Cultural Group Guides


The following guides emphasize information that can be used to stimulate thinking about cultural differences and prompt questions that will help providers understand how their patients identify with and express their cultural backgrounds. These are not fact lists to apply indiscriminately. An apt analogy to keep in mind is that learning about a specific model of car is helped by referencing the operator’s manual, but reading and even memorizing that manual doesn’t replace learning how to drive a car.

 

African American

The following cultural patterns may represent many African Americans, but do not represent all people in a community. Each person is an individual, as well as a community member. The term African American generally refers to people descended from Africans who did not come to the US voluntarily—descendants of the four million slaves brought to the US between 1600 and 1800.

Social structure

According to the University of California School of Nursing, in Culture and Clinical Care, many aspects of African American culture today reflect the culture of the general US population. The structure in African American families is often nuclear and extended with non-related “family” members. The family may be matriarchal, although father or mother may take on the decision-making role. For African Americans, women more than men tend to remain unmarried, and more women have been educated at the college level.

In general, the older generation is more conservative, may have a more traditional view of gender roles, and may shun interracial dating and marriage. Elders are respected and often provide care for their grandchildren. Institutionalization of elders has historically been avoided, with sons and daughters taking on the family caretaker role.

Diet

Many African Americans like hearty meals that may include meat, fish, greens, rice, grits, white and sweet potatoes, corn, turnips, eggplant, peanuts, and homemade desserts. Leafy greens may include spinach, collards, mustard, kale, and cabbage. Traditionally, many elders eat a large noon meal on Sunday after church.

Traditional African-American food—sometimes referred to as “soul food”—is diverse and flavorful with origins in Africa, the West Indies, and American southern states. The idea of what soul food is differs greatly among African Americans. Soul food may refer to meals made with fried chicken, pork chops, chitterlings, grits, cornbread, macaroni and cheese, and hushpuppies. Dishes such as hoppin’ John (rice, black-eyed peas, and salt pork), gumbos, jambalyas, fried porgies, and potlikker may all be considered soul food. Okra is the principal ingredient in gumbo, a Creole stew, and is believed to have spiritual and healthful properties. Many of these foods found their way from the south to the north via the Mississippi River. Cajun and Creole cooking, which originated from the French and Spanish in Louisiana, was changed in character and composition by the influence of African cooks.

In 1965, African Americans were more than twice as likely as whites to eat a recommended diet of fruit, vegetables, fat, fiber, and calcium. By 1996, 28 percent of this population was reported to have a poor-quality diet, compared to 16 percent of whites. A poor quality diet often can be attributed to greater access to packaged, processed, and fast foods; the common practice of using fats in cooking; and the high cost of fresh produce and lean meat. And fast foot companies have specifically targeted African American communities as a growing market for their products.

Although many African Americans eat foods such as greens, beans, and rice, which are rich in nutrients, economic issues and deep-rooted dietary habits create challenges for changing behaviors and lowering disease risk in this population. However, through health education and increased awareness of healthy eating practices, African Americans are replacing traditional pork products with turkey, fried foods with baked foods, and starchy vegetables with tomatoes and green vegetables. National programs to improve diet quality and the overall health of African Americans and other minority groups have been initiated. Body and Soul: A Celebration of Health Eating and Living for African Americans offers information targeted to African Americans on eating a health diet rich in fruits and vegetables.

Religion

African Americans often have strong religious affiliations. Many are affiliated with Christian denominations—notably Baptist and Church of God in Christ. Many follow Islam. Maintaining good health is associated with good religious practice. Many churches maintain a health ministry, through which congregations and parish nurses support good health with flu shots, blood pressure checks, and health education. Before the advent of health ministries, African American churches had mission volunteers who attended services and administered to parishioners.

Medical care

African Americans are becoming increasingly health conscious, seeking health screenings and treatments, although health literacy in this population tends to vary by generation. Older African Americans may be suspicious of clinicians, believing their health is personal and up to God’s will. Because they may be reluctant to share personal or family issues, building a trusting relationship is key.

African Americans are affected disproportionately by the leading causes of death in the US, with more morbidity and mortality from premature births, cancer, HIV/AIDS, obesity, and diseases related to obesity, including heart disease, hypertension, stroke, and type 2 diabetes.

* African American men have higher rates of getting and dying from prostate cancer than other men. * Forty-five percent of African American adults in the US are obese. * African Americans are more likely to die from asthma than other populations. * Nearly half of those infected with HIV/AIDS are African American.

Sickle cell anemia is the most common genetically inherited condition in African Americans. They also exhibit a higher incidence of lactose intolerance, periodontal disease, and have common skin problems such as melasma (discoloration of the face) and other pigment disorders. Death and dying

Many older African Americans believe that death is at God’s will, but tend to believe that life support should be continued as long as necessary. A family-centered approach is recommended for conveying serious medical information, seeking consents, and explaining issues such as autopsy and organ donation. Cremation is generally avoided in this community and organ donation may be viewed by some as a desecration of the body. Because of the importance of family in the African American culture, the family should be informed of an impending death so that extended family members who live out of state can be notified.

In the African American community, death is an important aspect of culture, with unique traditions, mourning practices, burial rites, and even the structure of cemeteries. Rather than a time of sadness, death is a time to celebrate that the deceased no longer has to endure the trials of the earthly world. Some present day customs associated with death can be traced back to African roots. Customs have been passed down in the form of expressions, superstitions, religious practices, and music. At the time of death, old beliefs and superstitions are remembered and may be acted upon, such as not burying the deceased on a rainy day or burying the deceased with feet facing east to allow rising on Judgment Day. Coins may be placed on the eyes or in the hands of the deceased, or placed around the grave site as the deceased’s contribution to the community of ancestors.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community.

Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

American Indian

The following cultural patterns may represent many American Indians, but do not represent all people in a community. According to the University of California School of Nursing, in Culture and Clinical Care, many aspects of Indian culture today reflect the culture of the general US population.

Social structure

The American Indian concept of family includes immediate and extended family members, as well as community and tribal members. Women are the traditional care givers. Grandparents help counsel and care for their grandchildren, and children are expected to respect and care for their elders and take pride in their culture. At powwows, elders are served meals first and are given special seating areas. Indian communities encourage education with an emphasis on the unique cultural legacies of the community. Younger people often leave home to become educated, then return to help their families and tribes.

Diet

The traditional diet of American Indians was generally nutritious and low in fat, but today a typical diet is similar to that of the general US population, although it is often poorer in quality, consists of high-fat, salty, and sugary foods, and lacks sufficient fruit, vegetables, grains, and dairy products. Indians are more likely to report not having enough to eat than other US households. Traditionally, the Anishinabe and Dakota ate fresh or dried wild game and foul and gathered wild rice, berries, acorns, ginger, and leaves and twigs for teas. They planted potatoes, corn, pumpkins, squash, and turnips, and made maple syrup. Fish, the principal food of the Anishinabe, was boiled, cooked over a fire on a stick, or eaten in soup, and was dried, salted, or frozen in the snow to preserve.

Religion

Spirituality is central to the identity of the American Indian, and is viewed holistically. People and nature are interconnected. Every animate and inanimate form of life has a spirit and is considered sacred. For example, water is viewed as a sacred, life-sustaining source and a way of connecting with the earth. The head and hair are considered particularly sacred. Respecting and nurturing life and developing a positive relationship with the spirits is core to Indian spirituality. Indians nurture that relationship through prayer and a purification ritual in a sweat lodge. They burn sage and sweet grass, and smoke a special ceremonial tobacco for cleansing, blessings, and healing. Drumming, dancing, and singing also are traditional spiritual expressions associated with healing. American Indians have endured decades of assimilation policies designed to strip them of their identity and integrate them into the dominant society. Many Indian people who grew up in the mid-twentieth century describe a feeling of shame in their heritage during that time. This was partly due to the fact that it was illegal for Indians to practice their religious ceremonies until the American Indian Religious Freedom Act was passed in 1978. As a result, many Indians today have Christian ties or practice no religion at all.

Medical care

According to the Centers for Disease Control and Prevention, the top causes of death in the American Indian population are heart disease, cancer, unintentional injuries, diabetes, and stroke. Also prevalent are chronic liver diease and cirrhosis, chronic respiratory disease, suicide, influenza/pneumonia, and kidney disease. Obesity, smoking, and alcohol abuse in this population are related to many of these diseases. Among racial and ethnic groups, the prevalence of smoking is highest among American Indians/Alaska Natives (32 percent). Because their lands are sovereign nations, Indians are not subject to taxes or to state laws prohibiting the sale and promotion of tobacco products to minors. Chronic cigarette smoking and spit tobacco used by this population have increased its risk of developing tobacco-related health problems, such as heart disease, cancer, and stroke.

Because health is related to spirituality in Indian culture, sickness may be viewed as a result of disharmony between the sources of life. A patient may seek western medicine for treatment as well as medicine from a traditional healer—a medicine man—to address the disharmony that caused the illness. The medicine man has been given the power to heal through his relationship with spiritual beings. Spirits work through him, helping him diagnose and treat physical and spiritual illness. Traditionally, the medicine man is chosen by the spirits and comes from a specific family lineage. His life is hard because he cannot deny a request for treatment and never charges for his services. Indian patients may be reluctant to discuss use of these traditional practices with a clinician. Indians have been taught to resist any expression of pain. Although they may not express pain directly, they may report feeling uncomfortable or may use storytelling or circular conversation to build trust and describe symptoms. A personal story about a sick neighbor may be used as a metaphor for the patient’s symptoms. Direct eye contact is often avoided out of respect or out of concern for soul loss. Time and silence are often used to prepare to listen, to maintain harmony, and to be non-confrontational. Patients may occasionally be late or miss appointments because of a different perception of the concept of time—time orientation for Indians has been traditionally cyclical and present-oriented compared to the linear, future-oriented concept of time in Western culture.

Death and dying

Because of the importance of family in American Indian culture, immediate and extended family members should be informed of an impending death. A family-centered approach is recommended for conveying serious medical information and explaining issues such as autopsy and organ donation. Organ donation may be viewed as a desecration of the body. The entire family may be included when making decisions and signing documents. Due to the misuse of signed documents throughout the history of the American Indian, some Indian patients may be unwilling to sign informed consents, advance directives, and durable power of attorney forms. Patients may perceive verbal agreement as sufficient.

Honoring ancestors is especially important in Indian culture. Several Indian nations across the US are currently in the process of attempting to retrieve the remains of ancestors that have been unearthed by archeologists so they can be properly buried.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community. Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

More Information

Asian Indian

Immigration of Asian Indians to America has taken place in several waves, in the 1700s, the early 1900s, and the 1950s (mainlystudents and professionals). The elimination of immigration quotas in 1965 prompted successively larger waves of Indian immigrants in the 1970s and 1980s, and with the technology boom of the 1990s, the largest influx of Asian Indians arrived between 1995 and 2000. This population is among the fastest growing ethnic groups in the U.S. and is the third largest Asian American ethnic group, following Chinese and Filipino Americans. California, New York, New Jersey, Texas, and Illinois have the largest Asian Indian populations in the country.

Social Structure

Although the U.S. Census has used the term Asian Indian for immigrants who came to America from India, the terms East Indian and South Asian are also commonly used terms for this population. Asian Indians also have emigrated from Indian communities in the United Kingdom, Canada, and other Southeast Asian nations.

Indians in the U. S.  represent diverse cultures, traditions, customs, and languages. Although legally abolished for many years, the caste system still influences social relations in India. The caste system is a hierarchy of four social classes: Brahmins (priest class), Kshatriyas (warrior class), Vaishyas (merchant class), and Sudras (laborer class). Individuals inherit their class from parents and believe that birth in a particular caste is predetermined by karma from previous lives. Asian Indians assimilate well into American culture, while at the same time, keeping the culture of their ancestors. They may assimilate more easily than other immigrant groups because they have fewer language barriers: English is widely spoken in India among professional classes; Indians in the U.S. are disproportionately well-educated; and they come from a democratic society. Indian culture, like many other Asian cultures, emphasizes achievement as a reflection upon the family and community. Younger persons often use titles to show respect, especially when greeting parents, older relatives, teachers, religious leaders, and persons of higher status. Indians and other Asians, have the highest educational qualifications of all ethnic groups in the U.S. Nearly 67 percent of the population has a bachelor’s or higher degree (compared to 28 percent nationally). Nearly 40 percent have a master’s, doctorate, or other professional degree—five times the U.S. average. A Duke University/ University of California Berkeley study revealed that Indian immigrants have founded more engineering and technology companies in the past 15 years than immigrants from China, Japan, Taiwan, and the United Kingdom, combined. One-third of the engineers in Silicon Valley are of Indian descent, with seven percent of hi-tech firms led by Indian CEOs.

Diet

The cuisine of India is characterized by the use of spices, herbs, vegetables, fruits, and a wide assortment of dishes that varies from region to region, reflecting the varied demographics of a large, ethnically diverse country. India’s religious beliefs and culture, as well as exposure to the foods of Greece, the Middle East, and Asia have influenced its cuisine. Hinduism encourages a vegetarian diet.

Staples include rice, whole wheat flour, red lentils, peas, and seeds. Most Indian curries are cooked in peanut, mustard, soybean, or coconut oil. The most frequently used Indian spices are turmeric, chili pepper, black mustard seed, cumin, ginger, coriander, cinnamon, clove, and garlic. Popular spice mixes are garam masala and goda masala. In southern India, a banana leaf is used as a plate for festive occasions. When hot food is served on banana leaves it adds a particular aroma and flavor to the food. Food is most often eaten using two fingers of the right hand, with bread, such as naan, puri, or roti, to scoop the curry without letting it touch the hands. Pan, or beetle leaves, are often chewed after a meal to aid digestion.

Religion

In India, nearly 83 percent of Indians are Hindus. Indians are also Muslim, Sikh, Jain, Buddhist, Parsis, Christian, Jewish, and Zoroastrian. While Hindus believe in one God, they worship many forms of gods and goddesses in temples or at home and read from holy scriptures (Vedas, Upanishads, and Gita).

Medical Care

Indians tend to accept and respect most Western medical practices, including regular exams, screening procedures, transfusions, and surgeries, although they may prefer to receive blood from persons in their own family or religion. Along with Western medical practice, Indian immigrants may also use faith and spiritual healing, including ritual acts and reciting charms, and the belief that yoga eliminates certain physical and mental illnesses. Hindus and Sikhs believe that disease is due to karma, the result of one’s actions in past lives. They may also attribute illness to body imbalances, which create toxins that can accumulate in weaker areas of the body, resulting in conditions such as arthritis. Many older Indian immigrants use home remedies based on the Indian medicine system called Ayurveda (knowledge of life/health), which uses spices and herbs for cold, congestion, and heart problems. Remedies may include turmeric paste as an antiseptic, ginger and lime juice for stomach ache, and buttermilk stored in an iron utensil for anemia. Asian ndians in the U.S. have a high prevalence and risk of coronary artery disease—three times as high as the general U.S. population. Type 2 diabetes is common in this population due to hypertension and a genetic resistance to insulin.

End of Life

Hindus and Sikhs believe in reincarnation— the body dies, but the soul is immortal. When death is imminent, the father, husband, or other responsible person decides whether to tell the patient and informs all relatives and friends. Indians strongly prefer death to take place at home, where they may perform religious rituals.

Among Hindus and Sikhs, the body is washed by close family members, dressed, and prepared for cremation. Hindus save ashes of the cremated body until they can be scattered into the sacred river Ganges in India. Organ donation and autopsy are unacceptable to many Hindu, Sikh, and Christian Indians.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community. Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients

Cambodian

Formerly known as Kampuchea, Cambodia faces the gulf of Thailand and is bordered by Thailand, Laos, and Vietnam. Cambodia has a population of over 14 million. Between 1969 and 1973, Cambodia was invaded by the U.S. and Vietnam, with more than 2 million Cambodians made refugees by the war. By 1975 the country was faced with famine, and the Communist Khmer Rouge, heavily influenced by China, took power.

Prior to 1975, a limited number of Cambodians who lived in the U.S. were children of upper income families or children who had received government funded scholarships and were sent abroad to attend school. In 1979, the U.S. government settled 150,000 refugees in various towns and cities throughout the country. The 2006 American Community Survey showed the largest Cambodian-American populations were in California, Massachusetts, Washington, Texas, and Minnesota.

Social Structure

Cambodian people are also referred to as Kampuchean or Khmer. They speak Khmer, Chinese, Vietnamese, and French. Throughout history, their culture has been heavily influenced by Thailand, Laos, China, and India.

Khmer are generally respectful, polite, and speak softly, communicating carefully and indirectly. Sompeah is a gesture of greeting with both palms brought together with fingers pointed upward. The higher the sompeah, the higher the status of the person being greeted. Khmer often raise large families if financially able to do so, with extended family members living together or nearby. The spokesperson for the family may be the father, or the eldest son or eldest daughter. Men are generally recognized as head of the family with women expected to be care givers—although roles are changing as Khmer become acclimated to American society and values. Women now often work outside the home. Elders are important in decision making and often take care of their grandchildren. Men and women protect and care for the disabled in the community.

Religion

Most Cambodians are Theravada Buddhists, one of the two major branches of Buddhism. Followers of Theravada, meaning the “Doctrine of the Elders,” adhere to the earliest surviving record of Buddha’s teachings. Buddha is believed to have lived and taught in northeastern India sometime during the fifth century BC. The two largest Cambodian Buddhist temples in Minnesota are located in Hampton and Rochester. Other Cambodians practice Islam, Cham, Christianity, or animist religions.

Health Considerations

Khmer often attribute good health to equilibrium, adopting the Chinese philosophy of balancing hot and cold. Many Khmer also believe in the inherent properties of balancing hot and cold foods. Food is deemed either hot, cold, or neutral. For example, chicken is hot, vegetables are cold, and rice is neutral. Khmer people who eat a traditional Cambodian diet eat rice at all three meals and prefer warm tea or water to drink. Most Khmer do not use ice and rarely consume dairy products. Many are lactose intolerant. Khmer who subscribe to traditional beliefs attribute illness to natural or super natural powers. Illness may be considered punishment for sins committed in a past life. Many believe evil spirits or ancestors cause mental illness.

Common health problems for older refugees who came to this country 30 years ago include nutritional deficits, hepatitis B, tuberculosis, malaria, and HIV/AIDs. Older Khmer may suffer from post traumatic stress disorder as a result of war and the brutality of the Khmer Rouge in Cambodia.

Khmer may seek traditional practices before they seek Western medicine, and often hold traditional healing ceremonies in the home. They may reject or not appreciate the value of preventive care, screening, or early detection.

Khmer are known for enduring pain stoically. Rather than asking general questions about pain or symptoms, clinicians should ask very specific questions. Common treatments for pain include herbal medicines, acupuncture, acupressure, cupping, coining, moxibustion, and use of Tiger Balm. In cupping and coining, cutaneous hematomas are made on the face and trunk by pinching and pulling the skin to release excessive air, by rubbing oiled skin with a coin or spoon, or by cupping—heating air in a cup with a flame, then placing the cup onto the skin. As the air cools, it contracts and pulls on the skin, leaving a purple mark.

Moxibustion, often combined with acupuncture, is the process of making circular superficial burns on the skin with ignited incense or other material placed directly on the skin.

Health care providers should be aware of dermabrasive procedures used by patients that leave marks on the skin—and not misinterpret the marks as a sign of physical abuse.

In the hospital, many family and friends may visit patients and often like to sleep in the patient’s room. Khmer may fear surgery and giving blood due to the belief that these procedures will result in heat loss.

End of Life

Most patient’s families prefer to discuss end of life issues with the physician, protecting the patient from the knowledge of a poor prognosis. Many patients prefer to die at home with family care and community support. When a person dies at home, the body may be kept in the home for 24 hours to allow for visitation and ceremonies.

Buddhists believe they will return in another life and should prepare for death calmly and thoughtfully. The family and monks may wash and shroud the body. Monks recite prayers and burn incense. Due to belief in rebirth, Buddhists rarely allow organ donations or autopsy.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community. Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

Ethiopian

Ethiopia is located in northeast Africa on the Horn of Africa. It is one of the most populous countries in sub-Saharan Africawith more than 85 percent of the population living in rural areas. Large numbers of Ethiopians—primarily young, urban males—came to the US after 1974 as refugees of war and famine and to join families already established in the US. In 2000, the Ethiopian population in the US was estimated to be between 300,000 to 500,000. Numbers from the 2000 census are unreliable because at that time most Ethiopians were categorized under “other.”

Social structure

Ethiopia is a nation of many ethnic groups and religions with strong cultural similarities, but political and language differences. The Oromo people represent 40 percent of the Ethiopian population and the Amhara people represent 25 percent of the population. In U.S. communities, the Oromo, Amhara, and other Ethiopian ethnic groups live and work together, although each group speaks its own language and relationships are often strained because of a long history of political differences. Most young people in the United States speak English.

Ethiopians tend to speak softy and politely. Bowing and offering a polite greeting using the formal title of Mr., Mrs., or Miss is appropriate for elders and authority figures. Hugging, kissing cheeks, and touching are acceptable forms of greeting among family and friends. Modesty is especially important to Ethiopian immigrants—matching the gender of a patient with that of the provider and interpreter can address this issue.

Unlike Western society, Ethiopians do not have family names. A person’s first name is their given name; the second name is the father’s given name.

Diet

Ethiopians place high importance on cleanliness and in eating and drinking moderately to stay healthy. The Ethiopian diet includes various meats with different types of spicy sauce, peas, lentils, cabbage, and green beans—all eaten with injera, a pancake like bread made of teff grain. Injera is a major food staple, and provides approximately two-thirds of the diet in Ethiopia. Teff contains high levels of calcium, phosphorous, iron, copper, aluminum, barium, and thiamine.

Religion often dictates nutritional habits. Ethiopian Orthodox Christians do not eat meat, eggs, or dairy products on Wednesdays and Fridays, and fast on a number of occasions, including 55 days at Easter.

Religion

Nearly half of the population in Ethiopia is Muslim, and half Christian, with Ethiopian Coptic Orthodox accounting for most Christians. Christian churches in Minnesota that offer services for Ethiopian immigrants, include the Minnesota Ethiopian Evangelical Church in St. Paul, and the Bethany Lutheran Church and Ethiopian Orthodox Church in Minneapolis.

Medical care

The health care system of Ethiopia is among the least developed in sub-Saharan Africa, with lack of access to basic health care facilities in rural areas. With widespread poverty, poor nutrition, low education levels, poor access to health services, and an increase in HIV infection rates, the current life expectancy of 54 years is expected to decline to 46 years in the near future. The median age in Ethiopia is currently 16.9 years.

Malnutrition and vaccine-preventable diseases, including tuberculosis, diphtheria, whooping cough, tetanus, polio, measles, hepatitis B, and cervical cancer are widespread.

Common health issues for Ethiopian immigrants in the U.S. are the long-term effects of malnutrition, physical and psychological trauma from war, and infectious diseases, including sexually transmitted infections. Changes in lifestyle and diet in the U.S. have brought western diseases, such as diabetes, hypertension, and high cholesterol to this population. A common belief among Ethiopians is that well being is based on a balance of spiritual, physical, social, and environmental forces. Illness can be attributed to God, destiny, nature, demonic spirits, emotional stress, or a breach of social taboos or vows. Ethiopian medicine relies heavily on magical and supernatural beliefs, such as the belief that miscarriages are the result of demonic spirits. Mental illness and some physical illnesses, such as epilepsy, are commonly attributed to evil spirits—with the view that these types of illnesses are a stigma. Many families do not disclose information to the community about family members with such illnesses for fear of being shunned. Men and women avoid marrying into families with members who are mentally ill or have other disabilities, and they generally resist psychiatric treatment for themselves and other family members.

Ethiopians often use home-based therapies and herbal remedies to heal common ailments. They may use healing ingredients from animals, minerals, and plants, such as eucalyptus leaves, oil seeds, and spices.

Providers should be explicit about the importance of completing a full course of antibiotics and explain conditions such as diabetes and hypertension. Patients may question illnesses with no apparent symptoms. Patients should be reminded not to double or triple dose if they miss a medication. This is especially important because many Ethiopians frequently fast for religious reasons and may not take their medications during these times.

Family members usually attend to the needs of the sick. They can overindulge the patient—rather than encourageing self care and attempts at recovery. Providers need to encourage movement, rehabilitation, and self care to stimulate recovery from an illness or surgery. Trust is important in the patient-provider relationship. Some patients may fear surgery and the process of blood donation, and require additional information and reassurance.

End of life

End of life in the Ethiopian community is marked by religious traditions, rituals, prayers, and gatherings. A religious person may be called to administer a sacrament to the patient. After a person dies, Ethiopian men may cry out loud and grow a beard as a sign of respect. Some women may wear black for at least a year and shave their heads or cut their hair very short. Women often cry uncontrollably, tear their clothes, and beat their chests.

Autopsy, organ donation, and cremation are generally unacceptable within this population.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community.

Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

European American

In spite of the variety of European American subcultures across the U.S., some generalizations can be made about this population. More so than many other cultures, European Americans tend to value individualism and independence. They believe in responsibility for self—that individuals, not fate, control their own destinies. European Americans in general have a logical, problem solving learning style. For example, if a political system or educational system is not working, they analyze the problems and take steps to solve them—and they don’t hesitate to challenge authority to overcome barriers.

European Americans are often described as being future oriented—believing the future will bring happiness. They see change as natural and positive, leading to improvement and progress—in contrast to some cultures that may view change as disruptive to their history, traditions, and continuity. European Americans tend to value practicality and efficiency, and place importance on promptness. They generally respect equality, fairness, and gender equity. Americans of European descent have a no-nonsense attitude toward work—they respect the dignity and intrinsic value of work. Many are identified by their professions and believe that they will be rewarded based on individual achievement. They tend to attach significant importance to taking the initiative, and believe in competition and in the capitalistic philosophy that free enterprise brings out the best in the individual.

In this population, the nuclear family is respected even though family members are often separated by distance. With the majority of mothers working outside the home, children are often cared for in homes or schools that provide day care.

Diet

The Western Pattern Diet (or Standard American Diet) is currently followed by many European Americans in Minnesota. The Western diet is characterized by high consumption of red meat, animal fats, sugary desserts, highfat salty foods, processed foods, and alcohol. According to the Journal of Food Composition and Analysis, one-third of daily calories come from fast foods and other junk foods.

The Western diet is low in fiber, complex carbohydrates, plant-based foods, vitamins, and minerals, compared to a healthy diet with more fruits, vegetables, whole-grain foods, poultry, and fish. Associated with the Western diet are epidemic obesity and chronic diseases, resulting in illness and death from diabetes, heart disease, stroke, and cancer. In the 1800s and early 1900s when Minnesotans lived a primarily agricultural life, heart attacks were unheard of. By 1960, heart disease accounted for more than 500,000 deaths per year nationally. By 2006, heart disease accounted for more than 800,000 deaths per year. On holidays and special occasions, European Americans often prepare traditional ancestral dishes, such as stollen (German), lutefisk and lefse (Scandinavian), and corned beef and cabbage or soda bread (Irish).

Religion

Christianity is the most common religion practiced by European Americans. Many Christians in The U. S. attend church or Sunday school regularly and on religious holidays, and many children attend private Protestant or Catholic schools. Most states also have an active Jewish population. The remaining 19% of the population practice other religions or follow no religious traditions.

Medical care

The practices of traditional Western medicine are favored by most European Americans in the U.S. Western medicine is characterized by rigorous safety protocols with treatments and medications that must pass a strict review before they can be used for patient care. Health care providers use methods developed according to medical and scientific traditions. Treatments may include medication, surgery, chemotherapy, radiation, and physical therapy. Western medicine differs from Eastern medicine in its approach to treatment. Western medicine’s greatest strength is in trauma care and therapies for acute problems. Increasing attention is being paid to preventive medicine to address growing rates of chronic diseases, preventable cancers, and the epidemic increase in obesity and diseases related to obesity, such as heart disease, hypertension, stroke, and type 2 diabetes.

The holistic approach of Eastern medicine is increasingly being incorporated into traditional medical treatment. Illnesses and conditions are uniquely treated according to the way a particular patient experiences a disease. For example, patients with fibromyalgia may use meditation or massage therapy to reduce stress and improve muscle function. Eastern medicine’s greatest strength is in the area of treating the whole person—mind, body, and spirit—not just the disease.

End of life

As part of the Western model of health care, families often use palliative care and hospice care services to manage advanced illness at end of life. Palliative and hospice care focus on relieving suffering and improving quality of life by customizing treatment to meet the needs of each individual, and by providing physical, emotional, and spiritual support. Hospice specializes in care for individuals in the last stages of a terminal illness, and provides grief support for surviving loved ones. Hospice provides therapies to relieve pain, teaches care techniques, arranges for necessary equipment such as a hospital bed or oxygen, and coordinates other services. Hospice services are provided in the home or at hospice or other health care facilities. At end of life, individuals may be visited by clergy and prayed for by members of a religious congregation. Funerals and memorial services may be religious or non-religious. Traditional burial and cremation are practiced equally by this population.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community. Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

Hispanic/Latino

Hispanic/Latino Americans are descended from Africans, American Indians, and Europeans, and include people of mixed ancestry who share historical backgrounds, cultural traditions, and the Spanish language. The US government created term, Hispanic, refers to the Spanish language, not place of origin. It is used by formal institutions, including Congress, government agencies, schools, nonprofit organizations, and the press. The term Latino is preferred by Latin American heritage groups and other community-based organizations to promote a community oriented environment. Most Hispanics/Latinos prefer to be referred to by their immediate ethnic group name, such as Mexican, Puerto Rican, Cuban, etc.

In 2000, the US Census reported 20.6 million documented Mexicans in the US, representing 60 percent of the Hispanic/Latino population. Most Mexican immigrants reside in California, Arizona, and Texas.

Social Structure

Traditional Hispanic/Latino families include extended family members, such as grandparents, aunts, uncles, cousins, godmothers, and godfathers. In the US, acculturation, assimilation, and separation of family members based on economic needs have changed family roles. The man is the traditional head of the household, although today with the increase of single parent homes, many women take on that role. The intergenerational connection that characterized earlier generations is no longer the norm, although workers in the US tend to send money home to support family members in their countries of origin.

Many cultural behaviors and practices are shared by people from Latin America and the Caribbean. Spending time with family and friends are vital parts of life. Children are highly valued and elders are respected and cared for. Friendliness and treating others with respect is important. Maintaining eye contact and friendly physical contact, such as touching the shoulder or arm is common.

Diet

The diet in Latin American countries is healthy with high amounts of fruits, vegetables, corn tortillas, whole grains, and eggs. The diet of assimilated Hispanics/Latinos in the US tends to be low in fruits and vegetables and high in flour tortillas, white rice, and processed foods; and Hispanics/Latinos in the US usually do not get as much exercise as they did in their native countries. Traditionally, meals are often eaten with the nuclear and extended family, with a large meal at noon and a lighter meal in the evening. Many acculturated Hispanics/Latinos are beginning to replace traditional meals with fast food meals, contributing to an increase in obesity, diabetes, and hypertension in this population. Over consumption of alcohol is also a health consideration. Preferred drinks include coffee with breakfast and aguas frescas (fresh fruit coolers), made with tamarind, cataloupe, or watermelon. Some traditional Hispanics/Latinos believe in treating a cold with hot foods and in preserving health by balancing hot and cold foods.

Religion

The majority of immigrants from Latin America are Roman Catholic Christians, who attend church regularly, pray to God, Jesus, the Virgin Mary, and saints. They light candles, observe baptisms and confirmations, maintain home shrines, and visit shrines throughout Mexico or Latin America when possible. Catholic Hispanics/Latinos celebrate religious holidays, including Christmas, Easter, and holy days.

Medical care

Diabetes is twice as prevalent in the Hispanic/Latino population as in the white population. Hypertension, overweight, and obesity are common in some groups. For example, 63.9 percent of Mexican- American men and 65.9 percent of Mexican-American women are considered to be overweight or obese, compared to 61 percent of European-American men and 49.2 percent of European-American women. The incidence of cervical cancer in Hispanic/Latino women is double that of European American women. Although Hispanics/Latinos have a lower incidence of breast, colorectal, oral, and urinary bladder cancers, their mortality from these is similar to that of the majority population.

Hispanics/Latinos may consult folk healers or spiritualists, especially if they lack health insurance. Herbal teas are popular remedies for some conditions, including yerba buena (spearmint) and te de manzanilla (chamomile).

Take advantage of the following tips to help you provide the most appropriate, culturally competent care for your Hispanic/Latino patients:

  • Be gracious. Acknowledge the patient’s arrival and offer them a seat. Building respect is essential. Address patients by their preferred name, such as Mr. or Señor, Mrs. or Señora, Miss or Señorita (e.g., Señora Fernandez for Mrs. Susana Fernandez-Ruiz ).
  • Establish a relationship with the family before care begins. Use a non-confrontational tone. Be receptive to family suggestions.
  • Friendly physical contact, such as touching the shoulder or arm, is appropriate between a female clinician and a female patient or between a male clinician and male patient.
  • Ask patients if they would like to have family members present during their visit. Provide a room large enough to accommodate the family.
  • Acknowledge male family members who are present. Males are typically the head of the household, especially in the older generation, and often answer all questions and sign papers. Listen to male family members, but try to direct questions to the female patient (or the mother in pediatric situations). Recognize that grandmothers often play a central role in child care, giving advice to the mothers and advocating use of traditional remedies and cures.
  • Explain why you use trained medical interpreters, not family members. Never use children as interpreters.
  • Ask open-ended questions, such as, “please describe what you are feeling,” rather than “do you have pain?”
  • Assess the importance of religion and the health care beliefs of your Latino patients.
  • Ask patients what they believe caused their illness, and explain the medical reason for their illness. Recognize that they may not agree with you about the cause.
  • Ask patients if they use home remedies and assess the safety of the remedies they use.
  • Ask patients to repeat back health information you provide to ensure understanding. Repeat information and offer reassurance frequently during long procedures.
  • Provide written educational materials with pictures or a video in Spanish to accommodate non-English speaking patients and family members.
  • Educate patients about diet and exercise and the importance of mammograms and pap smears.
  • Establish a child’s care plan with the assistance of the father and mother.
  • Explain how to navigate your health care facility.
  • Kindly explain why being on time for visits is important and affects other patients. Assist in scheduling appointments and arranging for transportation if necessary.

Death and dying

Families may consult a senior male or female, or one who is most educated or influential in the community when deciding on health care treatment and making end of life decisions.

Religious beliefs influence perceptions of death and dying. Roman Catholics may request a visit by a priest or the hospital chaplain to anoint the sick. Rosary beads and religious medallions are often kept near the patient. If the patient dies before the priest arrives, a sacrament still takes place before the body is removed. The elderly especially may wish to die at home. Some Mexicans believe that the spirit may become lost in the hospital. The family requires a supportive atmosphere and may need time and a private place to deal with the loss.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community. Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

Hmong

Hmong (the H is silent) in the US represent a small Southeast Asian minority group of people who immigrated to the US at the end of the Vietnam War. According to US Census 2005 American Community Survey data, the majority of Hmong live in California (65,345), Minnesota (46,352), and Wisconsin (38,814). Hmong people originally lived in the mountains of South China, Laos, Vietnam, Burma, and Thailand.

Social structure

Hmong are organized into 18 clans determined by ancestral lineage. They have large, extended families and practice traditional ceremonies to remember their ancestors. Clan leaders are the key decision makers. Each person has a last name that represents the clan they belong to. When a woman marries, she keeps her maiden name. The Hmong language, Hmoob (Hmong in English), has many dialects, although most Hmong speak either White Hmong or Green Hmong. Hmong was not a written language until the late 1960s and has few medical terms.

Diet

Traditional staples of the Hmong diet are rice, noodles, fish, meat, and green vegetables with hot chili sauces. Hmong tend to eat the same types of food at each meal, with very little fruit or dairy products. Hmong people often prefer hot dishes and drink hot or warm water. Traditionally, a sick person must eat hot food with certain vegetables. Within 30 days of childbirth, Hmong mothers usually eat only warm foods.

Religion

The Hmong shaman is a religious leader who makes all decisions related to spiritual healing and conducts religious ceremonies. The shaman acts as a medium between the visible world and an invisible spirit world, and practices rituals for healing, divination, and control over natural events. Since coming to the US, a number of Hmong have become Christian.

Medical care

Chronic diseases common among the Hmong population include chronic obstructive pulmonary disease, diabetes, congestive heart failure, and hypertension. The adoption of a Western diet and sedentary life style has lead to a dramatic increase in the prevalence of diabetes. A lack of roughage in the diet has resulted in chronic constipation and diarrhea among many Hmong. Refugees 30 years of age or older may have long-term effects from malnutrition and exposure to yellow rain and other war zone chemicals. Many refugees have intestinal parasites, tuberculosis, anemia, depression, and post traumatic stress syndrome. Although Hmong have been exposed to Western medicine since the 1950s, they traditionally view illness from a holistic perspective, with perfect health being a balance between the spirit and the body. Good health comes from the souls living within each person. When a person is ill, they seek the help of a shaman to determine if the cause of the illness is within the realm of the spirit. Spiritual causes require religious remedies. Traditional spiritual causes of illness may include evil spirits or because one’s own spirit has left the body. A person may be ill because an ancestor or evil spirit is unhappy with them or their family or because someone cursed the family or offended the family’s ancestors or spirits. The sick person may accept either the appropriate Hmong medicine or treatment, or the Western approach. Some Hmong people will not communicate dissatisfaction with the quality of health care they receive. If they are dissatisfied with their care, they may refuse care and turn to traditional treatments. Older Hmong may listen attentively to health professionals, but avoid direct eye contact, which is considered to be rude.

Many Hmong practice spiritual healing, which involves retrieving the lost soul from another plane of existence. They may consider an illness or an invasive surgical procedure to be the cause of soul loss. Hmong may conduct healing ceremonies in the hospital or in the home. Herbal medicine and traditional healing practices are often widely used before a person seeks Western medical remedies. A person also may use traditional herbal treatments as complements to Western treatments and practices. Surgery is usually not acceptable to older Hmong people unless laboratory or other tests identify a disease. Blood transfusions and organ donation also are considered unacceptable.

Recent immigrants are unaccustomed to doing things at specific times. In their native lands, farmers organized their activities around sun up and sun down. Appointment times need to be written down and fully explained. Take advantage of the following tips to help you provide the most appropriate, culturally competent care for your Hmong patients:

  • Demonstrate respect to Hmong patients by asking how they would like to be addressed. Hmong do not call each other by their first name. They address one another by their title, such as aunt, uncle, brother, etc. (The medical record is filed under first and last name.)
  • Maintain physical distance during an initial encounter. As trust develops, Hmong patients become comfortable shaking hands. Not using direct eye contact with the opposite sex demonstrates respect. Saying “no” to a Hmong patient demonstrates disrespect.
  • Involve the patient and family in the care plan and in obtaining consent signatures. Ask the patient, “In what language do you prefer to discuss your health with us?” Use trained medical interpreters rather than family members. Never use children as interpreters.
  • Ask patients what they believe is causing their illness. Be aware that Hmong health beliefs are intermingled with spirituality. Schedule longer appointments for Hmong patients, and take the time to explain care options. Explain the long term consequences of not taking care of chronic illnesses, and the need to take medications even when they are feeling well.
  • Ask elderly patients, “Who in your family can help you do this?” Solicit support from adult children in caring for their elderly parents.
  • Educate patients about the safety of non FDA-approved foreign medications. Ask if they use herbs or medications from Thailand, China, Laos, or France.
  • Provide the patient and family with current knowledge about an incurable disease. Explain that a cure has not yet been discovered for this disease. Hmong people sometimes feel they do not receive the same treatments others receive that could cure them.
  • Review instructions orally and ask patients to repeat them back to you. Hmong may say “yes,” but still do not understand. Explain by comparing a condition or disease to a familiar household process such as using heat to control room temperature.
  • Explain your telephone triage system. You may need to make appointments for some patients and to call them before their next scheduled appointment.
  • Provide educational materials in Hmong and English. The patient, family member, or someone else at home may be able to read at least one of the languages.

Death and dying

Traditional Hmong view life as a continuous journey, rather than the Western perspective of life as a journey with a beginning and an end. They believe that death is merely a phase people go through when passing from this plane of existence to the next. They believe people are destined to live to a certain age. When that age is reached, it is time for the person to depart. Hmong believe the spirit will reincarnate. Religious ceremonies conducted on behalf of a dying person are intended to make the person happier. The deceased is dressed in fine Hmong clothes to demonstrate to the community and family that the person has lived a good life, will be missed, and will make a proper entrance into the next world.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community. Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

Russian

The following cultural patterns may represent many immigrants from Russia and Eastern Europe, but do not represent all people in a community.

Social structure

The family is a source of stability for Russian Americans. Elders are expected to help raise their grandchildren if both parents are working and children are expected to care for their elders in old age. Children are expected to be respectful of their elders, addressing them as Mr., Mrs., Uncle, or Aunt. The strongest personality in a Russian family (mother, father, eldest son, or eldest daughter) is usually the spokesperson and decision-maker for the family. Family members have strong kinship bonds, provide support for each other during a crisis, and are often consulted during health care planning, especially when consents for release of information are required.

Compared with other major immigrant populations in the U. S., Russian Americans are generally older (83 percent are age 50 or older), have fewer children, and are more educated (95 percent have at least a high school diploma).

In addition to speaking Russian, most Russian immigrants also speak the language of the republics where they formerly lived (e.g., Belorussian, Ukrainian, and Uzbek). Native languages of Yiddish and Ladino are also spoken at home, although typically only the oldest generation of Russian Jews can still understand and speak these older languages. Many Russian Americans hold professional positions as physicians, engineers, and teachers, although many encounter difficulties pursuing careers in the U.S. due to certification or licensing requirements. The most recent arrivals tend to be less educated and are employed in manufacturing, trade, and service industries. Many small, Russian-owned businesses have been successfully launched in the United States.

Diet

Russian Americans often maintain a diet high in fat, carbohydrates, and sodium, contributing to health problems that include diabetes, hypertension, and coronary and gastrointestinal diseases.

During the early years of communism and food shortages in Russia, the main concern was eating enough calories to stay alive. Meals were heavy, fatty, and salty, though otherwise bland. The ideal meal for a working peasant included boiled buckwheat with lard and a fermented drink made from dense, sour, black bread—food that would “hold you to the earth” and last a full working day. Conventional wisdom dictated that the richer and more fatty the food, the harder one would work. Traditional meals eaten by some Russian Americans today include pickled and dried meats, fish, bread, potatoes, dumplings, porridge, cabbage and beet soup, and vegetables.

Religion

In the US, many Russian immigrants practice Judaism or Eastern Orthodox Christianity, Russia’s traditional and largest religion. The Eastern Orthodox church is widely respected by both believers and nonbelievers, who see it as a symbol of Russian heritage and culture. Many Russian immigrants in the US also belong to Christian Baptist and Pentecostal churches. Smaller numbers of Russians follow other Christian religions, such as Roman Catholicism, Armenian Gregorian, and various Protestant denominations. As a product of the anti-religion policy of the former Soviet Union established in the early 1900s, many Russian immigrants are atheists.

Medical care

Common diseases seen in immigrants from Eastern Europe include diabetes, hypertension, coronary disease, gastrointestinal problems, tuberculosis, mental illness, and alcohol and substance abuse.

Some Russians believe that disability or illness is caused by something the individual did not do right, such as not eating well or not dressing warmly enough. Good health is equated with absence of pain. Illnesses that do not cause pain often go undiagnosed and under-treated, such as diabetes, hypertension, and high cholesterol. Mental illness is regarded as disgraceful in many Eastern European countries. Immigrants often do not answer questions regarding a family history of mental illness or past treatment.

Expression of feelings in Russian culture is different from that in American culture. Many immigrants are unfamiliar with the cultural etiquette of American medicine and tend to expect more compassion and emotional closeness with their physician—seeking a professional yet close relationship with providers. In Russia, a patient can confess to a doctor as if speaking with a priest. Problems can arise in the health care setting directly from this cultural difference. Rather than appreciating the privacy and autonomy of American medical culture, patients may complain about the quality of medical treatment they receive and question the physician’s ability to understand their problems.

Practices associated with physical examinations in Eastern European culture are different from those in American medical culture. In Eastern Europe, hospital gowns are not provided during examinations. Most patients are examined in their undergarments; nudity is not considered shameful.

Some immigrants from Eastern Europe may be distrustful of physicians and reject health recommendations, such as refusing to take medications as prescribed or combining medications and therapies with home remedies and treatments. Home remedies are often used prior to seeking medical attention, such as oil rubs, mud or steam baths, and exposure to fresh air and sunlight. The “bonki” is a cold and flu remedy where glass cups are pressed on a sick person’s back and shoulders to ease symptoms. The bonki often leaves behind bruises and welts, which may be misinterpreted as a sign of physical abuse. When a Russian person is ill, family members and friends are expected to visit in order to provide support to the individual and immediate family. Bad health news is not given to a person who is ill or disabled. The family does not want the person to become anxious. It is commonly believed that the individual needs to be at peace so physical and emotional conditions do not worsen. The family prefers to receive the news first, then decides whether or not to tell the patient of the condition and prognosis. Eastern European immigrants tend to appreciate the high quality medical care, equipment, and variety of medications available in America. They especially value the right to choose their own physician and receive follow-up care from that same physician. They appreciate having excellent medical services available in cities and remote areas, with preventive check-ups covered by insurance, home health aides, transportation services, and programs like meals on wheels.

Death and dying

To ensure a more peaceful death, family may believe that the patient should not know of imminent death. The moment of death and the patient’s last words are highly significant. In some cases families may prefer to care for the patient at home rather than a nursing home. Some family members may ask a rabbi, priest, or others to pray for the patient. Depending on the person’s religion, family members may want to wash and dress the body. Jewish families never leave the body alone until after burial as a sign of respect. Some Jews believe that the body should remain intact. Because both Christians and Jews believe the body is sacred, organ donation is uncommon. Most Russians will refuse autopsy. Jewish law forbids euthanasia and assisted suicide.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community. Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

Somali

In 1992, large numbers of Somali refugees began arriving in the US after the devastation of civil war in the African country of Somalia.

Social structure

Family and clan groups define the social structure in Somalia, with membership in a clan determined by the father’s lineage. Families traditionally live in multi-generational households. Under Islamic law, a man may have as many as four wives if he can support them equally, and under law, he is bound to support his children. Somalis have three-part names. The first name is often the name of a grandparent, the second name is the name of the child’s father, and the third name is the name of the child’s paternal grandfather. Somalis are identified by their first and second names, which can be confusing to Americans who are used to using the first and last name. Women do not change their name after marriage. In a Somali home, the father is the decision-maker and wage earner for the family, and represents the family outside the home. When a father is absent, that role is passed on to an older male relative or adult son. In a Somali household, women have considerable influence and her status is enhanced by the number of children she has. Traditionally, Somali women marry and have children early—birth control practices are not widely used. Somalis commonly have large families. The women are responsible for care of the children and preparing their food. Children are valued highly in Somali culture and spanking is considered an acceptable practice.

Diet

Traditional staples of the Somali diet are rice, bananas, and the meat of sheep, goats, and cattle, with little fresh fruit or vegetables. All meat is ritually slaughtered according to Islamic law. Twin Cities’ stores sell Halal, a specially prepared meat. Traditional Somali bread is similar to pita bread. Coffee and teas are preferred Somali drinks.

According to custom, food is eaten with the right hand. Somali men and women eat separately. Qat, (also spelled khat, chat, kat) a mild stimulant used by some Somali men is derived from fresh leaves of the catha edulis tree. In the US, the federal designation of Qat was recently changed to a restricted drug due to concerns for potential abuse.

Religion

The majority of Somalis are Sunni Muslims. For Somalis, Islamic religious teachings provide meaning for living, dying, health, child rearing, and family life. In Islam, prayer is performed five times a day: at dawn, noon, mid-afternoon, sunset, and in the evening. Prayer can take place at home, at school, in the workplace, outdoors, or in a mosque. Hands, face, and feet are washed before prayer. Islam forbids eating pork, drinking alcohol, and touching or being near dogs. Ramadan is observed as the most important Islamic holiday, a month long holiday during which people refrain from taking medications, and eating and drinking during daylight hours, with the exception of pregnant women, the very ill, and young children.

Traditionally, men and women do not touch members of the opposite sex outside the family, such as shaking hands. According to Islamic tradition, women are expected to cover their bodies, including their hair. Most Somali women do not wear a full-face veil. In Islamic tradition, the right hand is considered the correct and polite hand to use for daily tasks such as eating, writing, and greeting people. If a child shows a left-handed preference, parents train the child to use the right hand. The Somali language is spoken universally by most Somali people, with Arabic, the language of Islam, a common second language.

Medical care

Major medical conditions in Somalia and among recent immigrants to the US are malnutrition, iron deficiency anemia, Vitamin A deficiency, and scurvy. Common infectious diseases are diarrheal disease, measles, malaria, and acute respiratory illness. At least 47 percent of recent arrivals to the US are affected by intestinal parasites. In 1997, Somalia’s HIV infection rate was 0.25 percent—well below that of other African nations. Depression and anxiety are common to Somali refugees, who may have lost family members or were separated from them. An estimated 30 percent of Somali refugees have been victims of torture; they have experienced horrific events and may be suffering posttraumatic stress. There is no word for stress in the Somali language.

Health prevention is practiced primarily through prayer and living a life according to Islam. Many Somalis believe that an individual cannot prevent illness, as the ultimate decision is in God’s hands. They believe that illness may be caused by a communicable disease, by God, by spirit possession, or by the “evil eye.” Mental illness is often believed to be caused by spirit possession or as a punishment from God. Traditional spiritual healers use religious rituals for healing.

Patients often wear amulets, believed to have medicinal value and to keep evil spirits away. Often, Somalis will not take medications such as anti-tubercular agents if they feel healthy. Most Somali patients agree to surgery and blood drawing. Health care decision making may involve the entire family, with a male family member acting as the family spokesperson. The father is expected to give consent for medical procedures and surgery.

Viewed as a rite of passage and required for marriage, circumcision is universally performed on both Somali males and females. Uncircumcised people are traditionally viewed as unclean. Female circumcision is performed before adolescence, and involves several different procedures in which varying amounts of genitalia are removed, after which the area is sewn together. Circumcision creates many health problems for women, including chronic pain, urinary tract infections, menstrual problems, and increased pregnancy risks. Before a child is born, a Somali mother’s circumcision site must be cut open to allow passage of the infant. After delivery, the area is again sewn together. Female circumcision in the US has become a complex and emotionally charged issue. Most Somalis in the US believe the practice to be obsolete, and it is not a requirement of Islam. US law forbids circumcision of a female child.

Take advantage of the following tips to help you provide the most appropriate, culturally competent care for your Somali patients:

  • Ask your Somali patients about their symptoms. They may describe pain by saying they hurt all over.
  • Ask about dietary restrictions and use of herbal medications.
  • Be aware of unexpressed depression, anxiety, and post traumatic stress common to Somali refugees who have experienced torture.
  • Be aware of female circumcision as a sensitive issue for Somali women. Keep lines of communication open.
  • Use trained medical interpreters, not family members, when possible. Never use children as interpreters.
  • Establish a child’s care plan with the assistance of the father and mother.
  • Consider changing medication schedules during Ramadan, when Somalis may be fasting during the day.
  • Repeat information and offer reassurance frequently during long procedures.
  • Provide information on American health care practices.
  • Establish a relationship with the family before care begins.
  • Be receptive to family suggestions. Building respect is essential.
  • Provide educational materials orally or in a video to accommodate limited English proficiency.
  • Use the right hand to give food or medications; the left hand is considered impolite.
  • Ask permission before touching a patient to offer comfort.
  • Provide a location and opportunities for prayer (at dawn, noon, mid-afternoon, sunset, and evening). Do not interrupt prayer. Somalis believe the divine is present during prayer.
  • Do not use finger gestures to get attention. It is viewed as disrespectful.
  • Consider establishing a walk-in clinic for Somali patients rather than scheduling appointments.

Death and dying

Somalis view dying as salvation and part of the life cycle. When a Somali person is terminally ill, it is considered uncaring for a health care provider to tell the dying person. The family tells the patient. When death is impending, a special portion of the Koran, called yasin, is read at the bedside. After death, a sheik prepares the body.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community. Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

Vietnamese

According to the 2006 American Community Survey, the Vietnamese American population in the US grew from 245,025 in 1980 to 1,599,394 in 2006, representing the second largest Southeast Asian American group.

Mass immigration to the US began in 1975 at the end of the Vietnam War with the fall of Saigon. More than 125,000 Vietnamese who had ties with the government or Americans escaped from invading communists. In 1977, a second wave of refugees began fleeing Vietnam as a result of the new communist policies of re-education, torture, and forced relocation. More than two million Vietnamese, who came to be known as “boat people,” fled in small, overcrowded boats to other southeast Asian countries for asylum.

The following cultural patterns may represent many immigrants from Vietnam, but do not represent all people in a community.

Social Structure

The traditional Vietnamese family is patriarchal, with two to four generations and extended family often living in the same home. Family members are expected to work and behave for the good of the group. Traditionally, the father has ultimate responsibility and acts as leader, although due to Western influence household structures and gender roles now vary greatly. In the US, arranged marriages are declining. Parents today take more of an advisory role in the choice of a child’s mate. Divorce is uncommon and is considered shameful within this population, especially for women. Vietnamese people use the family name first, then the middle name, with the first name last. Most names often have a specific meaning and can be used for either gender.

Diet

A typical Vietnamese diet is generally healthy, with rice or noodles, fresh vegetables, and fish or meat. However, the diet also can be high in sodium from fish sauce and MSG, and low in fiber from lack of whole grains. Dairy and soy products are not part of a typical Vietnamese diet, although most children drink milk. Many adults are lactose intolerant and lack calcium. Women generally believe that formula is more nutritious than nursing for their infants.

Some Vietnamese people do not understand that rice and traditional desserts high in sugar and saturated fats from coconut milk and oil cause weight gain and high blood sugar. In Vietnamese culture, chubby children are considered healthy and a sign of prosperity. This population may be susceptible to weight gain, high cholesterol, and diabetes.

Religion

Vietnamese people follow a variety of religions. Prior to the Vietnam War (often referred to as the American War by Vietnamese), Buddhism was practiced by 90 percent of the population in Vietnam. Many Vietnamese are Roman Catholics, a remnant of Vietnam’s occupation by the French, Portuguese, and Spanish. They also may worship spirits and natural forces, or practice ancestor worship or astrology. Confucianism and Taoism have strongly influenced Vietnamese cultural traditions. Many customs are rooted in both the Confucian respect for education, family, and elders, and the Taoist desire to avoid conflict. Stoicism is a highly respected trait.

Medical Care

Vietnamese Americans are at risk of poor health due to language barriers, lack of financial resources, inexperience with American culture, and under utilization of health care services. Many Vietnamese had severe health problems on arrival in the US from poor living conditions, starvation, and abuse during the Vietnam War and in refugee camps. Medical problems seen in this population include TB, hepatitis B, malaria, malnutrition, trichinosis, anemia, leprosy, and intestinal parasites. The most common cancers seen are prostate, breast, lung, and colorectal. Because of exposure to Agent Orange during the war, older Vietnamese immigrants are potentially at risk for cancers, immune deficiency, endocrine disruption, and neurological damage.

Rates of smoking among Vietnamese men are very high with smoking-related cancer endemic in this population. Providers are encouraged to screen especially for cancers of infectious origins, smoking, and exposure to second hand smoke.

Many Vietnamese believe that Asian people are different physiologically than white people. Western medicines are thought of as “hot” and too potent for their physiology. As a result, they may not take medicines as prescribed. Many people attribute symptoms to a physical weakness; for example, a weak heart is expressed by panic, palpitations, and dizziness; a weak kidney is expressed by impotence; a weak stomach or liver is expressed by indigestion; and a weak nervous system is expressed by headache or lack of concentration. Many elders do not trust western medicine and use it only as a last resort. They use traditional remedies as well as western medicines but may not reveal this to a provider. Vietnamese patients often resist invasive procedures and immunizations, and see a provider who does not intrude on the body as the best healer. Some patients believe a physician should be able to diagnose a problem by looking at them and feeling their pulse. Vietnamese people also believe in the medicinal properties of specific foods, such as mung beans, green beans, and bitter melon, which is believed to help control high blood pressure. Acupuncture is used widely for arthritis pain, stroke, visual problems, and other ailments.

Health care providers should be aware of dermabrasive procedures used by Vietnamese patients that leave marks on the skin—and not misinterpret the marks as a sign of physical abuse. Dermabrasive procedures based on the Chinese philosophy of hot/cold physiology are often used to treat headache, cough, nausea, and other maladies. Cutaneous hematomas are made on the face and trunk by pinching and pulling the skin to release excessive air, by rubbing oiled skin with a coin or spoon, or by cupping—heating air in a cup with a flame, then placing the cup on the skin. As the air cools, it contracts and pulls on the skin, leaving a purple mark. Moxibustion, often combined with acupuncture, is the process of making circular superficial burns on the skin with ignited incense or other material placed directly on the skin.

In Vietnam, elders were afforded great respect and roles of authority, but have since lost this special status in the US, leaving many feeling depressed and lonely. However, because many traditional Vietnamese believe that emotional pain is a physical symptom, they avoid referrals to mental health clinics. Mental illness is traditionally considered a shameful thing, often feared or denied. In Vietnam, the mentally ill were hidden away. Although many older refugees may suffer from post traumatic stress disorder, anxiety, and depression, they may not wish to discuss these disorders.

Vietnamese patients may smile easily and often, regardless of underlying emotions in situations other cultures find inappropriate. Because Vietnamese people value politeness and respect for authority, patients may not ask providers questions or voice concerns. If they disagree or do not understand, they may simply listen and answer yes, then not comply with recommendations or return for further care. They may not take appointment times literally, arriving late so as not to appear overly enthusiastic.

Death and Dying

Many Vietnamese people believe medicine is connected to religion and that suffering and illness are an unavoidable part of life. They feel that the length of one’s life is predetermined, and that prolonging life is futile. When a person is dying, family members take turns at the bedside and attend the body after death. Buddhists may ask a monk or elderly person to pray at the bedside to make the person happy before they die. The family may object to autopsy and organ donation.

Arranging a proper funeral for a loved one is one of the most important things a person can do and helps the living grieve and go on with life. Death rituals in the Vietnamese community provide the bereaved a chance to fulfill obligations and complete unfinished business with the deceased. The elaborate details of Vietnamese death rituals require extensive involvement of the family and entire community over a period of two to three years. Death rituals communicate communal responsibilities and can also recreate social order by communicating who will take the place of the deceased.

The information in these fact sheets gathered from www.stratishealth.org.
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