People of Arab Heritage

113

People of Arab Heritage

Chapter 6

ANAHID DERVARTANIAN KULWICKI

Overview, Inhabited Localities, and Topography

OVERVIEW

Arabs trace their ancestry and traditions to the nomadic desert tribes of the Arabian Peninsula. They share a com- mon language, Arabic, and most are united by Islam, a major world religion that originated in 7th-century Arabia. Despite these common bonds, even Arab residents of a sin- gle Arab country are characterized by diversity in thoughts, attitudes, and behaviors. Indeed, a poor tradition-bound farmer from rural Yemen may appear to have little in com- mon with an educated professional from cosmopolitan Beirut. Additional factors such as refugee status, time since arrival, ethnic identity, disparity between cultures, eco- nomic status, employment status, social support, and English language skills influence the immigration experi- ence and the Arab’s adjustment to life in America.

The September 11, 2001, al Qaeda terrorist attack on the United States has increased negative comments about Arabs by some people. Health-care providers need to understand that few Arab Americans support the terrorist attacks, and they must not pigeonhole people by their cultural background.

The diversity among Arabs makes presenting a repre- sentative account of Arab Americans a formidable task because of the primary and secondary characteristics of culture (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 newcom- ers of the period, they valued assimilation and were rather easily absorbed into mainstream U.S. society. Arab Americans tend to disappear in national 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 possible, including the large num- bers of new arrivals since 1965, literature that describes Arabs is used to supplement research completed by groups studying Arab Americans residing in Michigan and the San Francisco Bay area of California. An underly- ing assumption is that the attitudes and behaviors of first- generation immigrants are similar in some aspects to those of their counterparts in the Arab world.

Islamic doctrines and practices are included because most post-1965 Arab American immigrants are Muslims. Religion, whether official Islam, Christianity, or a local folk variant, is an integral part of everyday Arab life. Historically, Christians, Muslims, and Jews share a common religious background, and the three prophets are descendants from the same father, Abraham. Moses, the messenger of Judaism, and Jesus, the messenger of Christianity, are believed to be descendants of Isaac; whereas, Mohammed, the messenger of Islam, is believed to be a descendant of Abraham’s eldest son, Ishmael. Moreover, because Arabism and Islam are so intrinsically interwoven and because Islam has some elements of Christianity, Arabs, whether Christian or Muslim, share some basic traditions and beliefs. Consequently, knowledge of religion is critical to understanding the Arab American client’s cultural frame of reference and for providing care that considers specific reli- gious beliefs and practices of devout Arab Muslim clients.

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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. The Arab American Institute (2007) estimates 3.5 million Arab Americans live in the United States, with approximately 94 percent living in urban settings. The largest concentrations are in Los Angeles County, California; Wayne County, Michigan; and Kings, New York. However, Zogby International (2007) estimates the number of Arab American 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 between 1887 and 1913 seeking economic opportunity and per- haps the financial means to return home and buy land or set up 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, 39 percent of Arab Americans are from Lebanon, and 12 percent come from Syria (Arab American Institute, 2007).

Second-wave immigrants entered the United States after World War II; the numbers increased dramatically 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 immigrants 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 per- cent are age 65 years or older; their median age is 33 years (Arab American Institute, 2007).

EDUCATIONAL STATUS AND OCCUPATIONS

Because Arabs favor professional occupations, education, as a prerequisite to white-collar work, is valued. Not surprisingly, both U.S.- and foreign-born Arab Americans are more educated than the average American. Over 84 percent of Arab Americans have a high school education, compared with all Americans at 81 percent, and 41 per- cent have a college education, compared with 24 percent of the total population (U.S. Bureau of the Census, 2005).

In comparison with Americans, Arab Americans are more likely to be self-employed and much more likely to be in managerial and professional specialty occupations (U.S. Bureau of the Census, 2005). Nearly 42 percent are employed in managerial and professional positions, 32 percent in sales, and 11.7 percent in retail trade. Few Arab Americans are employed in farming, forestry, fish- ing, precision production, crafts, or work as operators and

fabricators (U.S. Bureau of the Census, 2005). Arab American households in the United States have a mean annual income of $47,000, compared with $42,000 for all households (Arab American Institute, 2007).

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 ranging from radio news- casts to lectures. Dialectal or colloquial Arabic, of which each community has a variety, is used for everyday spo- ken communication. Arabs often mix Modern Standard Arabic and colloquial 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 com- munication between Arab immigrants from Syria and Lebanon and Arab immigrants from Iraq and Yemen.

The Arab person’s speech is likely to be characterized by repetition and gesturing, particularly when involved in serious discussions. Arabs may be loud and expressive when involved in serious discussions to stress their com- mitment and their sincerity in the subject matter. Observers witnessing such impassioned communication may assume that Arabs are argumentative, confronta- tional, or aggressive.

English is a common second language in Egypt, Jordan, Lebanon, Yemen, Bahrain, and Kuwait. In contrast, liter- acy rates among adults in the Arab world vary from 44 per- cent in Yemen to 88 percent in Lebanon and Jordan. Literacy rates among women also vary, ranging from 23.7 percent in Yemen to 84 percent in Lebanon, where women often earn university degrees (Arab human develop- ment report, 2000). More than half (65 percent) speak a lan- guage other than English at home, although 44 percent report a good command of the English language (U.S. Bureau of the Census, 2005). Despite this, ample evidence indicates that language and communication pose formi- dable problems in American health-care settings. For example, 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 interper- sonal and communication problems, including erroneous assessments of patient complaints, delayed or failed appointments, reluctance to disclose personal and family health information, and in some cases, noncompliance with medical treatments (Kulwicki, 1996; Kulwicki, Miller, & Schim, 2000), and a tendency to exaggerate when describing complaints (Sullivan, 1993).

CULTURAL COMMUNICATION PATTERNS

Arab communication has been described as highly nuanced, with more communication contained in the

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context of the situation than in the actual words spoken. Arabs value privacy and resist disclosure of personal infor- mation to strangers, especially when it relates to familial disease conditions. Conversely, among friends and rela- tives, Arabs express feelings freely. These patterns of com- munication become more comprehensible when inter- preted within the Arab cultural frame of reference. Many personal needs may be anticipated without the individual having to verbalize them because of close family relation- ships. The family may rely more on unspoken expecta- tions and nonverbal cues than overt verbal exchange.

Arabs need to develop personal relationships with a health-care provider before sharing personal information. 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 impor- tant in evaluating a person’s character. Therefore, greet- ings, inquiries about well-being, pleasantries, and a cup of tea or coffee precede business. Conversants stand close to one another, 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; to do otherwise is taken as a lack of respect. Within the context of personal relationships, verbal agreements are consid- ered 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. When disputes arise, Arabs hint at their disagreement or simply fail to follow through. Alternatively, an intermedi- ary, someone with influence, 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 reassures the petitioner that maximum influ- ence has been employed (Nydell, 1987).

Guidelines for communicating with Arab Americans include

1. Employ an approach that combines expertise with warmth. Minimize status differences, as Arab Americans report feeling uncomfortable and self-conscious in the presence of authority figures. Pay special attention to the person’s feel- ings. Arab Americans perceive themselves as sen- sitive, with the potential for being easily hurt, belittled, and slighted (Reizian & Meleis, 1987).

2. Take time to get acquainted before delving into business. If sincere interest in the person’s home country and adjustment to American life is expressed, he or she is likely to enjoy relating such information, much of which is essential to assessing risk for traumatic immigration experi- ence (see Barriers to Health Care, later in this chapter) and understanding the person’s cultural frame of reference. 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 regarding history taking, performing physical examinations, and providing health information for newer immigrants. Although 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. Perform a comprehensive assessment. Explain the relationship of the information needed for physical complaints.

5. Interpret family members’ communication pat- terns within a cultural context. Recognize that a spokesperson may answer questions directed to the client, and that the family members may edit some information that they feel is inappropriate (Kulwicki, 1996). Family members can also be expected to act as the client’s advocates; they may attempt to resolve problems by taking appeals “to the top” or by seeking the help of an influential intermediary.

6. 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. Be mindful of the patient’s modesty and dignity. Islamic teachings forbid unnecessary touch (including shaking hands) between unrelated adults of opposite sexes (al-Shahri, 2002). Observation of this teaching is expressed most commonly by female patients with male health- care professionals, and may cause the patient to be shy or hesitant in allowing the professional to do physical assessments. Health-care providers must make concerted efforts to understand the patient’s feelings and to take them into consider- ation.

TEMPORAL RELATIONSHIPS

First-generation Arab immigrants may believe in predesti- nation; that is, God has predetermined the events of one’s life. Accordingly, individuals should work hard to make the best of life while acknowledging that God has ulti- mate control over all that happens. Consequently, plans and intentions are qualified with the phrase inshallah, “if God wills,” and blessings and misfortunes are attrib- uted 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 profes- sional occupations or who are in the business field, punc- tuality and respecting deadlines and appointments are considered important (Kulwicki, 2001).

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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. Devout Muslim men may not shake hands with women.

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”).

Family Roles and Organization

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 com- plementary division of labor. Men are breadwinners, pro- tectors, and decision makers, whereas women are respon- sible for the care and education of children and for maintenance of a successful marriage by tending to their husbands’ needs.

Although women in more urbanized Arab countries such as Lebanon, Syria, Jordan, and Egypt often have pro- fessional careers, with some women advocating for women’s liberation, the family and marriage remain pri- mary commitments for the majority. Most educated women still consider caring for their children as their pri- mary role after marriage. Arab women value modesty, especially among devout Muslim Arabs—modesty is expressed with their attire. For example, many Muslim women view the hijab, “covering the body except for one’s face and hands,” as offering them protection in sit- uations in which the sexes mix, because it is a recognized symbol of Muslim identity and good moral character.

Ironically, many Americans associate the hijab with oppression rather than protection. Similarly, the author- ity structure and division of labor within Arab families are often misinterpreted, fueling common stereotypes of the overtly dominant Arab male and the passive and oppressed Arab woman. Thus, by extension, conservative Arab Americans perceive the stereotypical understanding of the submissive role of women as a criticism to the Arab culture and family values (Kulwicki, 2000).

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 unfailing source of love and kindness. Although some fathers feel that it is advantageous to maintain a degree of fear, family rela- tionships are usually characterized by affection and senti- mentality. 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 familialism rather than individualism within the Arab culture, conformity to adult rules is favored. Correspondingly, child-rearing methods are ori- ented toward accommodation and cooperation. Family reputation is important; children are expected to behave in an honorable manner and not bring shame to the fam- ily. Child-rearing patterns 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 punishment and shaming. Children are made to feel ashamed because others have seen them misbehave,

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VIGNETTE 6.1

Mrs. Nasser arrived at the urgent-care center with her 16- year-old daughter, who had been experiencing burning upon urination, itching around her genital area, and a high fever. Mrs. Nasser appeared very anxious, explaining to the nurse that her daughter had never had these symptoms before. The nurse tried to calm Mrs. Nasser and asked that her daughter, Samia, get undressed in preparation for a physical examina- tion. Mrs. Nasser appeared concerned and requested that the nurse inform the doctor that she will not allow the doctor to perform a vaginal examination on her daughter.

The nurse explained to Mrs. Nasser that it will be neces- sary for the doctor to examine Samia so that she can deter- mine the cause of Samia’s discomfort. Mrs. Nasser became extremely agitated and explained to the nurse that in her cul- ture, young girls are not allowed to have vaginal examination for fear that their virginity will be compromised. Mrs. Nasser insisted that she would not allow her daughter to be exam- ined by the female doctor on duty. Mrs. Nasser requested that the nurse ask the doctor to write a prescription for her daugh- ter’s infection, or else she would leave the clinic immediately.

1. How should the nurse respond to Mrs. Nasser’s request? Explain your rationale.

2. Identify culturally congruent strategies that may be most effective in addressing the needs of Mrs. Nasser.

3. How might the nurse ensure that Mrs. Nasser’s con- cerns are addressed appropriately and that Samia has received the appropriate care?

HEAD OF HOUSEHOLD AND GENDER ROLES

Arab Muslim families are characterized by a strong patri- lineal tradition (Aswad, 1999). Women are subordinate 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 influence is overt. In pub- lic, a wife’s interactions with her husband are formal and respectful. However, behind the scenes, she typically wields tremendous influence, particularly in matters per- taining to the home and children. A wife may sometimes be required to hide her power from her husband and chil- dren to preserve the husband’s view of himself as head of the family.

Within the larger extended family, the older male fig- ure assumes the role of decision maker. Women attain

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rather than to experience guilt arising from self-criticism and inward regret.

Whereas adolescence in the West is centered on acquir- ing a personal identity and completing the separation process from family, Arab adolescents are expected to remain enmeshed in the family system. Family interests and opinions often influence career and marriage deci- sions. Arab adolescents are pressed to succeed academi- cally, in part because of the connections between profes- sional careers and social status. Conversely, behaviors that would bring family dishonor, such as academic fail- ure, sexual activity, illicit drug use, and juvenile delin- quency, are avoided. For girls in particular, chastity and decency are required. Adolescence in North America may provide more opportunities for academic success and more freedom in making career choices than can be accessed by their counterparts in the Arab countries. Cultural conflicts between American values and Arab val- ues often cause significant conflicts for Arab American families. Arab American parents cite a variety of concerns related 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 soci- ety. 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 ability 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 par- ents. 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 hus- band’s death, his family provides for his widow and chil- dren. In general, family leaders are expected to use influ- ence and render special services and favors to kinsmen.

Although educational accomplishments (doctoral de- grees), 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, particularly if the first wife is chronically ill or infertile, most marriages are monogamous and for life. Recent studies have reported that 2 to 5 percent of Arab Muslim marriages are polygamous (Kulwicki, 2000). Whereas homosexuality occurs in all cul- tures to some extent, it is stigmatized among Arab cultures. In some Arab countries, it is considered a crime; fearing

family disgrace and ostracism, 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 gay and lesbian rights in Arab American communities.

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 personal rela- tionships, guarding dignity and honor, and the impor- tance placed on maintaining one’s reputation. Arabs and Americans may also differ in attitudes toward time, instructional methods, patterns of thinking, and the amount of emphasis placed on objectivity. However, because many second-wave professionals were educated in the United States, and thereby socialized 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 sep- aration from family members, difficulty adjusting to American life, marital tension, and intergenerational con- flict, 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 per- ceptions and experiences of Arab American nurses in the aftermath of 9/11, the majority of nurses did not experi- ence major episodes of discrimination at work such as ter- mination and physical assaults; however, some did expe- rience other types of discrimination such as intimidation, being treated suspiciously, negative comments about their religious practices, and patient refusal to be treated by them (Kulwicki & Khalifa, 2007). Arab Americans are keenly aware of the misperceptions Americans hold about Arabs, such as notions that Arabs are inferior, backward, sinister, and violent. In addition, the American public’s ignorance of mainstream Islam and the stereotyping of Muslims as fanatics, extremist, and confrontational bur- den Arab American Muslims.

Muslim 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 inheritance. Individuals who wish to attend Friday prayer services and observe religious holidays frequently encounter job- related conflicts. Children are often torn between fulfill- ing Islamic obligations regarding prayer, dietary restric- tions, 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 dominated by deadlines, profit margins, and maintaining one’s

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competitive edge, a more relaxed, cordial, and relation- ship-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 influence and persuasion, and perfor- mance evaluations 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, hon- esty is an absolute value, facts and logic prevail, and direct and critical appraisal is regarded as valuable feedback. 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 com- plexions. Because color changes are more difficult 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, typhoid fever, dysentery, and parasitic infestations varies between urban and rural areas and from country 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 liv- ing quarters, open toilets are commonplace, and running water is not available. Schistosomiasis (also called bil- harzia), infecting about one-fifth of Egyptians, 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 urinating. Similarly, out- breaks 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 noncommunicable diseases such as cancer and heart disease. Correspondingly, seatbelt use, smoking

habits, and pesticide residues in locally grown produce are major issues. Campaigns directed at improving chil- dren’s health include hepatitis B vaccinations and dental health programs.

Glucose-6-phosphate dehydrogenase (G-6-PD) defi- ciency, 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 between first cousins—and the trend of bearing children up to menopause also con- tribute to the prevalence of genetically determined disor- ders 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 prob- lems in eastern Mediterranean countries (Kulwicki, 2001). In many countries, cardiovascular disease is a major cause of death. In Lebanon, the increased frequency of familial hypercholesterolemia is a contributing 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 limited. However, a Wayne County Health Department (1994) project, a telephone survey including Arabs residing in the Detroit, Michigan, area, identified cardiovascular disease as one of two specific risks, based on the high prevalence of cigarette smoking, 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 appropri- ate testing and screening, such as cholesterol testing, cholorectal cancer screening, and uterine cancer screen- ing, 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 com- pared with that of white males. Lung and colorectal can- cer are the two leading causes of death among Arab Americans. For Arab American men, lung cancer is the leading cause of death, and 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).

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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: antiarrhyth- mics, antidepressants, beta-blockers, neuroleptics, and opioid agents. Consequently, a small number of Arab Americans may experience elevated blood levels and adverse effects when customary dosages of antidepres- sants are prescribed. Conversely, typical codeine dosages may prove inadequate because some individuals 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 hospitality. Consistent with their cultural heritage, Arab Americans are characterized by higher smoking rates and lower quit- ting rates than European Americans (Darwish-Yassine & Wang, 2005; Rice & Kulwicki, 1992).

According to the 2001–2002 Special Cancer Behavioral Risk Factor Survey, Arab Americans who are 50 years and older have the highest smoking rates compared with other populations in Michigan. Smoking 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). Preliminary research results related to tobacco use among Arab Americans suggests that the rates of tobacco smoking among Arab American youth are considerably lower than those among non-Arab youth in Michigan, with only 16 percent of Arab youths smoking versus 34 percent of non-Arabs (Templin, Rice, Gadelrab, Weglicki, Hammad, & Kulwicki, 2003).

Limited information is available on alcohol use among Arab Americans. However, Islamic prohibitions do appear to influence patterns of alcohol consumption and atti- tudes toward drug use (Wayne County Health Depart- ment, 1994). Ninety percent of the Arab respondents in the survey reported that they abstain from drinking alco- hol. None reported heavy drinking, with a limited num- ber reporting binge drinking (2.2 percent) and driving under the influence of alcohol (1.4 percent). All respon- dents 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 infection 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 countries and among Arab Americans (Centers for Disease Contral and Prevention [CDC], 2006). The reported number of individuals having AIDS in the Arab countries varies and may not be an accu- rate 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 respondents surveyed by Kulwicki and Cass (1994) reported that they were at high risk for AIDS. In addition, the sample demonstrated less knowledge of primary routes of trans- mission and more misconceptions regarding unlikely modes of transmission than other populations surveyed.

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 screen- ing 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 immi- grants, may be at a higher risk for domestic violence because of the higher rates of stress, poverty, poor spiri- tual and social support, and isolation from family mem- bers owing to immigration (Kulwicki, 2001).

Sedentary lifestyle and high fat intake among Arab Americans place them at higher risk for cardiovascular diseases. For instance, 43 percent of the participants sur- veyed by Wayne County Health Department indicated that they had been told that their cholesterol level was high (Office of Minority Health [OMH], 2001). Studies in Arab countries and in Michigan have also reported higher rates of cardiovascular disease and diabetes among Arabs and Arab Americans.

Many Arab Americans are refugees fleeing war and political and religious conflicts, placing them at greater risk for psychological distress, depression, and other psy- chiatric illnesses (Hikmet, Hakim-Larson, Farrag, & Jamil, 2002; Kinzie, Boehnlein, Riley, & Sparr, 2002). Psycho- logical distress was also documented among immigrants who themselves were not victims of war and conflict but who worried over family members that were in areas of conflict. Studies conducted with Iraqi refugees and vic- tims of torture in the United States identified higher prevalence of post-traumatic stress disorder and depres- sion (Kinzie et al., 2002).

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 owner- ship and high recognition of the risks associated with having guns in the house. Conversely, lower rates of fire escape planning and seatbelt usage for adults and older children (car seats are generally used for younger chil- dren), as well as higher rates of physical assaults, threaten their safety.

In most health areas surveyed in Michigan, education and income were important determinants of risk for peo- ple of Arab descent. Socioeconomic status was also a strong indicator in accessing health-care services. The Wayne County Health Department (1994) indicated that 37.2 percent of the adult Arab respondents were not cov- ered by health insurance. Use of health-care services for prenatal care was, however, higher among Arab American

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females than other ethnic groups in Michigan (Michigan Department of Public Health, 1995). 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 Arab woman, whose primary role is caring for her husband and children, the preparation and presentation of an elabo- rate midday meal is taken as an indication of her love and caring. Similarly, in entertaining friends, the types and quantity of food served, often several entrees, is a measure of one’s 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 family, Arabic cooking shares many general characteristics. Familiar spices and herbs such as cinnamon, allspice, cloves, gin- ger, cumin, mint, parsley, bay leaves, garlic, and onions are used frequently. Skewer cooking and slow simmering are typical modes of preparation. 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.

Favorite fruits and vegetables include dates, figs, apri- cots, guavas, mangos, melons, papayas, bananas, citrus fruits, carrots, tomatoes, cucumbers, parsley, mint, spin- ach, and grape leaves. Lamb and chicken are the most popular meats. Muslims are prohibited from eating pork and pork products (e.g., lard). For Arab Christians, pork is not prohibited; however, pork consumption by Arab Christians is low. Similarly, because the consumption of blood is forbidden, Muslims are required to cook meats and poultry until well done. Bread accompanies every meal and is viewed as a gift from God. In many respects, the tra- ditional 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 prepared “from scratch,” con- sumption of preservatives and additives is limited.

Lunch is the main meal in Arab households. Encour- aging guests to eat is the host’s duty. Guests often begin with a ritual refusal and then succumb to the host’s insis- tence. 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 mixing 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 dependence on God and the poor who experience involuntary fasting, involves absti- nence from eating, drinking (including water), smoking, and marital intercourse during daylight hours. Although the sick are not required to fast, many pious Muslims insist on fasting while hospitalized, necessitating adjust- ments in meal times and medications, including medica- tions given by nonoral routes. In outpatient settings, health-care providers need to be alert to potential “non- compliance.” Patients may omit or adjust the timing of medications. Of particular concern are medications requiring constant blood levels, adequate hydration, or both (e.g., antibiotics that may crystallize in the kidneys). Health-care providers may need to provide appointment times after sunset during Ramadan for individuals requir- ing 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 abstinence is the head of every rem- edy” (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 elabo- rately 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, govern- ment subsidies for certain foods (e.g., bread, sugar, oil), and seasonal availability. Arab Americans most at risk for nutritional deficiencies include newly arrived immigrants from Yemen and Iraq (Ahmad, 2004) and Arab American households below the poverty level. Lactose intolerance sometimes occurs in this population. However, the prac- tice 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 alco- hol and pork have implications for American health-care providers. Conscientious Muslims are often wary of

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eating outside the home and may ask many questions 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 concerned about the ingredients and origins of mouthwashes, toothpastes, and medicines (e.g., alcohol-based syrups and elixirs), as well as insulins and capsules (gelatin coating) derived from pigs. However, if no substitutes are available, Muslims are per- mitted 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 1.9 in Tunisia and 2.2 in Lebanon to 5.9 in Yemen (UNICEF, 2005). Fertility prac- tices of Arabs are influenced by traditional Bedouin values supporting tribal dominance, popular beliefs that “God decides family size,” and “God provides,” and Islamic rul- ings regarding birth control, treatment of infertility, and abortion.

High fertility rates are favored. Procreation is regarded as the purpose of marriage and the means of enhancing 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 decreasing order of legitimacy, such as threat to the mother’s life, too frequent childbearing, risk of transmitting genetic dis- ease, and financial hardship. Moreover, irreversible 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 compro- mised by pregnancy-induced disease or her life is threat- ened (Ebrahim, 1989). Therefore, unwanted pregnancies are dealt with by hoping one miscarries “by an act of God” or by covertly arranging for an abortion. Recently, great decline in fertility rates has occurred in Arab coun- tries and among Arab Americans. According to Michigan’s birth registration data, fertility rates among Arab Americans are highest (approximately 4) when com- pared with those of the total population (OMH, 2001).

Among Jordanian husbands, religion and the fatalistic 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 steriliza- tion 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 because sterility in a woman could lead to rejection and divorce. Islam condones treatment for infertility, as Allah pro- vides progeny as well as a cure for every disease. However, approved methods for treating infertility are 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 occurred at a younger age and the fertility rate among Arab women was higher in the Arab world. However, as the educational and eco- nomic conditions for Arab women have improved both in the Arab world and in the United States, fertility pat- terns have also changed accordingly.

The pregnant woman is indulged and her cravings sat- isfied, lest she develop a birthmark in the shape of the particular food she craves. Because of the preference 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 dur- ing 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 coun- tries, home delivery, with the assistance of dayahs (“midwives”) or neighbors was common because of lim- ited access to hospitals, “shyness,” and financial con- straints. However, recently, the practice of home delivery has decreased dramatically in Arab countries, and hospi- tal 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 newborn’s ear. Male cir- cumcision is almost a universal practice, and for Muslims, it is a religious requirement.

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 2nd or 3rd 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

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lentil soup to increase milk production and tea to flush and cleanse the body.

Statistics describing the pregnancy and birth experiences of Michigan mothers, including 2755 Arab Americans, depict the experiences of Arab American mothers and infants as fairly comparable with their white counterparts with regard to adequacy of prenatal care, maternal com- plications, 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 disadvan- taged community of new immigrants with high rates of unemployment. Factors contributing to poor pregnancy outcomes include poverty; lower levels of education; 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 number 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. According 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 acceptance. 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 as soon as possi- ble 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 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. 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. For both Christians and Muslims, patients, especially children, are not told about terminal illness. The family spokesperson is usually the person who should be informed about 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 perceive 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 spe- cial cases, mourning can extend to 1 year. Although weep- ing 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 is that Islam has no priesthood. Islamic scholars or religious sheikhs, the most learned individuals in an Islamic community, assume the role of imam, or “leader of the prayer.” The imam also performs marriage ceremonies and funeral prayers and acts as a spiritual counselor or reference on Islamic teachings. Obtaining the opinion of the local imam may be a help- ful intervention for Arab American Muslims struggling with health-care decisions.

As with any religion, observance of religious practices varies among Muslims; some nominally practice their religion whereas others are devout. However, because Islam is the state religion of most Arab countries, 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 parenting is encour- aged, whereas adoption is forbidden. The infertility treat- ments available are those approved by Islamic jurists. Shariah, Islamic law courts, rule on matters such as mar- riage, divorce, guardianship, and inheritance. 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

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to facilitate fasting. Because Muslims gather for commu- nal prayer on Friday afternoons, the workweek runs from Saturday through Thursday. Finally, because of Islamic tradition that adherents of other monotheistic religions be accorded tolerance and protection, Jordan’s Christians have separate religious courts and schools, and non- Muslims attending public schools are not required to par- ticipate in religious activities.

For Arab American Christians, church is an important part of everyday life. Most celebrate Catholic and Orthodox Christian holidays with fasting and ceremonial church services. They may display or wear Christian sym- bols such as a cross or a picture of the Virgin Mary.

devout patient may request that her or his chair or bed be turned to face Mecca and that a basin of water be pro- vided for ritual washing or ablution before praying. Providing for cleanliness is particularly 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; prac- tice moderation in all activities; be conscious of hygiene; and face adversity with faith in Allah’s mercy and com- passion, 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 vehicle for repen- tance 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 character (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. Suffering 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, euthanasia and assisted suicide are forbidden (Lawrence, & Rozmus, 2001).

Spiritual beliefs and health-care practices for Arab American Christians are similar to those of Orthodox or Catholics. Caring for the body and burial practices are similar. A priest is always expected 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 inad- equate diet, hot and cold shifts, exposure of one’s stom- ach during sleep, emotional or spiritual distress, and envy or the evil eye. Arabs are expected to express and acknowledge their ailments when ill. Muslims often men- tion that the Prophet urged physicians to perform research and the ill to seek treatment because “Allah has not created a disease without providing a cure for it,” except for the problem of old age (Ebrahim, 1989, p. 5).

Despite beliefs that one should care for health and seek treatment when ill, Arab women are often reluctant to seek care. Because of the cultural emphasis placed on modesty, some women express shyness about disrobing for examination. Similarly, some families object to female family members being examined by male physicians. Because of the fear that a diagnosed illness, such as cancer or psychiatric illness, may bring shame and influence the marriageability 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

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VIGNETTE 6.2

Bilal, the terminally ill son of Mr. and Mrs. Khoury, has been on an inpatient unit for 3 weeks. Mrs. Khoury had been extremely critical of the nurses and the care they have been giving her son. Bilal has died. Upon being informed of their son’s death, Mrs. Khoury appeared shocked and started sobbing loudly. The nurse tried to comfort her without success. Mrs. Khoury blamed herself for not bringing their son to the hospital sooner. Mr. Knoury appeared upset about the death but still tried to comfort his wife, also without success. He seemed reserved, and despite all efforts to calm his wife, she continued crying and beating on her chest. Patients from nearby rooms gathered in the hallway and inquired about the incident.

1. Based on your readings about the Arab culture, what measures should the nurse have taken prior to inform- ing Mr. and Mrs. Khoury about their son’s death?

2. Explain Mrs. Khoury’s behavior, the critical behavior of the nurses, and the care they provided her son.

3. What is the role of Mr. Khoury in caring for his wife? How can a nurse ensure that Mr. Khoury’s emotional needs are being met?

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

For Muslims, adherents of the world’s second largest reli- gion, Islam means “submission to Allah.” Life centers on worshipping Allah and preparing for one’s afterlife by ful- filling religious duties as described in the Qur’an and the hadith. The five major pillars, or duties, of Islam are (1) declaration of faith, (2) prayer five times daily, (3) alms- giving, (4) fasting during Ramadan, and (5) completion of a pilgrimage to Mecca.

Despite the dominance of familialism in Arab life, reli- gious 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 medicine, performance of daily prayers, and reading or listening to the Qur’an with conventional medical treatment. The

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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 treat- ment was noted by a local health-care provider who diag- nosed “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 actual symptoms, preventive care is not generally sought (Kulwicki, 1996; Kulwicki et al., 2000). Similarly, pedi- atric 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’ pre- sent orientation and reluctance to plan and to the mean- ing 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 pre- ventive care services may be related to other factors such as insurance coverage, the availability of female physi- cians who accept Medicaid patients, 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 misunder- standing between Arab Americans and health-care providers (Abu Gharbieh, 1993). For example, individual- ism and an activist approach to life are the underpinnings of the American health-care system. Accordingly, prac- tices such as informed consent, self-care, advance direc- tives, risk management, and preventive care are valued. Patients are expected to use information seeking and problem solving in preference to faith in God, patience, and acceptance of one’s fate as primary coping mecha- nisms. Similarly, American health-care providers expect that the patient’s hope be “realistic” in accordance with medical science.

However, in Arab culture, quite the opposite values— familialism and fatalism—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, clients 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 mem- bers’ 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 responsibilities, as delineated in the Qur’an.

Although most American health-care professionals consider full disclosure an ethical obligation, most Arab

physicians do not believe that it is necessary for a client to know a serious diagnosis or full details of a surgical proce- dure. In fact, communicating a grave diagnosis is often viewed as cruel and tactless because it deprives clients of hope. Similarly, preoperative instructions are believed to cause needless anxiety, hypochondriasis, and complica- tions. Apart from the educated, most clients are not inter- ested in actively participating in decision making (Abu Gharbieh, 1993). Most Arabs expect physicians, because of their expertise, to select treatments. The client’s role is to cooperate. The authority of physicians is seldom challenged or questioned. When treatment is suc- cessful, the physician’s skill is recognized; adverse out- comes are attributed to God’s will unless there is evidence of blatant malpractice (Sullivan, 1993).

Not all Arabs may be familiar with the American con- cept of health insurance. Traditionally, the family unit, through its communal resources, provides insurance. Certain Arab countries, such as Saudi Arabia and Kuwait, provide free medical care, whereas in other countries, many citizens are government employees and are entitled to low-cost care in government-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 medical advice from pharmacists. In comparison with 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, witchcraft, 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 others 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 inter- preted as envy. Protection 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. Some believe that insanity, or jinaan (“possessed by the jinn”), may also be caused by the evil wishes of jealous individuals.

Traditional Islamic medicine is based on the theory of four humors and the spiritual and physical remedies pre- scribed 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 moisture, therapy involves treating with the disease’s opposite: hot disease, cold remedy. Although methods such as cupping, cautery, and phlebotomy may be

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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, moxibustion) or use cautery in combina- tion 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, dif- ferences in cultural values and norms, inability to pay for health-care services, and inability to speak English add to the stresses of immigration (Kulwicki, 2000; Kulwicki et al., 2000), affecting both health status and responses to health problems. Moreover, these immigrants are less likely to receive adequate health care because of cultural and language barriers, lack of transportation, limited health insurance, poverty, a lack of awareness of existing services, and poor coordination of services (Kulwicki, 1996, 2000).

Although a lack of insurance coverage affects a signifi- cant 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, lan- guage and communication remain serious barriers for recent Arab American immigrants (Kulwicki, 2000). Transportation to health-care facilities and culturally 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 con- trolled (Reizian & Meleis, 1986). Because of their confi- dence in medical science, Arabs anticipate immediate postoperative relief from their symptoms. This expecta- tion, in combination with a belief in conserving energy for recovery, often contributes to a reluctance to comply with typical postoperative routines such as frequent ambulation. Although expressive, emotional, and vocal responses to pain are usually reserved for the immediate family, under certain circumstances, such as childbirth and illnesses accompanied by spasms, Arabs express pain more freely (Reizian & Meleis, 1986). The tendency of Arabs to be more expressive with their family and more restrained in the presence of health professionals may lead to conflicting perceptions regarding the adequacy of pain relief. Whereas the nurse may assess pain relief as adequate, family members may demand that their rela- tive 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 evil spirits (Kulwicki, 1996). Underrecognition of signs and symptoms may occur because of the somatic orientation of Arab patients and physicians, patients’ tolerance of emotional suffering, and relatives’ tolerance of behavioral disturbances (El-Islam, 1994). Indeed, home management with stan- dard but crucial adjustments within the family may abort or control symptoms until remission occurs. For example, female family members manage postpartum depression 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 alcoholism and suicide, resulting in underreporting of these conditions because of a potential for severe social stigma.

When individuals suffering from mental distress seek medical care, they are likely to present with a variety 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 mental illness is accepted as a diagnosis, treatment by medications rather than by counseling is preferred. Hospitalization is resisted because such placement is viewed as abandonment (Budman, Lipson, & Meleis, 1992). Although Arab Americans report family and marital stress as well as vari- ous mental health symptoms, they often seek family counseling or social services rather than a psychiatrist (Aswad & Gray, 1996).

Yousef (1993) described the Arab public’s attitude toward the disabled as generally negative, with low expec- tations 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 educating some children with mild mental retardation in regular schools, special education programs are generally institutionally based.

PEOPLE OF ARAB HERITAGE • 125

VIGNETTE 6.3

Amal is a 22-year-old pregnant woman who has just immi- grated from Lebanon. She is 6 months’ pregnant and has not seen a doctor because she does not have health insurance. She is visiting the health department for the first time, hoping to be seen by a doctor and enroll in the Women, Infants, and Children (WIC) program. She, her husband, and her 4-year- old son fled Lebanon 1 year ago owing to the political unrest in their home country. Amal is hesitant to fill out the necessary paperwork or answer questions about her residency status for fear of being deported. She states that her son constantly coughs and has breathing problems, especially when her hus- band smokes. Her husband works in a local restaurant as a dishwasher but was recently laid off because of his frequent abscences from work owing to his constant coughing and breathing difficulties. Amal does not smoke, but her husband has smoked two packs a day since he was 18 years old. Amal speaks only limited English.

1. What additional information is needed to complete an assessment for Amal and her family? Given Amal’s lim- ited English proficiency, how would you obtain the necessary information?

2. Explain the cultural barriers Amal is experiencing in accessing prenatal care.

3. What type of intervention can the nurse provide to Amal regarding her husband’s smoking?

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Reiter, Mar’i, and Rosenberg (1986) found that parents who were most intimately involved with the develop- mentally disabled held rather positive attitudes. More tol- erant views were expressed among Israeli Arab parents, Muslims, the less educated, and residents of smaller vil- lages than among Christians, the educated, and residents of larger villages with mixed populations. Reiter et al. (1986) linked the less positive attitudes of the latter groups to the process of modernization, which affects a drive toward status and a weakening of family structures and traditions. Traditions include regarding the handi- capped as coming from God, accepting the disabled per- son’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 reference, 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 feelings about helping others by donating their organs to others or for scientific purposes (Kulwicki, 2001). Health-care profes- sionals should be sensitive to personal, family, or religious practices toward organ donation among Arab Americans and should not make any assumptions about organ dona- tion unless family members are asked.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

Although Arab Americans combine traditional and bio- medical care practices, they are very cognizant of the effec- tive medical treatments in the West and consider them- selves privileged to be able to use the American health-care system, which would not have been accessible to them in their country of origin (Kulwicki, 1996). Because of their profound respect for medicine, Arab Americans seek treat- ments for physical disorders or ailments. Medical treat- ments that require surgery, removal of causative agents, or eradicating by intravenous treatments are valued more than therapies aimed at health promotion or disease pre- vention. Although most Arab Americans have high regard for medicine related to physical disorders, many do not have the same respect or trust for mental or psychological treatment. A pervasive feeling among many Arab Americans is that psychiatric services or therapies related to mental disorders are not effective and are required 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 considerations in matching Arab patients and health-care providers. In Arab societies, unrelated males and females are not accus- tomed to interacting. Shyness in women is appreciated, and Muslim men may ignore women out of politeness. Health-care settings, client 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 professional of the opposite sex quite embarrassing and stressful. Discomfort may be expressed by refusal to discuss personal informa- tion 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 appropri- ately diagnose health conditions for high-risk Arab American females.

STATUS OF HEALTH-CARE PROVIDERS

Arab Americans have great respect for science and medi- cine. Most Arab Americans are aware of the historical con- tributions of Arabs in the field of medicine and are proud of their accomplishments. Knowledge held by a doctor is believed to convey authority and power. When ill, most Arab American clients 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 clients also feel that Arab American doctors understand them better, and they feel more at ease speaking with someone from their own culture. However, clients who are able to com- municate in English do not usually show preferences for seeing Arab doctors rather than American doctors. In some cases, these clients prefer to be seen by American doctors because they view American doctors as more pro- fessional and more respectful to clients than their Arab American counterparts.

Although medicine is perhaps the most respected pro- fession in Arab society, nursing is viewed as a menial pro- fession that conflicts with societal norms proscribing cer- tain female behavior. In this conservative culture, in which contact between unrelated males and females is often discouraged, nursing is considered particularly undesirable as an occupation 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 physicians (e.g., performing physical examinations). However, younger immigrants, and especially immigrants who come from Lebanon, Iraq, and Jordan, have more favorable perceptions about nursing as a profession 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 hier- archical family structure of Arab society. Physicians require that nurses “know their place” and leave the inter- pretation of data, decision making, and disclosure of

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129

People of Chinese Heritage

Chapter 7

YAN WANG and LARRY D. PURNELL

Overview, Inhabited Localities, and Topography OVERVIEW

Although some Western health-care providers categorize all Asians into one group, each nationality is very differ- ent. Cultural values differ even among Chinese according to their geographic location within China—north, south, east, west; rural versus urban; interior versus port city—as well as other primary and secondary characteristics of cul- ture (see Chapter 1). Chinese immigrants to Western countries are even more diverse, with a mixture of tradi- tional and Western values and beliefs. These differences must be acknowledged and appreciated.

Han Chinese are the principal ethnic group of China, constituting about 92 percent of the population of main- land China, especially as distinguished from Manchus, Mongols, Huis, and other minority nationalities. The remaining 8 percent are a mixture of 56 different nation- alities, religions, and ethnic groups. Substantial genetic, linguistic, cultural, and social differences exist among these subgroups. Because of the complexity of their val- ues, it is impossible to develop specific cultural interven- tions appropriate for all Chinese clients. Therefore, the information included in this chapter should serve simply as a beginning point for understanding Chinese people, not as a definitive profile.

Children born to Chinese parents in Western countries tend to adopt the Western culture easily, whereas their parents and grandparents tend to maintain their tradi- tional 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 pre- scribed interventions.

HERITAGE AND RESIDENCE

The Chinese culture is one of the oldest in recorded human history, beginning with the Xia dynasty, dating from 2200 B.C., to the present-day People’s Republic of China (PRC). The Chinese name for their country is Zhong guo, which means “middle kingdom” 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 rela- tionships embody power and rule.

During early Communist rule, an attempt was made to break down the values grounded in Confucianism and substitute values consistent with equal social responsibil- ity. 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, imprisonment, and even death. Later, during the Cultural Revolution, the young were held responsible for the deaths of many previously esteemed elderly and educated Chinese. Today, many of the Confucian values have reasserted themselves. Families, the elderly, and highly educated individuals are again considered important. Research completed by the Chinese Culture Connection, a group of Chinese sociolo- gists, lists 40 important values in modern China, includ- ing filial piety, industry, patriotism, paying deference to those in hierarchal status positions, tolerance of others, loyalty to superiors, respect for rites and social rituals,

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knowledge, benevolent authority, thrift, patience, cour- tesy, and respect for tradition (Hu & Grove, 1991).

The population of China is 1.31 billion people (China Population Information and Research Center, 2007), with 80 percent living in rural communities. The country is over 9.6 million square kilometers (3.7 million square miles), with 23 provinces; 5 regions including Tibet, Hong Kong, and Taiwan; and 3 municipalities. Each province, region, and municipality functions independently and in many different ways. The Chinese consider each region as part of greater China and predict that the day will come when all of China is reunited. Tibet has already been reas- similated, Hong Kong returned to Chinese control in 1997, and Macau in 1999.

Chinese Americans compose the largest subgroup among Asians/Pacific Islanders (APIs), exceeding 2.8 million people (Yu, Huang, & Singh, 2004). Every year since 1996, the quota for Chinese immigration to the United States has been filled, with more than 625,000 immigrants obtaining permanent legal status from mainland China, Taiwan, and Hong Kong (U.S. Department of Homeland Security, 2005). In the United States, the largest communities of Chinese Americans are in California, New York, Florida, and Texas.

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Chinese immigrated to the United States in three different waves: in the 1800s, in the 1950s, and in more recent years. Chinese immigration was initially fueled by economic needs. Over 100,000 male peasants from Guangdong and Fujian came to the United States without their families in the early 1830s to make their fortune on the transcontinen- tal railroad. This immigration continued through the Gold Rush of 1849. Many believed that they could make money in the United States to help their families 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 readily 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. Compared 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.

The most recent immigrants from Taiwan, Hong Kong, and mainland China are strikingly different from earlier Chinese immigrants in that they are more diverse. In addition, whereas many emigrated to reunite with fami- lies, 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

Education is compulsory in China, and most children receive the equivalent of a ninth-grade education. Middle

school students must complete a state examination to determine their eligibility to enter a general high school, to go to a preparatory high school before entering techni- cal school or college, or to begin their lives as workers. Those who complete either the general or the preparatory high school experience compete academically to con- tinue their education at college and university levels. The Chinese educational system is complex and is not pre- sented here in its entirety; further study is encouraged.

A university education is highly valued; however, few have the opportunity to achieve this life goal because 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 attend universities to seek more advanced education or research. A foreign education is considered prestigious in China.

In the West, initially the Chinese tend to be either highly or poorly educated. This dichotomy may result in health- care providers categorizing clients 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 significant number of Chinese students and scholars from the PRC and Taiwan come to the United States to study every year. Because of the competitive edu- cational system in mainland China and Taiwan, where only the brightest students go to a university, Chinese immi- grants with a college education are often very well edu- cated. Student immigrants are expected to return to China or Taiwan when their education and research are com- pleted. However, many do not return but elect to remain in Western countries, having obtained graduate degrees in the United States, and many find employment in high-tech- nology companies or educational and research institutes.

Another group of Chinese immigrants are profession- als from Hong Kong who moved to North America and other Western countries to avoid the repatriation in 1997. These immigrants usually have family connections or close friends in Western countries who are highly edu- cated and skilled. A third group of immigrants consists of uneducated individuals with diverse manual labor skills. Finding employment opportunities for these Chinese people may be more difficult. They often settle with fam- ily members who are not skilled or highly educated. This arrangement drains family resources for many years until they obtain financial security, learn the language, and become acculturated in other ways.

Communication

VIGNETTE 7.1

Mrs. Yu, a 48-year-old from Beijing, immigrated to the United States 5 years ago to live with her daughter. She speaks and reads very little English, but most of the time she seems to

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understand what physicians and nurses tell her. Today, she walked 12 blocks to the clinic for her monthly check-up regarding arthritis problems and chronic bronchitis from smoking when she lived in China. The physician on duty is a male and prescribes several new medicines. The nurse needs to give instructions on how to take her new medication three times a day with meals.

1. Does the gender of the physician have any implica- tions for Mrs. Yu’s visit?

2. Provide written instructions for Mrs. Yu to take her medications.

3. Given limited English language ability, how might the nurse ensure that Mrs. Yu understands how to take her medication?

4. Where might the nurse find someone to translate the English instructions into Chinese?

5. Does it make any difference which dialect Mrs. Yu speaks for the written instructions? Explain.

The official language of China is Mandarin (pu tong hua), which is spoken by about 70 percent of the popu- lation, 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 because 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 chil- dren are at least 10 to 12 years old before they can read the newspaper.

Although many times Chinese sound loud when talk- ing with other Chinese, they generally speak in a moder- ate 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 in English so that intentions are not misinterpreted.

When possible, health-care providers should use the Chinese language to communicate (see Table 7–1 for some common phrases), being careful to avoid jargon and 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 embarrass- ment. When asked whether they understand what was just said, the Chinese invariably answer yes, even when they do not understand. Such an admission causes loss of face; thus, it is better to have clients repeat the instruc- tions they have been given.

Negative queries are difficult for Chinese people to understand. For example, do not say, “You know how to

PEOPLE OF CHINESE HERITAGE • 131

T A B L E 7.1 Frequently Used Words and Phrases

English Word or Phrase Chinese Pinyin Phonetic Pronunciation

Hello Ňi hǎo Nee how (note tones to be used*) Goodbye Zài jiàn Dzai jee en How are you? Ňi hǎo mā Nee how mah Please Qing Ching Thank you Xīe xie Shee eh shee eh I don’t understand W̌o bù dǒng Wah boo doong Yes Sh̀i d̀e or d̀ui Shur da or doee (no real yes or no comparable

saying—this means I agree or okay) No Bú sh̀i d̀e or b̀u hǎo Boo shur or boo how My name is W̌o jiào Wah djeeow Very good Ȟen hǎo Hun hao Hurt Téng Tung I, you, he/she/it Wo, ňi, t ā Wah, nee, tah Hot Rè Ruh Cold Leňg Lung Happy Gāo xi ǹgu Gow shing Where Ňa li Na lee Not have ḾeiỲ́ou May yo Doctor Ȳi shēng Yee shung Nurse Hù s̀ hi Who shur

*Note: Each pu tong hua Chinese word is pronounced with five different tones: 1. First tone is high and even across the word (–). 2. Second tone starts low and goes high (–`). 3. Third tone starts neutral, goes low, and then goes high (ˇ). 4. Fourth tone is curt and goes low (·`). 5. Fifth tone is neutral and pronounced very lightly.

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do that, don’t you?” Instead say, “Do you know how to do that?” Also, it is easier for them to understand instruc- tions placed in a specific order, such as:

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

Chinese have a reputation for not openly displaying emo- tion. Although this may be true among strangers, among family and friends they are open and demonstrative. The Chinese 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 rela- tionships. In situations in which Chinese people perceive that health-care practitioners or other people of authority may lose face or be embarrassed, they may choose not to be totally truthful.

Touching between health-care providers and Chinese clients should be kept to a minimum. Most Chinese maintain a formal distance with each other, which is a form of respect. Some are uncomfortable with face-to-face communications, especially when there is direct eye con- tact. Because they prefer to sit next to others, the health- care practitioner may need to rearrange seating to pro- mote positive communication. When touching is necessary, the practitioner should provide explanations to Chinese clients.

Facial expressions are used extensively among family and friends. The Chinese love to joke and laugh. They use and appreciate smiles when talking with others. However, if the situation is formal, smiles may be limited. In most greeting and communication situations, shaking hands is common; hugs are limited. The health-care provider should watch for cues from their Chinese clients.

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 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 family 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 hus- band’s. Her family name comes first, followed by her given names, and finally, by her title. Many Chinese liv- ing in Western counties take an English name as an addi- tional 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. This practice can be confusing; there- fore, health-care providers should address Chinese clients 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 important, rec- ognized relationships between and among families in pol- itics and in business. Each family maintains 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 grad- ually 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. By the end of 2001, of the 351,234 million households in China, the average number of people in each household was 3.46 (Women of China, 2006c).

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 raising chil- dren 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 condi- tions make it possible for the younger generations to move out of the house and live apart from senior mem- bers 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 households. “Empty nests” will become the norm for seniors as parents of the first generation of single-child families get older. That, in turn, means a switch from an old system in which chil- dren looked after their parents to one in which seniors are cared for by society in general through benefits.

Another traditional practice in many rural Chinese families is the submissive role of the daughter-in-law to

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the mother-in-law. Many times, the mother-in-law is demanding 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 (Women of China, 2007).

The Chinese view of women is perpetuated to ensure male dominance in a society that has existed for cen- turies. Men still remain in control of the country, largely because of stereotypical roles of men and women. 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.

In 2001, almost half of the workforce were women. Favored professions are education, culture and arts, broadcasting, television and film, finance and insurance, public health, welfare, sports, and social services. In those trades requiring higher technical skills and knowledge, such as computer science, telecommunications, environ- mental protection, aviation, engineering design, real- estate development, finance and insurance, and the law. In 2001, the number of women employed increased from to 5 to 10 times what they were before China’s reform (Women of China, 2006a).

The traditional gender roles of women are changing, but a sense remains that a woman’s responsibility is to maintain a happy and efficient home life, especially in rural China. In recent times, some Chinese men include housework, cooking, and cleaning as their responsibili- ties when their spouses work. Most Chinese believe that the family is most important, 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 (China Turns One Child Policy into Law, 2002). Because of overpopulation in China, the government has mandated that each married couple may have only one child; however, in some rural areas if the first-born child is female, the couple may get permission to have a second child. 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 improve 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 years. Most Chinese chil- dren and adolescents value studying over playing and peer relationships. They recognize that they are con- stantly evaluated on having healthy bodies and minds and achieving excellent marks in school.

In rural communities, male children are more valued than female children because they continue the family lineage and provide labor. In urban areas, 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 television 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 interro- gated and ridiculed for their radical thoughts. Nationalism is important to Chinese children, and they want to help their country continue to be the center of the world. Children are also expected to help their par- ents in the home. Many times in the cities when children get home from school before their parents, they are expected to do their homework immediately 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 enroll- ment to colleges, parents and grandparents spoil most children. The children are expected to earn good grades and household chores are not encouraged; this is exhib- ited 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 achieve- ment and parental control over their children. One sur- prising finding was the high expectation for indepen- dence 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 read- ing, 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 jeopardize that unanimity. Adolescents question affairs of life and make great efforts to see at least two sides of every issue. They enjoy explor- ing different views with their peers and try to explore them with their parents.

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Teenage pregnancy is not common among the Chinese, but it is increasing among Chinese Americans. Young men and women enter the workforce immediately after high school if they are unable to continue their education. Many continue to live with their parents and contribute to the family, even after marriage, into their 20s, and with the birth of a child, in their 30s.

FAMILY GOALS AND PRIORITIES

The Chinese perception of family is through the concept of relationships. Each person identifies himself or herself in relation to others in the family. The individual is not lost, just defined differently from individuals in Western cultures. Personal independence is not valued; rather, Confucian teachings state that true value is in the rela- tionships a person has with others, especially the family.

Older children who experienced the Cultural Revolution may feel some discomfort with their traditional parents. During the Cultural Revolution, the young were encour- aged 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 “reeducation 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 educa- tion or reduce financial burdens. Relatives are expected to help each other through connections (guan xi), which are used by Chinese society in a manner similar to the use of money in other cultures. Such connections are perceived as obligations and are placed in a mental bank with deposits and withdrawals. These commit- ments may remain in the “bank” for years or genera- tions 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 assistance, health-care providers may be able to call on local Chinese organizations to obtain help for clients.

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 beyond. Traditional Chinese people view older peo- ple 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 relatives, they maintain respect and visit them frequently. 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 assessed on an individual basis. An extended-family pattern is com- mon and has existed for over 2000 years. The traditional

marriage still remains nuclear. Historically in China, marriage was used to strengthen positions of families in society.

Kinship relationships are based on the concept of loy- alty, and the young experience pressure to improve the family’s standing. Many parents give up items of daily liv- ing 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 important. 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 unless the person in power agrees. Even after negotiations have been concluded and contracts signed, the Chinese continue to negotiate.

The Chinese concept of privacy is even more impor- tant than recognized social status, corresponding values, and beliefs. The Chinese word for “privacy” has a nega- tive connotation and means something underhanded, secret, and furtive. People grow up in crowded condi- tions, 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 subject 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 client with sexual concerns. The client may feel uncom- fortable discussing or answering questions about sex with honesty. 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 nec- essary for harmonious working relationships.

ALTERNATIVE LIFESTYLES

The Chinese do not condone same-sex relationships. In many provinces, these are illegal and punishable by death. Divorce is legal, but not encouraged; although it is evident that divorce is a growing trend in China (Women of China, 2006d). Xu Anqi, an analyst at the Shanghai Social Science Academy and standing director of the China Research Association for Women and Family, said the reason for the growing number of divorces in China is multifaceted. First, society is going through a transitional period, which is greatly affecting the stability of mar- riages. Second, as living standards improve, people have higher expectations toward marriage and love. Third, the simplification of marriage and divorce procedures has made getting a divorce much easier (Women of China, 2006d).

For reasons such as tradition, consideration of chil- dren’s feelings, and difficulty in remarrying, many

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Chinese families would rather stay in an unhealthy marriage than divorce. Remarriage is encouraged, but some difficult relationships may occur in the blended family, especially remarriage with children from previ- ous marriages.

Workforce Issues CULTURE IN THE WORKPLACE

China is becoming more Westernized with high technol- ogy 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 regulations, and problem solving for families. Although recent immigrants know that the culture in the workplace 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 workplace. They observe people from the culture and listen closely for nuances in language and interpersonal connections. They frequently call on other Chinese peo- ple to teach them and to discuss how to fit into the new culture more quickly. Chinese Americans support one another in new cultures and help each other find resources and learn to live effectively and efficiently in the new culture. They also watch television, listen to music, and go to movies to learn about Western ways of life. They read about the new culture in magazines, books, and newspapers. They love to travel, and when an oppor- tunity 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 acculturate and adapt to the American workforce. Often, Americans seek opportunities to reciprocate with a gift, such as at a birth- day party, farewell party, or other occasion. Whereas a wide variety of gifts is appropriate, 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 wishes the recipient dead; and giving a clock could be interpreted as never wanting to see the per- son again or wishing the person’s life to end (Smith, 2002).

On the surface, Chinese Americans form classic exter- nal networks, including groupings by (1) family sur- name, (2) locality of origin in China, (3) dialect or subdi- alect spoken, (4) craft practiced, and (5) trust from prior experience or recommendation. Therefore, Chinese Americans approximate external networks with some characteristic of internal networks (Haley, Tan, & Haley, 1998).

Guanxi is a Mandarin term with no exact English trans- lation. This term includes the concept of trust and pre- senting uprightness to build close relationships and con- nections. 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 diffi- cult 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. However, the Western workforce expects independence, 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 alter- native, 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 dif- fer significantly in assertiveness.

Language may be a barrier for Chinese immigrants seeking assimilation into the Western workforce. Western languages and Chinese have many differences, 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 difficulty in understanding and speaking it.

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 undertones. 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.

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. Generally, 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 measure- ments are significantly smaller: Females are 4.14 cm smaller, and males 7.6 cm smaller 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-nega- tive blood group is rare, and twins are not common in

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Chinese families, but 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 experienced by other inner-city populations. For example, crowding in large cities often results in poor sanitation and increases the inci- dence of infectious diseases, air pollution, and violence.

The three leading causes of death were, among men, malignant neoplasms, heart diseases, cerebrovascular dis- ease, accidents, and infectious diseases, and among women, heart diseases, cerebrovascular disease, and malig- nant neoplasms (He, Gu, Wu, Reynolds, & Cao, 2005).

The average life expectancy in China is 72.58 years (CIA, 2007), thanks to improved living conditions and medical facilities, as well as a nationwide fitness cam- paign. In 1949, the average life expectancy was only 35 years (People’s Daily, 2002). Disease incidence has decreased as well, but major problems still exist in rural China, where perinatal deaths and deaths from infectious diseases remain 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 condi- tions 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 different types of can- cer, 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

Multiple studies outlining problems with drug metabo- lism and sensitivity have been conducted among the Chinese. Results suggest a poor metabolism of mepheny- toin (e.g., diazepam) in 15 to 20 percent of Chinese; sensi- tivity to beta-blockers, such as propranolol, as evidenced 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 effects, despite a decreased sensitivity to them. In addition, 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.

High-Risk Behaviors High-risk behaviors are difficult to determine with accu- racy among Chinese in the United States because most of the data on Chinese are included in the aggregate called Asian Americans. Smoking is a high-risk behavior for many Chinese men and teenagers. A study by Yu, Edwin, Chen, Kim, and Sawsan (2002) indicated that the male preva- lence of smoking in Chicago is higher than that reported in California, the National Health Inventory Survey (NHIS), and the Behavioral Risk Factor Surveillance System (BRFSS); exceeds the rate for African Americans aged 18 years and older; is comparable with the rate for African American males aged 45 to 64 years; and is far above the Healthy People 2010 target goal of less than 12 percent (Healthy People 2010, 2000). Most Chinese women do not smoke, but recently, the numbers for women are increas- ing, especially after immigration to the United States. Travelers in China see more cigarette vendors than any other type in the streets. The decrease in smoking in the United States resulted in cigarette manufacturers’ identify- ing China as a good market in which to sell their product.

Even though alcohol consumption among Chinese has been high at times, the level is currently low (Weatherspoon, Danko, & Johnson, 1994). Despite these findings, the use of alcohol contributes to a high incidence of vehicle accidents and related trauma. HIV, AIDS, and sexually transmitted diseases are lower among Chinese and other Asian Americans compared with other groups in the United States (Centers for Disease Control [CDC], 2001).

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 cele- brations 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 disease and injury. Traditional Chinese medicine frequently uses food and food deriva- tives to prevent and cure diseases and illnesses and increase the strength of weak and older people.

COMMON FOODS AND FOOD RITUALS

The typical Chinese diet is difficult to describe because 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 instead of rice. The Chinese eat steamed and fried rice noodles, which are usually prepared with a broth base and include vegetables

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and meats. Meat choices include pork (the most com- mon), 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 pro- tein, 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 inter- spersed with speeches, or the speeches may be incorpo- rated in 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. Chopsticks should never be stuck in the food upright because that is considered bad luck (Smith, 2002). Westerners soon learn that slurping, burping, and other noises are not considered offensive, but are appreciated. 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 vegeta- bles are sources of contamination owing to unsanitary conditions in China. The Chinese enjoy their vegetables lightly stir-fried in oil with salt and spice. 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 cold while eating or may believe that it is damaging to their body and shocks the body systems out of balance. Conversely, hot drinks are enjoyed and believed to be safe for the body. This “goodness” of hot drinks may stem from tradi- tion 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 sig- nals 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 harmony. 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 educa- tion regarding the use of salty fish and condiments, which increase the risk for nasopharyngeal, esophageal, and stomach cancers.

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

Little information is available about dietary deficiencies in the Chinese diet. The life span of the Chinese is long

enough to suggest that severe dietary deficiencies are not common as long as food is available. Periodically, 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 encour- aged to enhance the diets of people with goiters. Native Chinese generally do not drink milk or eat milk prod- ucts because of a genetic tendency for lactose intoler- ance. Their healthy selection of green vegetables limits the incidence of calcium deficiencies. Health-care providers may need to screen newer Chinese immi- grants 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.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

China continues to make efforts to slow the rate of popu- lation growth by enforcing a one-child law. The most popular form of birth control is the intrauterine device. Sterilization is common even though oral contraception is available. Contraception is free in China. Abortion is fairly common, but statistics are hard to find.

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 family rejoice in the new family member. Overall, pregnancy is seen as a woman’s business, although the Chinese man is beginning to demonstrate 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” program was initiated in 2003 to promote the social status of women, and attempts are being made to decrease gender identification abortions without a medical purpose and the abandonment of newborn girls (XinHua News Agency, 2006)

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.

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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 government 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 shellfish during the first trimester because it causes allergies. 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 years were reduced to 30 per 1000 and 35.9 per 1000 (Women of China, 2006e). 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 a qualified personnel. This has reduced the maternal mortality rate significantly to 50.2 in 100,000 (Women of China, 2006e). 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 recov- ery, with the mother eating cooked and warm foods that decrease the yin (cold) energy. The Chinese government supports this 1-month recuperation 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 importance 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 con- tinue among many Chinese women during the postpar- tum period. Drinking and touching cold water are taboo for women in the postpartum period. Raw fruits and veg- etables are avoided because they are considered “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 because it helps rebuild blood loss. Drinking rice wine is encouraged to increase the mother’s breast milk production. 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 outside or bathe for the first month post- partum because the cold air can enter the body and cause health problems, especially for older women. Some women wear 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 chil- dren. 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 publicity 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 antibody concentra- tions and reimmunized as necessary (Schulpen, 2001).

Death Rituals DEATH RITUALS AND EXPECTATIONS

Chinese death and bereavement traditions are centered on ancestor worship. Ancestor worship is frequently mis- understood; it is not a religion, but rather a form of pay- ing 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 stoicism and fatalism is a myth. In fact, most Chinese fear death, avoid references to it, and teach their children this avoid- ance. 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, especially 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 pronunciation 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 insurance 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

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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 fam- ily 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 person’s spirit, and other articles made of paper. In China, cremation is pre- ferred by the state because of a lack of wood for coffins and a limited space for burial. The ashes are placed in an urn and then in a vault. As cities grow, even the space for vaults is limited. In rural areas, many families prefer tra- ditional burial and have family burial plots. It is prefer- able 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 emotions to strangers. During bereavement, a person does not have to go to work, but instead can use this mourning time for remem- bering the dead and planning 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 recog- nized 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 different religions are practiced alone rather than with people coming together to participate in a formal religious service. In recent years, in some parts of China, religion is becoming more popular. The main formal religions in China are Buddhism, Catholicism, Protestantism, Taoism, and Islam.

As immigration from China increases, Chinese people who practice Christian religions have become more visible on the American landscape. Chinese immigrants from the PRC 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 permitted to practice Christianity. At first, they may go to a church attended by other Chinese people; eventually some are bap- tized, and others continue to attend 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, students, scholars, and their families. An understanding of this con- cept is essential when the health-care provider attempts to obtain religious counseling services for Chinese clients.

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 interrelation- ships, 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 interrelated. When the Chinese attempt to explain life and what it means, they speak about what happened to them, what hap- pened 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 frame- work.

“Life forces” are sources of strength to the Chinese. These forces come from within the individual, the envi- ronment, the past and future of the individual, and soci- ety. Chinese use these forces when they need strength. If one usual source of strength is unsuccessful, they try another. The individual may use many different tech- niques such as meditation, exercise, massage, and prayer. Drugs, herbs, food, good air, and artistic expression may also be used. Good-luck charms are cherished, and tradi- tional and nontraditional medicines are used.

The family is usually one source of strength. Individuals draw on family resources and are expected to return resources to strengthen the family. Resources may be finan- cial, emotional, physical, mental, or spiritual. Calling on ancestors to provide strength as a resource requires giving back to the ancestors when necessary. The interconnected- ness of life provides a source of strength for individuals from before birth to death and beyond.

Health-care providers need to understand this multidi- mensional manner of thinking and believing. Assessments, goal setting, interventions, and evaluations may be differ- ent for Chinese clients than for American clients. The con- text 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 hospi- tal. Traditional Chinese medicine shops abound (Fig. 7–1). Even department stores and supermarkets have Western medicines and traditional Chinese medicines and herbs.

The focus of health has not changed over the cen- turies, and includes having a healthy body, a healthy mind, and a healthy spirit. Preventive health-care prac- tices are a major focus in China today. An additional focus is placed on infectious diseases such as schistosomi- asis, tuberculosis, childhood diseases, and malaria; can- cer; heart diseases; and maternal-infant care. Chinese Ministry of Health statistics indicate China had 840,000 HIV-infected people in 2004 (Chinese Ministry of Health, 2004). That means that China had the 14th highest num- ber of HIV-infected people in the world and the second highest in Asia. Between 2000 and 2005, the percentage

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of people infected with HIV rose from 19.4 percent to 28.1 percent (Women of China, 2006b). China now faces a critical period in the fight to curb the spread of, and ulti- mately cure, HIV and AIDS. The World Health Organization (WHO) has predicted that China, if it fails to control the disease’s spread, will have 10 million AIDS sufferers by 2010 (Gu, 2006). A new 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, 2006b).

Whereas many Chinese have made the transition to Western medicine, others maintain their roots in tradi- tional Chinese medicine, and still others practice both types. The Chinese are similar to other nationalities 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 traditional Chinese medicine. Conversely, older people may try traditional Chinese medicine first, and only seek Western medicine when tra- ditional 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 seek- ing Western medical care, many older Chinese continue to practice traditional Chinese medicine in some form. However, some Chinese clients 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 clients so that all information can be disclosed. Health- care providers must impress upon clients the importance of disclosing all treatments because some may have antagonistic effects.

RESPONSIBILITY FOR HEALTH CARE

Chinese people often self-medicate when they think that they know what is wrong or if they have been successfully 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 prac- tices among the Chinese. Thus, health-care providers should inquire about this practice when making assess- ments, setting goals, and evaluating the results of treat- ments. A trusting relationship between members of the health-care team and the client 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, tak- ing medicine, and the expected outcomes. Western medi- cine needs to be explained to Chinese people in equally concrete terms.

Traditional Chinese medicine has many facets, includ- ing 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 vessels, and skin. The scope of traditional Chinese medi- cine is vast and should be studied carefully by profession- als who provide health care to Chinese clients.

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 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 sys- tem. The same systems approach is used to produce local- ized anesthesia.

Moxibustion is the application of heat from different 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 substance, and the medi- cine 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

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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 inter- play of these functions, rather than the structures, are important to 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 channels, 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 out- ward 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 practitioner uses listening, smelling, and questioning techniques in the assessment. Palpation is used by feeling the 12 pulses and different parts of the body. Treatments are based on the imbal- ances that occur. Many are directly related to the obvious problem, but many more are related through the inter- connectedness of the body systems. Many of the treat- ments 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. Practitioners take many years to become adept in all phases of diagno- sis 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 breathing 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 (T’ai Chi Chen Homepage, 2007). A recent survey in China indicated that 41.3 percent respondents believe that “Yoga” is the most fash- ionable kind of exercise among women (Women of China, 2006c). Yoga incorporates meditation, relaxation, imagery, controlled breathing, stretching, and other physical movements. Yoga has become increasingly pop- ular 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 conventional medical care.

Herbal therapy is integral to traditional Chinese medi- cine 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, includ- ing 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

VIGNETTE 7.2

The Chiang family brings their 6-year-old daughter, Yan, to the Emergency Department (ED) on 2 consecutive days. Yesterday, when they first brought her to the ED, the nurse found six quar- ter-sized round ecchymotic areas on the child’s back from tradi- tional Chinese medicine. Yan was discharged on liquid antibi- otics for a pulmonary infection. The parents bring Yan to the ED again today because she does not seem to be improving and has diarrhea. Mrs. Chiang has the medicine in a plastic bag with a tablespoon. After much discussion and calling the language interpretation line, the nurse determined that Mrs. Chiang was using a tablespoon instead of a teaspoon of the liquid antibiotic.

1. What type of traditional Chinese medicine leaves round ecchymotic areas?

2. For what type of conditions is this treatment used? 3. Why does Yan have diarrhea? 4. What could the nurse have done initially to ensure that

a teaspoon would have been used instead of a table- spoon?

5. What Chinese beliefs regarding Western health care are perpetrated by Yan’s reaction to the antibiotic?

In China, the government is primarily responsible for pro- viding 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 clients 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) summa- rized these barriers as the following:

1. Language barriers: This is one of the major reasons that Chinese Americans do not want to see Western health-care providers. They feel uncom- fortable and frustrated with not being able to com- municate with them freely and not being able to adequately express their pains, concerns, or health problems. Even highly educated Chinese Americans, who have limited knowledge in the medical field and are unfamiliar with medical ter- minology, have difficulty complying with recom- mended procedures and health prescriptions.

2. Cultural barriers: Lack of culturally appropriate and competent health-care services is another key obstacle to health-care service utilization. Many Chinese Americans have different cultural

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responses to health and illness. Although they respect and accept the Western health-care provider’s prescription drugs, they tend to alter- nate between Western and traditional Chinese physicians.

3. 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 assure 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 companies. 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.

4. Systemic barriers: Not understanding the Western health-care system and feeling inconvenienced by managed-care regulations deters many from seeking Western health-care providers unless they are seriously ill. The complexity of the rules and regulations of public agencies and medical assistance programs such as Medicaid and Medicare blocks their effective use.

Tan (1992), in a different perspective, summarized bar- riers for Chinese immigrants seeking health care:

1. Many Chinese Americans have great difficulty facing a diagnosis of cancer because families are the main source of support for patients, and many family members are still in China.

2. Because many Chinese Americans do not have medical insurance, any serious illness will lead to heavy financial burdens on the family.

3. Once the client responds to initial treatment, the family tends to stop treatment and the client does not receive follow-up care or becomes non- compliant.

4. Chinese American families may be reluctant to allow autopsies because of their fear of being “cut up.”

5. 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 opportunity or options for those Chinese Americans who prefer to seek tradi- tional Chinese treatment for certain illness.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

VIGNETTE 7.3

Mr. and Mrs. Lin, first-generation Chinese Americans, bring Mrs. Lin’s 75-year-old father, Mr. Xu, who does not speak

English, to the neighborhood clinic because he has not been eating well or socializing with the family. This morning, he is complaining of fire in his chest and stomach. Mr. Lin admits finding several empty alcohol bottles in the trash, which they said were put there by neighbors. Mr. Lin is adamant that his father is not drinking the alcohol. When the physician sug- gests family counseling, Mr. and Mrs. Lin leave with Mr. Xu, replying that this was not necessary.

1. Mr. and Mrs. Lin have the same surname. How does this compare with traditional Chinese when they marry?

2. What was Mrs. Lin’s family name before she married Mr. Lin?

3. How does Mr. Xu’s description of pain vary from what a European American might describe?

4. What might the complaint of “fire in the chest and stomach” signify?

5. What drug metabolism issues are relevant to the assessment?

6. Identify a more appropriate approach for the physician to use when prescribing medication and conducting family counseling.

7. What cultural concerns might a social worker have to consider to effectively assist this family?

8. How are Mr. and Mrs. Lin showing respect for Mrs. Lin’s father?

Chinese people express their pain in ways similar to those of Americans, but their description of pain differs. A study by Moore (1990) included not only the expression of pain but also common treatments used by 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 explanations of pain from the traditional Chinese influence of imbalances in the yang and yin com- bined 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 ill- ness results more from metabolic imbalances and organic 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 Chinese do not readily seek assistance 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

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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 sup- portive of the disabled, but for the most part, support ser- vices are popular. Because the focus has been on improv- ing 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 will be held September 6 to 17, 2008, and will open 12 days after the 29th Olympic Games. A successful Paralympics in Beijing will promote the cause of disabled persons in Beijing as well as throughout China. The Games will urge the whole of society to pay more atten- tion to this special segment of our population and will reinforce 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 client. 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 acculturated may exhibit some of the traditional roles associated with ill- ness. Each client needs to be assessed individually for responses to illness and for expectations of care. Traditionally, the Chinese ill person is viewed to be pas- sive 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 the connections can be incorporated into treatment regi- mens. The Chinese believe that because the illness or injury is caused from an imbalance, 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 treatments that are comfortable and do not hurt. Treatments that hurt are physically stressful and drain their energy. Health-care providers who have been ill themselves can appreciate this way of thinking, because sometimes the cure seems worse than the illness. Treatments will be more successful if they are explained in ways that are con- sistent 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 pri- mary people assume this responsibility, usually a spouse. Health-care providers need to include the family mem-

bers 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 essen- tial, 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 Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

China uses two health-care systems. One is grounded in Western medical care, and the other is anchored in tradi- tional Chinese medicine. The educational preparation of physicians, nurses, and pharmacists is similar to Western health-care education. Ancillary workers have responsi- bility in the health-care system, and the practice of mid- wifery is widely accepted by the Chinese. Physicians in Chinese medicine are trained in universities, and tradi- tional Chinese pharmacies remain an integral part of health care.

STATUS OF HEALTH-CARE PROVIDERS

Traditional Chinese medicine practitioners are shown great respect by the Chinese. In many instances, they are shown equal, if not more, respect than Western practi- tioners. The Chinese may distrust Western practitioners 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 receive more respect than women, but that is beginning to change. Physicians receive the highest respect, followed closely by nurses with a university edu- cation. Other nurses with limited education are next in the hierarchy, followed by ancillary personnel.

Health-care practitioners are usually given the same respect as older people in the family. Chinese children 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 generally per- ceived as caring individuals who perform treatments and procedures as ordered by the physician. Nursing assis- tants provide basic care to patients. Adult Chinese respond to practitioners 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.

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The Chinese respect their bodies and are very modest when it comes to touch. Most Chinese women feel uncomfortable being touched by male health-care providers, and most seek female health-care providers.

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