
Germans and, 225
Guatemalans and, 154
Haitians and, 243–244
Iranians and, 256
Japanese and, 272
Jewish people and, 289
Koreans and, 305
Mexicans and, 318–319
Polish people and, 350
Russians and, 333
Thais and, 367
Southern dialect, Russian, 327
Spirit houses, 366–367
Spirituality, 45–46. See also Meaning of
life; Sources of strength
African Americans and, 68–69
Amish and, 88–89
Appalachian people and, 106
Arabs and, 122–123
Egyptians and, 169–170
Filipinos and, 190
French Canadians and, 208
Germans and, 225
Guatemalans and, 154
Haitians and, 243–244
Iranians and, 256
Japanese and, 272–273
Jewish people and, 250
Koreans and, 304–305
Mexicans and, 318–319
Russians and, 333
Thais and, 366–368
Standard American English (SAE), 58
Standard Russian, 327
Stereotyping, defined, 7
Subcultures, defined, 7
Sunni Arabs, 249
Surnames, 29–30
Sympathetic magic, 70
Synagogues, 289
T
Ta’arof, 250
Taboo behaviors (children/adolescents),
30–31
African Americans and, 59–60
Amish and, 80
2780_Index_489-506 16/07/12 12:19 PM Page 503

504 Index
Appalachian people and, 100
Arabs and, 116–117
Chinese and, 133–134
Egyptians and, 162
Filipinos and, 181
French Canadians and, 201
Germans and, 218
Guatemalans and, 148
Haitians and, 236
Iranians and, 251–252
Japanese and, 264
Jewish people and, 280–281
Koreans and, 297
Mexicans and, 312
Polish people and, 343–344
Russians and, 328
Thais and, 358
Taboo childbearing practices, 43–44
African American families and, 67
Amish and, 86–87
Appalachian people and, 105
Arabs and, 121–122
Chinese and, 137–138
Egyptians and, 169
Filipinos and, 188
French Canadians and, 206–207
Germans and, 224
Haitians and, 242
Iranians and, 255
Japanese and, 269–270
Jewish people and, 286
Koreans and, 303
Mexicans and, 317–318
Polish people and, 349
Russians and, 332
Thais and, 364–366
Tae-kyo, 303
Tae-mong, 303
Tagdir, 256
T’ai chi, 141
Tatars, 325
Technological power of United States, 24
Temporal relationships, 29
African Americans and, 59
Amish and, 79
Appalachian people and, 99
Arabs and, 115
Egyptians and, 160–161
Filipinos and, 180
French Canadians and, 199–200
Germans and, 217
Guatemalans and, 146
Haitians and, 235
Iranians and, 251
Japanese and, 262
Jewish people and, 280
Koreans and, 296
Mexicans and, 311–312
Polish people and, 342
Russians and, 328
Thais and, 357
Thai heritage
alcohol consumption and, 362
alternative lifestyles and, 358–359
autonomy issues and, 359
biocultural ecology and, 359–360
biological variations and, 359
blood transfusion and, 369
children and adolescent behaviors
and, 358
common foods and food rituals and,
363–364, 363f
communication and, 357–358
cultural communication patterns
and, 357
cultural responses to health and illness
and, 369
death rituals and, 366
dietary practices for health promotion
and, 364
diseases and health conditions and, 360
dominant languages and dialects
and, 357
dominant religion and, 366–367
drug metabolism and, 360
educational status and occupations and,
356–357, 357f
family goals and priorities and, 358
family roles and organization and,
358–359
fertility practices and, 364
folk and traditional practices and,
368–369
format of names and, 357–358
gender roles and, 358
genetic disorders and, 360
head of household and, 358
health-care barriers and, 369
health-care practices and, 360, 368–369
health-care responsibility and, 368
health-seeking beliefs and behaviors
and, 368
heritage and residence and, 356
high-risk behaviors and, 360–362
HIV/AIDS and, 360–362
iodine deficiency and, 364
meaning of food and, 362–363
meaning of life and, 367
migration and associated economic
factors and, 356
nutrition and, 362–364
nutritional deficiencies and food
limitations and, 364
organ donation and, 369
overview of, 355–356
pregnancy and childbearing practices
and, 364–366
responses to death and grief and, 366
skin color and, 359
smoking and, 362
sources of strength and, 367
spiritual beliefs and health-care practices
and, 367–368
spirituality and, 366–368
temporal relationships and, 357
topography and, 355–356
use of prayer and, 366–367
workforce issues and, 359
workplace culture and, 359
The American Pain Society, 50
Third National Healthcare Disparities
Report, 3
Timeliness, multicultural workforce and,
33–34
Topography, health care problems and, 38
Torah, 279, 288
Touching, cultural patterns and, 28.
See also Nonverbal communication
Traditional Chinese medicine, 140–141,
140t
Traditional health-care practices, 48
African Americans and, 70
Amish and, 90–91
Appalachian people and, 107–110
Arabs and, 126
Egyptians and, 171
Filipinos and, 192
French Canadians and, 209
Germans and, 228
Haitians and, 244–245
Iranians and, 257
Japanese and, 274
Jewish people and, 291
Koreans and, 305–306
Mexicans and, 320–321
Polish people and, 351
Russians and, 334
Thais and, 368–369
Transcultural, defined, 8
Transcultural adaptation. See Workplace
culture
Transcultural health care, need for, 1–2
Translation, 21
Treyf, 284
Turkish heritage, 399–400
Two-tier labor market, 24
U
Ukrainians, 325
Ultra-orthodox Judaism, 278
United States
becoming superpower and, 23
dominant languages and dialects, 26–27
educational status and occupations, 25
explosion of older population and, 31–32
heritage of, 23–24
immigration and, 3, 24
migration and, 24
population and census data, 2–3
racial and ethnic disparities in health
care, 3–4
size of, 23
technological power and, 24
topography of, 23
Utang na loob (gratitude), 178
V
Values, defined, 6
Variant cultural characteristics, 8–12
Velorio, 318
Viddui, 287
Vietnamese heritage, 401–402
Visiting, Amish and, 78
Voice volume and tone, 27
Voodoo (voudou), 68, 240, 243–246
W
Weight issues, 40
Western ethical principles, 8–10
Wisconsin v. Yoder, 77
Workforce issues, 33–36
African Americans and, 60–61
2780_Index_489-506 16/07/12 12:19 PM Page 504

Index 505
Amish and, 81–82
Appalachian people and, 101
Arabs and, 117–118
Chinese and, 135
Egyptians and, 164–165
Filipinos and, 183–184
French Canadians and, 202–203
Germans and, 219–220
Guatemalans and, 148–149
Haitians and, 237–238
Iranians and, 252–253
Japanese and, 265–266
Jewish people and, 281–282
Koreans and, 299
Mexicans and, 313–314
Polish people and, 344–345
Russians and, 329
Thais and, 359
Workplace autonomy. See Autonomy
issues, workplace
Workplace culture, 33–35
African Americans and, 60–61
Amish and, 81–82
Appalachian people and, 101
Arabs and, 117
Chinese and, 135
Egyptians and, 164–165
Filipinos and, 183–184
French Canadians and, 202–203
Germans and, 219–220
Guatemalans and, 148–149
Haitians and, 237
Iranians and, 252–253
Japanese and, 265–266
Jewish people and, 282
Koreans and, 299
Mexicans and, 313–314
Polish people and, 344
Russians and, 329
Thais and, 359
Workplace tensions, 60–61
World diversity, 2–3
Worldview, defined, 7
Y
Yangban, 294
Yiddish, 279, 327
Yue Fai, 365
Z
Zaher, 251
Zar ceremony, 171
Zoroastrian, 249
2780_Index_489-506 16/07/12 12:19 PM Page 505

2780_Index_489-506 16/07/12 12:19 PM Page 506

Copyright
Foreword
Preface
Contributors
Reviewers
Table of Contents
Contents – DavisPlus
Introduction
Unit 1:
FOUNDATIONS FORCULTURAL COMPETENCE: Individual and Organizational
Chapter 1: Transcultural Diversity andHealth Care
The Need for Culturally Competent Health Care
World Diversity and Migration
U.S. Population and Census Data
Racial and Ethnic Disparitiesin Health Care
Culture and Essential Terminology
Culture Defined
Important Terms Related to Culture
Individualism, Collectivism, and Individuality
Variant Characteristics of Culture
Ethics Across Cultures
Chapter 2: The Purnell Model for Cultural Competence
Assumptions Upon Which the Model Is Based
Overview of the Theory, the Model,and the Organizing Framework
Macro Aspects of the Model
Micro Aspects of the Model
The Twelve Domains of Culture
Overview, Inhabited Localities, and Topography
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Generational Differences in the Workforce
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Health-Care Providers
Status of Health-Care Providers

Chapter 3: Individual Cultural Competence and Evidence-Based Practice
Individual Cultural Competence
Self-Awareness and Health Professions
Measuring Individual Cultural Competence
Evidence-Based Practice and Culturally Congruent Best Practices
Understanding the Four Components of Evidence-Based Practice
Chapter 4:
Organizational Cultural Competence
Health Disparities
Culturally Competent Health-Care Organizations
CLAS Standards
Cultural Competence Assessment Profile
The Purnell Model
Knowledge and Skill Acquisition
Language Assistance Services
Community Resources and Partnerships
Advocacy
Transparency
Outcomes Metrics to Assess Cultural Competence
Resources to Support Culturally Competent Health-Care Organizations
The Future of Culturally Competent Health-Care Organizations
Chapter 5:
Perspectives on Nursingin a Global Context
Overview
Definitions of Health, Global Health, One Health, and Global Nursing
Global Health Frameworks
Global Health Organizations
Forces Shaping Global Health and Nursing
Policy and National Economies
Population Trends
Environmental Factors
Access to Technology
The Global Nursing Workforce
International Migration
Trade and Mutual Recognition Agreements
Nursing Education
U.S. Nursing Workforce Recommendations
Ethical, Safety, and Health Considerations When Studying or Working Abroad

Unit 2:
AGGREGATE DATA FOR CULTURAL SPECIFIC GROUPS
Chapter 6:
People of African American Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Roles for Children and Adolescents
Family Roles and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practicesin the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 7:
The Amish
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Languages and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 8:
People of Appalachian Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illnesses
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 9:
People of Arab Heritage
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Religious Practices and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 10:
People of Chinese Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Cultural Communication Patterns
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Traditional Chinese Medicine Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Health Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 11: People of Cuban Heritage
Overview, Inhabited Localities,and Topography
Overview
Cuban Economy
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head Of Household And Gender Roles
Prescriptive, Restrictive, and Taboo Practices for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals And Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Health-Care Providers
Traditional Versus Biomedical Providers

Chapter 12:
People of European American Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Health-Care Providers
Traditional Versus Biomedical Providers

Chapter 13:
People of Filipino Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workforce
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and the Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 14:
People of German Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Health Behaviors
Health-Care Practices

Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 15:
People of Haitian Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Practices for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 16:
People of Hindu Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles And Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion And Use Of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 17:
People of Hmong Heritage
Overview, Inhabited Localities, and Heritage
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Health Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibiity for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 18:
People of Japanese Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Practices for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death, Grief, and Suffering
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donations
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 19:
People of Jewish Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Status of Health-Care Providers

Chapter 20:
People of Korean Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 21:
People of Mexican Heritage
Overview, Inhabited Localities,and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 22:
People of Polish Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Health-Care Practices
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Providers
Status of Health-Care Providers

Chapter 23:
People of Puerto Rican Heritage
Overview, Inhabited Localities,and Topography
Overview
Heritage and Residence
Reasons for Immigration and Associated Economic Factors
Educational Status and Occupations
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Biological Variations
Disease and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Dominant Religion and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusions and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Health-Care Providers
Status of Health-Care Providers

Chapter 24:
People of Russian Heritage
Overview, Inhabited Localities, and Topography
Overview
Heritage and Residence
Reasons for Migration and Associated Economic Factors
Communication
Dominant Language and Dialects
Cultural Communication Patterns
Temporal Relationships
Format for Names
Family Roles and Organization
Head of Household and Gender Roles
Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents
Family Goals and Priorities
Alternative Lifestyles
Workforce Issues
Culture in the Workplace
Issues Related to Autonomy
Biocultural Ecology
Skin Color and Other Biological Variations
Diseases and Health Conditions
Variations in Drug Metabolism
High-Risk Behaviors
Nutrition
Meaning of Food
Common Foods and Food Rituals
Dietary Practices for Health Promotion
Nutritional Deficiencies and Food Limitations
Pregnancy and Childbearing Practices
Fertility Practices and Views Toward Pregnancy
Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family
Death Rituals
Death Rituals and Expectations
Responses to Death and Grief
Spirituality
Religious Practices and Use of Prayer
Meaning of Life and Individual Sources of Strength
Spiritual Beliefs and Health-Care Practices
Health-Care Beliefs and Practices
Health-Seeking Beliefs and Behaviors
Responsibility for Health Care
Folk and Traditional Practices
Barriers to Health Care
Cultural Responses to Health and Illness
Blood Transfusion and Organ Donation
Health-Care Providers
Traditional Versus Biomedical Care
Status of Health-Care Providers

Appendix: Cultural, Ethnic, and Racial Diseases and Illnesses
Abstracts
American Indians and Alaska Natives
People of Baltic Heritage: Estonians,Latvians, and Lithuanians
People of Brazilian Heritage
People of Egyptian Heritage
People of French Canadian Heritage
People of Greek Ancestry
People of Guatemalan Heritage
People of Iranian Heritage
People of Irish Heritage
People of Italian Heritage
People of Somali Heritage
People of Thai Heritage
People of Turkish Heritage
People of Vietnamese Heritage
Glossary
Index

Running head: MODULE 5 ASSIGNMENT SELF-ASSESSMENT PAPER 1

MODULE 5 ASSIGNMENT SELF-ASSESSMENT PAPER 20

Module 5 Assignment Self-Assessment Paper

Cindy Rodriguez

St. Thomas University

Module 5 Assignment Self-Assessment Paper

I presently live in Miami, Florida. The region isn’t thickly populated; in this way, the gamble of irresistible illnesses is insignificant. What’s more, there are relatively few homegrown and wild creatures in the area, which further limits the gamble of contracting infections that exude from creatures. I have a blended family; my dad came from Cuba and my mom too. In this way, I come from a Hispanic foundation. A portion of my neighbors are likewise Hispanic, albeit the region is yet overwhelmed by Whites as far as populace thickness. As a Hispanic, I am mindful of the various wellbeing gambles with that are related with minority bunches in the country. For instance, the Centers for Disease Control and Prevention (2020) has recognized minority bunches in the nation as being additional inclined to higher paces of hospitalization from irresistible sicknesses contrasted with whites. I was brought up in Miami, Florida. There is no set of experiences of natural calamities in Miami, nor does my family have history of inherited afflictions that emerge from living in a polluted climate. I have lived in United States since I was conceived 25 years prior. Hence, I have become absorbed to the America culture, as I have no relationship with the nation of my progenitors’ starting point.

My folks relocated to the United States at an exceptionally youthful age. My mom came from Cuba when she was 12 and my farther came from Cuba, he was 21. My folks came to the U.S. to experience the American Dream. The land where I reside is reasonably populated. Nonetheless, it gets exceptionally damp during the summers in light of the fact that as air transports through the living, breathing people of water, it gets together something beyond heat; it additionally gets water fume. This stickiness is a critical gamble factor for respiratory infections like influenza and asthma (Zhang et al., 2020).

My yearly pay is about $65,000, According to Purnell (2018), pay level has suggestions for bearing the cost of drugs, dressings, and prescriptive gadgets. I use part of my pay to pay for protection expense for wellbeing inclusion which is given to me through my present place of employment. I have Bachelor of Science in Nursing (BSN). This capability furnishes me with a benefit of filling in as a Registered Nurse. In this manner, I am ready to comprehend wellbeing solutions and go to the fundamental lengths to limit the gamble of infections for myself as well as my family.

My present occupation is a Gastroenterology Nurse in a short-term office. I’m presented to sicknesses, for example, TB and COVID-19 while treating or interfacing with tainted people. Likewise, I face the capability of contracting sicknesses, for example, MRSA and other transmittable infirmities. I have never served in the military. I’m at present not wedded however I have a beau who I have been with for a very long time, we don’t have any youngsters yet will very much want to have 3 later on.

I go by Cindy Rodriguez; it is my lawful name. I truly do communicate in English, yet I likewise communicate in Spanish which it was the principal language I learned on the grounds that my family is Hispanic, and they said I will learn English once I began school which I did. Here and there, I find it challenging to impart my musings to my relatives and companions, particularly when I dread that I will be misjudged. Essentially, I find it challenging to impart my contemplations and thoughts to my kindred experts, particularly on issues that might have huge moral ramifications on the calling. For instance, sharing a patient’s data might be gainful as far as tolerant result, yet may add up to an infringement of security strategy (Mendelson and Wolf, 2017). Along these lines, prior to talking about or imparting a patient’s information to my expert partners, I initially decide the moral ramifications. All the more significantly, it is essential to speak with the concerned persistence to acquire assent prior to sharing any data.

I wouldn’t fret being moved by companions, outsiders, or colleagues, as I accept that it is important for non-verbal correspondence. Various individuals have different approaches to articulating their thoughts, and this incorporate contacting, motion, and looks (Kogi, 2019). As far as I might be concerned, contacting somebody while conversing with them is an indication of interest and mindfulness in the communication. Nonetheless, I would not touch others except if I am sure that they are alright with such activities. I don’t have a specific inclination for hello. Rather, I am available to any type of hello that the other individual is OK with. Regardless, I accept that a handshake is an indication of expectation and trust, while the gesture of the head or waving addresses detachment. As a social and cordial individual, I have met and collaborated with various individuals. Such associations have made me profoundly accommodative and lenient to the various types of good tidings and affirmations. I’m dependably on schedule for my arrangements. I accept time is significant for everybody and I hate having individuals look out for me. Consequently, I am normally early all the time for arrangements. I’m ordinarily on schedule for social commitment since I am anxious all the time to meet and communicate with others. I’m normally a cordial individual; hence, I have a characteristic tendency to cooperate and trade thoughts with companions and outsiders the same. Moreover, I view social arrangements as any open doors for growing my organizations.

Patients from high-setting societies put more prominent worth on quietness and implied correspondence and may invest in some opportunity to give a reaction. In this way, I communicate with such patients in manners that best suit their way of life. I generally ask or inform the patient before I contact them and where I contact them. The explanation is that patients have various inclinations; accordingly, it is essential to comprehend them prior to contacting them. Most patients stand inside arms distance next to their relatives. Nonetheless, they are anxious to stand further away while communicating with medical care suppliers. At the point when the topic of conversation is touchy, numerous patients habitually turn away their look while chatting with the medical services supplier.

My dad is the fundamental leader. He generally settles on He settles on choices connecting with finance, venture, wellbeing, and schooling. Men are the forerunners in families and guarantee that the prosperity of everybody is provided food for. My mom then again settles on family and venture choices, and he work at home is to support families and contribute monetarily. Kids should be respectful, buckling down in school, and aiding at home to establish a decent connection for them and for the family. Kids in our way of life ought not be affected by peer tension or substance misuse so they can establish a decent connection for them and for the family. In our family kids are to not have terrible habits like utilizing foul language and disregarding grown-ups. Youthful grown-ups should convey t themselves in a good way and staying safe with the specialists and ought to try not to take part in criminal operations, for example, substance misuse and clutter. Teenagers are prohibited from substance misuse and unreliable sex.

Needs for my family are to live morally and regard the privileges of others. Growing up the jobs of more seasoned grown-ups is to direct the youthful age and shape them to become mindful residents. What gives my family and I family status is that everybody in the house tries sincerely and helps one another. It is satisfactory to live with one another without being hitched. We see being hitched as only a title. My family is very open to various sexualities we have faith in individuals’ freedom to communicate their sexuality.

I’m the sort to constantly get to meeting and work on schedule. I accept everybody’s time is significant I’m typically the first. I have no worries in working with other people who are inverse orientation I accept a work environment needs an equilibrium. I really buckle down and I view myself as a faithful worker. At the point when I realize something is off connecting with my work, I counsel my manager or an accomplished partner. In spite of the fact that I communicate in Spanish and English its troublesome talking all the time to another person who doesn’t talk by the same token. At work anyway we have numerous choices assuming this was the situation.

Fortunately, I am not sensitive to any prescriptions that I am mindful of. Issues did you have when you assumed control over-the-counter prescriptions would be a fever or a hack. In my family we don’t have any significant sicknesses and illnesses, just infrequent FLU. I’m viewed as Hispanic because of my experience I am white, lean, and short. I don’t smoke, and I can’t be close to somebody smoking I truly detest the smell. Nobody in my family smokes by the same token. I do in any case, drink liquor I would see myself as a moderate consumer. I love to work out I for the most part run for between 1 to 3 miles, I likewise go to the rec center 3 to 5 times each week to lift loads. Insurances I take to forestall getting a physically communicated contamination/HIV is I use assurance during sex.

I love my weight at this moment, and I truly do feel fulfilled. Keeping up with my weight is minimal troublesome I for the most part watch what I eat and eat food that is low in fat substance. I attempt to stay away from red meat and inexpensive food since I feel better when I don’t have it. Likewise, on the grounds that they have elevated cholesterol content, which is a huge gamble factor for wellbeing sicknesses. Whenever I’m sick in my home we have food wealthy in fiber, including vegetables and organic products as well as soups. Disease I eat specific nourishment for is the point at which I have the FLU or a gastritis episode. I attempt and equilibrium my eating routine by eating vegetables and fish. There is no age-or orientation explicit food locally. I ordinarily have three suppers every day: breakfast, lunch, and supper. I have breakfast at 8 AM, lunch at somewhere in the range of 1 and 2 PM, and supper at between 7 PM and 8 PM additionally I nibble between dinners ordinarily have a yogurt, nuts, or cheddar. In my family we observe Halloween, Thanksgiving, Christmas eve, Christmas Day, and New Year’s Day. Hispanics typically cook their food by steaming bubbling, browning simmering, or baking.

I as of now don’t have any youngsters yet plan to have some later on. I likewise have never been pregnant. I use contraception to keep from getting pregnant on the grounds that my sweetheart and I are not prepared. A kid in my family generally implies a gift. In our way of life, we don’t have any exceptional food when we are pregnant anyway, we really do limit from cheap food and pop. We additionally go on with a similar movement as you were doing prior to getting pregnant. When I have a child, I would adore my significant other and mother to be with me while I’m conveying. In my way of life when somebody has a child everybody helps spouse, mother, father, and the remainder of my family. I’ve heard numerous things about keeping the placenta and umbilical string, yet I have not pondered me keeping I’d need to accomplish more exploration once I’m anticipating.

At the point when somebody dies in the family, we plan for it by grieving and supplications. When it’s my chance to go I’ve counseled my family that I would incline toward incineration. Typically, the internment after death is around 2 to 3 days after the individual passes however it differs with variables like assets and questions. Men in my way of life lament we realize men lament, particularly direct relations of the people who passed. In burial services everybody typically wears dark except if told in any case. Demise in my family implies end of life and progress to the hereafter. In my home we trust in the great beyond.

My family and I are Christians, I view myself as profoundly strict. I supplicate around two times each day and now and then considerably more. At the point when I implore, I should be in a calm and peaceful spot, as well as when I reflect. What invigorates me and significance in my life is absolution and accommodation to a Supreme Being.

Exercises I take part in keep up with my wellbeing is abstaining from smoking and medications. In my family my folks assume the liability for the family wellbeing. For over-the-counter prescriptions I for the most part use acetaminophen. In my family we don’t drink natural teas and society meds. Individuals in my way of life view or treat this with psychological instability very much like we treat every other person, they’re dealt with by relatives and the local area. Same goes for those with an actual inability. Whenever we are debilitated, we generally look for clinical mediation from a certified specialist. Individuals with persistent ailments in my way of life are seen equivalent to somebody with no constant ailment they are furnished with all the consideration they need, including prescription and moral arrangement. We additionally will acknowledge blood if necessary and would consider an organ relocate of required also. Some customary medical care rehearses I use is acupunctured to assist me with unwinding. At the point when my family and I are sick we generally see doctors and medical attendants. We don’t care either way if the medical services supplier isn’t a similar sex.

References

Centers for Disease Control and Prevention. (2020, May 13). COVID-19 in Racial and Ethnic Minority Groups. Retrieved July 10, 2020, from

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html

Kogi, S. (2019). The effects of palm orientation during gesticulation on perceived dominance and persuasiveness (Doctoral dissertation, San Francisco State University).

Mendelson, D., & Wolf, G. (2017). Health privacy and confidentiality. Health Privacy and Confidentiality.

Mota, N. P., Tsai, J., Sareen, J., Marx, B. P., Wisco, B. E., Harpaz-Rotem, I., Southwick, S. M., Krystal, J. H., & Pietrzak, R. H. (2016). High burden of subthreshold DSM-5 post-traumatic stress disorder in U.S. military veterans. World Psychiatry, 15(2), 185-186.

https://doi.org/10.1002/wps.20313

Purnell, L. (2018). undefined. Journal of Transcultural Nursing, 30(2), 98-105.

https://doi.org/10.1177/1043659618817587

Zhang, H., Liu, S., Chen, Z., Zu, B., & Zhao, Y. (2020). Effects of variations in meteorological factors on daily hospital visits for asthma: A time-series study. Environmental Research, 182, 109115.

https://doi.org/10.1016/j.envres.2020.109115