Respecting Differences Celebrating Diversity

RespectingDifferences, Celebrating Diversity Understanding and Working with Health Care Clients and Students from Other Cultures Kern Resource Center 5801 Sundale Avenue Bakersfield, CA 93309 (661) 827-3266 (661) 827-3304 (fax) www.health-careers.org October 2005 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 2 Respecting Differences, Celebrating Diversity: This project is supported by Carl D. Perkins Vocational Education Act of 1998 funds (Title 1, Part A, Section 112), P.L. 105-332, administered by the California Department of Education. The activity which is the subject of this handbook is supported in whole or in part by the U.S. Department of Education and the California Department of Education. However, the opinions expressed herein do not necessarily reflect the position of either the U.S. Department of Education or the California Department of Education, and no official endorsement by the U.S. Department of Education or the California Department of Education should be inferred. ○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures Contents Basic Information Introduction ___________________________________________________________________________________ 7 Immigration Facts ______________________________________________________________________________ 7 Legal Status _________________________________________________________________________________ 8 Countries of Origin ___________________________________________________________________________ 8 English Language Proficiency ___________________________________________________________________ 9 Refugees ____________________________________________________________________________________ 9 Working with Health Care Clients from Other Cultures _______________________________________________ 10 Clients Who Speak Little or No English __________________________________________________________ 10 Culturally Competent Health Care ______________________________________________________________ 12 Suggestions for Culturally Competent Patient Interaction __________________________________________ 14 Cultural Concerns in Caring for the Dying Patient ________________________________________________ 17 Working with Latino/Hispanic Clients ___________________________________________________________ 17 Working with Asian Clients ____________________________________________________________________ 19 Working with Middle-Eastern Clients ___________________________________________________________ 20 Religion and Health Care _______________________________________________________________________ 21 Buddhism ________________________________________________________________________________ 22 Islam ____________________________________________________________________________________ 22 Confucianism _____________________________________________________________________________ 23 Taoism ___________________________________________________________________________________ 23 Complementary and Alternative Medicine __________________________________________________________ 25 Working with Students _________________________________________________________________________ 26 Immigrants and English Language Learners in California Schools _____________________________________ 26 Latinos in California High Schools ______________________________________________________________ 27 What’s in a Name? ___________________________________________________________________________ 27 Culturally Competent Teaching _________________________________________________________________ 28 Conclusion ___________________________________________________________________________________ 32 References and Resources ________________________________________________________________________ 33 Countries of Origin for California’s Largest Immigrant Groups Latin America Mexico ____________________________________________________________________________________ 39 El Salvador _________________________________________________________________________________ 49 Guatemala __________________________________________________________________________________ 57 Eastern Asia China _____________________________________________________________________________________ 67 South Korea ________________________________________________________________________________ 79 Japan ______________________________________________________________________________________ 87 3 Southeast Asia Philippines _________________________________________________________________________________ 99 Vietnam ___________________________________________________________________________________ 107 Laos _______________________________________________________________________________________ 115 Thailand ___________________________________________________________________________________ 125 Cambodia __________________________________________________________________________________ 133 Other Countries India ______________________________________________________________________________________ 145 Iran _______________________________________________________________________________________ 153 Armenia ___________________________________________________________________________________ 163 Russia _____________________________________________________________________________________ 169 . Celebrating Diversity: Contents. cont.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 4 Respecting Differences. Basic Information Introduction Immigration Facts Working with Health Care Clients from Other Cultures Religion and Health Care Complementary and Alternative Medicine Working with Students Conclusion . ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 6 Respecting Differences. Celebrating Diversity: . ○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures Introduction Virtually every health care professional and educator in California encounters immigrants as a regular part of the day’s work. Whether these interactions are positive or negative, satisfying or frustrating, depends at least in part on the knowledge and understanding the health care professional or educator brings to the encounter. We all have good days and bad days in which we meet the full range of clients and students, but even on the worst of days with the most recalcitrant client or unresponsive student, understanding where that client or student is coming from will almost always contribute to a positive outcome. This handbook provides basic information about the countries from which California’s largest immigrant groups come. As of the 2000 census, Hispanics—both immigrants and California-born—made up 32 percent of our state’s population, with the majority of new immigrants coming from Mexico. According to the 2003 American Community Survey, nearly 10 million California residents have Mexican heritage. Together with Asians and other groups, the various minority Californians combine to outnumber white residents. With the nation’s largest immigrant population, California is a microcosm of what the entire United States is projected to look like in 2050, when Hispanics are expected to make up nearly one-fourth of the nation’s residents and Asians close to 10 percent. In 2002, the population of Los Angeles was 44 percent Latino and 12 percent Asian, and more than 100 languages were spoken by students in the city’s schools. Health care professionals and educators need to equip themselves with information that will help them meet the challenge of working with immigrants, non-English speakers, and English language learners competently and compassionately. Rather than viewing immigrant clients and students as problems, with increased knowledge we may come to appreciate the contributions they make to our nation—which is, after all, made up almost entirely of immigrants. The Center for Religion and Civic Culture at the University of Southern California observed, in a recent report on immigrants in Los Angeles, that these new arrivals have much to share: “Anchored in community, immigrants know something about extended family ties, the value of community, and the importance of preserving a cultural heritage while contributing to the new society.” Virtually every health care professional and educator in California encounters immigrants as a regular part of the day’s work. Whether these interactions are positive or negative, satisfying or frustrating, depends at least in part on the knowledge and understanding the health care professional or educator brings to the encounter. Immigration Facts In 2004, the foreign-born in the United States, some 34.2 million people, accounted for 12 percent of our total population. Fifty-three percent of the immigrant population was born in Latin America, 25 percent in Asia, 14 percent in Europe, and 8 percent in other regions. U.S. citizens are some of the most fortunate people in the world. Except for Native Americans, we all are the descendants of immigrants, a fact that we tend to overlook in our dealings with more recent arrivals to our nation and state. Much of the United States at some time belonged to other nations, most notably Mexico, which for centuries counted California and other Western states as part of its territory. The fact that we live in the richest and most powerful nation in the world should not blind us to the fact that our position is a matter of good fortune rather than divine favor. To get an idea of the lure of the United States, we might imagine ourselves as citizens of a nation ravaged by civil war, earthquakes, famine, tsunamis, multinational corporations— alone or in combination—who live in shanties on land we do not own, with no reliable Much of the United States at some time belonged to other nations, most notably Mexico, which for centuries counted California and other Western states as part of its territory. 7 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 8 Respecting Differences, Celebrating Diversity: source of water, no hope of employment, no access to medical care. This is the reality of life for millions of the world’s people, and we should not be surprised that many will risk death for the chance to make a better life for themselves and their families in this country. Legal Status Non-citizens fall into one of four major legal status groups: legal permanent residents, refugees, temporary residents, and un- Immigrants are differentiated between those who have become U.S. citizens and those who remain non-citizens. U.S. citizens are classified as native-born or naturalized. According to the Urban Institute, more than half of all legal immigrants to the United States eventually become naturalized citizens. Non-citizens fall into one of four major legal status groups: ➊ documented immigrants. ➋ ➌ ➍ Census 2000 identified more than 100 countries as home to the nation’s foreign-born population. In a survey conducted by the Urban Institute in 1999–2000, immigrant families in Los Angeles Legal Permanent Residents. These individuals have permanent visas or “green cards.” Most achieve their status as a result of family reunification laws allowing citizens and legal permanent residents to apply for permission for spouses, parents, siblings, and children to immigrate. Others are admitted when employers apply for visas for them. After five years as a legalized permanent resident (three years if married to a U.S. citizen), an individual may apply for citizenship. Refugees/Asylees. These are people admitted for humanitarian reasons, generally fleeing war or persecution in their native countries. They are screened by the U.S. Department of State and international organizations before admission. Once in the United States, refugees are usually resettled by family members or resettlement organizations. Unlike most other immigrants, refugees are eligible for a variety of federal social services. Individuals fleeing persecution who arrive in the United States without approval can apply for asylum. Temporary Residents. Most of these individuals have visas for temporary employment or education. Undocumented Immigrants. These immigrants have no authorization to be living or working in the United States. Most estimates show the population of undocumented immigrants doubling from 4 million to more than 8 million during the 1990s. Immigrants move freely between these four groups as their circumstances change. In 2000, between 10 and 11 million foreign-born in the United States were naturalized citizens; the same number were legal permanent residents; some 8.4 million were undocumented immigrants; 2.5 million had arrived as refugees after 1980; and about 1.5 million were temporary residents. The Urban Institute estimates that each year during the decade of the 1990s the following numbers of immigrants entered the United States: ■ ■ ■ Legal Residents: 700,000 to 900,000 Refugees/Asylees: 70,000 to 125,000 Undocumented Immigrants: 300,000 to 500,000+ County, home to one of the nation’s most diverse A study by the Pew Hispanic Center released in June 2005 estimated the total of undocumented immigrants now in the United States at 10.3 million, about a third of the foreign-born population. communities, were found to have come from Countries of Origin 75 different countries. Census 2000 identified more than 100 countries as home to the nation’s foreign-born population. In a survey conducted by the Urban Institute in 1999–2000, immigrant families in Los Angeles County, home to one of the nation’s most diverse communities, were found to have come from 75 different countries. While new immigrants continue to settle in California, Florida, New York, and Texas, traditionally the destination of the largest numbers, the 2000 census showed states in the Midwest, South, Northeast, and Pacific Northwest among those with the fastest-growing immigrant populations. Some 22 states that had relatively ○ ○ ○ ○ ○ ■ ■ ■ ■ ■ ○ low immigrant populations in 1990 saw those numbers grow by over 90 percent by the 2000 census. California remained the principal first destination for immgrants, but as housing prices continue to rise and living in California becomes increasingly expensive, more immigrants will settle elsewhere. In the 2003 American Community Survey, seven California cities and five California counties were in the top ten cities and counties for foreign-born population. Countries/regions of origin for the foreign-born identified in the 2000 census are: ○ Understanding and Working with Health Care Clients and Students from Other Cultures In the 2003 American Community Survey, seven California cities and five California counties were in the top ten cities and counties for foreign-born population. Mexico: 9.2 million, 30 percent Asia: 8.2 million, 26 percent Other Latin America: 6.9 million, 22 percent Europe and Canada: 5.7 million, 18 percent Africa and Other: 1 million, 3 percent English Language Proficiency Census 2000 showed that 47 million U.S. residents, or 18 percent of the population age 5 and older, speak a language other than English at home, with 40 languages listed. Some 28 million of these speak Spanish. The fact that most of these people have limited proficiency in English poses a significant challenge to their integration into U.S. life. Those with limited English proficiency tend to have less desirable jobs, earn lower wages, and experience hunger. An Urban Institute report states: “Food insecurity and other hardship measures were more closely associated with limited English proficiency than with either legal status or length of residency in the United States.” As immigrants live longer in the United States, their language proficiency generally increases. Some 44 percent of all foreign-born residents counted in the 2000 census were limited English proficient. About 10 percent of all U.S. public school students are English language learners (ELLs); their numbers have doubled to more than 2 million since 1990. In California, the 2003 American Community Survey identified 40.8 percent of the population over age 5 who spoke a language other than English at home. Nearly 1.5 million California students were classified as English language learners in 2002. “Food insecurity and other hardship measures were more closely associated with limited English proficiency than with either legal status or length of residency in the United States.” The Urban Institute Refugees Between 1975 and 2000, the United States admitted 2,284,956 refugees, with the largest number coming from Asia. Before arriving in the United States, many refugees have spent time as refugees in an intermediary country. Large numbers of Hmong, for example, have spent long periods of time in refugee camps in Thailand before settling in California or other states. Both between resettled groups and within groups there is great diversity, depending upon the status and experience of the individuals prior to fleeing their native land and/or being resettled from a refugee camp. In the case of resettlement, refugees generally receive health screenings and orientation to U.S. life prior to their arrival. The Justice Department conducts interviews to establish that they are indeed in danger if they return to their native country. Voluntary agencies, working with State Department contracts, facilitate the resettlement process and provide for or arrange housing, medical care, job training, school enrollment, and other social services for a limited time. Some of the best information on refugee health issues has been compiled by Charles Kemp and is found on the Baylor University Web site: http://www3.baylor.edu/ ~Charles_Kemp/refugee_health_problems.htm. Kemp notes that refugees first come into Between 1975 and 2000, the United States admitted 2,284,956 refugees, with the largest number coming from Asia. 9 and inquiry. we can make better decisions on when to treat.000 patients studied were minorities. From seemingly small matters. such as a patient’s preference for water without ice. even though the importance of cultural factors in the treatment of mental disorders has been well documented in medical journals. Celebrating Diversity: the health care system through local health departments. the cross-cultural encounter is approached as an opportunity for learning and growth. interest. with other conditions being referred more or less successfully to the primary care sector. awareness of personal biases is a prerequisite for cross-cultural competence. An article in the journal Academic Medicine states: “Without understanding the fundamental nature of culture and the integrity of differing belief systems. 20 percent of the population has limited English ability. Caseworkers or previously settled family members assist new refugees in navigating the health care system. the inability of health care providers to understand the language and culture of clients is a barrier to giving and receiving appropriate care.” The Web site Diversity Rx.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 10 Respecting Differences. with more than 50 percent of both Hispanic and Asian American patients reporting difficulty. but this is not always a flawless process. the complexity of information coupled with the emotion and anxiety of illness creates substantial opportunities for miscommunication. especially with medications. The report of a 2003 dialogue among health care professionals in San Francisco opened by stating: “Even for those who are fluent in English and acculturated to the American medical system. the inability of health care providers to understand the language and culture of clients is a barrier to giving and receiving appropriate care. only TB and sexually transmitted diseases are treated in the health department.” . A 2002 study by The Commonwealth Fund reported that many patients have difficulty understanding health care information. Refugees are screened for TB and other communicable diseases. 20 percent of the population has limited English ability. the risk of conflict and its negative impact on health outcomes is inevitable. to life-anddeath situations involving the reporting of symptoms or directions for medication use. From this viewpoint. A psychiatrist at Columbia University stated: “If we understand that our definition of pathological isn’t pathological in other countries. The competent professional cultivates a non-judgmental attitude of respect. discussing the importance of language and culture. to lifeand-death situations involving the reporting of symptoms or directions for medication use. puts the matter in a nutshell: Nearly 50 million people in the United States speak a language other than English as their primary language. All health care personnel should learn to regard the patient and his or her family as unique and aim to develop skills to assess the role of culture in any given situation. For professionals in the health care setting. such as a patient’s preference for water without ice. From seemingly small matters. where they undergo a screening called the Refugee Domestic Health Assessment to eliminate health-related barriers to successful adaptation to the new culture. Clients Who Speak Little or No English Nearly 50 million people in the United States speak a language other than English as their primary language. in California. Often.” Researchers from UCLA studying clinical trials for psychiatric drugs recently found that only 8 percent of more than 9. California health care professionals at all levels must be able to do that in order to provide culturally competent care to the immigrant patients and families with whom they interact every working day. in California. Working with Health Care Clients from Other Cultures Putting oneself into another person’s shoes is a difficult task. Throughout the United States. When a community advocacy organization tested hospitals in 2003 for compliance with federal and state laws requiring that they provide access to services for those with limited English proficiency. organized from the most effective to the least effective method: ➊ ➋ ➌ ➍ ➎ ➏ bilingual/bicultural professional staff interpreters (never from non-health care staff ) language skills training for existing staff internal language banks (back-up measure only) phone-based interpreter services (emergency back-up) written translation (never use as only means of communication) Printed patient education materials are available in many languages on a wide variety of topics from a number of Internet sources. explains: ○ Understanding and Working with Health Care Clients and Students from Other Cultures 11 In a 2003 survey of California immigrants conducted in 11 languages and dialects. The National Alliance for Hispanic Health has excellent resources for working with Spanish-speaking patients and clients. a service of New California Media in San Francisco. and Iranians surveyed reported being confused by post-hospitalization instructions. The Office of Minority Health of the U. . Nor have they been trained to develop the memory and communication skills needed to interpret accurately and efficiently. in more than half of the 70 hospitals surveyed by phone and personal visit no Spanish-speaking staff person could be contacted. this is surely a cause for concern. Hmong. Department of Health and Human Services published 14 standards for culturally and linguistically appropriate services (CLAS) in health care in December 2000. In a state where Hispanics make up 32 percent of the population. Hmong. and friends usually aren’t familiar with specialized medical terminology in their own languages let alone in English. and one-third of all immigrants have trouble understanding prescription drug labels. researchers found that half of all immigrants who do not speak English reported problems understanding medical information. which some cannot even read. The standards encourage. More than half of the Hispanics. many health care providers will find themselves in situations where they must cope on their own. the organization discusses six approaches to overcoming language barriers. They make mistakes that can have serious and sometimes dangerous consequences. The Office of Civil Rights of the Department of Health and Human Services in 2000 issued guidelines requiring that recipients of federal funds provide oral interpreter services. and one-third of all immigrants have trouble understanding prescription drug labels. some of these are listed in the Resources section. researchers found that half of all immigrants who do not speak English reported problems understanding medical information. In the Bay Area. health care organizations to ensure that patients receive understandable and respectful care consistent with their preferred language and health beliefs and practices. When translators or interpreters are available. and staff training. which some cannot even read. a means to make services accessible to non-English speakers. Children.S. More than half of the Hispanics. Not just any bilingual person can be an effective medical interpreter. In A Primer for Cultural Proficiency: Towards Quality Health Services for Hispanics. When a community advocacy organization tested hospitals in 2003 for compliance with federal and state laws requiring that they provide access to services for those with limited English proficiency.○ ○ ○ ○ ○ ○ In a 2003 survey of California immigrants conducted in 11 languages and dialects. translated written materials. in more than half of the 70 hospitals surveyed by phone and personal visit no Spanishspeaking staff person could be contacted. Alice Chen of Language Access. and Iranians surveyed reported being confused by posthospitalization instructions. refugees and immigrants who speak no English or have limited English proficiency pose challenges to health care providers. family members. but do not require. in the Los Angeles area. an interpreter is preferable because he/she is professionally trained to interpret the meaning of words and phrases between health care provider and client. Even though Title VI of the Civil Rights Act of 1964 and the Joint Commission on the Accreditation of Healthcare Organizations also require health care insitutions to provide translation services. 60 percent of the hospitals surveyed were able to access a Spanish speaker. As Dr. the figure was 56 percent. a fam- ○ which is not always a safe assumption. which is not always a safe assumption. ○ sumes that the patient or some family member ○ The use of printed patient education materials as- ○ 12 Use pictures. Their guide to breast cancer diagnosis and treatment. a family member other than the client is the primary decision-maker. Chinese. The manual addresses the major challenges health care providers face in serving their clients: the scarcity of capable interpreters proficient in medical terminology. lack of equivalent terms in other languages. recently published an excellent manual for health care providers working with limited English proficient patients. and Thai in addition to English. Habel. can be downloaded in Chinese. if not the only one. It includes a wealth of information and promising practices drawn from California community clinics and health centers in rural and urban settings serving Asian and Spanish-speaking clients. It is only natural that every individual grows up believing that his or her culture is. and cultural norms that conflict with Western medicine. After giving the information. for example. In most cases family members or friends should be included in the patient teaching. and cultural norms that conflict with Western ○ medical terminology. Use audiotapes made in the patient’s language. Russian. models. ○ staff. The California Primary Care Association. Spanish.health-careers. that person will be largely responsible for the patient’s understanding of and compliance with treatment directions. that person will be largely re- ○ ily member other than the client is the primary Respecting Differences. This handbook includes some useful words and phrases in the individual country profiles. suggests the following means of communication for those providing patient education in situations where the patient does not speak English: ■ ■ ■ ■ In many cultures. Use simulations to show what is being taught. Many helpful resources are available through state and county health departments.org.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ medicine. The California Healthcare Interpreting Association provides a brochure about the role of interpreters in Spanish. ○ or friend is literate in the native language. test the patient’s understanding by asking him/her to communicate in some way what he/she is supposed to do. Culturally Competent Health Care The success of provider-client interactions is influenced significantly by the patient’s cultural and language background and by the ability of the provider to understand. and Russian. DiversityRx cautions: “All health care personnel should learn to regard the . certainly the best—an ethnocentric point of view. In many cultures. and demonstrations with actual equipment. and selecting an appropriate reading level that is neither too simple for clients with good reading skills nor too complicated for the less literate. Appropriate translation from English to other languages is complicated by cultural nuances—both between the health care provider’s culture and the culture in which the translated materials are to be used. ○ sponsible for the patient’s understanding ○ decision-maker. which often have patient education materials available in languages spoken by significant percentages of their clients. Korean. in an on-line education module for nurses. Handbooks for working with clients who speak Spanish or Punjabi can be downloaded from www. as well as materials that can be used with clients. the shortage of bilingual staff. Celebrating Diversity: The use of printed materials assumes that the patient or some family member or friend is literate in the native language. Hmong. the shor tage of bilingual ○ the scarcity of capable interpreters proficient in ○ Major challenges include ○ of and compliance with treatment directions. and take into account that background. appreciate. The California Health Department Web site offers excellent patient education materials in languages spoken by the state’s citizens. established in 1994 to help ensure that the state’s low-income and minority residents receive high-quality health care. Korean. ○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 13 patient and his or her family as unique and aim to develop skills to assess the role of culture in any given situation.” Kagawa-Singer and Kassim-Lakha state: The objective of health practitioners is to improve health outcomes and increase the quality of life for each individual patient. . . . When we understand that the purpose of every culture is to ensure the individual’s survival and well-being, the stage is set to negotiate with patients and their families among a wider set of options. Cultural competence is being widely discussed these days. The Internet provides many excellent resources, in addition to the language resources mentioned above, to help health care professionals understand and work effectively with clients from other cultures (see Resources). Cultural competence in health care may be considered “the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs” (Betancourt et al. 2002). The University of Michigan Health System Web site, which offers comprehensive materials for health care providers, suggests that culturally competent health care: ➊ ➋ ➌ ➍ ➎ ➏ ➐ ➑ ➒ ➓ makes more effective use of time with patients increases disclosure of patient information helps with negotiating differences increases patient compliance in treatment protocols positively affects clinical outcomes improves communication with patients decreases stress builds trust in a relationship increases patient satisfaction meets increasingly stringent government regulations and medical accreditation requirements Camphina-Bacote advises health care providers to seek common ground with clients by using the LEARN Model (Berlin and Fowkes, 1982) of listening, explaining, acknowledging, recommending, and negotiating. She and others make the important point that there is more variation within any specific culture than between two different cultural groups. The health care practitioner who takes the time to learn about the beliefs and practices of another culture must remember to take into account the perspective and experience of each individual client from that culture. Camphina-Bacote cautions: Interacting with patients from diverse cultural groups will refine or modify one’s existing beliefs about a cultural group and will prevent stereotyping. However, the [health care professional] must be cautious and recognize that interacting with only three or four members from a specific ethnic group does not make one an expert on the cultural group. . . . [T]hese three or four individuals . . . may not truly represent the stated beliefs, values, and/or practices of their specific cultural group. Jezewski and Sotnik suggest that health care providers working with individuals from other cultures need both knowledge of the specific culture of the persons with whom they are working and knowledge about the basics of working with clients from any culture other than that of the service provider. They draw attention to the importance of understanding the client’s worldview—fundamental beliefs about existence that form the basis of an individual’s approach to life, including health care. Our traditional Western worldview places primary value on individualism—self-expression, assertiveness, etc.—in contrast to the worldview of many cultures in which the individual is less important than the family and community. Cultural competence in health care may be considered ‘the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs.’ Betancourt et al. The health care practitioner who takes the time to learn about the beliefs and practices of another culture must remember to take into account the perspective and experience of each individual client from that culture. Our traditional Western worldview places primary value on individualism, in contrast to the worldview of many cultures in which the individual is less important than the family and community. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ verbal behavior. ○ equality, concept of time, and attitudes about non- ○ saving face, source of self-esteem, concept of ○ cept of fate, attitude toward change, concept of ○ care interaction include: attitude toward age, con- ○ expectations of and receptivity to the health ○ Elements of worldview that enter into a client’s ○ 14 Respecting Differences, Celebrating Diversity: These two differing worldviews make for very different approaches to and expectations of health care. Individual clients from other cultures will have adopted aspects of the Western worldview, or become acculturated, based on such factors as length of residence in the United States, language ability, nature and extent of interactions with people in this country, and the strength of their identification with their culture of origin. Rankin and Stallings discuss ways in which to assess the client’s degree of what they call “cultural embeddedness” by considering the following: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ How recently did the patient immigrate? Was the immigration voluntary or involuntary? Did the patient live in intermediate countries before coming to the United States? What country did the patient immigrate from and how different is that culture from U.S. culture? Whom does the patient associate with? What type of neighborhood does the patient live in? Does the patient follow traditional dietary habits? Does the patient wear native dress? Does the patient leave his/her neighborhood to participate in the larger culture? Does the patient use folk medicine or use the practices of a native healer? Does the patient come from an urban or rural area in the native country? Elements of worldview that enter into a client’s expectations of and receptivity to the health care interaction include: attitude toward age, concept of fate, attitude toward change, concept of saving face, source of self-esteem, concept of equality, concept of time, and attitudes about nonverbal behavior such as eye contact, shaking hands, etc. See the chart on the facing page for a comparison of cultural norms and values. Suggestions for Culturally Competent Patient Interaction The University of Michigan Health System suggests using the following questions to help lay the foundation for an effective relationship with a patient from another culture: ➊ ➋ ➌ ➍ ➎ ➏ ➐ ➑ ➒ Can you tell me what languages are spoken in your home and the languages that you understand and speak? Please describe your usual diet. Also, are there times during the year when you change your diet in celebration of religious or ethnic holidays? Can you tell me about beliefs and practices including special events such as birth, marriage, and death that you feel I should know? Can you tell me about your experiences with health care providers in your native country? How often each year did you see a health care provider before you arrived in the U.S.? Have you noticed any differences between the type of care you received in your native country and the type you receive here? If yes, could you tell me about those differences? Is there anything else you would like to know? Do you have any questions for me? (Encourage two-way communication.) Do you use any traditional health remedies to improve your health? Is there someone, in addition to yourself, with whom you want us to discuss your medical condition? Are there certain health care procedures and tests which your culture prohibits? Are there any other cultural considerations I should know about to serve your health needs? Diversity Resources provides the following tips for working effectively with patients from other cultures: ■ Everyone likes to feel special. Check your records. What cultural groups did you serve last month? Decide to learn a little about one of those cultures every week. ○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 15 Comparing Cultural Norms and Values Aspects of Culture U.S. Culture Some Other Cultures ◗ informal ◗ handshake ◗ formal ◗ hugs, bows, handshakes ◗ explicit, direct communication ◗ emphasis on content; meaning found in words ◗ implicit, indirect communication ◗ emphasis on context; meaning found around words ◗ “dress for success” ideal ◗ wide range of accepted dress ◗ more casual ◗ dress seen as a sign of position, wealth, prestige ◗ religious rules ◗ more formal ◗ eating as a necessity; fast food ◗ dining as a social experience ◗ religious rules Time and Time Consciousness ◗ linear and exact time consciousness ◗ value on promptness ◗ time=money ◗ elastic and relative time consciousness ◗ time spent on enjoyment of relationships Relationship, Family, Friends ◗ focus on nuclear family ◗ responsibility for self ◗ value on youth; age seen as handicap ◗ focus on extended family ◗ loyalty and responsibility to family ◗ age given status and respect Values and Norms ◗ individual orientation ◗ independence ◗ preference for direct confrontation of conflict ◗ emphasis on task ◗ ◗ ◗ ◗ group orientation conformity preference for harmony emphasis on relationships ◗ ◗ ◗ ◗ egalitarian challenging of authority gender equity behavior and action affect and determine the future ◗ ◗ ◗ ◗ hierarchical respect for authority and social order different roles for men and women fate controls and predetermines the future ◗ ◗ ◗ ◗ linear, logical problem-solving focus internal locus of control individuals control their destiny ◗ ◗ ◗ ◗ lateral, holistic, simultaneous accepting of life’s difficulties external locus of control individuals accept their destiny Sense of Self and Space Communication and Language Dress and Appearance Food and Eating Habits Beliefs and Attitudes Mental Processes and Learning Style Work Habits and Practices ◗ rewards based on individual achievement ◗ work has intrinsic value ◗ rewards based on seniority, relationships ◗ work is a necessity of life Source: Lee Gardenswarthz and Anita Rowe: Managing Diversity: A Complete Desk Reference and Planning Guide. Burr Ridge, Ill.: Iwrin, 1993). p. 57. Found at http://www.med.umich.edu/multicultural/ccp/tools.htm Rephrase your question or information in other words. and gain support for your medical ○ ■ ○ vidual. Be aware that patients may be reluctant to make health care choices or decisions. he or she is likely to take little responsibility for participating in treatment and may have little faith in your ability to cure this illness. What do you want me to do?” At this point. which. Write it down and learn to say it in the patient’s language. . where. use questions that begin with when. Hint: The patient may turn the question back to you. . and reading matter will appeal to diverse segments of your patient population. health decisions are not indi- ○ ■ ○ ■ ○ ■ ○ ■ tion of authority. Try to accommodate them. saying. the patient will be really pleased with your effort. Use different words and expressions each time. If the answer is vague or inappropriate. it is best to say something like. If the patient is unable to answer. Hint: In many cultures. it’s considered rude to smile at strangers and impolite to look directly at anyone who is older or in a position of authority. if family members are included in the con- ○ and frustration. Hint: In general. but family decisions. who. there is a great possibility that he or she hasn’t understood the question.” Learn what colors. It may be considered inappropriate to disclose personal information about yourself or “prying” to ask people about their job or their family. how. . Even if you mispronounce it. avoid too much “small talk. or punished for past sins. “Well. but if your patient does. Wanting to be part of the decision-making process is a uniquely CaucasianAmerican cultural trait. Make your practice or facility “patient friendly. it is a very good idea to give the same information or ask the same question in at least two or three different ways. Do you?” Don’t be angry or disturbed if a patient is accompanied by one or even a group of friends or family when visiting a hospital or clinic or medical office. but I’m required by law to have you make the final decision. Celebrating Diversity: Hint: Start with the calendar. Be sensitive to the possibility that asking the opinions of patients who belong to a culture in which the physician is viewed as the ‘knower’ who will make the best choices and take full charge of the patient’s cure may destroy the patient’s faith and trust in the physician or medical facility. and gain support for your medical advice. you might have tea . rephrase the question and start again. my sister. Don’t make any assumptions about the patient’s basic beliefs about how to best maintain health or cure illness. Smile and look at the patient when greeting him or her.○ ■ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ sultation should the patient request that they be present. Hint: These questions require a basic understanding of the question itself in order to supply the necessary information. my son . but family decisions. Hint: If the patient believes that he or she has been hexed. it’s con- ○ 16 Respecting Differences.” Keep your language simple and not cluttered with extraneous questions or information. You can save time ○ In many cultures. Hint: Adopt a line of questioning that will help you learn some of the patient’s beliefs: “Many of our [name of country or culture] patients believe/do . Make sure your waiting room looks and feels like a secure. if it were I (my mother. ■ ■ ■ ○ advice. comfortable place for all patients. If a patient says “What?” or “Sorry” or “Could you repeat that?” in response to something you have said or asked. health decisions are not individual. Are there any festivals or holidays that your patients will observe this month? Ask the first patient you see from each cultural group if there is any specific greeting that is used for that occasion. . or bewitched. if family members are included in the consultation should the patient request that they be present. it will affect his/her health and compliance and satisfaction with treatment. . but don’t feel offended if the patient doesn’t smile back or establish eye contact. Hint: “Friendly chatter” is not considered friendly in many cultures even if the person does understand you. “I don’t know. When speaking to patients who are not proficient in English.) I would do/choose X. When taking patient information.” Don’t discount or ridicule the power of the belief in the supernatural. Hint: If many of your patients are from Asia or the Middle East. it probably means that the patient doesn’t understand. You can save time and frustration. not that he or she doesn’t hear. images. ○ look directly at anyone who is older or in a posi- ○ sidered rude to smile at strangers and impolite to ○ In some cultures. Hint: In some cultures. You may not believe in those things. why. make use of available resources. refugee status. They may tell you much more than the interpreter can. particularly about the meaning of death. and language translators. Determine who controls access to the body and how the body should be approached after death. prognosis. Assess how hope for a recovery is negotiated within the family and with health care professionals. not the interpreter. To aid the complex effort of interpreting the relevance of cultural dimensions of a particular case. including community or religious leaders. ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess the language used to discuss the patient’s illness and disease. rephrase your questions or information.” and that 81 percent use either “Latino” or “Hispanic” as a self-descriptor. a poor prognosis is never given to the patient. and belief in miracles. but that among those who had a preference “Latino” is the preferred term in California and among more recent immigrants. Cultural Concerns in Caring for the Dying Patient The Stanford University Center for Biomedical Ethics. such as the family. Assess the patient’s degree of fatalism versus an active desire for the control of events into the future.. family members. a healing tradition To aid the complex effort of interpreting the relevance of cultural dimensions of a particular case. like cancer. they devote many pages to a discussion of this issue. ○ Understanding and Working with Health Care Clients and Students from Other Cultures 17 In many cultures. The American Public Health Association (APHA) notes that Hispanics may use folk remedies and practices along with Western medicine. The study found that 88 percent of Latinos refer to themselves by their country of origin. Determine whether decisions are made by the patient or a larger social unit. a poor prognosis is never given to the patient. in the article “Understanding Cultural Difference in Caring for Dying Patients. both within the patient’s family and in interactions with the health care team. and language translators. the existence of an afterlife. Hint: Observe the patient’s body language and facial expressions carefully. and certain words. e. make use of available resources. When communicating through an interpreter. Consider the relevance of religious beliefs. Working with Latino/Hispanic Clients In the following section on Working with Students. past discrimination.g. particularly poverty. like cancer. When the words and expressions don’t match. . Are health signs and posters meaningful to the cultures you serve? Be aware that cultural factors affect how to best relate bad news or to explain in detail the nature of a disease or complications that might result from a course of treatment to the patient. Curanderismo. as “Mexicans” or “Salvadorans. gender and power relationships. are never used. family members. Make sure you have magazines and/or newspapers in the languages of your patients. Follow their advice about how much to disclose to the patient. Researchers found that 53 percent had no preference as to which term was used. face and direct your comments to the patient. and certain words. The Pew Hispanic Center and the Kaiser Family Foundation conducted a national survey of Latinos in 2002. Talk to the family first. A gesture or facial expression is worth a thousand words. we discuss the complex question of appropriate terms to use for clients and patients from Spanish-speaking countries. Specific information for distinct religious and ethnic groups is included as available in the individual country profiles that follow this basic information section. Hint: In many cultures. including community or religious leaders. Consider issues of generation or age.○ ○ ○ ○ ○ ■ ○ ■ available. including the degree of openness in discussing the diagnosis. and lack of access to care. are never used. and death itself. Take into account the political and historical context.” presents the following general guidelines for health care professionals working with patients nearing the end of life. prayer. Respecting Differences. and massage. In return. cousins. siblings. The health provider must verify that the patient understands the treatment and try to get the patient to agree to follow it. Establishing a relationship based on personalismo may seem ➋ tion for patient understanding and compliance with care. they may not be able to say definitely when it started or ended. Mrs/Señora Y. leaning forward. The health care provider should ask the client what he/she believes is the cause of his/her complaint. What may seem like an unruly and noisy gathering is probably an important part of the healing environment for the patient and should be accommodated when possible. and close friends. without necessarily expecting reciprocation. but it can save time in the long run by laying a founda- ○ counter in Latin American countries. People from many Hispanic cultures offer (and expect to receive) deference on the basis of age. Patients from many Hispanic cultures expect to establish a oneon-one (but not informal) relationship with the health provider. Patients will naturally offer respeto to the health provider. educational. Celebrating Diversity: embraced by many Latino cultures. sex. The agency further notes that Hispanic patients may find our system of prescriptions and referrals difficult to understand and navigate. Make an effort to establish understanding and agreement. Many people from Hispanic cultures do not have a precise sense of time in the matter of keeping appointments. the extended family may show support by visiting at the hospital. and status. some patients may consider it disrespectful to look an authority figure in the eye ■ speaking directly to the patient. even when speaking through an interpreter Show personalismo. but not informal. a phase of the moon. Show personalismo by: ■ treating patients in a warm and friendly. . or Madam/Doña) ■ shaking hands at the beginning of each meeting ■ using usted (formal) rather than tu (familiar) for “you” when speaking Spanish ■ making eye contact. patients may too readily agree to take a medication or follow a derstands the treatment and try to get the patient ○ establish a one-on-one (but not informal) rela- The health provider must verify that the patient un- ○ ➊ treatment plan they do not really understand. or an occurrence such as a celebration. and should not make light of the patient’s beliefs. manner ■ showing genuine interest in and concern for patients by asking questions about themselves and their families ■ sitting close.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ tionship with the health provider. Be aware that la familia may include parents. Establishing a relationship based on personalismo may seem time-consuming. patients expect to be treated with repect. Accept a different sense of time. Families are a source of emotional and physical support and are expected to participate in important medical decisions. is practiced in immigrant neighborhoods by curanderos/ as using herbal medications. and economic status. patients may too readily agree to take a medication or follow a treatment plan they do not really understand. The APHA suggests that respecting and integrating these practices can build patient confidence and increase compliance. grandparents. ➌ Out of their respect for authority. as many medications that require ○ scriptions and referrals difficult to understand ○ Hispanic patients may find our system of pre- ○ 18 ➍ ➎ to agree to follow it. but it can save time in the long run by laying a foundation for patient understanding and compliance with care. Out of their respect for authority. and using gestures when speaking with the patient Involve the family in decision-making and care. When a member is hospitalized. often to remove hexes that may make Western medicine ineffectual. Many Hispanic patients see illness as a result of both physical and spiritual/supernatural/psychological forces. Respect the spiritual side of physical complaints. ➏ Show respeto. ○ prescriptions here are available over the ○ and navigate. In describing a medical complaint. Show respect by: ■ addressing adults by title and family name (Mr/Señor X. The following general guidelines are adapted from Diversity Resources: What Language Does Your Patient Hurt In?: A Practical Guide to Culturally Competent Care: Patients from many Hispanic cultures expect to time-consuming. They may link it to a season. as many medications that require prescriptions here are available over the counter in Latin American countries. aunts and uncles. an authority figure with high social. Health care practitioners should ask appropriate questions (as indicated in the section above) and support the client in using any complementary practices that do not conflict with the practitioner’s recommended treatment regimen. Western health care professionals are increasingly paying attention to the importance of incorporating a Latino client’s use of curanderismo into an overall health plan. ■ ■ ■ ○ ■ ○ ■ ○ ■ Follow the rules of etiquette. Age and social structure are more important in Asian societies than our own. Regardless of rank, younger people greet older people first and address them in a formal manner. Physicians generally hold a high position in Asian society, so clients may show respect by avoiding eye contact. When seated, avoid crossing the legs, leaning on a table or a desk, or pointing at anything with the foot when talking; these are considered signs of contempt. Use proper forms of greeting and address. Chinese, Japanese, and Koreans address each other using surnames; they may address family members in terms of family position, e.g., Older Brother, Mother. Understand the importance of the head. Most Asians consider the head the most sacred part of the body. One should not touch a patient’s or child’s head without permission. If a child becomes ill after being patted on the head by a caregiver, that person may be blamed for taking the child’s soul and causing the illness. Understand the importance of the blood. Because most Asians view blood as a vital element that represents the essence of a person, blood is not drawn for medicinal purposes in traditional medicine. Some believe that drawing blood weakens the body and upsets its natural balance. When blood must be drawn, health care providers should assure the client that his/her blood will not be given to anyone else. Yin and yang, hot and cold. Asians view health as the balance between the forces of yin and yang. Everything in the universe is classified as either yin (negative, dark, feminine, cold), or yang (positive, bright, masculine, warm). Every aspect of life and nature is believed to contain these opposite but complementary forces. They believe illness results when this balance is upset; it can be cured by searching for and remedying the imbalance. Health care providers need to understand that this use of hot/cold does not refer to temperature but rather to attributes of the substance. A disease or symptom considered “hot” is treated by a medication considered “cold” in order to restore balance. If clients hold the hot/cold theory, they may refuse treatments or question the knowledge of caregivers who prescribe them. A common misunderstanding arises in the hospital setting, where iced water is generally served to all patients. Asian patients generally would prefer warm water or tea when sick or following childbirth. Foods served to the hospitalized patient may be rejected as inappropriate to the hot-cold balance. Understand the view of medications. Most Asians expect physicians to prescribe medication, but they are not used to taking pills and tend to believe injections are more effective. They may adjust the medication dosage down due to a belief that Western medicines are “hot” or overly potent to Asians. Understand the importance of harmony and saving face. The widespread Asian concern for maintaining harmonious relationships and protecting their own and others’ dignity may interfere with their understanding of and compliance with treatment regimens. Rather than admit they do not understand a health care provider’s instructions, Asian clients may appear to understand and accept it. Caregivers can test for patient understanding by observing signs of confusion or by asking patients to describe what they have been told in their own words. ○ ■ ○ While there are many important differences between immigrants from the Asian countries represented in California, both health care providers and teachers can benefit from understanding some of the similarities in the worldview and outlook of their clients and students from China, Korea, Japan, the Philippines, Laos, Cambodia, Vietnam, Thailand, and other Asian countries. People from all of these countries have been influenced by Buddhist, Confucian, and Taoist teachings common to their cultures but still largely not understood in the United States. Salient points of these belief systems are discussed in the next section. The excellent resource from Diversity Resources: What Language Does Your Patient Hurt In?: A Practical Guide to Culturally Competent Care, provides the following information that will help health care providers understand and work effectively with Asian clients. ○ Working with Asian Clients ○ Understanding and Working with Health Care Clients and Students from Other Cultures 19 Most Asians consider the head the most sacred part of the body. One should not touch a patient’s or child’s head without permission. If a child becomes ill after being patted on the head by a caregiver, that person may be blamed for taking the child’s soul and causing the illness. Asians view health as the balance between the forces of yin and yang. Everything in the universe is classified as either yin (negative, dark, feminine, cold), or yang (positive, bright, masculine, warm). Every aspect of life and nature is believed to contain these opposite but complementary forces. They believe illness results when this balance is upset; it can be cured by searching for and remedying the imbalance. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ kinds of food for their hospitalized relatives. ○ should be allowed to provide the appropriate ○ for sick people. If possible, family members ○ eggs. Rice soup with chicken is often prepared ○ persons who are ill should not eat beef or ○ ■ ○ products. Some Southeast Asians believe that ■ ○ tose-intolerant and should not be served milk ○ relationship of food to illness. Many Asians are lac- ○ cold constraints and to other beliefs about the ○ strange to the Asian patient, both due to hot- ○ ■ ○ Hospital food may be ○ 20 Respecting Differences, Celebrating Diversity: Dietary preferences. Hospital food may be strange to the Asian patient, both due to hot-cold constraints and to other beliefs about the relationship of food to illness. Many Asians are lactose-intolerant and should not be served milk products. Some Southeast Asians believe that persons who are ill should not eat beef or eggs. Rice soup with chicken is often prepared for sick people. If possible, family members should be allowed to provide the appropriate kinds of food for their hospitalized relatives. Qi/Ch’i. The Chinese and other Asian people pay considerable attention to the flow of qi, energy, in the body. They use acupuncture to restore the flow when it is disrupted by disease or a broken bone. Traditional practices. Many Asians use both Eastern and Western medical practices, believing that certain illnesses or conditions are best treated by either one or the other approach. Western physicians are frequently consulted for such things as heart attack, stroke, diabetes, and cancer, while traditional healers and herbalists are used to treat such conditions as asthma, arthritis, and stomach problems. Even when a client consults a Western physician, he/she may also use herbal remedies and traditional practices. Common practices and remedies are described in the following country profiles, but those widespread throughout Asia include acupuncture, coining and pinching, cupping, moxibustion, and the use of herbal teas or slushes as well as patent medicines. An important part of caregiver-client interaction involves determing what traditional practices the client is using. Working with Middle Eastern Clients Within the larger group of people we refer to as Middle Easterners, we find wide diversity of ethnic and religions affiliation. While most Middle Easterners are Muslim, some are Jewish, Christian, or Coptic Christian. Beware of assuming that your Middle Eastern clients are necessarily Muslim. The following suggestions, adapted from Diversity Resources: What Language Does Your Patient Hurt In?: A Practical Guide to Culturally Competent Care, should help health care providers establish comfortable relationships with their patients and clients from the Middle East region. ■ ■ Because of the importance of establishing a personal relationship, an appointment with a Middle Eastern patient may take longer than with a patient from an- ■ other group. ■ ■ ■ ■ Greet patients and their family members by title, shake hands, and say something personal about the patient, the patient’s family, or the patient’s country of origin. Try to establish a close enough relationship with the patient that he or she will view you as a friend and a person to be trusted with important information. In the process, share information about yourself so the patient will know you are a trustworthy person. Because of the importance of establishing a personal relationship, an appointment with a Middle Eastern patient may take longer than with a patient from another group. Sharing food and drink is an important means of establishing trust. If the caregiver offers a cup of tea, the patient may refuse out of politeness the first time, so a second and third offer should be made. Patients may expect the health care professional to intuitively know things the patient has not revealed. If you believe this is the case, use indirect questioning to elicit the necessary information. Sometimes patients are unwilling to complete history and physical questions, not seeing the relevance of these questions to their current medical complaint, or being unwilling to share information with strangers. Use of a loud voice probably indicates the importance of the subject matter rather than anger. Be sure to include the family in medical decisions, especially the eldest male. Make sure the patient understands and intends to follow instructions. Authority figures are not to be questioned or contradicted, but this does not mean the patient agrees to follow the advice he or she has been given. Personal space issues may arise because the comfort zone of Middle Easterners allows much closer physical contact than Western health care providers may be comfortable with. ○ ○ ■ ○ ■ ○ ■ ○ ■ Matching patient and caregiver by gender is desirable whenever possible. Patients may refuse to disclose personal information or disrobe for an exam if paired with a health care provider of the opposite gender. Negative medical news should be revealed in stages as part of other information, in the presence of a family spokesperson. In the case of Arab-American patients, such things as childbirth and death are believed to be in the hands of Allah and not to be interfered with by humans. Muslim patients may not want to take a medication containing alcohol or be in contact with anything derived from a pig. Arabs tend to believe that the more intrusive a medical intervention is, the more effective it is, which means that they may choose surgery over radiation or chemotherapy in the case of cancer, for example. ○ ■ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 21 Matching patient and caregiver by gender is desirable whenever possible. Patients may refuse to disclose personal information or disrobe for an exam if paired with a health care provider of the opposite gender. Religion and Health Care The Center for Religion and Civic Culture at the University of Southern California published a report in 2002 on immigrant religion in Los Angeles. The authors note: “Religious institutions, rather than merely incorporating people into the Americn mainstream, serve the dual functions of preserving national identities and aiding incorporation.” In the following country profiles, there is a section on the religions practiced in each country, with information on the role of religion in the life of the people. Making generalizations about religion is certainly risky, and health care providers should understand that not all adherents of a particular religion will have the same attitudes and beliefs about health care. Dr. Harold Koenig, director of Duke University’s Center for the Study of Religion/Spirituality and Health, stated: “I recommend that physicians ask every patient if they consider themselves spiritual or religious. . . . Religion has a power to heal, and we have an obligation to value that alongside medicine.” More and more physicians and hospitals are coming to terms with the role of religion in their clients’ health care decisions. A 2005 Los Angeles Times article reported that 101 medical schools now incorporate patient spirituality in their curricula, an increase of 84 since 1995. Speaking at a conference in Kuala Lumpur in 2002 on religious pluralism , Harvard University professor Diana Eck stated: Health care providers should understand that not all adherents of a particular religion will have the same attitudes and beliefs about health care. New immigrants have come to American shores from all over the world and have become citizens. They have brought with them not only their luggage and economic aspirations, but their Qur’ans and Bhagavad Gitas, their images of Krishna and Murugan, their incense to light before the Bodhisattvas on their Buddhist altars. She emphasizes that people of many religions must learn how to coexist peacefully in the 21st century: “People of different religious traditions live together all over the world—as majorities in one place, as minorities in another.” She notes that U.S. history does not offer a positive example of religious tolerance, what with early Pilgrims and Puritans treating the Native Americans as heathens and burning supposed witches at the stake, not to mention our long tradition of anti-Catholicism and anti-Semitism. Our nation’s founders wanted religious freedom for themselves, but they were often not tolerant of diverse practices. Both health care providers and educators will benefit from information about the religious heritage of their clients and students. Religion plays a central role in the lives and decisions of many immigrants and refugees and is often an important source of assistance in navigating both the health care and education systems. “People of different religious traditions live together all over the world—as majorities in one place, as minorities in another.” Diana Eck ○ The Buddhist concept of as the result of sins committed in this or a previ- ○ ➌ ➍ that Buddhists often see their suffering in this life ○ Health care providers in California will almost certainly come into contact with Buddhist patients of the Theravada (lesser vehicle) branch widely practiced in Cambodia. and Hajj (pilgrimage to the Muslim holy city. Japan. letting go of life without clinging. and (8) right meditation. illness. Buddhist scriptures do not directly address health. and/or the Mahayana (greater vehicle) branch more commonly practiced by people from China. The way to cease to desire is to follow the Eightfold Path: (1) right belief. Laos. and Burma. The same could be said of many other large California cities. Buddhist communities representing the full gamut of Buddhist practice can be found side by side. as immigrants from many Asian countries.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ous life. and the choice of burial or cremation of a dead body seems to be more cultural than religious. death. and amulets may be placed near the dying person. and Vietnam. ○ dhism have obvious applicability to the health ○ health. Allah. which mandates doing right to be born into a higher life in the next existence. The Buddhist concept of karma. Islam Muslims see illness as atonement for their sins. They also believe in angels. fasting (sawm). The way to end suffering is to cease to desire. The Buddhist outlook may be expressed in the following ways in the health care setting: ■ ■ ■ ■ Buddhists may be reluctant to complain or express pain as they see it as a natural part of life. Most Buddhists have no problem with organ transplantation or autopsy. (7) right mindfulness. Sri Lanka. Death itself may be seen as less important as the manner in which one lives and dies. (2) right intent. requires healthy adult Muslims to abstain from all food and drink from sunrise to sunset each day. or while there is enough natural light to distinguish a white thread from a black thread. which is observed at slightly different times each year. to security. Birth. Muslims see illness as atonement for their sins. which mandates doing right to be born ○ care setting. as they do not view the world in either/or terms. Satan. (4) right conduct/action. . Heaven and Hell. as well as Western practitioners. and to others. which is manifested by attachment to life. Celebrating Diversity: Buddhism ➊ karma. A monk or lay religious leader may be called upon to lead chants. but the Four Noble Truths of Bud- ○ Buddhist scriptures do not directly address ○ 22 All sentient beings suffer. Buddhists often accept a blend of different approaches to health and healing. Thailand. and they consider death a part of their journey. at least five times daily). The lunar holy month of Ramadan. and God’s last messenger. regular worship is held in mosques. means Respecting Differences. Mecca). (6) right effort. incense may be burned. means that Buddhists often see their suffering in this life as the result of sins committed in this or a previous life. and they consider death a part of their journey. Mohammed. “Islam” means “peace and submission to the will of God (Allah). The cause of suffering is desire. flock to meditation centers of all kinds. Many patients and their families place importance on staying conscious during the dying process so that the person can focus on wholesome thoughts. the Day of Reckoning. and other separations are inescapable parts of life. but the Four Noble Truths of Buddhism have obvious applicability to the health care setting: ➋ into a higher life in the next existence. and the prophets of the Judaeo-Christian faith. (3) right speech. The Five Pillars of Islam are faith.” Muslims believe in one God. (5) right livelihood/endeavor. prayer (salat. The Muslim holy book is the Qur’an (Koran). charity (zahat/zakat). Friday is the most important day of worship. Eck notes that in Los Angeles. The Islamic Medical Association of North America has a Web page containing useful information and links for health care providers working with Muslim patients. Confucianism has had a profound effect on the worldview of Asian cultures. Always examine a female patient in the presence of another female. hands. Allow the family to bring the hospitalized Muslim food unless forbidden. Key teachings regarding social interaction are reciprocity (pao) and loyalty (chung). Benevolence and righteousness are two other important teachings directing how people should treat one another. They may make exceptions for medications containing alcohol. Allow the Imam (religious leader) to visit patients in the hospital. Assisted suicide and euthanasia are not permitted. This derives from a Confucian teaching that expressing good wishes requires the giving of gifts. if individuals believe that only by dying with an intact body will they go to heaven. for example). This derives from a Confucian teaching that expressing good wishes requires the giving of gifts. provide vegetarian. and feet are washed at least five times a day before prayers.” Taoism is based on the teachings of Lao-Tse. allow the family and Imam to follow Islamic guidelines for preparing the body for an Islamic funeral.○ ■ ■ ■ ○ ■ ■ ■ ○ ■ ○ ■ Blood transfusions are permitted after proper screening. anything cooked with ham. Both health care providers and teachers find that Asian clients and students give gifts liberally. This would include gelatin. Abortion is not allowed except to save the mother’s life. The body is regarded as being on loan to a person on earth and is to be returned intact at death. Non-Muslims should not touch the body. among other things. Cleanliness is of the utmost importance. This belief has implications for surgery and organ donation. provide same-sex physicians and nurses. or Kosher meals because of dietary restrictions. Attitude toward the body. Social interaction. ○ ■ ■ ○ Some Muslim Health Beliefs and Practices ○ Understanding and Working with Health Care Clients and Students from Other Cultures 23 Muslim dietary restrictions include pork and meat from animals killed outside of Muslim custom as well as eating with dishes or utensils that have come into contact with such food. for example). Organ transplantation is allowed with some restrictions. ice cream made with animal fat. In the case of death. the mouth. . Allow the hospitalized Muslim to pray and read the Qur’an. Confucian teachings indicate that individuals have a particular destiny and role in society and that they should practice moderation and avoid excess. anything fried or roasted in lard. If possible. Dietary restrictions include pork and meat from animals killed outside of Muslim custom as well as eating with dishes or utensils that have come into contact with such food. Maintaining a terminally ill patient on life support in a persistent vegetative state is not encouraged. Muslims may have a living will. with the expectation that a gift or favor will be returned (in the form of restored health or a good grade. ice cream made with animal fat. The Diversity Resources Web site discusses elements of Confucian thought that have an impact on health care. Confucianism Although it is more a philosophy or system of thought than a religion. The Qur’an allows people who are ill to defer Ramadan fasting to another time. Muslim. who was born in Both health care providers and teachers find that Asian clients and students give gifts liberally. ■ ■ ■ ■ The role of fate (ming). with the expectation that a gift or favor will be returned (in the form of restored health or a good grade. anything cooked with ham. Muslims do not drink alcohol or eat anything made with it. This would include gelatin. Gift-giving. Genetic engineering to cure a disease is acceptable. anything fried or roasted in lard. In the hospital. Taoism The Diversity Resources Web site states that “much of the Asian perspective on health comes from Taoist thought. From these teachings developed the widespread respect for and obedience to elders and authority figures. Tips for Caregivers ■ ■ ■ ■ ■ ■ ■ ■ ■ Respect the patient’s modesty and privacy. Qi is influenced by the opposing forces of yin (negative energy) and yang (positive energy). based on the premise that the healing force of the therapist affects the patient’s recovery. Qi gong Component of traditional Chinese medicine that combines movement. Reiki Japanese word representing Universal Life Energy. Ayurveda Alternative medical system practiced primarily on the Indian subcontinent for 5. Traditional Chinese Medicine Based on the concept of balanced qi (“chee”) or vital energy that is believed to flow throughout the body and regulate a person’s spiritual. amino acids. Some osteopathic physicians practice osteopathic manipulation. Healing is promoted when the body’s energies are in balance. maintains. includes diet and herbal remedies and emphasizes the use of body. restorative physical exercises. Osteopathic Medicine (Osteopathy) A form of conventional medicine that emphasizes diseases arising in the musculoskeletal system. highly diluted quantities of medicinal substances are given to cure symptoms. Chiropractors use manipulative therapy as an integral treatment tool. acupuncture. Homeopathic Medicine Alternative medical system based on the concept that “like cures like. metallic needles that are manipulated by the hands or by electrical stimulation. and metabolites. minerals. Japan.000 years ago. Reiki is based on the belief that when spiritual energy is channeled through a Reiki practitioner. exercise.” Small. mental. The practice includes herbal and nutritional therapy. by passing their hands over the patient. the patient’s spirit is healed. herbs or other botanicals. and regulation of breathing to enhance the flow of qi (“chee. a full-body system of hands-on techniques designed to alleviate pain. organ tissues. Naturopathic Medicine Alternative medical system based on the belief that there is a healing power in the body that establishes. restore function. healers can identify energy imbalances. improve blood circulation. A family of procedures involving stimulation of anatomical points on the body by a variety of techniques. Disease results from disturbance in the flow of qi resulting in an imbalance of yin and yang. American practices incorporate medical traditions from China. meditation. medicinal plants. homeopathy. and trees to promote health and well-being. mind. Dietary Supplements Products taken by mouth that contain dietary ingredients intended to supplement the diet. Practitioners work with the patient with a goal of supporting this power through treatments such as nutrition and lifestyle counseling. and promote health and well-being. dietary supplements. Celebrating Diversity: COMPLEMENTARY AND ALTERNATIVE MEDICINE GLOSSARY Acupuncture Method of healing developed in China at least 2. Aromatherapy Use of essential oils (extracts or essences) from flowers. . Chiropractic Alternative medical system that focuses on the relationship between bodily structure and function and how that relationship affects the preservation and restoration of health. Massage Manipulation of muscle and connective tissue to enhance function of those tissues and promote relaxation and wellbeing.000 years. and enhance immune function. and substances such as enzymes. meditation. and restores health. and physical balance. The underlying belief is that all body systems work together and that disturbances in one system may affect function in other systems. may include vitamins. solid. herbs.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 24 Respecting Differences. which in turn heals the body. the same substances given at higher or more concentrated doses would actually cause those symptoms. and traditional Chinese medicine. and spirit in disease prevention and treatment. and remedial massage. emotional. The technique most studied scientifically involves penetrating the skin with thin.” an ancient term for vital energy) in the body. Korea. and other countries. Therapeutic Touch Derived from an ancient technique known as the layingon of hands. death. Complementary medicine refers to practices used together with conventional medicine. such as the use of meditation to lessen chronic pain. In the following country profiles some of these practices are discussed under the heading “traditional practices. Taoist teaching centers on the importance of finding the tao or “way. ALTERNATIVE MEDICAL SYSTEMS are complete systems of theory and practice that often have evolved apart from and earlier than the conventional U. MIND-BODY INTERVENTIONS comprise a variety of techniques designed to enhance the mind’s capacity to affect bodily function and symptoms. (doctor of osteopathy) degrees and by their allied health professionals including physical therapists. taken from http://nccam. Types of Complementary and Alternative Medicine 1. Many of the patients California health care providers see. When an individual sees himself or herself as involved in an ongoing natural process. and products not currently considered part of conventional medicine. health care professionals should be aware of some salient points.. such as the use of vitamin therapy for macular degeneration and the prevention of birth defects. part of the National Institutes of Health. Taoism advocates living in harmony with the seasons. . and even death with acceptance and stoicism that might be misunderstood. and even death with acceptance and stoicism that might be misunderstood. is the U. government’s lead agency for scientific research on complementary and alternative medicine. Some techniques previously considered CAM are now part of mainstream medicine (e.S. A person influenced by Taoist thought is likely to approach life. avoiding extremes. a system developed in India. practices. Alternative medicine is used in place of conventional medicine. also called Western or mainstream medicine. are now part of conventional medicine. the Web URL of the NCCAM Clearinghouse. such as the use of shark cartilage in place of chemotherapy or radiation to treat cancer. Western alternative medical systems include homeopathic medicine and naturopathic medicine.” This involves living in harmony with the natural world. and products not considered part of conventional medicine. his philosophy is set forth in the Tao Te Ching.O. both native-born and immigrants.nih.D. practices. medical approach. Integrative medicine combines mainstream medical therapies and CAM therapies for which high-quality scientific evidence of safety and effectiveness exists. Life is considered a cycle of birth. ○ Understanding and Working with Health Care Clients and Students from Other Cultures 25 A person influenced by Taoist thought is likely to approach life.○ ○ ○ ○ The National Center for Complementary and Alternative Medicine (NCCAM). Conventional medicine.gov.g. and psychologists. with the phases of the moon and the rhythms of day and night. Alternative medicine is used in place of conventional medicine.S. illness. referred to on the organization’s Web site as CAM. registered nurses. ○ Complementary and Alternative Medicine ○ China in 604 BC. patient support groups. 2. (medical doctor) or D. non-Western systems include traditional Chinese medicine and Ayurveda. Practices and products once considered CAM. the idea of surgical interventions and lifesaving measures makes less sense than to one who has no confidence in anything other than his or her immediate existence.” but because the use of these methods is becoming so widespread throughout our culture. and reincarnation. will be using complementary and/or alternative medicine. is that practiced by those with M. illness. Definitions Complementary and alternative medicine is a group of diverse medical and health care systems. Complementary and alternative medicine is a group of diverse medical and health care systems. Complementary medicine refers to practices used together with conventional medicine. The following information. is in the public domain and may be freely copied. experiencing the oneness in all things and living by the golden mean or chung-yung. BIOLOGICALLY BASED THERAPIES use substances found in nature such as herbs. Korean (1.598. Immigration—Trends and Implications for Schools. Armenian (0. Japanese (0. and vitamins. The authors project that by 2015 the children of immigrants will constitute 30 percent of the nation’s school population.2%). pointed out that the children of immigrants now account for one in five of all children in grades K through 12. and Hindi (0.S.6%). Punjabi (0. Mandarin (0. Examples include dietary supplements. The Urban Institute projects that some 14 million immigrants will enter the United States between 2000 and 2010. and therapies that use creative outlets such as art.7%).598.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ tem developed in India. or through. prayer. U. that manipulate biofields by applying pressure and/or manipulating the body by placing the hands in. Filipino (1. about one-fourth of all students. 4.3%). foods. and 21 percent for less than five years.5%). 48 percent for five to nine years. about one-fourth of all students.3%).5 million students in that group. Western alternative medical systems in- ○ earlier than the conventional U. 6. Working with Students Children of immigrants now make up one in five of all children in grades K through 12—10. and the use of natural but scientifically unproven therapies.4%). such as pulsed fields. A quarter of these students were born in other countries.5%). Five percent of all students in U. Hmong (1. or dance. second-generation.6%).535 English language learners in California public schools. but three-quarters were born in the United States. Immigrant children make up a larger share of the secondary than of the elementary school population. or alternating-current or direct-current fields. Arabic (0. The glossary on page 24 outlines some of the more common complementary and alternative medical practices with which health professionals may come in contact as they work with both foreign-born and native-born patients. followed by Vietnamese (2. Mind-body techniques still considered CAM include meditation. ○ traditional Chinese medicine and Ayurveda. .535 English language learners in California public schools.3%).5 million students. Cantonese (1. Celebrating Diversity: cognitive-behavioral therapy). Lao (0. nonWestern systems include ○ clude homeopathic medicine and naturo- ○ proach. a sys- ○ pathic medicine. medical ap- ○ tice that often have evolved apart from and ○ tems are complete systems of theory and prac- ○ Alternative Medical Sys- ○ 26 Respecting Differences. Farsi (0.4 percent as opposed to 3. The countries profiled in the major portion of this handbook were selected on the basis of both the numbers of immigrants from each country identified in the 2000 census and the number of English language learners in our public schools.3%). magnetic fields. Russian (0. the fields of energy believed to surround and penetrate the body. The largest number of English language learners—1.8 percent.7%). making them first-generation. (2) Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields. 5.5%). The authors of the study found that a substantially smaller share of English language learners in high schools receive language instruction than those in elementary school.4%). such as shark cartilage as a cancer cure. schools are limited English proficient or English language learners.S. MANIPULATIVE AND BODY-BASED METHODS include chiropractic or osteopathic manipulation and massage. herbal products. with 10. Nearly half of firstgeneration Mexican immigrant K–12 students are limited English proficient. Khmer (0. 3.S. In the spring of 2004 there were 1. Immigrants and English Language Learners in California Schools The California Department of Education reports that in the spring of 2004 there were 1.359. music. ENERGY THERAPIES involve the use of energy fields and are divided into: (1) Biofield therapies.792 (85 percent of the total)—speak Spanish. mental healing.1%). such as Qi gong and Reiki. A 2003 report by The Urban Institute. 30 percent have been here for ten years or more. Of these. Central American. whose student body is 93 percent Latino and 70 percent low-income.3 million children enrolled in California public elementary and secondary schools in 2003–2004 were Latino. .5 percent of the enrollment. an additional 46 percent grew up speaking Spanish but are now considered proficient in English. for Tijuana. Prior to about 1930.5 percent of the enrollment. NonHispanic Whites accounted for 32. To assist teachers who teach large numbers of Latino students. we have the privilege and responsibility to ensure that all students have an equal opportunity to be successful. .1 percent and Asian students making up 8 percent of all students that year.” In 2003. ○ Understanding and Working with Health Care Clients and Students from Other Cultures 27 “California has the largest and most diverse student population of any state in our nation.” The campus has an informal but noticeable border between an area called TJ. Their families have often been in California for several generations. we have the privilege and responsibility to ensure that all students have an equal opportunity to be successful. Chicano/a—in addition to being called Mexican. and drill teams.1 percent and Asian students making up 8 percent of all students that year. 14 percent of California schools had Latino enrollments of 80 percent or higher. some children of Mexican-Americans rejected the dominant culture and decided to refer to themselves by the formerly derogatory term “Chicano. He stated: “California has the largest and most diverse student population of any state in our nation. making them the largest segment of the state’s student population. Non-Hispanic whites accounted for 32. . at social events and at lunch—between those who seem more Americanized and those who feel more connected to their Latino immigrant roots. making them the largest segment of the state’s student population. . students here are delicately split— in classes. As educators of over 6.3 million children enrolled in California public elementary and secondary schools in 2003–2004 were Latino.” According to the East Los Angeles segment on the PBS series ○ What’s in a Name? ○ Some 46 percent of the nearly 6.1 million children. . the term “Mexican-American” came into use. When the first generation of the children of refugees from the Mexican Revolution came of age in the 1930s. . with African-American students at 8. Diversity presents us with a unique opportunity to interact and learn from one another. the term Mexican was most widely used. highlighting schools with successful programs and providing resources for teachers and administrators. folklorico dance. A recent discussion of differences within and between Spanish-speaking student groups is found in a December 2004 Los Angeles Times article focusing on Montebello High School. and Senior Park. The author states: “As at many schools in California. and Spanish club.” Jack O’Connell California Superintendent of Public Instruction Some 46 percent of the nearly 6. Mexican-American. . with African-American students at 8. including football. Salvadoran. they are involved primarily in soccer. sports and clubs. ○ Latinos in California High Schools ○ In his January/February 2004 newsletter. Guatemalan. Diversity presents us with a unique opportunity to interact and learn from one another. During the Civil Rights Movement of the 1960s. As educators of over 6. etc. and South American descent in this country are referred to by a variety of inclusive names—Hispanic. page 29 provides excerpts from a slang dictionary found on the PBS Web site in conjunction with the “American Family” series segment on a Latino family in East Los Angeles. Students on the TJ side come from homes where Spanish is spoken.1 million children. Latino students on the Senior Park side of the border are immersed in traditional high school culture. California Superintendent of Public Instruction Jack O’Connell focused on diversity. basketball. Latino/a. The writer notes that students who have moved into regular classes at Montebello seem to be doing better on the California High School Exit Exam than their English-only counterparts. and some of them do not know Spanish. About 28 percent of the students are limited English proficient.○ ○ People of Mexican. a professor at UCLA. Otto Santa Ana. .○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ differences between national groups. “Latino” is a Spanish term preferred by many from these countries who feel that differences between national groups are better represented by that term. and educators’ attitudes and expectations prompted this conclusion by Robert Peña: Both minority and nonminority students learn better in settings where they interact with others different from themselves. In 1968. The term “Hispanic” is an English word that was introduced at the time of the 1970 census when U.A. and with tongue in cheek) that in the future we all call ourselves “Americanos. In the useful book Educational Interventions for Refugee Children. accommodating different learning styles. we can begin to understand the lives of the students who compose our multicultural society. University of Michigan researcher Patricia Gurin conducted several extensive studies that showed that both minority and non-minority students learn better in settings where they interact with others different from themselves. .”emerged as leaders in the Mexican-American community and took a confrontational approach to social justice.S.” some who used this label. Analysis of the relationship among student achievement. Superintendent O’Connell states: Through the study of the many complex forces that influence young people. Culturally Competent Teaching Teachers can support diversity in instruction by accepting and valuing differences. ○ were looking for a generic term for people from the ○ the 1970 census when U. more than 30. which means “a pro-active approach to selfrespect and dignity. In a state with as many different immigrant and refugee groups as California. This means that educational leaders and school practitioners become knowledgeable of minority cultural traditions. government officials ○ English word that was introduced at the time of ○ The term “Hispanic” is an ○ 28 Respecting Differences. Celebrating Diversity: “American Family. and that these individuals become more reflective in their thinking about culture. teachers working in diverse classrooms—and that would appear to include most California public school teachers—will have a better chance of establishing successful working relationships with their ethnic and language “minority” students when they make an effort and take the time to learn about their students’ cultural background. for example. government officials were looking for a generic term for people from the Spanish-speaking countries of Latin America. The teacher or health care professional working with Spanish-speaking students or clients would be wise to look for cues as to preference. students walked out of five high schools to protest inequities in their education. student culture.S. ○ these countries who feel it better represents the ○ “Latino” is a Spanish term preferred by many from ○ Spanish-speaking countries of Latin America. suggests (optimistically. the authors emphasize the need for teachers to support diversity in instruction by accepting and valuing differences. and to understand the interplay of these in both the school and community. and understanding and building on the cultural background of their students. As stressed in the earlier section on providing culturally competent health care. this can pose a huge challenge. In the newsletter mentioned above.” as that would cover all the Americas. both north and south. . ultimately winning concessions from the school board. It is essential that students prepare for an international workforce by understanding and appreciating other cultures. accommodating different learning styles.000 East L. [I]t is equally important to understand the relationship between minority and majority cultures. and understanding and building on the cultural background of their students. She found that white students with the most experience with racial diversity both in and outside of school demonstrated: ■ ■ ■ ■ ■ ■ increased scores on a test used to measure complex thinking more motivation to achieve greater intellectual self-confidence and engagement the highest level of interest in graduate degrees greater understanding that group differences are compatible with societal unity higher level of motivation to understand the perspectives of others . ... amolado ............................................. crazy person friend brother or sister........ aware candies......... trapos ......... tunes crazy hot stuff square.. sincho ................................... carrucha ........ arrastrado ............. cholo . ice cream big party... andale .S........ bote................ perica ........................................ chocho ...... rata ..................... fregado ........... nieve ............. cama .................. carnal . fink the family....................... alambre ... cuico. absolutely yeah sister song silly easy for sure... Chicano .... huevos ............................... thick-headed nut case............................... cuate .............. sieta .............. chamacon .............................. Raza. jefe . panchanga ......... sopitas .... songa ................ beautiful woman Latin neighborhood a fight............... vale................... pissed off hurry up............pbs................ noisy argument jail day laborer stubborn.... suave . screwed up angry............. close relative car............ chavala ........ barrio ............. loco .. threads truck a guy.................. masa . fresco ............... sirol ... agarrado ..... lonche ...... huisa ................................. menso ..... alalba ... neto .. padelante .. a la brava ..... huiri huiri ............. person who takes advantage stingy............................. sweet stuff low-rider............. 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La .. chanza ................. safado ........... a dude dollar the movies (adapted from http://www....... blow-out fiesta pregnant word................... chale .... chamaca ............................. huelga ..................... anda bravo .... totacho .............. chispa ............. tenis..... low-rider political cause free smuggler of illegal aliens rude. way cool Mexico/US border fence illegal alien from Mexico messed up....... coyote .... the wife money U........................... gang member cheater go for it dude slob tease cool... baby.............. crudo ................. varo ........................... fachoso ..J.................................... girlfriend a job the boss....................................................... right on Chicano from Texas shoes ticket Tijuana Chicano slang clothes. chafa ................. dude girlfriend cop worthless no way young girl young man joke girlfriend Mexican American wow! Dude! smart........ no-good far-out...... flor . cuera ........org/americanfamily/ eastla..................... chupasa ...... perro ........... the truth! balls radio cruel person teacher rat............. community music...... a tona madre .............. gasofa .................. vista .............. gringo .......... vato .... unbelievable catch you later hottie female........ profe ...... clan.....html) ... get to it a white American gossiper lazy.......................................... tambo ................... linea ............................................................... Ay te huacho ............. ese ....... tejano ... palabra .................................. bracero ............... salsa ............... agringado .... rola ............... .......... entrale .....................○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 29 SPANISH SLANG abuson ....-Mexican border woman chaser crazy dude lunch market or store dough stupid person the truth snow....... zapos ............. see pelotas gossip girl........................ alambrista ................... cuacha ................... not cool chair of course.......... arguendero .... kewl gas glacos .............. cheap assimilated to white middle class impulsive far-out....... lana ........ sonsa .................. causa ........ huachate ........ marqueta .. along with the Common Destiny Alliance at the University of Maryland. and social class interact to influence student behavior. and language diversity provide the nation and the schools with rich opportunities to incorporate diverse perspectives. Those directly connected to well-run diverse schools find that students of every background benefit both academically and socially. issues. Katz suggests that the teachers themselves were trying to reach the immigrant students but were hampered by such institutional problems as tracking and high teacher turnover that kept them from establishing caring relationships. and characteristics ○ schools with rich opportunities to incorporate ○ guage diversity provide the nation and the ○ “Cultural. . and equity. and assessment principles are discussed here as they relate to working with high school health careers students. “Effective teachers for a multicultural society contextualize instruction by first understanding how their own teaching styles and preferences may hinder the learning of students who have different learning styles and preferences. and co-workers from diverse racial and ethnic backgrounds after graduation Eileen Kugler. society and the ways in which race. ethnic. I heard the same message over and over. . To forge a common destiny.S. Perhaps the best resource for the classroom teacher on working effectively with students from a variety of cultures is a publication from the University of Washington. cultural. They state: Effective teachers for a multicultural society contextualize instruction by first understanding how their own teaching styles and preferences may hinder the learning of students who have different learning styles and preferences. This creates a significant gap between teachers and their ethnically diverse students. The book presents the work of experts at the Center for Multicultural Education at the university. region of origin. effective teachers use knowledge of their students’ culture and ethnicity as a framework for inquiry. language. . and values needed to become participating citizens of the commonwealth. educators must respect and build upon the cultural strengths and characteristics that students from diverse groups bring to school. student learning. and characteristics into the nation and the schools in order to strengthen both (5). educators must help all students acquire the knowledge. They also use culturally responsive activities. organization.washington. The authors point out that most teachers come to their diverse classrooms unprepared for the challenge of providing what Banks calls an “equity pedagogy” that provides all students with equal opportunities for academic and social success. and school governance. religion. At the same time. Celebrating Diversity: higher levels of citizenship greater likelihood of having friends.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ strengthen both.edu/coe/programs/ci/pubs/ DiversityUnity. researching her book Debunking the Middle-Class Myth: Why Diverse Schools Are Good for All Kids.” A year-long ethnographic study by Susan Katz of the University of San Francisco of eight Latino immigrant students in an urban Northern California middle school revealed that the students identified teacher discrimination against them as Latinos as the main reason they took little interest in school. Diversity within Unity: Essential Principles for Teaching and Learning in a Multicultural Society. and language diversity. issues. Cultural.” ○ schools find that students of every background ben- ○ over. Those directly connected to well-run diverse ○ rural Iowa. Teacher and student learning.pdf.” Diversity within Unity Teacher Learning Principle 1: Professional development programs should help teachers understand the complex characteristics of ethnic groups within U. ethnicity. intergroup relations. generation. social class. who developed 12 essential principles for teacher learning. skills. This is available on the Web at http://depts. found: “From urban areas in California to factory towns in rural Iowa. intergroup relations. I heard the same message over and ■ ■ ○ “From urban areas in California to factory towns in ○ 30 Respecting Differences. resources. . . and extent of urbanization on the behavior of students from different cultures. Rather than relying on .” Diversity within Unity ○ into the nation and the schools in order to ○ diverse perspectives. and strategies to organize and implement instruction (7). . They emphasize that teachers need to be aware of the impact of gender. neighbors. ethnic. The authors state: An important goal of the schools should be to forge a common nation and destiny from the tremendous ethnic. and lan- ○ Eileen Kugler ○ efit both academically and socially. generalized notions of ethnic groups that can be misleading. (2) a safe and orderly learning environment. and charity). freedom.” Diversity within Unity . and economic contexts in which they live and work. Assessment Principle 12: Teachers should use multiple culturally sensitive techniques to assess complex cognitive and social skills. cultural. focusing as they do on hands-on learning in small classes using current health care technology. (3) time actively engaged in learning. ethnic. and attitudes that increase academic achievement and foster positive interracial relationships. in which often the dominant group is portrayed as good and noble and everyone else appears in a negative light. The authors point out that teaching students different interpretations of history will help them develop empathy for differing points of view and the ability to think critically about information. An exhaustive and helpful research publication by the National Academy of Sciences. and conflict resolution. and (8) access to extra-curricular activities. 7. equality. This is another instance in which HOSA makes a significant contribution to the education of health careers students. and language groups.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 31 Student Learning Principle 2: Schools should ensure that all students have equitable opportunities to learn and to meet high standards. compassion. and active student participation in Health Occupations Students of America (HOSA). The Model Curriculum Standards for the Health Science and Medical Technology Industry Sector include standards on understanding and respecting cultural differences (7. (7) sophistication and currency of learning resources and information technology used by students. and attitudes that increase academic achievement and foster positive interracial relationships.6. does an admirable job of fulfilling this principle. Principle 3: The curriculum should help students understand that knowledge is socially constructed and reflects researchers’ personal experiences as well as the social. justice. and especially health careers education through Health Occupations Students of America (HOSA). as they learn such social and workplace skills as getting along with others. skills. One researcher “Schools should provide all students with opportunities to participate in extra. peace. suggests the importance of giving language-learners extensive opportunities to interact with native speakers. The authors emphasize the importance of using a variety of assessments to enable students with different learning styles to demonstrate mastery.. portfolios.5. Improving Schooling for Language-Minority Children.and co-curricular activities that develop knowledge.g. Principle 7: Students should learn about the values shared by virtually all cultural groups (e. This relates primarily to the teaching of history. skills. They suggest such techniques as observations. (4) student-teacher ratio. performance behaviors. Career and technical education of all kinds. Intergroup Relations Principle 6: Students should learn about stereotyping and other related biases that have negative effects on racial and ethnic relations. and problem-solving that are frequently part of the health careers education classroom. grouping students by interest rather than ability. Principle 4: Schools should provide all students with opportunities to participate in extra. Principle 8: Teachers should help students acquire the social skills needed to interact effectively with students from other racial. The authors enumerate the most important learning opportunities as: (1) teacher quality.5). political. (6) grouping practices that avoid tracking and rigid forms of student assignment based on past performance. working with diversity.and cocurricular activities that develop knowledge. 9. (5) rigor of the curriculum. Health careers education classes appear to meet most of these criteria admirably. practice a different religion. up-to-date information while keeping the profiles brief.” Geri-Ann Galanti ○ ferences. Improving Schooling for Language-Minority Children ○ electives. Conclusion An excellent new resource. The book looks at English language learners and recent immigrant students in Los Angeles. if we do not make the effort our jobs as teachers and health care providers will be more difficult. but it ○ ferent language. Do not make assumptions and do respect differences. Recognize that other people’s views are ○ “Do not make assumptions and do respect dif- ○ is worth the effort. Geri-Ann Galanti puts our mission succintly: Treat the patient/[student] as a whole person with psychological and spiritual needs as well as physical/[educational] ones. . Another researcher found that while all learners benefit from this kind of interaction. Recognize that other people’s views are just as valid as yours (146). Do not assume that patients/[students] or co-workers will view the world the same way that you do. not [simply] as individuals. Public school teachers and health care providers are key factors in the equation for establishing a state and national culture in which people from around the world can live together in mutual respect and harmony. Beyond “Bilingual” Education. practice a different religion. Hispanic students benefit more than most. they may have different values and different ways of looking at things. In order to reap the benefits of the opportunities provided by immigrant students. and ○ cating with students and clients who speak a dif- ○ The process of understanding and communi- ○ projects. The process of understanding and communicating with students and clients who speak a different language. In her excellent resource Caring for Patients from Different Cultures: Case Students from American Hospitals. and in alternative activities such as projects—all of which can be accomplished quite easily within the framework of a health careers education program. San Francisco. See [them] as members of a family unit. states and the federal government need to become more attuned to the wide range of challenges facing recent immigrants and provide programs and services that help schools integrate them economically and socially. The task has been challenging. Celebrating Diversity: found that successful programs provide opportunities for contact between monolingual English speakers and English language learners during instruction in core content. as sources vary even on information as basic as country area and dates of important historic events. Statistics in the “Quick Facts” sections have for the most part been taken from the April 2005 on-line version of the CIA World Factbook. ○ eat different foods than we do is not easy. and eat different foods than we do is not easy. May increased harmony and mutual understanding result. We have much to learn from one another. but it is worth the effort. parental involvement in the student’s school program was found by several researchers to be beneficial. and our students and clients will suffer. The authors state: Teaching language is only one important aspect of educating immigrants effectively. in ○ lingual English speakers and English language ○ vide opportunities for contact between mono- ○ Successful programs pro- ○ 32 Respecting Differences.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ just as valid as yours. and Fresno. in electives. Long Beach. San Diego. and in alternative activities such as ○ learners during instruction in core content. keeping in mind the key concept of individual differences. That said. Indeed. Every effort has been made to provide accurate. educators and health care providers should be able to broaden their knowledge of students and clients from other cultures by studying these materials. As with native English-speaking students. The country profiles on the following pages are intended to introduce health care providers and educators to the cultures from which the largest numbers of California immigrants and English language learners come. recognizes the challenges California teachers and administrators face as they attempt to help immigrant students benefit from public education when they lack health care and other social services—all in a climate of reduced budgets and required accountability measures that dilute teacher energy and effectiveness. /aspGraph2.urban org/url. B. “What It Means to Be Latino. http://www. A. The Urban Institute. 1997. Hamilton. 2003. National Immigration Forum.S. Erika.html (20 Feb. http://www. 2003). 2005). Cs of U. University of Washington. Fix.edu/cprc/rumbaut. http://data1. http://www. 2004). Gershberg. Educational Interventions for Reguee Children: Theoretical Perspectives and Implementing Best Practice. http://www.cfm?ID=410654 (18 Feb. Vol.html (4 Oct.pdf.html (4 Oct.pbs. 2004. . 1996. “Immigrants’ Kids Found to Make Gains: Income. “At the Crossroads: Latinos in the New Millennium. ———. 9 Oct. 1.S. 2005).pbs. http://www. California Department of Education. http://www.asp?Level=State (19 Feb.A. 2004).” American Family. Marech. 2004.dataquest. “Lure of the North: ‘I Had to Come.gov/dataquest (20 Feb.gov.gov.cfm?ID=310844 (15 Feb. “About the Family.” American Family. Communities. English Learners in California Public Schools. Enrollment in California Public Schools. and Dennis Moore. Seattle.org/ americanfamily/latino1.org/url. Jan/Feb. Their Teachers. eds.cde.S.edu/coe/programs/ci/pubs/DiversityUnity. http://www. 1997. A New Religious America: Managing Religious Diversity in a Democracy: Challenges and Prospects for the 21st Century. 2003). http://immigrationforum. James A.nap. Educating Language-Minority Children. Cultural Differences and the Construction of Meaning: Implications for the Leadership and Organizational Context of Schools. 2003). http://www.ca. and the Structures of Schooling.cde. 2002. Teachers College Record 100: 809–840. Ibarra.sfgate. 1998. et al. 2004. Boyd. Kugler. http://www. Katz.washington. Education Policy Analysis Archives.html (20 Feb. http:// depts.doc (7 Jan 2005). Eileen. Hispanic Education in California. Multicultural and Multilingual Literacy and Language: Contexts and Practices. http://www. Beyond “Bilingual” Education: New Immigrants and Public School Policies in California.” San Francisco Chronicle.ca. East L. Education August. 2004. 2005).com/news/ (3 Dec. http://epaa. O’Connell. 2005). “ The Evidence Is In: Diversity Helps Students. Statewide English Learners by Language and Grade. 2004). Educational Demographics Unit. 2003. Benitez. Diana. DC: The Urban Institute.html (4 Feb.edu/epaa/v5n10. “Cultural Divide on Campus. Hayasaki.html (28 Mar. http:// data1. 2005). Immigration: Trends and Implications for Schools.html (4 Oct. 2005). and Jeffry Scott.cde.tcrecord.asu. Peña. 22 Feb.org/americanfamily/latino3. Richard.com (23 Feb.pbs. College of Education. Ignacio. Rona. Education. http:// www. Commission on Behavioral Social Sciences and Education.cde.my/eck.edu/openbook/0309064147/html/R1. Diane.dataquest (19 Feb.ca.: Past and Present. 2004. Statewide Fluent-English-Proficient by Language and Grade. Commission on Behavioral Social Sciences and Education. 2000. ———. 2004. National Council of La Raza.com/journey/day1. 29 Oct.usembassymalaysia.cde. and Kenji Hakuta. Eck. Job Status Higher.dataquest (19 Feb. 2003).org/americanfamily/ eastla. 2003. http://www. 2005). High School: A Newsletter for California Educational Leaders. Fenice..asp?ContentID=11405 (19 Nov. Rumbaut.azstarnet. Ruben. http://data1. ———.org/PrintContent.’” Arizona Daily Star. (10 Feb. and Jeffrey Passel. Capps.html (27 Mar. Martinez.org. 2003). et al. http:// www. U. http://data1. et al. 3 Dec. Immigration Studies Program. The New Neighbors: A Users’ Guide to Data on Immigrants in U.latimes.ca.ucop. Banks.nap. 8 Apr.urban. 2003. 1999.ca. Rodriguez. Diversity within Unity: Essential Principles for Teaching and Learning in a Multicultural Society. Center for Multicultural Education. 2005). Clara. Alec. Washington.html (20 Feb.org (20 Feb. Jack. Randy. Immigration. Tomas. 3.nclr. Census Data Show. International Conference on Religious Pluralism in Democratic Societies.edu/openbook/0309054974/html/R1. 2003.com/ac2/wp-dyn/A63524-2003Oct8?language=printer (9 Oct. ———. 2005. 2003. The Urban Institute. 2005).” Los Angeles Times.○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 33 Resources and References Immigration. 2005). Susan R. Ruben. http:// www.org (28 Mar. 2005)..gov/re/pn/nl/documents/janfeb2004. http://www. 2004). Michael. New York: Guilford Press. http:// www.washingtonpost. 2004.gov. California Department of Education. 2001. Robert. and Jeffrey Passel. No. 2004). Improving Schooling for Language-Minority Children: A Research Agenda.” Washington Post.” American Family. 2005). The New Californians: Assessing the Educational Progress of Children of Immigrants. Fact Sheet. Teaching in Tensions: Latino Immigrant Youth. Santa Ana.health.chia. New York: Farrar. Kaiser Family Foundation. Australia. http://www.ncmonline. et al.pbs. http://www. Putting Patient Teaching into Practice. 2004. 2005.ncmonline. “Is There Such a Thing as Latino Identity?” American Family. 2005).gih. Feb. http://www. Caring for Patients from Different Cultures: Case Studies from American Hospitals.ca. http://www.pdf (24 Feb. 26 Jul. 2004). . et al.apha. Brigid.htm (7 Oct. 2004). 2005).html (20 Feb. http://www. Healthfinder. 2004. http:// www. Philadelphia: University of Pennsylvania Press.gov.com/e40. 28. 2005). http://news. 2003. 2004). Culturally Competent Care American Medical Student Association.org (20 Apr. American Public Health Association.harvard. http://www. Celebrating Diversity: Resources and References. Josepha. http://www. 2004). 1 Aug. Islamic Medical Association of North America. 1. 2005). Duhigg. Information for Health Care Providers When Dealing with a Muslim Patient. “A Spiritual Treatment?” Los Angeles Times. Nurse Week Continuing Education Course. http:// www. The Rehabilitation Provider’s Guide to Cultures of the Foreign-Born. No. Health Care Providers Handbook on Muslim Patients. The Commonwealth Fund. The Commonwealth Fund. 2004. 18.kff. The Spirit Catches You and You Fall Down.gov.cpehn. Providing Health Care to Limited English Proficient Patients: A Manual of Promising Practices. Shahid.org/fileadmin/Additional_Accomplishments/ National_report.com. http://www. 2004).com Collins. http://www. http://www. California Primary Care Association.html. Charles.gov. Joseph. http://ggalanti. Diverse Communities. Strauss. Habel.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 34 Respecting Differences. 2004).cpca. http:// www.edu/mseries. 2005). 2002. 2nd Ed. 1997.acorn. California Pan-Ethnic Health Network.com (14 Feb. California Healthcare Interpreting Association.” The Fresno Bee. Common Concerns: Assessing Health Care Quality for Minority Americans. Cultural Competency in Medicine. 2002. Speaking the Language of Care: Language Barriers to Hospital Access in America’s Cities. Henry J.hsph. cont. Compendium of Cultural Competence Initiatives in Health Care. http://news.au/multicultural/pdf/islamgde.pdf (10 Oct. 1996.htm (14 Feb. http://www. http://www.aapcho.org (24 Feb. Geri-Ann. 2003. Schulte. “Language Hinders Health-Care Service.edu/healthliteracy.dhs.htm (16 Feb. and Giroux.islam-usa.org/programs/gpit/cultural/ cfm (7 Oct. 2004). Campinha-Bacote. Association of Community Organizations for Reform Now (ACORN). 2005).” Online Journal of Issues in Nursing. California Department of Health Services. Center for International Rehabilitation Research Information and Exchange (CIRRIE).org (10 Oct. Issue Brief No.latimes. 2004). http://cirrie. 2003. Fadiman. Latin America: Health Culture Sketch. “Beware of the Know-It-All-Interpreter.healthfinder. 1997. http://www.org (23 Feb.amsa. “Many Faces: Addressing Diversity in Health Care.org (7 Jan. Vol 8. “Teaching Teachers How to Connect with Urban Students.org.” New California Media.cyberchalk. http://www. Galanti. 2005). Barbara. 2003. Harvard School of Public Health. Betancourt. Cultural Diversity in Healthcare Web site.htm (7 Oct. Anne. http://nursingworld.cmwf. Association of Asian Pacific Community Health Organizations.” Washington Post.cmwf. http://www.org/ojin/topic20/tpc20_2. http://www.org/ppp/red/laintro.com/nurse/courses/nurseweek/nw0650/course. Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. Otto.com/features/health (28 Feb. Athat. Karen. 2003. 2003. Anderson.buffalo. In the Right Words: Addressing Language and Culture in Providing Health Care.org/americanfamily/ latino2. 2002.washingtonpost. Chen.org. http://www. 1 Oct. ———. Grantmakers in Health.qld. 2004). Islamic Council of Queensland. Health Literacy Studies. Maureen. Alice.com/ac2/wp-dyn/A13886-2004Jul25?language=printer (26 Jul. org (21 Feb. 2005). Houkje. 2002 National Survey of Latinos. eds.hrsa. 163:244–249.msh.chcf. http:// www. Health Resources and Services Administration. http://www3. and Jan Gates-Williams. Kagawa-Singer. Culture and Nursing Care: A Pocket Guide. http://www. 2005). ———. http://www. 2003. Pew Hispanic Center/Kaiser Family Foundation. Lipson. Donald. Jann.edu/multicultural/. Ross. Office of Minority Health Resource Center.” Closing the Gap.org. Resources for Cross Cultural Health Care. (3 Mar. Murray-Garcia.org.edu/~Charles_Kemp/backgroundonrefugees.washingtonpost. 2005). What a Difference an Interpreter Can Make: Health Care Experiences of Uninsured with Limited English Proficiency.org/cgi/content/full/78/6/577 (8 Jan. 2001. 2005). Barbara A. Morales. 1995.edu/~Charles_Kemp/religion_and_refugees. http://gucchd. Marjorie. 2004).LatinoSurveyReportFinal. Vedantam.baylor. http://www. California HealthCare Foundation. nttp://www.omhrc.baylor. Center for Religion and Civic Culture. http://www. 2002. National Alliance for Hispanic Health. S.diversityrx. Refugee Health. Immigrant Religion in the City of the Angels.georgetown.baylor. et al.gov (23 Feb. Feb/Mar. http://www. http://www3.med.gov/financeMC/ftp/cultural-competence. 2001.pewhispanic. Religion and Refugees.edu/~Charles_Kemp/refugee_health_problems.htm (14 Feb. 2005). et al. January.. Center for International Rehabilitation Research Information and Exchange (CIRRIE). 2005).htm (14 Feb. 2005). Pryor.accessproject. Koenig. http:// cirrie. “Moving Toward Consensus on Cultural Competency in Health Care. Leo S.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 35 Resources and References. 2000. http://www. University of Michigan Health System Program for Multicultural Health. 2005). Office of Minority Health. What Is Complementary and Alternative Medicine (CAM)? http://nccam.html. Improving Patient Satisfaction Surveys to Assess Cultural Competence in Health Care. http:// www.” Washington Post.edu. http://www. et al.” Closing the Gap. 2005. Kemp. 2004). and Paula Sotnik.nih. Michelle. Meadows. http://ethnomed. Multicultural Health 2002: An Annotated Bibliography.org.. “Office of Minority Health Publishes Final Standards for Cultural and Linguistic Competence. 2001.gov (21 Feb. Cultural Competence Works: Using Cultural Competence to Improve the Quality of Health Care for Diverse Populations and Add Value to Managed Care Arrangements.omhrc. A Primer for Cultural Proficiency: Towards Quality Health Services for Hispanics.culturediversity.org/programs/providerrs_guide. Department of Health and Human Services.org/site/ docs/pdf.pdf (24 Feb. Jezewski. The California Endowment.calendow. 2003. Shankar.. U. 2005). 2001. 2005). ———.hispanichealth. 2005).academicmedicine. and Shaheen Kassim-Lakha.ncihc. U. National Council on Interpreting in Health Care. 1997.baylor. “Patients’ Diversity Is Often Discounted.omhrc.org (25 Feb.com (26 Jun. National Center for Complementary and Alternative Medicine. . et al.” Western Journal of Medicine.edu/nccc. cont. National Center for Cultural Competence.htm (21 Apr. http://www3. 2002. “Understanding Cultural Difference in Caring for Dying Patients..edu/~Charles_Kemp/ hispanic_health. 2005).org/pdf/primer/pdf (21 Feb. Provider’s Guide to Quality and Culture. ———. 26 June. Department of Health and Human Services.pdf (23 Feb. Culture Brokering: Providing Culturally Competent Rehabilitation Services to Foreign-Born Persons. 2nd Ed. Transcultural Nursing.umich. http://www. Office of Minority Health.” Academic Medicine 78:577–587.org. “A Strategy to Reduce Cross-cultural Miscommunication and Increase the Likelihood of Improving Health Outcomes. Mary Ann.buffalo. U. http://www. http://www.org. Miller. Juliene G. http://www.gov. Charles. http://www3. 2001. The Access Project. http:// www. Mexican and Mexican-Americans: Health Beliefs and Practices. Background on Refugees. San Francisco: University of California San Francisco Nursing Press. 2005). Department of Health and Human Services.S. University of Southern California. Carol. S. http://www. 2002.gov (21 Feb.htm (14 Feb. and literacy for health care practitioners working with patients with limited English skills.gov Source for listings of health materials in many Asian languages.xculture. cont. Combined Health Information Database.msh.edu Excellent resources for understanding other cultures and providing culturally competent health care. Commonwealth Fund: http://cmwf. includes patient education materials in various languages.org An excellent Web site with resources on health care for minorities and the underserved.org Site developed by University of Washington Harborview Medical Center provides medical and cultural information on immigrant and refugee groups in the Seattle area.cal.org. Cross Cultural Health Care Program: http://www. Exceptional resource. including profiles of many different cultures focusing on health concerns. Center for Cross-Cultural Health: http://www.diversityrx. . etc.nih. refugees. Celebrating Diversity: Resources and References.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 36 Respecting Differences. Diversity Rx: http://www.org Seattle organization provides profiles of ethnic communities.org Excellent resources on language and culture.org Guide to culture.com Minnesota Department of Health Web site with good information on integrating the role of culture in improving health. Includes sources for health materials in various languages.org Excellent resources for providing culturally competent health care. immigrant education. EthnoMed: http://ethnomed. Includes The Provider’s Guide to Quality & Culture.buffalo. Nursing World: http://nursingworld.crosshealth. Manager’s Electronic Resource Center: http://erc. Includes many resources on diversity. National Institutes of Health: http://chid.edu/library/html/culturedmed State University of New York Institute of Technology Web site that promotes culturally competent health care for refugees and immigrants. includes link to Creating Access: Language and Academic Programs for Secondary School Newcomers. Other Resources Center for Applied Linguistics: http://www. health.worlded. CIRRIE: Center for International Rehabilitation Research Information and Exchange http://cirrie. World Education: http://www. CulturedMed: http://www.org Comprehensive information from Management Sciences for Health on working with health-care clients from other cultures. resources for caregivers.sunyit. Includes links to health education materials and Web sites. Latin America Mexico El Salvador Guatemala . ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 38 Respecting Differences. Celebrating Diversity: . Other 6% United Mexican States.487 (29. wheat. president elected to six-year term. General Congress consists of Senate and Chamber of Deputies. tomatoes. dairy products. petroleum. consumer durables. Tzotzil. Amerindian (Natl. Mixtec. other) Roman Catholic 88%. textiles.885.287. poultry. services 58% . mining. beans. silver food and beverages. 31 states. Other 1% Spanish. gold.066 sq.5%) 25. Tzeltal. Otom.202.619 (2003 American Community Survey) 3.701 (44. coffee. wood products fruit. federal republic.903 24. cotton. cotton. soybeans. copper.177. natural gas. vegetables. 1 federal district. manufactured goods. zinc.19 years 40% 92. timber 13% corn. capital is Mexico City tropical to desert depending upon location tsunamis. coffee. Protestant 6%. White 9%. rice. clothing. tobacco.974 (2003 American Community Survey) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 756.2% Mexican peso (MXN) Mestizo 60%. miles (nearly three times the size of Texas) 106.17% 75. hurricanes petroleum. earthquakes.93 years 1. Maya. volcanoes.3%) 9. fruit. chemicals. iron and steel. beef. oil and oil products. silver. industry 24%.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 39 Mexico Census Figures (2000) United States Residents Born in Mexico: United States Residents of Mexican Descent: California Residents Born in Mexico: California Residents of Mexican Descent: 9. tourism agriculture 18%. lead.928. Amerindian 30%. motor vehicles. for whom the present-day Zapatista revolutionaries are named. leading to the Mexican-American War. a 2004 Jimmy Carter building project built 150 homes of autoclaved aerated concrete blocks in five days in Puebla and Veracruz. Congress voted to annex Texas. Carlos Salinas de Gortari was elected president in a controversial election in 1988. with perhaps one-third of the adult population living in substandard housing. counterparts. The traditional role of the male. with the father’s family name first. people construct shelter of anything available—leaves. In the rural areas. In some rural areas. working for the rights of indigenous peoples in Chiapas. Celebrating Diversity: Mexico. Toltecs (600 AD). In 1990. In large cities. cardboard. nationalizing oil and instituting land reform. Brief History Our neighbor to the south has a long and proud history.000 people. was first grown in the Tehuacan Valley in the current-day Puebla region of Mexico. The French withdrew in 1867. gender. what is now Texas. a 10-year revolution started under the leadership of land reformer Emiliano Zapata. an improvement over 70 percent in 1980. Diaz was overthrown in 1911. traditional family structures tend to persevere. during that time. One-room wooden and adobe huts with dirt floors are common. to the United States.S. Respeto dictates appropriate behavior between individuals based on age.S. prostitution. In 1994 Zapatista National Liberation Army rebels. Utah. and a downturn in maquiladora profitability with resulting unemployment as multinational corporations move factories to countries where labor is even cheaper. An earthquake in Mexico City in 1985 killed at least 10. with the father or eldest male being the final authority. . and an estimated 40. tin. California. Arizona. machismo. and most of Arizona and New Mexico. a traditional descriptor of the female role. or corn. The National Revolutionary Party took control of Mexico in 1934. Children are protected and taught to be obedient and treat their elders with respect. Mexican individuals generally have the last names of both their mother’s and father’s families. Traditions Housing: Family: Lack of adequate housing is an ongoing problem in Mexico. In 1864.000 houses in Mexico. new president Francisco Madero introduced land reform. Housing. Family. The 1968 summer Olympic Games were held in Mexico City.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 40 Respecting Differences. Mexicans emphasize the family. U. Colorado. and Benito Juarez became president. were brutally suppressed by government troops. the French under Napolean conquered Mexico City and installed Austrian Archduke Maximilian as emperor. Maya (250 AD). While less than 20 percent of houses overall had dirt floors in 1990.000 children are on the streets. Mexico gave nearly half its territory. Current problems include the displacement of farmers and the introduction of genetically modified corn. Work. la familia. dating to at least 9000 BC when maize. Zapotecs (300 BC). social position.S. Habitat for Humanity has constructed more than 12. or violent crime. the figure was more than 50 percent for families in Oaxaca. Utah. In 1910. In 1845. Vicente Fox of the National Action Party was elected president in 2000. whatever comes to hand. Colorado. Dictator Porfirio Diaz ruled Mexico from 1878 to 1911. The Mexican empire at that time included what is now California. nearly 80 percent of Mexican households had access to running water (not necessarily within a house). economic status. Other early peoples include the Olmecs (1800 BC). he signed NAFTA and privatized many industries. Under terms of the Treaty of Guadalupe in 1848. cont. indicates the male’s responsibility for the family’s welfare and honor. Texas. city families look more like their U. In 1916. thousands live in shanty towns surrounding the city. drugs. and Aztecs (1325 AD). the U. indicates women’s spiritual superiority and ability to suffer. Texas declared its independence from Mexico following the Battle of the Alamo in 1836. over the individual and include the immediate and extended families in important decisions. stealing. Maximilian was executed. using local materials where possible. often involved with alcohol. hundreds of students were killed in demonstrations. Traditionally. and authority. Marianismo. parts of Wyoming. respeto. and most of Central America. New Mexico. Spanish explorers conquered the Aztecs in 1521 and ruled Mexico for 300 years. forces crossed the border in search of the notorious bandit Francisco “Pancho” Villa. agua fresca. No dietary taboos. and cumin. Caldo de pollo. vanilla. Puebla. chocolate. Corn kernels are softened in water and lime. a combination of chocolate. cuisine is not as hot as in some other regions. Small-scale farmers have suffered since the implementation of NAFTA in 1994. pepper. no one would hire someone like me with no education. a sweet potato dessert. Urban residents generally have a six-day work week. Nopales. often served refried or refritos. are used in many dishes. 2005 Los Angeles Times. UNICEF estimated that in 1996 some 3.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 41 Mexico. chicken soup. Fruits. Beans are another staple. with Sunday the only day off. phlegm. Most Californians are very familiar with a wide variety of Mexican foods. a pasta or rice dish. prickly pear cactus paddles. comida. this underground economy has been the only source of job growth. and made into tortillas and tamales. a sauce made of achiote (red annatto seeds). is a local delight. ground. Many regions are noted for special dishes. and sugar).6 million. chiles. cold. and coconut. moisture. Chiles are used both fresh and dried. Employment: Recreation: The largest percentage of Mexican workers are employed in the service sector. pineapple. and spices served over turkey or chicken. Tomatoes and tomatillos are mainstays for salsa and sauces. Pibil. is eaten between two and four in the afternoon. cont. depending more on fruits. . Beverages include agua de Jamaica. ranging in hotness from mild to volcanic. Squash blossoms. garlic. and even if there were. sopa aguada. a crop native to the area. Beans and tortillas (preferably corn) are staples. Mexico City has the world’s largest bullfighting arena. Since the election of President Vicente Fox in 2000. two hours south of Mexico City. agua de horchata (made with rice flour. pumpkin seeds. given our large Mexican population. as their unsubsidized crops cannot compete with cheap. neither Mexican job creation nor labor demand in the United States have been able to absorb the large and growing cohorts of Mexican workers . tequila. . Illnesses considered cold are treated with hot foods and vice versa. are served as a vegetable or in desserts. Camotes. According to Migration Information Source. and pepitas. pulque. Herbal teas are used for medicinal purposes. papaya. “In the last several decades.” According to an article in the May 9. government-subsidized produce from the United States. In Yucatan. something like flan or fruit.oranges. . and dryness. but cities have restaurants that serve comida. One vendor explained: “It’s all up to me. Dessert is light. . mezcal. the number of street vendors has grown by 40 percent to more than 1. is a favorite in times of illness. The main course might be something like meat or chicken guisado (stew) or chiles rellenos. The main meal of the day. is the birthplace of mole sauce. Foods and Eating Habits Dietary Practices: Everyday Diet: Popular Foods: Beverages: Some Mexican Americans adhere to traditional hot/cold beliefs about keeping the body’s four humors (blood. are eaten fresh and in various dishes. black bile) in balance using qualities of heat. There aren’t any jobs.” Soccer is the most popular sport.3 million jobs in 2001. Even the growth of the maquiladora (exportoriented factory) sector along the border. yellow bile. Communal preparation and sharing of tamales is a strong Mexican tradition. followed by the sopa seca. Mexican cuisine is based on corn. unregistered businesses that provide cheap goods and services for low-income people but pay no employment taxes. is used on pork or chicken baked in banana leaves. Food is an important part of Mexican daily life as well as its festivals and celebrations. and coffee.5 million children between the ages of 12 and 17 were part of the labor force. between 40 and 50 percent of Mexico’s workforce is engaged in the informal sector. has not been able to provide enough job opportunities to Mexico’s growing labor force. which accounted for a record 1. but Mexicans also enjoy baseball and football as well as rodeos and bullfighting. Most people eat this meal at home. Industry employs the next largest group. Coastal Veracruz is noted for its fish dishes and unusual fruits. which starts with a soup course. flores de calabaza. and this would be followed by beans. including mango. 000 students were enrolled in primary schools. many of the students whose families emigrate from Mexico to the United States come from the southern states where education is poor. close to 88 percent of Mexicans suveyed identified themselves as Roman Catholics. many of whom work in the mornings to help support their families. and Las Posadas. and teacher-training institutes. There are vast differences in opportunity between urban and rural areas. racial and economic disparities. and Mexico is making slow progress toward improving its high school graduation rate. An Urban Institute study found that more than 1 million school-age children in this country were born in Mexico. Education Status: Primary School: Secondary School: High School: Higher Education: Nine years of education are required. Each state in Mexico has at least one public university. Some rural children are sent to cities to work in exchange for room and board and the opportunity to attend better schools. Catholicism was introduced to Mexico by missionaries who arrived with the Spanish. According to an article in Education Week. Following graduation from primary school. including Semana Santa. The National Autonomous University of Mexico City has more than 350. More than 3. served by an estimated 14. . Students who attend Preparatoria have a choice between a college-preparatory course and technical training. and who receive an inferior education. about 66 percent of 15-year-olds in Mexico were attending school.000 students were enrolled in Mexico’s secondary schools. Celebrating Diversity: Mexico.000 Catholic churches in the country. and funding often depends on political pressure and bribes. Geography.5 percent Pentecostal and Protestant Evangelical. which was 60 percent in 2002. Religion Roman Catholicism: Protestantism: In the 2000 census conducted by the National Institute of Statistics. the government reported an overall primary school completion rate of 62 percent. and afternoon sessions for poorer children. 14.000 students. Some city schools have morning sessions primarily for middle-class children.766.000 priests and nuns as well as 90. Many people blame a powerful national teachers’ union for resisting changes in teacher training and curriculum. some with campuses in several cities. The program reaches one-third of Mexico’s secondary school students. Migration and the need for children to be employed are two factors behind poor school attendance and graduation rates. cont.209. respondents identified themselves as roughly 4. In the 2000 census. There are still areas where schools do not offer all six primary grades. Many students attend secondary school through a world-renowned program. the Feast of Our Lady of Guadalupe. In the 1999–2000 school year. Students attend primary school for six years. Many holidays and celebrations revolve around the faith. In the 1999–2000 school year. The nation’s education system is widely acknowledged to be deeply corrupt. About 55 percent of the population reported attending religious services at least once a week. students attend the Secundaria for grades 7 through 9. Schools in cities and rural areas vary widely in resources and teacher qualifications. Estimates of the size of various Protestant groups in Mexico vary considerably. There are some 11. In addition. Telesecundaria. 19 percent said they attended once a month.000 laypersons.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 42 Respecting Differences. that broadcasts courses by government-owned satellite from Mexico City to schools throughout the country and in other Latin American countries. and Computation. and about 20 percent attended less than once a month. and the national average is nearly eight years. In November of 2003. In 1995. technological schools. some 5.000 schools are linked to a new network via the Internet. accounting for about 36 percent of all school-age immigrants to the United States. there are private universities. President Vicente Fox made education his top priority when elected. 000 religious associations registered with the federal government. and lack of access to health care contribute to a lessthan-optimal health profile. In 1995 there were 121 doctors per 100. with the state of Chiapas claiming a non-Catholic population of about 36 percent. salvia (sage) for diabetes and to prevent hair loss. Church organizations generally claim much larger numbers. and/or fruits. the “evil eye. but such diseases as pneumonia and influenza still pose grave threats and are among the top 20 causes of death. gobernadora (chaparral) as a poultice for arthritis or a tea for cancer and tuberculosis. Of nearly 6. and respiratory illnesses accounted for nearly 70 percent of deaths in 1940. including mal de ojo. unsanitary living conditions. 7. manzanilla (chamomile) for nausea and colic. “Cold” conditions include menstrual cramps. and Quintana Roo have large Protestant populations. parasitic. as are the verbero (herbalist). now catering to the Latinos who make up nearly 45 percent of the city’s population. Other: Health and Health Care Health Status: Traditional Practices: Medical System: As might be expected in a nation where more than half the people live on less than $2 per day. Another traditional healing system followed in Mexico is cantero or brujería. About 3. The curandero/a can assist with both physical and spiritual healing. pneumonia. Mexico has small Jewish and Muslim populations. malnutrition. and colic. and modern medicine. Common folk remedies used by Mexicans include ajo (garlic) for hyptertension or as an antibiotic. cont. An article from the Feb. homeopathic. Formal-sector workers and their families (about 50 percent of the population in 1995) receive health care through the nation’s social security program. 2005 Los Angeles Times discusses the large number—some 500 in Southern California—of botánicas. damiana as an aphrodisiac or for chickenpox. cities with large Hispanic populations are cooperating with curanderos to facilitate optimal care for Hispanic clients. or partera (midwife). herbal medicine shops. sobador (massage therapist). Spanish. a system of healing magic that originated in Africa. Health care facilities in some U. this figure had dropped to 20 percent by 1990.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 43 Mexico. and anemia. a combination of Aztec. The states of Tabasco. Campeche. and uña de gato for stimulating the immune system.000 persons for those covered by social security.S. spices. Jehovah’s Witnesses. Others receive health care from various government . measles. spirtualistic. and Seventh-Day Adventists also represented. hypertension. Organizations of traditional doctors have been formed in Chiapas and nationwide to work on regulating medical practice with the goal of favoring the use of traditional medicine and protecting places where medicinal plants are found and grown. balance may be restored by such things as correcting the balance of “hot” and “cold. Mexicans may attribute illness to an imbalance between the individual and the environment. with mainline Protestants. and indigestion. about 53 percent are Protestant evangelical and 47 percent are non-Protestant Christian. Curanderismo. In Chiapas. along with nutritional deficiencies.” which may affect infants or women. Female relatives or neighbors are often consulted.” which are intrinsic properties of substances and conditions. where a Catholic/Mayan traditional religion forms the basis for daily life and celebration. Home remedies are popular and include teas made from various herbs. Infectious. tensions between non-native Protestant evangelicals and indigenous residents has led to harassment and expulsion from communities. is used throughout Latin America. and indigenous religious practices are followed in many places. Health care workers might hear Mexican patients referring to any of a number of folk illnesses or conditions. Health care availability varies widely from urban to rural areas and within cities depending on income level and employment status.5 percent of respondents claimed to have no religion. Mormons. The Protestant population is found primarily in the southern part of the country. “hot” conditions include pregnancy. Important medical decisions may require consultations involving the entire family. Clients may ask for the provider’s opinion on choices. Overall. Nonverbal Behavior: Touching by strangers is often considered inappropriate or seen as disrespectful and can be stressful.S. who may wish to shield the patient from knowledge of the gravity of the illness. In 1997.618 physicians in Mexico in 1997. Tips for Health Care Providers Refer to the section on Working with Latino/Hispanic Clients (pp. Health care providers. citizens cross the border to purchase medications and for medical and dental treatment. Mexico City is the principle center for specialized medical care. Dying at home may be preferable. Clients may be more comfortable disclosing information to health care providers of the same gender. If the patient is Catholic. especially among men.506 hospitals in Mexico. Verbal Exchange: Health care providers should give clear explanations of medical conditions and options. Common antibiotics and other drugs available only by prescription in the United States are sold over the counter in Mexico. Relatives or family members may want to assist with the body and will probably request time alone with the body to say farewell. Some Mexican American patients may refuse foods based on the idea of hot foods being used to treat cold illnesses and vice versa. Stoicism is common when dealing with pain. make sure his or her priest or the hospital chaplain is available for appropriate rites. many U. New Year’s Day Dia de los Santos Reyes. Attitudes: Many Mexican Americans use both traditional practices and conventional Western medicine. Health care providers should determine who is the person in charge and be sure to include that individual in decision-making. as well as fear of deportation. Handshaking is considered polite and is generally welcome. agencies. 1. Celebrating Diversity: Mexico. Health care workers should be sensitive to the client’s request for such Catholic rites as baptism and the anointing of the sick. Celebrations and Holidays January 1 January 6 February 5 February 14 February 24 Año Nuevo. A study conducted in Los Angeles in 2000 found that many Latinos did not use available public health services due to language and transportation problems and perceived cultural insensitivity. Flag Day . Hospitalization: Family members are traditionally quite involved in care and may see hospital regulations as an impediment to their role.539 of them public. there were 147. but many Mexicans who can afford to do so travel outside the country for treatment and surgery. especially physicians. Many Catholic Mexican Americans believe the body must be kept intact for burial and so will resist autopsy and organ donation. there were 4. Death and Dying: Information about a terminal illness is often handled by a family spokesperson such as the oldest son or daughter. Addressing Clients: Clients should be addressed in a formal manner. Male physicians are generally accepted provided they show respect for modesty and privacy. The following information may also be useful. with fewer resources than those covered by social security. Public health care is generally considered inferior to that provided by private physicians and hospitals. Family Authority: The father or oldest male traditionally is the highest authority.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 44 Respecting Differences. cont. especially in the case of elders and women. Three Kings’ Day (Epiphany) Dia de la Constitución. Therapeutic touch is an integral part of traditional healing. Most sensitive health information is kept within the family. Valentine’s Day Dia de la Bandera. 17–18) for general guidelines to follow in working with patients from Mexico. Wailing is a socially acceptable sign of respect. using usted rather than tu if speaking in Spanish. who fail to show respect may be seen as racist or classist. Constitution Day Dia de la Amistad. citizens born in Mexico—these people form a subgroup of the permanent migrants. San Juan Bautista. Many communities clean and decorate graves with branches and flowers. between San Diego and Sonoma. New Year’s Eve Mexicans in the United States Fr. and skull shapes. more rural parts of Mexico. featuring a plastic skeleton baked into a rich dough.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 45 Mexico. Junipero Serra and other Spanish missionaries were the first Mexican presence in what is now California. mainly in agriculture. Cry of Independence: Marks the day Miguel Hidalgo announced the Mexican revolt against Spain. but whose primary residence is in Mexico. cont. family members tell stories about departed family members as they share food enjoyed by the departed. Cinco de Mayo: National holiday commemorating Mexican victory over the French in 1862. Nochebuena. Mothers’ Day Nationalization of Petroleum Industry: Commemorates the nation’s taking over oil producing properties from foreign interests. This miracle was recognized by the Vatican in 1745. Day of the Race Dia de los Muertos. roughly one day’s walk apart. Celebrates the three appearances of the Virgin Mary to Juan Diego. and feasting. movement between Mexico and the United States was relatively easy. migrants to the United States from Mexico can be divided into three categories: (1) sojourner or circular migrants—authorized and unauthorized migrants. music. Easter Sunday Primero de Mayo: National holiday honoring workers. dancing. Dia de la Raza.000 accepted the offer and are the ancestors of today’s fourth-. some 80. At the gravesites. feast of St.S. skeleton. as the living and the dead eat and drink together. but traditions vary considerably by region and town. John the Baptist Death of Benito Juarez El Grito de Dólores. Mexicans came to the United . just north of Mexico City in 1531. By 1823. millions of pilgrims come to the Basilica of Guadalupe. who come to the United States to work. It is believed that the spirits of the dead return to Earth to visit friends and relatives. Dia de la Revolución: Celebrates the Mexican Revolution of 1910. about equally male and female with higher education levels whose residence is in the United States. coming in 1769 to establish the presidio and Catholic mission of San Diego. citizenship with the promise of property rights. Early settlers were primarily farmers and ranchers. with the celebration being more important and elaborate in the southern. Christmas Eve Navidad. February/March March 21 March/April May 1 May 5 May 10 May 18 June 24 July 18 September 15 October 12 November 1 & 2 November 20 December 12 December 16–24 December 24 December 25 December 31 Carnaval (five-day celebration. and they created additional mixtures by marrying native California Indians. Most were of mixed racial background. 21 missions were strung along the California coast. feasting) Birthday of Benito Juarez Semana Santa. Mexicans living in the territories ceded to the United States in 1848 were offered U. Las Posadas: Festival celebrated with processions that commemorate the journey of Mary and Joseph to Bethlehem. Before 1929. and sixth-generation Mexican Americans. Dia de la Madre. Holy Week. fireworks. These meals are often elaborate and include a special Pan de Muerto. dancing.S. November 1 is also called Day of the Little Angels. According to the Migration Information Source. (2) settled or permanent migrants—authorized and unauthorized migrants. a poor Indian. generally young and primarily male with little education. as well as sweets in animal. Celebrations include parades. This is a festive occasion. The Day of the Dead is observed throughout the country. fifth-. begins the week before Lent—parades. Day of the Dead. Christmas Day Vispera de Año Nuevo. dedicated to children who have died. includes Holy Thursday. Feast of Our Lady of Guadalupe. Mexico’s patron saint (also called the Virgin of Guadalupe). and (3) naturalized U. Good Friday. similar to Labor Day. Hasta la vista. the occasion of a Mexican girl’s 15th birthday and entry into the adult world.S. Differences include: “ll” is pronounced “y. citizens. What happened? ¿Qué pasó? . States in the 1800s to work on railroad construction.6 percent (35. Language. Mexicans have continued to emigrate to the United States.S. accounting for three-fourths of the state’s population growth in the decade between 1990 and 2000. . 25). the stress falls on the next to the last syllable if the word ends in a vowel or the letters “n” or “s”. Establishment of the maquiladora districts in 1965 has brought millions of people from all over Mexico to border towns. These figures include native Hispanics. Spanish is pronounced much like English. you’re an American. Buenos noches. you’re a Mexican. De nada/No hay de que. Hello. that figure is expected to grow to 24.6 million people) of the U. Hispanics accounted for 12. .health-careers. Mexicans began migrating to the United States in large numbers during World War II when the United States asked for Mexican workers. During the Great Depression of 1931 to 1940. Good night. available at www.org. And you? Muy bien. Adiós. social programs. and they were recruited during World War I. Combined “minority” groups now make up a majority of the state’s population. people born in the United States of Hispanic origin. . braceros. with Mexicans from both urban and rural areas throughout the country seeking opportunities in the United States. .4 percent. with about 300. an estimated 458. “ñ” is pronounced “ny. offering education. See you later. . Good afternoon. Celebrating Diversity: Mexico. and foreign-born Hispanics of whatever citizenship status.S. provides words and phrases the health care provider can use with Spanish-speaking patients. Of these.” “h” is silent. which is quite different from the world of immigrants (U. Buenos tardes. not authorized to be in the United States. .” “j” is pronounced “h.6 million people. health care. Quinceañeras. As of the 2000 census.” Unless otherwise indicated by an accent mark. but the sheer size of the applicant pool and a recent downturn in the maquiladora industry have increased the number of undocumented individuals crossing into the United States. If you’re Mexican American and you go to Mexico. is widely celebrated in the United States. cont. Catholic. The movement is primarily motivated by the need for employment. Hola. population in 2000. The U. or 102.S. an estimated 4. gracias. more than half are undocumented. Useful Words and Phrases Spanish for Health Care Workers. . In a 2004 interview. on the last syllable if it ends in a consonant. Y usted? What is your name? ¿Cómo se llama? My name is .000 per year coming across the border either legally or illegally in the 1990s. Most of the world is either Mexican or American. So what you learn to do is hang out with your own kind. . to contribute to the war effort by providing temporary agricultural labor in this country. You’re welcome. by 2050. .000 Mexican Americans were repatriated and deported back to Mexico. The church often serves as a center for support and socialization. Me llamo . From 1942 until the bracero program ended in 1964. Good morning. If you’re in this country. Goodbye.-born Latino. thank you. Gracias. Yes/No Sí/No Thank you. How are you? ¿Cómo está? I am fine. Buenos días.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 46 Respecting Differences. 32 percent of Californians were Hispanic.S. Census Bureau estimates that there are more than nine million Mexican immigrants living in this country. a Roman Catholic priest with Mexican and Guatemalan roots serving in East Los Angeles stated: I think Mexican Americans have a very small social space. about one in five are naturalized U.5 million workers came to the United States from Mexico. and assistance with immigration matters. a place for celebrating and organizing. There’s a bit of schizophrenia that you learn to negotiate when you’re a U. html (8 May 2005). 21 Dec. 2004). Hilary. 2004). Dudley. 2005. 1 Feb.bbc.org/mexicol. http://countrystudies. Habitat for Humanity Mexico. 2004). San Francisco: University of California San Francisco Nursing Press. “Foreign-Born Hispanics in the United States.” Habitat World.com/features/ (9 Feb.uk (23 Feb. http:// www. “Mexico: A Brief History. Cevallos.allrefer.uk (23 Feb.fm (24 Mar.mpl/ special/mexnewsun/752137 (24 Mar. “Building Dreams . Grieco. http://www3. Country Study and Guide.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 47 Mexico. Mexico. “Mexico Runs on Sidewalk Economy. Lee. and Houses.com/cs/CDA/printstory. 2004). Daniel. 2003. http://www.html (28 Feb. 2004).latimes.org/Profiles (5 Mar. Cecilia. Learning through TV and Internet in Mexico. . Library of Congress.lonelyplanet..bbc. Multiculturalism and Native Issues Centre.com/destinations/north_america/mexico (23 Feb. http://newsvote. “Mexico: A Crucial Crossroads. 2002.html.org/intl/countryprofiles. 2001. University of Toronto.” Migration Information Source. http://www. Federal Research Division.baylor. 9 May. Country Profile: Mexico. Country Studies: Mexico..chron. 2000. Kemp. http://reference. http://reference.com/country-guide-study/mexico/mexico52.cia. 22.settlement. 2004).com/ dailystar/printDS/3119. Timeline: Mexico. 2004). 2004). http://www. 2004). Faculty of Social Work. 2000. 20 Nov. BBC News. http://newsvote.habitat. Mexico. 2005.org (5 Feb. 2005.co. 2005). Lonely Planet World Guide: Destination Mexico.unesco. No. Susan. Area Studies. Mexico.” Los Angeles Times. “A People in Want. 7 Feb. http://www. July. http://www. 2004).com/cs/CDA/printstory.allrefer. http://www.com/days/m2. Mexico: Health and Social Security.” Migration Information Source. 2004). Juliene G.org/education/efa/know_sharing/ grassroots_stories/mexico_3. 2002. et al.” Houston Chronicle. 2004). Vol. 2005.edu/~Charles_Kemp/ hispanic_health. Culture and Nursing Care: A Pocket Guide. Mexican and Mexican-Americans: Health Beliefs and Practices.htm (21 Mar.migrationinformation.mpl/special/ mexnewsun/752144 (24 Mar.com/country-guide-study/mexico/mexico52. eds. 2004). Diego. 2004). Are you cold? Are you hungry? Are you thirsty? breakfast lunch dinner Do you need to go to the bathroom? Do you want to sit up? I am going to take your temperature.lingnet. http://www.shtml (24 Mar. . Charles.us/mexico (25 Mar.co. Anti-Racism. Canada. Basic Facts. Lipson. Marla.shagtown. BBC News. Where does it hurt? Let me help you. 1997. Dickerson. http://www2. http:// www.org/cp/english/guatemala (29 Feb. References Alba. Elizabeth. 2003. http://www.php (24 Apr. 1. ¿Tiene frío? ¿Tiene hambre? ¿Tiene sed? desayuno almuerzo cena ¿Necesita ir al baño? ¿Quiere sentarse? Voy a tomarle la temperatura. “Mexico.azstarnet. 2004).html (23 Mar. 2004). Central Intelligence Agency. ed. ¿Dónde le duele? Déjeme ayudarle. http://www.” The World Factbook.htm (21 Apr. “Mexico Lags in High School Graduation.gov/cia/publications/factbook/geos/mx. Latin America: Mexico.” Los Angeles Times. http://wrc. .chron. “Mainstream Medicine Is Beginning to Explore the Aisles of Botanicas. http://www. 21 Nov. cont.latimes.” Houston Chronicle. Ferriss.” Arizona Daily Star. MacGregor. Encyclopedia of Days. Rebekah.com/business/la-fi-vendors (9 May 2005).migrationinformation. Althaus. Francisco. S. An Introduction to Mexican Culture for Rehabilitation Service Providers. 2004. 2004). http://spanishabroad.state.com/mexico/country_guide/mex_dotd.com/food/ethnic_cuisine/mexico.” San Francisco Chronicle.htm (25 Feb. 20 March.htm (25 Mar. ———. Human Rights. 2003. http:// news. U.cr. 2004). Society and Conduct. Mary Ann. Catholic.S.gov/g/drl/rls/irf/2002 (28 Feb.DTL&type=printable (18 Mar. Thompson.sallys-place. Department of State Bureau of Democracy. ———. Mexico.htm (25 Feb. 2005).” U. New York: Palgrave MacMillan. http://www. eds. 2004). Zehr. SVD. http://gomexico. Raymond. Sandra. 2004). Day of the Dead.htm (25 Feb. 23–28. National Park Service.public. Morgan and P. The Culture.” El Observador.h21 (23 Mar. 2004). to Look a Lot Like Californa by 2050. et al.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 48 Respecting Differences. Vol. and Felipe Santana. cont. http://cirrie.edu/~rjsalvad/scmfaq/muertos.” Education Week. ———. http://spanishabroad. 2004). Study Abroad in Mexico. 2001. 2004). 2002. G. “Educating Mexico. II. Riebe-Estrella. http:// www.cfm (24 Mar. http://spanishabroad. 2004). http://www.cfm?slug=27mexico. 2004).html (17 Feb. 2003. Ginger. A Brief History. 2003.organicconsumers. Nigenda. The Statesman’s Yearbook: the Politics. 2001.about. Seligman. ———.mx/salud/43/eng/i43_5. . Laungani. “U.pdf (21 Apr.edweek.html (24 Feb. 2004). 2004). http://www. Mexican Public Holidays. Gary.buffalo. Barry. The Festival of Our Lady of Guadalupe. Fr. http://www. Katherine.com/ cgi-bin/article.com/news/view_article. “When Worlds Collide: Culture Clashes Coming to a Parish Near You. 2004). 2002.gov/history/online_books/5views/ 5views5. and Labor. John D. Rosario. 2001.html (5 Feb. Value and Meaning Series.com/mexico/country_guide/mex_society. 2005).htm (25 Feb. Santana.htm (25 Mar. Center for International Rehabilitation Research Information and Exchange.htm (24 Mar. http://www.about. http://sfgate. Salvador. 2004).com/mexico/country_guide/mex_food. Death. Cultures and Economies of the World.ncmonline. “The Practice of Traditional Medicine in Latin America and the Caribbean” Salud Publica de Mexico 43:41-51. 2004). Globalization Is Killing Mexican Agriculture.edu/mexico. http://spanishabroad. ed.com/cs/mexico/public_holidays_p. 2004.iastate. “What Do Mexicans Celebrate on the Day of the Dead?” Death and Bereavement in the Americas. Ricardo J. Celebrating Diversity: Mexico. International Religious Freedom Report 2002: Mexico.org/ew/ ew_printstory. “Spanish Being Embraced by Californians of All Backgrounds.S. Vital. ———. 4 Dec. Traditional Food. Resendes. www.insp. Sosa.nps. NY: Baywood.com/cs/mexico/a/lady of guadalupe_p.htm (25 Feb. http://gomexico. Elaine. http://spanishabroad.org/corp/ mexglobalization. 18 Mar. Amityville.com/mexico/country_guide/mex_culture.cgi?file=c/a/2004/03/18/MNGTB5MUOG1. 2004). A History of Mexican Americans in California.com/mexico/country_guide/mex_history. Turner. December.htm (25 Feb. country divided into 14 departments. corn. services 65. Amerindian 1%. geothermal power. dollar (USD) mestizo 90%.673 (4. sugar.336 (2. offshore assembly exports. dairy products coffee. sugar.22 years 36.704.6%) 359. textiles. smallest. president serves five-year term. most densely populated country in Central America 21. fertilizer. textiles. Other 23% Republic of El Salvador: capital San Salvador.932.1%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 8.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 49 El Salvador Census Figures (2000) United States Residents Born in El Salvador: California Residents Born in El Salvador: 817. sorghum.S.2% U.85% coffee. shrimp. beef. Legislative Assembly popularly elected.1% 80. petroleum 31. cotton. Nahua Roman Catholic 55%. industry 17. chemicals. departments divided into districts in which municipalities are governed by elected council. tropical. White 9% Spanish (official).124 sq.57 years 1. shrimp.8% . electricity food processing. light metals agriculture 17. petroleum. Protestant 22%. rainy season May–November volcanoes. furniture. rice. oilseed.1%.75% 71. mayor. hurricanes hydropower. beverages. chemicals. earthquakes. miles (slightly smaller than Massachusetts) 6. beans.1%. the FMLN and the government signed a UN-sponsored peace accord in which the FMLN was recognized as a political party. and Martí was executed. Traditions Housing: Family: Cities are very crowded as people come from rural areas seeking work. San Salvador. have caused the traditional family unit to break down.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 50 Respecting Differences. The few wealthy live in neighborhoods protected by high walls and security systems. . The Pipil economy was based on maize (corn). Women may begin living with a partner very young.S. 30. It is estimated that one-third of Salvadorans live abroad. Children are brought up to show respect to their elders. In about 1200 AD.000 peasants and Indians were killed. cement blocks and other sturdier materials are being used for homes. Most live in one-room apartments with communal facilities.-backed military and its death squads. In 1524 the Spanish conquistador Pedro de Alvarado arrived in El Salvador. human rights campaigner Archbishop Oscar Romero was assassinated while celebrating Mass. astronomy. Boys are encouraged to show machismo. Older family members tend to be looked up to because of their age and experience. especially since the coffee market downturn. Brief History The Olmec people established settlements in the western part of El Salvador by 2000 BC. Women who never marry continue to live at home until the parents die. President Gerardo Barrios introduced coffee cultivation in 1859. running the home while other family members work for wages. Housing. right-wing ARENA candidate Tony Saca was elected president with 57 percent of the vote. Then they may live with a close relative. Because so many men were killed in the long civil war. and trade routes extending over two continents. 90 percent of the land was owned by 5 percent of the population. Family. Augustine Farabundo Martí organized a peasant uprising to protest injustices. The present-day FMLN. most homes are adobe with dirt floors and thatched roofs. This can take up to 15 years and often does not happen. The poorest urban residents live in shacks made of cardboard or tin on riverbanks or in ravines. The father or mother often emigrates to find work and make enough money to allow the family to join them for a better future. the first civilian president since 1931. Work. In 1961. In 1998. at least 25 percent of households are headed by women. usually a male. establishing death squads to deal with rising popular unrest and guerilla activity. Most families include two or three generations living together. often having children in their teens. following a coup. Spanish settlers established plantations of cotton. balsam.000 Salvadorans were killed. Civil war broke out in 1979 as peasants rose up to protest 60 years of brutal military rule. Land of Jewels— from Mexico following the collapse of the Maya empire. Jose Napolean Duarte. and they had a complex culture including laws and taxation. José Matias Delgado. In rural areas. came to El Salvador—which they called Cuzcatlan. Following the devastating earthquakes of 2001. was elected in 1980. but a few wealthy colonists controlled most of the land. Often the grandmother is very important. War and high unemployment. conquering it for Spain in 1540. At the time. El Salvador gained independence from Spain in 1821. pitting the FMLN against the U. In March 2004. Middle class individuals live in row houses or apartments. One-third of all Salvadorans live in the capital.” Between 1972 and 1991 some 80. the right-wing National Conciliation Party (PCN) gained control of the government. In 1992. earthquakes in 2001 killed 1. most in the United States. and indigo and destroyed much of the indigenous culture. In 1932. Hurricane Mitch devastated coastal areas. known as the “14 families. is named for him. Frente Martí Liberación Nacional. The very poor live in huts made of woven branches covered with mud.200 Salvadorans and left millions homeless. and girls are trained to be modest. the Pipil. hieroglyphic writing. descendants of the Toltecs and Aztecs. and it has been a major crop ever since. In 1980. cont. toughness. Celebrating Diversity: El Salvador. mathematics. Adult children usually live with parents until they marry. President Maximiliano Hernandez Martinez ruled as a dictator from 1931 to 1944. Following a revolt organized by Fr. they are often exploited and forced into prostitution. and coffee. Coffee with tortillas or bread is a common breakfast. These are often eaten for breakfast. Hojuelas is a corn dish eaten with honey during All Saints’ Day celebrations. and/or bacon. and coffee (plus meat if affordable). nearly one-tenth of them never begin school. and fried plantains form the basic diet of most Salvadorans. Town plazas are important gathering spots. and fruit. from age 7 to 15. Education Status: Primary School: Many children in rural and high-poverty areas do not have access to schools. Horchata is a drink made of roasted rice flour mixed with milk or water and sweet spices.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 51 El Salvador. for nine years. cheese. the one non-work day. and other fish. mashed refried beans. Although primary school is free. The country has the highest concentration of manufacturing in Central America. Casamiento. a mixture of rice and beans. rice. Cebada is made of barley flavored with cinnamon. basica. beans. meat. and many do not complete primary school. Pupusas are internationally famous and consist of toasted corn or rice tortillas filled with pumpkin flowers. No dietary taboos. Employment: Recreation: About one-third of Salvadorans support themselves by farming. fried plantains. and other items for export. and powdered pumpkin seeds. black beans. Soccer is a favorite national sport. sweet corn gruel. Children may begin working at a very young age to help support their families. Human Rights Watch recently studied Salvadoran children employed as domestic workers. with most towns having stadiums and villages having playing fields. made from sugar cane. fried plantains. tortilla. Getting together around the dinner table is an important family tradition. Atol de elote. tortillas. mostly maquiladoras. gruel made from dark corn. Prosperous Salvadorans might eat a breafast of eggs. The school year in El Salvador runs from February through November. cheese. Foods and Eating Habits Dietary Practices: Everyday Diet: Popular Foods: Beverages: Some Salvadorans subscribe to the hot-cold theory of illness and treatment by opposing foods. crab. Coyoles and torrejas are special sweet foods eaten during Holy Week or Easter. Children attend compulsory primary school. They found that 25 percent of children in domestic service began working between the ages of 9 and 11. they may work in factories. prepared with fermented pineapple peel and cashew. and attend special night schools designed for them. According to Human Rights Watch. and torito and tic-tack. Many children work as street vendors. salad. They do not like ice in beverages. Frescos/refrescos or liquados are made of tropical fruits. especially on Sundays. rice. many children in the capital city of San Salvador work as domestics as many as 16 hours each day. cont. Tamales are very popular. They are popular at special celebrations. Coffee and hot chocolate are popular. Alcoholic beverages include chicha. and shuco atol. are popular drinks. Pasteles de chucho is a dish of fried yucca and beef patties. Mariscada is a fish stew including lobster. Beverages are usually served at room temperature. and many teenaged children are kept at home to care for younger siblings and assist in housework or in the fields. lunch might be soup. and deep fried. Many people eat them at small restaurants called pupuserias. . eaten with spicy pickled cabbage and special hot sauce. Many foods and drinks are made of corn. Most urban families now have television and cell phones. Fast food is becoming very popular. dinner would be mashed beans. clothing. made into crescent shapes. furniture. Others cannot afford to attend. shrimp. Pasteles are pockets of corn flour dough stuffed with meat. producing textiles. They may own small plots of land or work on large estates. Migration interferes with school attendance. In the cities. the church under Archbishop Luis Chavez Gonzalez began taking an active role in seeking to better the lot of the campesinos. Celebrating Diversity: El Salvador. Following primary school. Open sewage is a health threat in cities. four U. and health. uniforms. In the late 1960s. Until the 1930s. In San Salvador today. . Most towns have a patron saint who is honored annually. liturgy. often in base communities that functioned like extended families. 1989. 1980 while saying Mass. Secondary School: Higher Education: students must buy uniforms and supplies and may pay an enrollment fee each year. On November 16. Also in 1980. Many people suffer from chronic malnutrition and illnesses linked to unsanitary conditions. established in 1841.000 lay leaders received training in Bible.S. Preventable diseases such as measles are still prevalent. The government operates universities. The nation’s celebrations and holidays revolve around Roman Catholic saints and feast days. Classes run from February to December and are conducted in Spanish. the clergy became more involved in the life of the people. Protestant missionaries. Archbishop Oscar Romero. where Catholics meet twice a week to support one another in faith and life. Preschool is offered but not required. cont. The University of El Salvador. cooperativism. with 10 to 60 members each. Right-wing groups opposed these efforts. and impure water continues to cause cholera outbreaks. one offering a college preparatory degree and the other a technical/vocational degree following three years of coursework. media. have been active in El Salvador at least since the Central American Mission was established in El Salvador and Guatemala in 1898. following Vatican II. leadership. During the rainy season. door-to-door evangelizing. Health and Health Care Health Status: About a quarter of the Salvadoran people have no access to health services. Religion Roman Catholicism: Protestantism: About 55 percent of Salvadorans are Roman Catholic. During the civil unrest related to longtime repression of the majority by landowners and politicians. was assassinated on March 24. Chavez’s successor and a champion of the poor. six Jesuit priests and their housekeeper and her daughter were killed at the University of Central America by members of the Salvadoran army. primarily from the fundamentalist and evangelical denominations and sects. Missionaries in the 1970s and 1980s used crusades. School fees. and direct food and health aid to spread their message of personal salvation through faith in Jesus. Many private schools are operated by the Roman Catholic and other churches. students have a choice of three-year courses at two kinds of secondary school. radio programs. However. and national schools of agriculture and physical education. a leading killer of children under age five. Public and private universities and specialized institutions provide higher education. religious women were abducted and killed by national guardsmen. leading to dysentary. especially during the economic depression and political repression of the 1930s. The curriculum is similar to that of the United States. waste materials are washed into the drinking water supply. Most British and German immigrants were Protestant. Protestantism grew steadily.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 52 Respecting Differences. and a third do not have clean drinking water. Their emphasis on putting up with the trials of this life while awaiting a heavenly reward continues to appeal to many people as well as to those in political power. the Catholic Church was conservative. In the late 1970s. agriculture. The late Pope John Paul II silenced liberation theologians who sought to bring about social reforms. has schools of law and medicine. there are 53 base communities. which views them as overly political. some 15. technical institutes. and supplies cost up to $300 per year. there is much opposition to these communities from the conservative church hierarchy. mal de mayo. health care practitioners should inform that individual. Attitudes: Traditionally. the President attempted to allow U. Employees of formal businesses participate in a social security program that provides medical insurance. it is customary for several women to participate in labor and delivery. Women may be shy and prefer a woman physician. Mint or chamomile tea is a remedy for stomach ache. especially in rural areas. who may not want the patient informed. Traditional Practices: Medical System: Brujeria is the Indian tradition of natural healing presided over by curanderos who perform special rituals and/or prescribe natural remedies of herbs and spices. Death and Dying: Diagnosis of terminal illness should be given to father or eldest son. like priests and teachers. Catholics will want a priest to administer the sacraments. Herbs are used instead of commercial medications among older people. Many Salvadorans will seek help from traditional healers or pharmacists before Western physicians. Addressing Clients: Although most Salvadorans understand Spanish and may have some English. and would not question their authority. Massive strikes and demonstrations led to agreements in June 2003 between the government and health care unions that appear to have stopped the government’s attempt at privatization. and meat are believed to strengthen the mother. under pressure from the World Bank and the Inter-American Development Bank. Verbal Exchange: Procedures should be explained carefully.S. Nonverbal Behavior: Touching between members of the same sex is accepted. . applies to El Salvador as well. and good health may be associated with the ability to perform their daily tasks. Chicken soup. Semana Santa: Good Friday celebrated with music. Global Policy Forum reports that many people cannot pay the “voluntary contribution” required for health care services. In 2002. They believe health is related to the balance of hot and cold. A study conducted in Los Angeles in 2000 found that many Latinos did not use available public health services due to language and transportation problems and perceived cultural insensitivity. The information on traditional practices in the section on Mexico. Tips for Health Care Providers Refer to the section on Working with Latino/Hispanic Clients (pp. processions. workers compensation. Hospitalization: Salvadorans may be stoic in enduring pain. Celebrations and Holidays January 1 March/April New Year’s Day Holy Week. as well as fear of deportation.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 53 El Salvador. Family members may wish to prepare the body for burial and to stay with the body to say goodbye. cont. Family Authority: The father or eldest son is the primary decision-maker. Private hospitals are also available. Salvadorans and other Central Americans may have difficulty understanding such concepts as patients’ rights and informed consent. multinational HMOs to take over the health system. Salvadorans have held their physicians in great respect. Address clients in a formal manner. and disability pensions. 17–18) for general guidelines to follow in working with clients and patients from El Salvador. The Ministry of Health operates 30 hospitals as well as clinics in rural areas. Other citizens depend on government-subsidized care. perhaps due to the cost involved. Many Salvadorans would prefer to die at home with family. Many Salvadorans use these complementary treatments in addition to consulting physicians. Coconut water is used as a diuretic. Organ donation may be accepted if the body is treated respectfully. others may speak native languages. page 44. and sliced raw tomatoes are used for severe burns. Cremation is not common. New mothers are to avoid cold foods and drinks as well as strong emotions. bananas. During childbirth. In cases of terminal illness. Over-the-counter medications are widely used. The following information may also be useful. The crowd shouts “Viva El Salvador. writing in The Christian Science Monitor: “More than a quarter of El Salvador’s 6.5 billion back to El Salvador each year. The Salvadorans send about $2. a replica of the statue was brought to Mission Dolores in Los Angeles. .” referring to both the savior and the nation. children dress up in Indian costumes and accompany the Virgin in procession. a member of the U. Salvadorans in the United States According to Catherine Elton. which means “the descent. high unemployment and a large pool of men with military or police experience — many of whom were U. It takes its name from the fact that campesinos from the surrounding hills come down to the city to honor the saint.S. who have spent many years working with and studying immigrants in Los Angeles. All Souls’ Day First Call for Independence Day: Commemorates the 1811 battle for independence from Spain. Families decorate crosses in their front yards with flowers.-led military coalition in Iraq. 2005. nativity scenes.. Nearly one-third of the population lives outside the country. area.S.C.” Elizabeth DiNovella. In March 2001. An exceptional resource for understanding health care clients and students from El Salvador is the recent book Seeking Community in a Global City: Guatemalans and Salvadorans in Los Angeles. about 15 percent of the country’s gross national product. writing in The Progressive. families attend midnight Mass. children receive gifts from El Niño. About half a million Salvadorans live in the Washington. aggressively recruiting in El Salvador.S. viewing it as an ideal source of guards. 9. . where nearly 60 percent of the Salvadoran immigrants to the United States live. On Jan. The festival features a statue of El Divino Salvador dressed in purple robes being lowered into a globe representing the world. Traditional celebrations take place on Christmas Eve. the residency and work permits were extended for a second time. their immigration to the United States. the United States granted Temporary Protection Status (TPS) to Salvadorans fleeing the devastation of the massive earthquakes of January and February. The country has low wages. nearly 1 million.S. The authors. states: “Most Salvadorans I meet have a family member who is living abroad. D. Many families have elaborate nacimientos. private U.trained — from the 12-year civil war that ended in 1992. and their adaptation to U.S. Dia del Padre. fruits. May 1 May 3 June 17 June 22 June August 6 September 15 November 2 November 5 December 12 Christmas Labor Day Day of the Cross: This festival is believed to have originated in an Indian festival honoring the rain god and praying for rain before being appropriated by the Spaniards into a celebration honoring the cross. Celebrating Diversity: El Salvador.” More than 2 million Salvadorans live in the United States.5 million citizens live in the U. He likens the flow of remittances to a life-support system for the country’s poor economy.” .000 Salvadorans took advantage of the opportunity to receive special visas allowing them to live and work in the United States and send money back to family members in El Salvador. in Los Angeles. Independence Day: Commemorates the declaration of independence of Central America from Spain in 1821. provide an excellent history of the two groups. The statue reemerges dressed in white robes representing the transfiguration. Fathers’ Day Schoolteachers’ Day Corpus Christi La Bajada: Celebrated throughout the capitol. culture. and paper ornaments and participate in a ceremonial adoration of the cross. the baby Jesus. firms are now .○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 54 Respecting Differences. 2006. until Sept.” honors the nation’s patron saint. military unable to meet security needs in Iraq. 6. The Washington Post reported: “With the U. Virgen de Guadalupe: To honor the Virgin of Guadalupe. about half in California with the majority of those. In 2003. and Salvadoran economist Robert Rubio estimates that remittances account for 16 percent of the country’s economy. Salvadorans were being recruited in 2004 to help the United States fight the war against Iraq. La Bajada. patron saint of Latin America. Some 248. San Salvador. describing their persecution and dislocation within Latin America.S. cont. co.org/english/Newsletter/index.” “j” is pronounced “h. Differences include: “ll” is pronounced “y.org/english/ docs/2004 (25 Feb./Aug.htm (21 Mar. provides words and phrases the health care provider can use with Spanish-speaking patients. Buenos días. Are you cold? ¿Tiene frío? Are you hungry? ¿Tiene hambre? Are you thirsty? ¿Tiene sed? breakfast desayuno lunch almuerzo dinner cena Do you need to go to the bathroom? ¿Necesita ir al baño? Do you want to sit up? ¿Quiere sentarse? I am going to take your temperature.htm.edu/elsalvador.cispes. Basic Facts. Good morning.unicef. Human Rights Watch.org/infobycountry/elsalvador/html (23 Feb. Committee in Solidarity with the People of El Salvador. Hasta la vista. 2001.buffalo. .S. gracias. Buenos noches. Adiós. Hello. .org/elsalvad. Good night. . 2004). Goodbye. Betancur. 2004). http://wrc. the stress falls on the next to the last syllable if the word ends in a vowel or the letters “n” or “s”.health-careers.bbc. Buenos tardes. 2004). . Area Studies. http://www. References “Abuses against Child Domestic Workers in El Salvador. From Madness to Hope: the 12-Year War in El Salvador: Report of the Commission on the Truth for El Salvador. 2004). http://newsvote. “A People’s Victory: Healthcare Workers Defeat Privatization. . Useful Words and Phrases Spanish for Health Care Workers. See you later. Eileen Giron. on the last syllable if it ends in a consonant. Language. Jul. Batres.” “h” is silent.usip.” The World Factbook. http://www. De nada/No hay de que.gov/cia/publications/factbook/geos/ es. Yes/No Sí/No Thank you. 2005.” 2004.cia. Voy a tomarle la temperatura. . . An Introduction to the Culture of El Salvador for Providers of Disability Services in the U. http://www.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 55 El Salvador.lingnet.org. thank you.uk (23 Feb.html (24 Feb. 1993. Latin America: El Salvador.html (24 Feb. “El Salvador. Country Profile: El Salvador. How are you? ¿Cómo está? I am fine. Good afternoon. 2004). Central Intelligence Agency. http://hrw. http:/ /www. UNICEF.org/library/tc/doc/reports/el_salvador/ tc_es_03151993_toc. “ñ” is pronounced “ny. (25 Feb. United States Institute of Peace. available at www.cirrie. And you? Muy bien. 2004). Gracias.html (8 May 2005). Spanish is pronounced much like English. Me llamo . Déjeme ayudarle. 2004). Belisario. El Salvador Watch. 16:1(B) Jan. You’re welcome. At a Glance: El Salvador. What happened? ¿Qué pasó? Where does it hurt? ¿Dónde le duele? Let me help you.” Unless otherwise indicated by an accent mark. Hola. Y usted? What is your name? ¿Cómo se llama? My name is .” 2003. cont. et al. http://www. BBC News. /Dec.html (11 Feb. ed.elsalvador. 2004). Faculty of Social Work. and Paul Jeffrey.” Dateline.washdiplomat. http://www. Luxner. The Statesman’s Yearbook: the Politics. Police Officers.shtml (25 Feb.html (11 Feb. a Religious Turf War.” Washington Post. 2004).shagtown. Lonely Planet World Guide: Destination El Salvador. http://campusapps. U. Elton. Orleans.com/destinations/central_america/el_salvador (23 Feb.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 56 Respecting Differences. United States Extends Temporary Protected Status for Salvadorans. et al. Solomon. 2004). Christian Foundation for Children and Aging.com/03-09/a6_03_09. “Poor Salvadorans Chase the ‘Iraqi Dream’: U. 2003.” Upstream Journal.com/days/elsalvador. Kellerman. http://www. Embassy of El Salvador in the United States. “Salvadorans’ Stay in U. http://lcweb2.A.com/2004/0319 (23 Mar. Multiculturalism and Native Issues Centre. 2005). Chu. 1988. New York: Palgrave MacMillan.edu/news/people/2004/print/solano/html (28 Feb.html (29 Feb.settlement. 9 Dec.gov/wh/Archive/2005/Jan/07-910002. 2005. 2002.htm (23 Feb. “El Salvador Food Fest. 2004). Holidays: El Salvador. Celebrating Diversity: El Salvador. 2002. El Salvador.” Los Angeles Times. http://www.org/ Prensa (11 Feb.gov (23 Feb.com/ElSalvador.cfcausa. 2005.org/countries/ElSalvador/ElSalvador. 2004).: A24 (11 Feb. http://www. “Salvador: From the Bullet to the Ballot. El Salvador. Now in Disarray. Sullivan. “Base Communities. Barry. Cultures and Economies of the World. Elizabeth. Hamilton. 2005). Anti-Racism. San Francisco: University of California San Francisco Nursing Press. to Be Extended. University of Toronto. http://www. Salvadorans. 2004). “In Latin America. Culture and Nursing Care: A Pocket Guide. California State University. 19 Mar.S. http://www.holidayfestival. 2004). El Salvador. and Norma S. http://commongroundradio. Turner.” Los Angeles Times. 2004).org/cp/english/elsalvador (29 Feb. 15 April. 2005).loc. Larry. “Fighting the Privatization of Health Care in El Salvador. Community Leader. 2003.. 2004. . 5 Feb. Federal Research Division. Barbara.html (28 Feb. Catherine. Fullerton. 2003.org/shows/03/0319. 1997.S. 2004. Pereira-Papenburg. Kevin. DiNovella.S. Gloria. Sept. 2003. http://www. Philadelphia: Temple University Press. eds. 2004. 2004). Seeking Community in a Global City: Guatemalans and Salvadorans in Los Angeles. “El Salvador Vote Recalls Cold-War Power Play.org (26 Feb. Nov. http:// usinfo.” The Christian Science Monitor. http://www.globalpolicy. Henry.org/socecon/bwi-wto/wbank/2002/novdecelsal.latimes. 7 Jan. Country Studies: El Salvador. Encyclopedia of Days..: 12–16. Nora. Maureen.com/news/ nationworld (15 Apr.state. 2004. Lipson. Security Firms Find Eager Recruits Among Former Soldiers. Canada.elsalvador. Department of State. “El Salvador’s Ambassador León Both Diplomat.htm (24 Feb.” Washington Diplomat.” National Catholic Reporter. Library of Congress. 2004. and Swarnalatha Vemuri. Chinchilla.fullerton. 2005. http:// csmonitor. 6 Jan. May 13. cont. http://www.” The Progressive. 2004). March: 26–29. http://www. 12 Nov. “Professor Studies ‘La Bajada’ Among L. 2001. Fraser. Moore. 2005). Once Hope of Church.lonelyplanet.” Common Ground Radio. 2005). 2004). Valerie. Juliene G. dollar (USD) Mestizo/Ladino. textiles and clothing. country divided into 22 departments. fish. nickel. chickens coffee. rare woods. hurricanes petroleum. Amerindian or predominantly Amerindian. tropical. beans. miles (slightly smaller than Tennessee) 14. petroleum. Whites and Others 2% Spanish 60%. earthquakes.57% 65. Protestant. bananas. approximately 43%. sheep. furniture.189 18. metals. cattle. U.14 years 75% 70. rubber. petroleum.5%) 211. bananas.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 57 Guatemala Census Figures (2000) United States Residents Born in Guatemala: California Residents Born in Guatemala: 480. sugar. pigs. coffee. Guatemala City is the capital. services 35%. approximately 55%.458 (2. rainy season May–October volcanoes. one-house Congress. chicle. fruits.47 years 2.5% sugarcane. corn. members elected for five-year terms. electricity sugar. a democratic republic: president serves five-year term. meat. Amerindian Languages (23)–40% Roman Catholic. Indigenous Mayan Republic of Guatemala.4%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 42.S. tourism agriculture 50%.042 sq.6% quetzal (GDQ). apparel. cardamom.655. hydropower 12. chemicals. industry 15% .665(1. vegetables. cardamom. some 100. When he began expropriating foreign-owned land. acting to protect the vast holdings of United Fruit Company. Rigoberto Menchu. however. Juan Jose Arevalo became president in 1944 following the overthrow of repressive president Jorge Ubico. In 1981. Guatemala gained its independence in 1821. Mayan women have woven the fabric on backstrap looms for two centuries. Those who objected were massacred. Arevalo introduced democratic reforms such as land redistribution and social security. “The huipil is the ultimate . the U. the military candidate. as governments encouraged foreign investment. he modernized the country and introduced coffee as a cash crop. In 1996. with Mayan groups or indigenas. those who follow a more Westernized lifestyle and speak Spanish. backed a coup that brought Colonel Carlos Castillo to power in 1953. ending 36 years of civil war in which an estimated 200. They far outnumber ladinos. Exploitation of indigenous peoples continued. Rural houses might be adobe enclosures for sleeping with a packed earth floor and a tin or thatched roof. Democratic rule was restored in 1966 with the election of Cesar Mendez. and most obtain water from public taps or privately owned water trucks. Guatemalan textiles are famous around the world. As Guatemalans adopt more North American values. The largest groups are the Kiche. paving the way for Spanish colonization. death squads and the military killed 11. Guatemala has the highest proportion of indigenous people of any Central American nation. cont. Housing. Celebrating Diversity: Guatemala. Squatters receive no city services. Mayan civil rights activist. CIA. Traditions Housing: Family: Indigenous Peoples: Traditional Textiles: Recent estimates suggest that more than half of Guatemalans. A clean water supply is one of the city’s critical problems. President Alvaro Arzu signed peace accords with the guerillas.000 people and left more than a million homeless.000 people had been killed and 40. padrinos. In 1873.000 were among the missing. the population will double every 22 years. The city nearly doubled in population between 1955 and 1995 and is now home to more than 3 million residents. By 250 AD. By 1989. The various linguistic groups tend to cluster in separate areas. Castillo was assassinated in 1963. live in inadequate housing. family structures are changing. was elected. the Maya were building great temple cities in the highlands. At the current growth rate. Conservative businessman Oscar Berger was elected president in 2003.000 people died. some with designs more than a thousand years old.S. Women tend to marry young and have large families. even giving communally owned land to investors and allowing them to use 25 percent of the male population to work the plantations.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 58 Respecting Differences. Mam. with perhaps a married son or daughter and family as well as elderly relatives and godparents. live in the streets of the capital. Forced evictions of residents from squatter settlements and a shortage of 1. Work.000 people in response to guerilla activities. An earthquake in 1976 killed 27. and Mayan marriage rituals differ from those of the Roman Catholic church. In rural areas. Guatemala City. According to The Center for Maya Textiles. especially indigenous peoples. In 1970. about 75 percent of whom live in poverty. common-law marriages are frequent. who are an important part of the family. Kaqchikel. His efforts to eliminate anti-government elements resulted in the death of 50. and Q’eqchi. Guatemala has one of the highest fertility rates in Latin America. Colonel Jacobo Arbenz Guzman continued these reforms when he was elected in 1951. including 5. Most families consist of parents and their unmarried children.000 or more people in the coming decade. including those killed in 626 massacres in Mayan villages. Spanish conquistador Pedro de Alvarado conquered the Maya. who follow traditional customs and speak one of the 23 officially recognized dialects. liberal Justo Rufino Barrios became president. Carlos Arena. In 1523. Brief History Fishing and farming villages on the Pacific coast of Guatemala go back at least as far as 2000 BC.000 children. Family.5 million houses mean many homeless people. surrounded by a larger room that serves as a kitchen and all-purpose room. Conservative dictator Rafael Carrera ruled from 1844 to 1865. They wear beautiful blouses called huipiles. received the Nobel Peace Prize in 1992 for her efforts on behalf of her people. and salad. Coffee and champurrado. both religious and secular. In rural areas. They may have their own livestock and garden plots for growing beans. found in Guatemala. rice cakes. and perhaps fried plantains. many women work as live-in domestics and in maquiladoras supplying U. Many families cannot afford fees for books and uniforms. compared with one-fifth of children in rural areas. Education is compulsory through grade six. Arroz con pollo chapina is a chicken and rice dish that includes onions. vegetables. and beef accompanied with rice and guacamole. chiles. called cortes. The large midday meal might begin with soup and be followed by meat.S. Jocon combines chicken and a green sauce made from squash seeds. scallions. including bananas (which may be eaten with chocolate sauce.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 59 Guatemala. Corn originated in this area in the teocinte plant. Those who live in houses in the cities probably begin the day with coffee. others prefer to teach their children agricultural skills. sesame seeds. egg yolks. All schools teach a curriculum established by the Ministry of Education. the Commission for the Verification of Codes of Conduct. School attendance varies widely depending on location and economics. tomatoes. Subanik is a dish combining chicken. This staple of life is endangered by the introduction of genetically modified seed. and flans.” Each Mayan village has its distinctive pattern. Guatemalans enjoy many tropical fruits. Tamales and chile rellenos are also popular. The Spanish conquerors and later the army used those patterns as a means of identifying specific Mayan groups. pork. is a traditional food eaten on All Saints’ Day. Pepian is a beef stew with vegetables and a sauce of roasted seeds and peppers. Public schools are free. as is fruit juice. fried dumplings with honey. Employment: expression of native weaving artistry. rum. and seasonal vegetables. Education Status: The school year in Guatemala runs from January to October. rice. a serious threat to a crop that forms the backbone of the country’s agriculture. Bunuelos. Rural Guatemalans eat mainly black beans and corn prepared in various ways. is now working with international companies doing business in Guatemala to monitor and improve working conditions and labor practices both in factories and in coffee and banana fields. and social life. . Foods and Eating Habits Dietary Practices: Everyday Diet: Popular Foods: Beverages: No dietary taboos. or orange juice and whipped cream). and South Korean corporations. cured pork. rice. a punch made from milk. pitahayas. tomatillos. are made of fabric woven by men on foot treadle looms. A nonprofit group. Half the children who start primary school in urban areas complete it. Fiambre. others in the afternoon. facing discrimination and exploitative working hours and conditions. eggs. mameys. Only 58 percent of all municipalities have secondary schools. Most rural families labor on plantations of the small percentage of people who own the majority of land. In the cities. beans and rice mixtures. Recent figures show that about 33 percent of children attend preschool and 82 percent attend primary grades. and rum. Some students attend in the morning. mangoes. Traditional skirts. where about 60 percent of school-age children live. including fried bean paste. children often work in the fields or as household laborers to help support their families. rice custards. are popular beverages. wine. and jocotes. porridge or beans. peppers. honey-cinnamon syrup. Alcoholic drinks include locally made beer. and sugared figs are popular desserts. Children from wealthier families attend the many private schools. cont. and cilantro. markets. and rompopo. honey crisps. Some indigenous people in Guatemala and Mexico refer to themselves as Corn People. chocolate coffee. proclaiming the wearer’s identity as a woman and individual within her community. garlic. but students must buy textbooks and uniforms. and corn tortillas. and corn. Celebrating Diversity: Guatemala. Religion Roman Catholicism: Protestantism: Mayan Religion: According to the International Religious Freedom Report of 2002. the percentage of Roman Catholics in Guatemala has declined to perhaps 50 to 60 percent. Mayan religion was based on synchronizing human activities with the orderly cycles of nature. the Church of God of the Complete Gospel. focusing on the believer’s personal realtionship with Jesus Christ and on individual success and prosperity rather than social justice. called brujas. mainline denominations such as Presbyterian. particularly those in the evangelical Protestant community. dysentary. Health and Health Care Health Status: Traditional Practices: Nearly half the population of Guatemala has no access to health services. typhus. are believed to have powers related to planting crops. and bringing back lost objects. a healer who cures illness using charms and prayers. Many indigenous peoples believe that plants have spirits linked with . and the Prince of Peace Church. foretelling the future. with the remainder of the population identified as Protestant. The largest Protestant groups are the Assembly of God. which makes Catholicism in Guatemala distinct. The Maya developed several calendar systems for various aspects of their activities. There is no national health insurance. using offerings of liquor and incense. and accountant. Indigenous peoples outnumber ladinos. cont. elementary school teacher. Lutheran. Evangelical Protestant churches. but they are looked down upon and their religious practices are regarded as witchcraft or devil worship by many. students may begin and even complete career training. The Maya worshipped many gods and envisioned the universe as having multiple layers both above and below the earth. Rural residents are subject to malaria. The University of San Carlos was founded in 1681. They believed their rulers were descendants of the gods. The only public university. There are six private universities specializing in various fields of study. and six elementary grades. They conduct their rituals in caves or houses. The church has incorporated indigenous Mayan beliefs and practices that do not conflict directly with church teachings. ajkunes. Baptist.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 60 Respecting Differences. healing the sick. Mayan calendars served as astronomical almanacs controlling behavior and religious ceremonies. curanderos or yerbaristes. for herbal remedies. Elementary School: Secondary School: Higher Education: Schooling begins at age four with pre-kindergarten. Mayan spiritual leaders report that about half the population practices some kind of indigenous spiritual ritual. with only about 10 percent doing so openly. Many Guatemalans have little access to modern medicine and depend on traditional healers. primary grades. it has campuses in nine locations in addition to the capital. Guatemala City. Some also use a zahorin. and Episcopalian are also represented. generally do not tolerate indigenous beliefs and tend to be conservative in their political outlook. Traditional prayer men. Other careers require three to six years of university training. During the five years of secondary school. and other diseases aggravated by unclean water and poor nutrition. including secretary. high school training is sufficient. For several careers. now claiming some 25 percent of the population as members. Agricultural chemicals cause problems for plantation workers. Catholicism was established in Guatemala by Dominican friars who made the faith understandable to the Mayan people. followed by kindergarten. Church attendance is reported to be high among evangelical Protestants and lower among Catholics.000 years. Most sources put the Roman Catholic population at over 80 percent. and chuchkujawes. reaching a calculation accuracy of one day off every 6. and flowers on graves of family members and friends. giant kites flown in some cemeteries. cont. Some Indians believe illness is caused by the evil eye. Attitudes: Many Guatemalans. Mayan healers often administer their herbs based on magically important numbers. Guatemala’s public hospitals have experienced serious shortages of basic medicines and equipment. celebrated before Lent begins: People dress in costumes and masks. Holy Week. a traditional Qeqchi Maya festival Independence Day Indigenous Peoples Day Revolution of 1944 Day: Celebrates overthrow of Jorge Ubico. Hospitalization: Particularly for indigenous peoples. A full range of medical care is available in Guatemala City. In cases of terminal illness. and they make special efforts to protect women and children from strangers. Therapeutic baths are often used. Verbal Exchange: Procedures should be explained carefully. The following information may also be useful. They may view illness as a disruption in the hot-cold balance. 17–18) for general guidelines to follow in working with clients and patients from Guatemala. Celebrations and Holidays January 1 January 6 February/March March/April Easter Day May 1 May 2–3 June 30 July 21–26 September 15 October 12 October 20 November 1 December 7 New Year’s Day Epiphany Carnaval. hospitalization may be very frightening if they are isolated from family members and traditional support systems. break open painted eggs filled with confetti. especially indigenous peoples. Celebrated with processions and special foods Labor Day Day of the Cross Army Day: Celebrates revolt for agrarian reform in 1871. state-run hospitals and clinics are available. A study conducted in Los Angeles in 2000 found that many Latinos did not use available public health services due to language and transportation problems and perceived cultural insensitivity. Medical System: their healing powers. Central Americans. Family Authority: The father or eldest son is the primary decision-maker. Rabin Ajau. especially the Maya. Streets are decorated with flowers and colored sawdust for processions where images of Jesus and the Virgin Mary are carried through the streets. but medical care outside the city is limited. these are burned in front of the house to purify it for Christmas. Semana Santa. Physical Contact: Touching between members of the same sex is accepted. . who may not want the patient informed. Women may prefer a woman physician. may have difficulty understanding such concepts as patients’ rights and informed consent. In cities and towns. health care practitioners should inform that individual. as well as fear of deportation.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 61 Guatemala. Devil-Burning Day: People search their houses for things that can be thrown away. Death and Dying: Diagnosis of terminal illness should be given to father or eldest son. have little if any experience with Western medicine. Families often eat dinner at the graves and offer food to the dead. communication may be difficult. Catholics will want a priest to administer the sacraments. Address clients in a formal manner. pine needles. Addressing Clients: In the case of Guatemalans who are Maya or members of other indigenous peoples. and they may classify herbs as male or female and use them in pairs. drinks. Tips for Health Care Providers Refer to the section on Working with Latino/Hispanic Clients (pp. All Saints’ Day: Guatemalans place food. Yes/No Sí/No Thank you. Good morning.health-careers. De nada/No hay de que. like many Case Farms workers. Gracias. Today.” Unless otherwise indicated by an accent mark. Hasta la vista. See you later.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 62 Respecting Differences. The authors. and South. Once here. with an approval rate of 8.821 Guatemalans sought assylum in the United States. a poultry plant in the North Carolina foothills where most of the workers at that time were illegal immigrants from Guatemala: Alberto.000. In 1998. available at www. Y usted? . Buenos tardes. culture in Los Angeles. Spanish is pronounced much like English.org. The INS reported that in 1996 there were 165. Buenos días. who have spent many years working with and studying immigrants in Los Angeles. is from the rural Guatemalan town of Huehuetenango. An exceptional resource for understanding health care clients and students from Guatemala is the recent book Seeking Community in a Global City: Guatemalans and Salvadorans in Los Angeles. Guatemala ranks third behind Mexico and El Salvador as a source of illegal immigrants into the United States. How are you? ¿Cómo está? I am fine. gracias. Northeast. describing their persecution and dislocation within Latin America. inhumane and fraught with danger. Hola. provide an excellent history of the two groups. Guatemalans who do not have legal status tend not to use the health care system for fear of being deported.” “h” is silent. children living in the thatched-roof huts of Huehuetenango eat better because of the paychecks distributed on the factory floor at Case Farms. but the poverty endures. Celebrating Diversity: Guatemala. Although until recently most immigrants from Mexico and Central American have settled on the West Coast. Adiós. cont. the stress falls on the next to the last syllable if the word ends in a vowel or the letters “n” or “s”.000-plus native-born Guatemalans living in the United States is probably conservative. Alberto earns about $54 a day. Useful Words and Phrases Spanish for Health Care Workers. An award-winning 1997 series by Marcus Stern in the San Diego Union-Tribune reported on the system that allows illegal immigrants to find work in such places as Case Farms. and their adaptation to U. the average annual growth rate of illigal immigration from Guatemala was 12. provides words and phrases the health care provider can use with Spanish-speaking patients. Good night. Goodbye. Hello. You’re welcome. thank you. on the last syllable if it ends in a consonant. over the period 1992–1996.7 percent. But the illegal workers pay dearly for this opportunity.000 Guatemalans living illegally in this country. 5. they remain vulnerable to exploitation. their immigration to the United States.S. Like the other Guatemalan workers. Day of the Innocents Guatemalans in the United States According to the Immigration and Naturalization Service (INS). This means that the 2002 census figure showing some 480. And you? Muy bien. December 8 December 12 December 24–25 December 28 Feast of the Immaculate Conception Feast of the Virgin of Guadalupe Christmas Eve festivities include eating tamales and setting off fireworks. Language. Differences include: “ll” is pronounced “y. “ñ” is pronounced “ny.” “j” is pronounced “h. During the 1980s it was the site of nightmarish political violence. The killings ended years ago. Entering the United States through its ‘back door’ is undignified. Buenos noches. Good afternoon. far more than the $3 he said he’d earn in Guatemala. increasing numbers of Latinos are being recruited to work in meat packing plants in the Midwest. Carlos. http://newsvote. ¿Cómo se llama? Me llamo .bbc.guatemalaweb.com/planeta/98/ 0598central.htm (21 Mar.lingnet.htm (21 Mar. Ling. . et al. Guatemala.salvonet. eds. 2005. Guatemala: Meals near the Mayans. 2005). cont.html (24 Feb.html (21 Mar.org/pha2000/ stories/icu. http://www. Chinchilla.html (24 Feb. Embassy of Guatemala to the United States. . BBC News.” May. 2004). 2004). http://wrc. http://www. Seeking Community in a Global City: Guatemalans and Salvadorans in Los Angeles. Hamilton. 15 April.html (28 Feb. Christian Action of Guatemala. http://www. 2004) Our Living Maya Culture. Chu.au/publications/connections/ september_2002/letterfromguatemala. Kat. Center for Maya Textiles. a Religious Turf War.lonelyplanet. What is your name? My name is .shagtown.com/news/ nationworld (15 Apr.cia. Food Network. 2004). Philadelphia: Temple University Press. Lonely Planet World Guide: Destination Guatemala. 2001. Encyclopedia of Days.planeta. 2004).com/ (24 Feb. Are you cold? Are you hungry? Are you thirsty? breakfast/lunch/dinner Do you need to go to the bathroom? Do you want to sit up? I am going to take your temperature. Guatemala: General Information. “In Latin America. BBC News. ¿Qué pasó? ¿Dónde le duele? Déjeme ayudarle. http://www. Icu.globalministries. 2004).com/guatemala/guatemalainfo. .” People’s Health Assembly.com/destinations/central_america/guatemala (23 Feb.latimes. . 2004).co. The World Factbook: Guatemala.co. Global Ministries of Latin America and the Caribbean.org.org/ lac/spo8.org/ guatemala/cap-piet04. http://nimpot. http://www. Lipson. 2004).” Oxfam Connections. 2004). 1997.com/QuetzalNET/MayaCulture. 2004). Culture and Nursing Care: A Pocket Guide. 2004). Juliene G.htm (21 Mar. 2004). 1998.html (23 Feb. 2005. Country Profile: Guatemala. “Letter from Guatemala.uk (23 Feb. 2004). http://newsvote. 2004). Guatemala. General Information on Guatemala. 2004). Nora.htm (23 Feb. http://www.. 2000. Dec. Culture and Education. http://phmovement. (24 Feb. Basic Facts.com/days/guatemala. . The National Folk Festival and the Arts.com/ed/index/shtml (24 Feb. ¿Tiene frío? ¿Tiene hambre? ¿Tiene sed? desayuno/almuerzo/cena ¿Necesita ir al baño? ¿Quiere sentarse? Voy a tomarle la temperatura.gov/cia/publications/factbook/geos/gt. 2002.guatemala-embassy. http://www. Hugo. http://www.quetzalnet. .html (5 May 2005). What happened? Where does it hurt? Let me help you. http://www.” Los Angeles Times. 2004). Morgenstern. . 2004).uk (23 Feb. http://www.caa.foodnetwork.com/2/generalinfo.com/food/ck_gc_guatemala/text (21 Mar.bbc. http://centralamerica. Latin America: Guatemala.peacebrigades. Sept.. http://www.org/culture. San Francisco: University of California San Francisco Nursing Press. Timeline: Guatemala. http://www. http://www. A War Called Peace: A Visual Journey with Peace Brigades International. and Norma S. Henry. “Central America’s Traditional Plant Medicine. Central Intelligence Agency.org/guatemal.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 63 Guatemala.asp (23 Feb. “Health Care Reform in Guatemala. References Area Studies.htm. Vemuri. “Fair Trade vs Free Trade in Mesoamerica. 2002. U. http://www. Oxfam.wri. Department of State Bureau of Democracy.org. Human Rights. cont. Barry. 2002. . “Jobs Magnet.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 64 Respecting Differences.unicef. 2002. Stern.caa.html (19 Mar.peacecorps. 2004) Williams. http://www.org/katz1998. Marcus. Canada. Guatemala. 2003. and Labor. http://www. 2 Nov. Celebrating Diversity: Guatemala.org/enved/suscom-guatemala.htm (25 Feb. http://hrw.” 2003.. 2004). Friends.org/infobycountry/guatemala/html (23 Feb. Guatemala. Human Rights Watch. http://www. 1997.html (27 Mar. Water Provision: Guatemala City. Dec. 2004).” San Diego Union-Tribune. 2004). Peace Corps.org/cp/english/guatemala (8 May 2005).settlement. 2004) World Resources Institute Education Center: Sustainable Communities.state. New York: Palgrave MacMillan. and S.html (21 Mar.” Peace Corps Kids World. ed. http://www.S. Turner. E. Faculty of Social Work. “Food.au/publications/ connections/september_2002/fairtradevsfreetrade. 2004). Multiculturalism and Native Issues Centre. Cultures and Economies of the World. Anti-Racism. http://www.cis.gov/kids/ like/guat-celebration2. Sept. At a Glance: Guatemala. UNICEF.html (24 Feb. 2002.gov/g/drl/rls/irf/2002 (28 Feb. University of Toronto. International Religious Freedom Report 2002: Guatemala. “Overview of Human Rights Issues in Guatemala.” Oxfam Connections. http://www. and Fun: Holidays in Guatemala.org/english/docs/2004/01/ 21/guatem6985_txt. The Statesman’s Yearbook: the Politics. 2004). Eastern Asia China South Korea Japan . Celebrating Diversity: .○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 66 Respecting Differences. iron ore. tsunamis. damaging floods. molybdenum. antimony.0%) 327. tungsten. barley. also referred to as the renminbi (RMB) Han Chinese 91. Christian 3%–4% People’s Republic of China: communist state. Xiang.101 (1. vanadium. mercury.775 (1. Hong Kong 203. potatoes. tin. cotton. petroleum. footwear. Minnan (Hokkien-Taiwanese). chemical fertilizers. wheat. fish machinery/equipment. 5 autonomous regions.4% rice.611 (3. Yue (Cantonese). industry 22%. Hong Kong 91. consumer electronics. Tibetan.4%. based on the Beijing dialect) spoken by more than 70%.58% 72. Korean. millet. cement. tea.313. droughts. Buddhist 8%. peanuts.2%). Mongol. Buyi. toys.1% . capital Beijing. Wu (Shanghaiese).6 years 0. Taiwan 326. Muslim 1. mineral fuels iron and steel.215 (1. services 29% . and other groups 8.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 67 China Census Figures (2000) United States Residents Born in China: California Residents Born in China: 988. lead. textiles/clothing. land subsidence coal. Minbei (Fuzhou). natural gas.696. minority languages Officially atheist. Taiwan 151. country divided into 23 provinces. Uygur. textiles and apparel. petroleum. manganese. sorghum. armaments. Gan. automobiles. Manchu. China has 55 ethnic minority groups Seven major language groups: Standard Chinese or Mandarin (Putonghua. magnetite. telecommunications agriculture 49%. Miao. Hakka dialects.7%).0%). footwear. machine building. food processing.812 32. coal.9%.7%).9% yuan(CNY ). toys/sporting goods. Hong Kong and Macau considered special administrative regions extremely diverse: tropical in south to subarctic in north frequent typhoons (about five per year along southern and eastern coasts).7%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 3. zinc. aluminum. Hui. pork.580 (0. earthquakes. Zhuang. uranium. Taoist. hydropower potential 15. miles (comparable in size to the United States) 1. and 4 municipalities. Taiwan considered a province. oilseed.100 sq.306.857 (3.27 years 10% 90. Yi. as a Special Administrative Region. invasion and occupation by Japan. established the traditional Chinese state with Mandarin civil service. Intellectuals and those suspected of harboring dissident views were sent to camps for re-education. 1050 to 770 BC. and paper was invented. destroyed many cultural artifacts. Emperor Qin conquered all the other kingdoms for a united China and began building the Great Wall. 1838–40.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 68 Respecting Differences. foreign exploitation by capitalists and missionaries. was a golden age of peace. his successor. and the Chinese Communist Party. Chiang Kai-shek and many of his supporters fled to Taiwan.000 people were injured. Traditions Housing: Family: Housing in Chinese cities is likely to be scarce and crowded. The population of China at that time was 58 million. having survived the Long March across China. During this period. 25 to 220. 207 BC to 9 AD. the Warring States period. it consists of very general principles and leaves implementation up to local governments. and included the radical youth organization the Red Guard. From 475 to 221 BC. and developed blue and white ceramics. About 10. organized under Mao Zedong and took power. Under Mao’s Great Leap Forward. The situation came to a head in Tiananmen Square on June 3 and 4. but the size of urban living units makes this difficult. Chinese live in extended families. still used today. some 100. as standards of living vary tremendously from city to city. On May 4.000 years. welcomed Jesuits to their court. Some couples are opting . He banned all non-military books and built the recently discovered tombs with the terra cotta warriors. A minimum standard of living was established nationwide in 1993. was established when the Mongols were overthrown by native Chinese. during Mao’s regime. 618 to 906. was unable to resume power following World War II. it lasted until 1911 when a revolution inspired by Sun Yat-sen established the Chinese Republic. During this time the Chinese explored India and East Africa. the Chinese perfected bronze casting and developed a written language. people were forced to move to agricultural communes and required to produce quotas of crops often not suited for their bioregions. Urban families are allowed to have one child. The government declared martial law on May 20. China’s written history alone extends for more than 4.000 students and workers peacfully marched in Beijing to demand democratic reforms and protest government corruption. rural to urban area. Jiang Zemin was re-elected president and Zhu Rongji was selected as premier. Mao’s successor. 770 to 475 BC. In an attempt to control population growth. The Shang Dynasty ruled China from 1900 to 1050 BC from its capital in Luoyang. also known as the Spring and Autumn Period. During this period opium became a prime commodity as western traders set up shop in Guangzhou. Buddhism was introduced during the Eastern Han Dynasty. The Ming Dynasty. From about 5000 to 1900 BC Neolithic Chinese lived in settlements along the Yellow River. rural families can have two children.. depending on which source one reads. The Western Han Dynasty. In 1998. dance. and east to west throughout this vast country. It was returned to China on July 1. 1368 to 1644. the Chinese government in 1979 enacted the onechild-per-family policy. Chiang Kai-shek. Lao Tsu developed Taoism. and several generations may live together and contribute to the family. established an Open Door Policy in 1979 that introduced market-oriented reforms and decentralized economic decision-making.600 people. Confucius set forth his code of ethics and Sun Tzu wrote The Art of War. The Qing Dynasty was established by invading Manchus in 1644. when the People’s Liberation Army violently confronted peaceful demonstratorrs and killed between 400 and 2. The period 1911 until 1949 was a time of civil unrest. During the Qin Dynasty. and poetry. The Tang Dynasty. many of starvation. Hong Kong was ceded to Britain in 1842 as a result of the first Opium War. Brief History Creating a brief history of one of the world’s four oldest civilizations is a difficult task. following Deng’s death. Work. cont. Rural houses are larger. Tens of millions of Chinese people died. music. During the Eastern Zhou Dynasty. Family. In the 1920s SunYat-sen organized the Chinese Nationalist People’s Party. Families can pay substantial fines to have additional children. 1997. The Cultural Revolution pitted one faction of communist leadership against another. Traditionally. is noted for the concept of the Mandate of Heaven. The Western Zhou Dynasty. Celebrating Diversity: China. 221 to 207 BC. Housing. 1989. Deng Xiao Ping. low-paying jobs. 2005 article in the International Herald Tribune described a labor shortage in Guangdong Province. and cold drinks. (b) reduce corruption and other economic crimes. the government needed to find jobs for about 14 million people. From 80 to 120 million surplus rural workers are adrift between the villages and the cities. steamed. From 1990 to 2003. soy products. Chinese checkers. a game of skill played with tiles. Confucian philosophy advocates sacrificing individual needs for the common good. basketball. farmers are required to produce a certain amount for the state.000 years ago. roasted. Abortion and infanticide of female children have been inevitable results of this policy. Cold foods include fruits. Hot foods are avoided when a person has a hot illness and vice versa. along with cooked vegetable and meat . and xian gi. Gender discrimination in wages has been illegal for more than 50 years. Chinese movement arts such as tai chi and qi gong are popular around the world. More than 2. eggs. Employment: Sports: not to have children in order to enjoy a higher standard of living. The family remains the fundamental and most important unit of Chinese society. Nearly half of the newly employed in urban areas during the period worked in individual and private economic entities. many of which had been shielded from competition by subsidies and had been losing the ability to pay full wages and pensions. the government has struggled to (a) sustain adequate jobs growth for tens of millions of workers laid off from state-owned enterprises. In 2003. peasants appear to be unwilling to travel thousands of miles to endure poor working conditions for meagre wages—as low as 500 yuan or $60 a month. where 70 percent of 329 manufacturing companies. and soccer being among the most popular.7 million. the Chinese were printing cookbooks and developing sophisticated cooking techniques. women have virtually the same standing as men. chess. Under the communist system. many subsisting through part-time. and calories. A March 30. Chinese food is stir-fried. cont. About 90 percent of Chinese women work outside the home. even though only 15 percent of the land is suitable for growing crops. The Chinese are avid participants and spectators in a variety of sports. some 8 million city dwellers were registered as jobless. reported ongoing difficulty in recruiting workers. cooked in every way imaginable. The country has a large workingage population with a relatively low level of education. sugar. they can use or sell in the open market whatever they produce beyond that. it is difficult to characterize the work environment accurately. as are tiaoqi. In urban areas. Hot foods are generally those high in protein. Rice and noodles are the staples of the Chinese diet. most vegetables. According to the writer. Respect for elders and filial piety are still important values to most Chinese. they include meats. with table tennis. About half of all Chinese work in the agriculture sector. baked. which has nevertheless been very successful in urban areas. Dairy products are not part of the usual Chinese diet. and new entrants to the work force. According to the CIA World Factbook. Foods and Eating Habits Dietary Practices: Everyday Diet: Food is seen as an important part of maintaining the balance of yin (cold) and yang (hot) in the body. Karaoke has spread to China from Japan. is popular. most of which depend heavily on migrant labor. and alcoholic beverages. As the Chinese economy is becoming more westernized. Children are raised to be obedient and to control emotions and impulses. employment in rural sectors declined by about 8 percent. The 2008 Summer Olympic Games will be held in Beijing. Mahjong. and the number of Chinese employed in state-owned entities decreased by 34. and (c) keep afloat the large state-owned enterprises. working outside the home and being treated as equal partners in the marriage. migrants. fat. children are cared for in day-care centers. According to a Chinese government white paper reported in an April 2004 article in Xinhua. on the southern coast of China.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 69 China. poultry. centered on Guangdong province and its capital. beef. found in the cities of Shanghai and Hangzhou and the surrounding provinces. and dumplings are more commonly eaten than rice. Sugar. and many fruits and vegetables. Foreign contact has brought European influences to the cooking of this region. with central and provincial governments in charge of higher education. They first produced alcoholic beverages more than 3. Popular Foods: Beverages: dishes. a classic Sichuan dish. noodles of all kinds. moon cakes. Fish and shellfish from the Yangtze River and the ocean are abundant. and finally a soup made of the bones. Celebrating Diversity: China. with mutton especially popular in the Muslim northwest. rice porridge. The poorest peasants eat simple grain foods with salty pickles adding flavor. with the classic meal consisting of three courses in which nearly every part of the duck is consumed—first the skin wrapped in pancakes. Salt and oil are liberally used. Tea is the best-known and most popular drink. mandated in 1986 along with standardization of exams and free education. consists of soft tofu cubes in a numbing-spicy sauce of ground pork and red chiles. similar to Korean kimchee. the conclusion of the Lunar New Year celebration. Local governments are mainly responsible for primary education. Eastern Chinese cuisine. Mutton and pork are the preferred meats.Steamed buns. cont. garlic. Jaizoi. The Mandarin word fan means both “rice” and “food.400 years ago. Pork is the best-loved meat throughout the country. boiled sweet sticky-rice dumplings with various fillings. Non-governmental agencies are increas- . soups and soupy dishes are popular. called cai. Chinese wine (jiu) is made from fermented rice and other grains. with Dragon Well tea from Hangzhou province considered the finest tea produced in China. One of the best-known dishes is Peking/Beijing duck. Poultry and seafood are rarely used.” The Chinese generally eat three meals a day. provided they can afford to do so. Yue bing. About 91 percent of children have access to primary education. is probably the best known in California and widely considered the best in China. The cuisine of southern China.400 years. Green teas are perhaps most popular. Guangzhou (Canton). scallions. especially pork fat. are eaten for breakfast in the north along with zhou. are round cakes with sweet fillings eaten during the Moon Festival. Dinner is the main family meal. Wheat products such as pancakes. are popular. cuisine emphasizes the freshest ingredients and a light cooking touch. In the northern part of the country. The Ministry of Education is implementing a plan for nine years of compulsory education nationwide. leeks. wines. Education Status: Education is a high priority for the Chinese government. is noted for sweet dishes. dumplings filled with meat or vegetables and dipped in black vinegar sauce. Chinese cuisine is generally divided into four major types or schools according to region. then stir-fried duck meat. and chiles are widely used. steamed buns. The Sichuan/Szechuan school of cooking is perhaps the most popular and best known of this region. called mantou or baozi. The Szechuan style food served in American restaurants outside the Chinatowns where large immigrant populations live bears only a faint resemblance to the real thing. A strong sorghum liquor called bai jiu is especially popular in the northern part of the country. Bean dishes such as dou fu (tofu) are popular.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 70 Respecting Differences. Chinese teas come in all colors and flavors. and vinegars are used to create sweet tastes and subtle flavors. with abundant use of hot chiles. Ma po dou fu. Tang yuan. with many varieties. and spirits are also grain-based. The heat index of western cuisine rivals that of Thai or Mexican food. as is fat. are a popular northern dish traditional at Lunar New Year celebrations. are eaten at Lantern Festival. Preserved vegetables. although Hunanstyle food is also notable. where Beijing is located. but the Chinese have been drinking it for only about 1. which adds calories that help during the long winters. Western Chinese cooking combines a wealth of spices with pork. The mild climate makes Guangdong the world’s premier rice-growing region and yields abundant culinary resources. there are some 16. with more than 100. is considered a cult. and ancestors are widely practiced. the people often have to pay the teacher’s salary and keep up the facilities. Adult education includes literacy programs and all levels of education for adults. Physical education is encouraged. Buddhism. Common higher education includes junior college programs lasting two to three years. Traditional folk religions involving the worship of local gods. The five officially recognized religions are Buddhism.to three-year master’s programs. The program lasts for three years. four-year bachelor’s programs.000 in Guangzhou. physics. ingly involved in education financing. classes such as art and music. Religion Status: Buddhism: The Chinese Constitution provides freedom of religious belief. the equivalent of our grades 7 through 9. approximately 8 percent of the population was Buddhist. polytechnic schools. history. Less than 50 percent of students are accepted. Other Education: Occupational education comprises mid-level professional schools. determine admission. The more than 100 million members are primarily from the dominant Han ethnic group.000 Buddhist temples and monasteries and more than 320. A 2002 government white paper stated that there were 200 million religious adherents in China. politics. Junior Middle School: Three years are required. students study Chinese language. Falun Gong. Senior Middle School: Entrance is by competitive examination taken at the end of ninth grade. heroes. math. It seeks to prevent the rise of groups that might constitute sources of authority outside the government and the Chinese Communist Party. common higher education. geography. moral education. and other subjects and participate in sports and other activities. According to government figures.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 71 China. and Protestantism. Most schools are not entirely free. Competition for good schools is very high. In rural areas. according to a March 2005 article this may cost more than $3. The degree of repression varies from region to region. students select either the humanities exam or the science/engineering exam and apply for institutions and departments in order of preference. Students take an exam after sixth grade to determine which junior middle school they will attend. Islam. students must pass a national college entrance exam held the first 10 days of July. biology. occupational education. and sports. occupational middle schools. but overall membership in religious organizations is growing. mathematics. To enter a university. with a curriculum including chemistry. requiring a variety of fees—for uniforms. Harsh measures have been taken against groups perceived to threaten the government. cont. and the teachings of Li Hongzhi. Foreign languages are available in the senior year.—that put a heavy burden on many families. meals. Taoism. Curriculum includes English. The educational system comprises basic education. the equivalent of our grades 10 through 12. members have been arrested and imprisoned. with officials in some areas encouraging Western religious groups to get involved in social service projects. Children attend kindergarten for three years before primary school. two. science. and three-year doctoral programs. 2005 article in China Daily notes that the average Chinese family spends up to 50 percent of its income raising a child. Examination results. etc. plus investigation into social behavior and moral character. and many families pressure their only child to excel in school and outside activities.000 sites for religious activity. Chinese literature. An April 1. but the government tries to restrict religious practice to government-sanctioned organizations and registered places of worship. .000 monks and nuns in China. the exercise discipline qi gong. Primary School: During six years of primary school education. a blend of Taoism. Nearly all Chinese Buddhists are adherents of the Mahayana school. history. and foreign languages. and adult education. Catholicism. In 2002. and short-term occupational and technical training programs. and government.000 places of worship and more than 45. Taoism has no deity.000 temples and 10. Government figures put Muslim believers at 20 million. Although officially recognized as a religion. This was blamed on poor working habits. . Qi is influenced by the complementary forces of yin (negative energy) and yang (positive energy). restorative physical exercises. inadequate government funding. Herbal treatments and teas. and lack of health education. Taoism is a philosophy that developed slightly before Confucianism. The Vatican is working to unify these groups.000 churches. The Taoist principle of feng shui (wind-water). In the days when most industry was owned by the state. Many people— nearly 50 percent according to a recent survey—would not go to a hospital even when ill. an article from China Daily of April 2. cont. While there are no official figures on Taoist adherents. with 35. The unofficial Vatican-affiliated Catholic Church claims as many as 10 million members. only the tao.000 years and is based on the concept of balanced qi (“chee”) or vital energy that is believed to flow throughout the body and regulate a person’s spiritual. China does not have an affordable system to serve the uninsured. Disease results from disturbance in the flow of qi resulting in an imbalance of yin and yang. reported that nearly 45 percent of urban residents and 79 percent of rural residents had no medical insurance. The Tao Te Ching. focuses on the importance of living in harmony with the nature of the universe in order to avoid suffering. but rather a philosophy of life that. and physical balance. Confucianism is a strong force for social harmony in that it prescribes clearly defined roles and responsibilities for every person in society.000 counties. collectives. The government reports as many as 15 million registered Protestants with more than 12. Celebrating Diversity: China. poor disease prevention.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 72 Respecting Differences. The goal of TCM is to restore balance through acupuncture and the use of compounds.000 imams nationwide. forms the underpinnings of Chinese culture. according to the Chinese government. Confucianism: Taoism: Christianity: Islam: Confucianism is not technically a religion. workers were organized into work groups that provided for most of their needs. Health and Health Care Health Status: Traditional Practices: Medical System: A survey of 16 cities with populations larger than 1 milliion reported in 2004 revealed that up to 75 percent of urban Chinese are in poor health. the central government began building a voluntary cooperative medical system in rural areas. meditation. mental. read widely throughout the world. Cufucianism. have been used for thousands of years. to be funded with contributions from individuals.000 monks and nuns.000 churches. which developed in the sixth century BC. The practice includes herbal and nutritional therapy. dictates the placement of buildings and objects to ensure harmony with nature. and pharmacies often dispense both Western and traditional Chinese medicines. made from a selection of more than 5. Pilot programs are underway in 310 of China’s 2. Premier Wen Jiabao reiterated the government’s intention of improving the public health system at the National People’s Congress held in March 2005. The registered Catholic Church has about 5. and remedial massage. Job-based medical insurance is increasingly rare. about 600 BC. 2005. Both Catholic and Protestant churches are officially registered with the Chinese government. In 2002. including health care. acupuncture. along with Taoism. Many Chinese use both traditional and Western medicine. Christianity was introduced in 1246 by a Franciscan. emotional. 60 percent of medical expenses are paid by consumers. the capital city of Hubei Province in central China.000 different plants. widely practiced in China and becoming popular in the West. stressed the concept of filial piety and reinforced the Chinese tradition of ancestor worship. Wuhan. or way. opened Huimin Hospital in 2005 to serve the poor and disabled. Foreign sources say that about 30 million Chinese worship in independent house churches. Traditional Chinese Medicine (TCM) has been practiced for more than 3. the Chinese government in 1997 reported more than 1. Smiling may indicate embarrassment or shyness rather than a positive reaction. Chinese language depends a great deal on tone for meaning. Direct eye contact may be seen as an intimidation tactic. 2005. and they may be reluctant to complain. According to several sources. Death and Dying: Diagnosis of terminal illness should be given to the eldest male family member. family members are expected to care for their sick members. handshakes may be acceptable. Eye contact with authority figures is generally avoided. Even when speaking English. which does try to incorporate complementary medicine when appropriate. Nonverbal Behavior: Chinese traditionally bow slightly or nod politely when greeting another person. and that they tend not to take advantage of preventive care measures. Family Authority: The oldest male of the family is generally the final authority. Chinese may resist surgery due to the belief in the importance of keeping the body intact so the soul will have a place to live when making future visits to Earth. or Mrs. Attitudes: In the Chinese culture. Verbal Exchange: In order to save face. Organ donation and autopsy may be resisted because of a belief in the importance of keeping the body intact. who may not want to share it with the patient. Practitioners must take care to ensure that patients understand procedures and medications and to verify this understanding and the patient’s willingness to comply with treatment protocols. Medical professionals are advised not to schedule appointments during the Lunar New Year celebration season. described two hospitals in Southern California that have been reorganized to better meet the needs of Chinese American patients. They do not like physical contact with people they do not know. Educated immigrants probably know Mandarin or Cantonese and perhaps a local dialect. if one is needed. especially women. Staff at the Garfield Medical Center in Los Angeles report having to watch for family members trying to sneak in acupuncturists or herbal remedies without the knowledge of the staff. Tips for Health Care Providers An article in the Los Angeles Times of February 11. Immigrants from Taiwan may speak only Taiwanese dialects. Water and other beverages should be served without ice. Hospitalization: Family members may want to be involved in patient care. incorporating the latest medical technology with the preferences and needs of their Chinese American clients. The client may appear to agree to a procedure when he or she does not really understand it. When appropriate following dietary consultation. and their family name.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 73 China. Mainland Chinese women keep their own family name when they marry. A 1997 survey of Chinese and Chinese Americans in San Francisco found that half took Chinese herbal remedies. while others might believe the spirit could be lost if a person dies in a hospital. Addressing Clients: Because there are so many Chinese dialects. Thus family members may play an important role in the interaction between a health care professional and Chinese American client. Males are generally more respected than females in the Chinese culture. family members may bring requested foods or even herbal preparations. At the time of death. Chinese Americans may seem to be very loud and abrupt. cont. Some patients may prefer acupressure or acupuncture to pain medication. Garfield Medical Center in Monterey Park and Whittier Hospital Medical Center in Whittier are implementing policies and procedures to make these patients more comfortable. . among Chinese more than many other cultures it may be common for relatives not to reveal a terminal diagnosis and for the patient to pretend that he/she does not know what is happening. a Chinese client may not want to disclose personal information. Some Chinese prefer to die in a hospital because dying at home may bring bad luck. Address older persons by Mr. family members may want to prepare the body for burial. are very modest. the health care provider should determine which dialect the client speaks in order to find an appropriate interpreter. Chinese people. Patients may refuse foods due to yin-yang/hot-cold beliefs. Chinese may not want to discuss a terminal illness. At this time. making offerings to pay respects to the dead. replaced by an Immigration Act that assigned an annual quote of 20. a day to celebrate the harvest.000 immigrant visas to every country outside the Western Hemisphere. Incense is burned to honor the ancestors. under the brightest moon of the year. then they play games and await fireworks at midnight. unity.” Qingming Festival/Festival of Pure Brightness: 12th day of the 3rd lunar month. Most Chinese arriving under the provisions of this legislation came as families and settled in the areas of major cities where Chinatowns had been established. a symbol of family reunion. Children’s Day: Celebrates children. lion and dragon dances. long life. International Labor Day Youth Day: Marks first mass student movement in 1919. etc. International Women’s Day Tree Planting Day. In 1930 the law was ammended to allow wives of Chinese merchants and Chinese women married to American citizens before 1924 to immigrate. On new year’s morning. began in 1970s with campaign for a “green nation. Chinese in the United States The first large numbers of Chinese came to the United States in the 1840s looking for work. In 1943. wealth. Doors and windows are decorated with paper cutouts and posters expressing hopes for happiness. Prior to 1978. Lunar/Chinese New Year or Spring Festival: First day of the first lunar month of the year.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 74 Respecting Differences. remember the 14th-century uprising against Mongol rule. Mid-Autumn/Moon Festival: Celebrated on the 15th day of the 8th month. Lantern Festival: This takes place on the 15th day of the first lunar month and marks the conclusion of the new year season. Families gather to feast on new year’s eve. cont. Celebrating Diversity: China. many found work with railroads or providing services for mining towns in the West. holding memorial ceremonies. Teacher’s Day: Started in the 1980s to reverse anti-intellectualism of the Cultural Revolution. and exchanging gifts. and feast on yue bing. family visits. a poet and statesman who drowned himself in 277 BC to protest government corruption. including special taxes. Celebrations include lantern exhibits. boiled sticky-rice dumplings filled with beans and sweets. small round cakes with various sweet fillings. gifts of money wrapped in red paper. more important with “one child” policy. children receive hong boa. Early Chinese immigrants faced rampant discrimination. when the United States normalized relations . Birthday of Chinese Communist Party. most important festival in China and much of East and Southeast Asia. and happiness. activities include cleaning ancestors’ graves. moon cakes. people celebrate with parties. colorful dragon boat races attract many spectators. Celebrations and Holidays January 1 February/March February March 8 April 1 April May 1 May 4 June 1 July 1 August 1 Summer September 1 October 1 Fall New Year’s Day: Employees get a paid day off. groups of American-born Chinese began to gather in Chinatowns. National Day: Anniversary of founding of People’s Republic of China. but that wives and families could not live here. repeal of the Chinese Exclusion Act enabled more Chinese families to reunite and paved the way for Chinese men to return to China to find wives and then bring them to the United States. The day and following days are spent visiting relatives and neighbors. 1921 Army Day: Marks beginning of Red Army (later the People’s Liberation Army) in 1927 uprising against the Nationalists. people eat tang yuan. Families clean their homes thoroughly to rid them of bad luck and make way for good luck in the new year. and loss of property. The National Origins Quota Act was repealed in 1965. racial violence. Dragon Boat Festival: Commemorates Chu Yuan. The Chinese Exclusion Act of 1882 put an end to Chinese immigration until 1924. 1949. when the National Origins Quota Act provided American citizens of Chinese ancestry could work in the United States. and flying kites. usually around April 4 or 5. affection. government for all Chinese names and places. Ni hao (knee how). and appears to be higher among immigrants. Each character’s “assigned” tone is simply learned when you study or “acquire” Chinese.000 characters. including the majority of those born in Taiwan and 30 percent of those born in China. Hong Kong was allowed to send 600. then falls sharply and strongly to the bottom. Basic literacy requires knowledge of about 2. Goodbye. for example. is the reason we now know the country’s capital as Beijing rather than Peking. Taiwanese made up the largest part of these immigrants.5 to 3 times more common than among Caucasian women.2 percent in the United States and by 48. and many characters have been simplified. Zai jian. is called pinyin. and also because people from many cultures are afraid or ashamed of seeking help for psychological problems. the number of foreign-born from China in the United States increased by 87 percent. Finally. which express word meanings rather than sounds. 2005 Los Angeles Times discussed the ongoing friction between mainland Chinese and Taiwanese in Los Angeles County. The following Mandarin phrases may be helpful to health care professionals working with Chinese clients. and a knowledge of at least 4. the national language.113 Chinese as of Census 2000. See you later. with mainland China. Among Asian women in the United States. Xia wu hao.000 immigrants per year. Good afternoon. suicide is 2. according to a 2003 report by Pacific News Service. officially adopted in 1979. one of seven major languages and more than 50 ethnic languages and dialects. Cantonese is spoken in Macau and Hong Kong and by many Chinese immigrants.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 75 China. Language. An article in the April 3. nor do they indicate which tones they are to be pronounced in.000 characters. Los Angeles County has the largest population of Chinese in the United States. The official system for writing Chinese words phonetically using Latin script. The third tone starts low. Good evening. China has been streamlining the system of writing characters since 1956.000. Following the Tiananmen Square incident in 1989. about 300. adopted by the U. There are some 60. Feelings were running especially high following recent enactment of an anti-secession law by China. possibly in part because of the absence of a social support system. California received 26 percent of immigrants to the United States. Tones also have nothing to do with parts of speech or any other variable. the United States granted special permament residency status to many Chinese students and visiting scholars. a system developed in China beginning in the 1950s to help fight illiteracy. In the year 2000. the fourth-largest immigrant group in the nation. Between 1990 and 2000.5 percent in California. Replacement of other Chinese-English romanization systems such as Wade-Giles and Yale with pinyin. Hello. Zao jian. which carries the threat of military force in the event that Taiwan tries to become permanently independent. organized into a chapter of the Formosan Association for Public Affairs. flat tone with no emphasis. The total number of those who identified themselves as Chinese during that period increased by 66. each year. there is the neutral.000 is needed to be able to read a Chinese newspaper.000. Chinese American women have the highest suicide rate of any ethnic group. only about 8. The second tone starts at a medium pitch and rises. Good morning. the United States is home to about 1 million foreign-born from China. The fourth tone starts at the top. The city of San Francisco was home to 160. Spoken Mandarin has four tones—five if you count the “neutral” tone—and pronouncing the tone just right is very important. want the country to be recognized as a sovereign nation. cont. simply by saying “ma” in the four different tones one can say “Did your mother scold the horse?” The first tone is high and level.S. with some 35. Many in Taiwan. find themselves alienated from the larger Chinese community. Taiwanese in Los Angeles County who support independence. Useful Words and Phrases All Chinese languages and dialects use the same characters. Written characters don’t reveal their initials and finals. Cao shang hao (pronounced tsow shawng how). . later increased to 5. both Taiwan and mainland China had the right to 20.000 who consider themselves full Taiwanese and want nothing to do with mainland China. About 70 percent of Chinese speak Mandarin (Putonghua). the island nation formerly known as Formosa 100 miles from the mainland.000 are commonly used. For example. Wan shang hao. At that time. and then rises. dips to the bottom. http://www. San Francisco: University of California San Francisco Nursing Press.” 2001. http://www.cn/english/MATERIAL/ 17542. http://www.cn/ 200404. “The Foreign Born from China in the United States.html (8 May 2005).eastgreetswesttravel. Charles. Chin. Elizabeth. Chinese Culture. Chinese Outpost.travelchinaguide.cfm?ID-190 (5 Feb. Fuller. Anti-Racism. 2005). 2005).countreports. 2004. China.shtml (1 Apr. “China Quickens Medical Insurance Reform.htm (30 Mar.chinese-outpost. (30 Mar. Education in China.shtml (30 Mar.” 2004.China—General Overview. Multiculturalism and Native Issues Centre.cn/200409/20/ print20040920_157647. Falice. 2005). 1997.. 2005.com/ChinaWindows/history. International Labor Organization.about.com. cont. 2005).settlement.” Calgary Herald.htm (14 Feb.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 76 Respecting Differences. 30 Apr. http://english. Grieco. http://www. CountryReports. Do you speak English? Do you speak Chinese? Happy New Year! Shi/Bu Qing (prounounced cheeng). How are you? Fine/Good Excuse me. Dui bu qi.” International Herald Tribune. Culture and Nursing Care: A Pocket Guide. et al. 2005). 2005). Kemp.. Chin. Xie xie (sheeuh sheeuh). Juliene G. Ni hui shuo yingwen ma? Ni hui shuo zhongwen ma? Xin nian kuai le! References Brief History of China. 2002.html (30 Mar. http://www. China Education. 2004. The World Factbook: China.org/expandedprofile. http://chineseculture.migrationinformation.org/cp/english/china (29 Mar.print20040426_141526. Huan ying. 2005).” Press Release.26.china. “Chinese Education System Needs an Overhaul.baylor. http://www3. 2005). You’re welcome.asp?countryid=51& countryname=China (3 Apr. Ni gui xing? Hen gaoxing renshi ni.” Migration Information Source. University of Toronto. http://www.people. http:// www.canada.cia.com (30 Mar.org/greetings.org/issues_05/printer_033105LB.com (1 Apr. 2005). “China’s City Dwellers in Poor Health. Faculty of Social Work. Xinhua. et al.people. “China Faces Prominent Employment Problem. http://english. http:// www.org. 2005).edu/~Charles_Kemp/chinese. Mandarin Chinese Pronunciation.com/intro/education/ (1 Apr. Canada. Health. Xinhua. 15 Aug. Celebrating Diversity: China. China—In Their Language.gov/cia/publications/factbook/geos/ch. China Online. 30 Mar.htm (1 Apr. Central Intelligence Agency. 24 Mar. 2004). Yes/No Please Thank you. “The Workplace: Seeking Unskilled Workers. http://www.com. 26 Apr.html (2 Apr. People’s Daily. 2005). .comn/language/pronunciation/ (4 April 2005). eds.org/USfocus/print. Immigrants. “China Employment Forum Concludes with Focus on Decent Work for All. http://www. Refugees. 2005). Ni hao ma? Hao. ———. 2005. 2005.” 2004. Thomas. http://www. 20 Sept. 2005).index-china.asp?countryid=51& countryname=China (3 Apr.countreports. Elizabeth. 2005).truthout. http://www.com/index-english/education-s. Lipson. What is your name? I’m pleased to meet you. David. 2004). WuChin.com. China. cont. http://www.htm (30 Mar.htm (1 Apr. “Split Over Taiwan’s Future.org/wiki/Tiananmen_Square_protests_of_1989 (30 Mar.cn/english/doc/2005-04/ 02/content_430420. 2005).com/news/local/ (3 Apr. “Public Health System Needs Overhaul.S. 2002. Buffalo. 7 May. 2001. Jason. ———.” 2005. “Parents Pay Too Much for Education. Rachel. Minimum Standard of Living System in China: An Interview.wikipedia.gov/g/drl/rls/irf/2002/13870pf.latimes. 2005).china. 2005). 2003. 2005. U. Vongs. 2005. 2002. 1 Apr. Denis M. 11 Feb. Gloria Zhang. Department of State Bureau of Democracy.com. http://www. 2005).htm (30 Mar. http://www. Wikipedia. Center for International Rehabilitation Research Information and Exchange (CIRRIE). http://www. 2003. (14 Feb. 1 Apr. (14 Feb.edu (23 Mar. 2005. Human Rights.org.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 77 China. 2004).com/food/ethnic_cuisine/china. 2005). China Daily.S.htm (31 Mar. Chinese Education System.buffalo. 2004). Timmons.” Los Angeles Times. Chinese Culture and Disability: Information for U. Telephone Interview.” Pacific News Service.htm (28 Feb.state. . Service Providers. http://sallys-place. 3 Apr. Sally’s Place.cn/english/2002/ Feb/26986. “Tiananmen Square Protests of 1989. http:/ /cirrie. Xiaoping. 2005).” China Daily. Yuan. Survey Lists Top 10 Issues of Concern to Urban Citizens.com/news/local/ (11 Feb.cn/english/2001/ Aug/17444.china. “International Religious Freedom Report 2002: China. Pierson.org. http://www. 2005).Ethnic Cuisine: China. 2 Feb. 2005).” http://en.org. 2005).” http://www. Taerea.chinadaily. “The Problem of Health Care in Asian Communities.chinadaily.” APA News and Review. Pueng. NY: State University of New York. 22 Dec. and Labor.htm (2 Apr. 2001. http://www. “Reaching Out to Asian Patients. Yang.cn/english/ doc/2005-04/01/content_430102. “Hiding the Pain: Suicides High Among Asian Immigrant Women.latimes. Stohler. Buffalo. 2005.” Los Angeles Times. Liu. Celebrating Diversity: .○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 78 Respecting Differences. fruit. automobile production. Buddhist 26%. wireless telecommunications equipment. ships.38% 75.51 years 0. country divided into 9 provinces and 7 metropolitan cities. graphite. motor vehicles.000 Chinese) Korean. with rainfall heavier in summer than winter occasional typhoons. steel agriculture 8%.18% rice. Christian 26%. Seoul is capital temperate. Confucianist 1%. eggs.644 34.9% South Korean won (KRW) homogeneous (except for about 20. telecommunications. hydropower potential 17.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 79 South Korea Census Figures (2000) United States Residents Born in Korea: California Residents Born in Korea: 864.125 (2.422.452 (3.82 years 4% 97. industry 19%. high winds. English widely taught in junior high and high school No affiliation 46%. steel. cattle. Other 1% Republic of Korea.023 sq. chemicals.0%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 38. services 73% . barley. chickens. floods. milk. vegetables. tungsten. low-level seismic activity common in southwest coal. shipbuilding. fish semiconductors. lead. root crops. petrochemicals electronics. miles (slightly larger than Indiana) 48. molybdenum. computers. pigs.8%) 268. to be succeeded by the oldest son. North Korea remains isolated from the rest of the world. a small room with mats and dressers that served as a family room during the day and a sleeping room for the parents at night. Work. who is responsible for caring for the parents in their old age. and perhaps the husband’s parents. Siberia. Written history goes back to the Three Kingdoms period. and a strong labor effort. That marked the beginning of internal conflicts that led to the establishment in 1948 of the People’s Republic of Korea in the north. In the 1990s. Brief History Archaeological discoveries indicate that the Korean peninsula may have been inhabited for 40. triggering the Korean War that ended with an armistice in 1953 that made the 38th Parallel demilitarized zone. a historic first North-South summit took place between the South’s President Kim Tae-chung and the North’s leader Kim Jong Il. Temperatures fluctuate between very hot in summer and very cold in winter. including directed credit. Manchuria. Housing. What is called the direct family is more common. increasing population density in urban areas. a middle-class family in Seoul would have lived in a small apartment with a hallway. most Korean houses have inner yards and back yards with terraces. South Korean voters elected Roh Tae-woo to the presidency. The Korean people are the descendants of tribes that migrated into the peninsula from central Asia. ending 26 years of military dictatorships. backed by communist China and Russia. The belief in filial piety or duty is strong—children treat parents with respect.or U-shaped and has one story separated by sliding doors into three to five rooms.000 years. Celebrating Diversity: South Korea. comprising a married couple. and a living room. sponsorship of specific industries. and the Republic of Korea in the south.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 80 Respecting Differences. so houses are well insulated. a small kitchen area. South Korea today is a democracy with a GDP per capita 18 times North Korea’s and equal to the lesser economies of the European Union. a small bedroom with bunkbeds for the children. as well as a larger room divided into a dining area. Heating is usually by means of flues beneath the floors of the house which are connected to a woodburning stove or other heat source. A table may be brought out to create a dining room and later put away when mattresses are spread out to create a bedroom. when Japan imposed colonial rule. Rooms may be multi-functional. its people impoverished and unable to move freely about the country or to emigrate to other countries. Korea was under Chinese control beginning in 1392. or DMZ.000 years ago. care for them when . Following the war. roofing materials are straw or tiles. Confucianism holds harmony and order in high regard and prescribes strict roles for husband and wife in the marriage relationship. United Nations forces from 16 nations joined the war to defend South Korea. The Choson Dynasty ruled from 1392 to 1910. it took nearly 10 years for South Korea to become a stable and economically prosperous nation. Economic development. and other areas. The government promoted the import of raw materials and technology at the expense of consumer goods and encouraged savings and investment over consumption. cont. but Korean state structures continued. According to one source. the border between the two nations. Traditions Housing: Family: A typical Korean house is made of wood and clay. and escalating land prices have made home ownership difficult for lower-income Koreans. This success through the late 1980s was achieved by a system of close government/business ties. In June 2000. People sit on the floor on cushions and eat off low tables. In 1987. this ended at the conclusion of World War II in 1945. their children. The traditional Korean family developed during the Choson period with influence from Chinese Confucianism. The first political state emerged in what is now North Korea more than 5. The father is head of the family. In 1950 North Korea attacked South Korea. supported by the United States. Two or three generations might live together under one roof. import restrictions. 57 BC to 668 AD. A traditional Korean home is L. The Koryo Dynasty (from which the name “Korea” comes) which ruled from 918 to 1392 was noted for its beautiful blue and green celadon pottery with incised designs. with strict kinship relations in which relatives are identified by titles given to their positions within the family. Family. all Koreans are descended from a common ancestor. In 1986. In interpersonal relationships. loose skirt with a long-sleeved top. radishes. red pepper paste. Rice and vegetables are the staples of the Korean diet. Women are treated as less important than men except for their importance in providing male heirs to ensure continuation of the family. Children are often indulged until they go to school. Bean curd. and vegetable side dishes (banchan). The largest percentage of Koreans are employed in the service sector. and remember them with rituals after death. cont. pressure to combat trafficking in women and girls. and silence is valued. This well-known Korean condiment is made of vegetables including cabbage. loosely translated as “state of mind. Until recently. each participant is responsible for assessing the other’s kibun and acting so as not to upset it. or other spices. ginger. garlic. eating this soup marks the individual’s being one year older and is a means of setting out on a new year marked with health and strength. Ginseng is widely used in foods for its healing properties. which contributes to such health problems as high blood pressure and diabetes. sesame oil. According to Korean tradition. generally steamed. slices of dried meat (yukp’o). green onion and red pepper.” “aunt” or “uncle” even if they are not related. tkokkuk. cold noodles (naengmyon). lifting the rice bowl to the mouth is not considered good manners. and various leaves and roots fermented with ginger. Breakfast is the most important meal of the day.S. followed by industry. Vegetables are usually eaten raw. give them a proper burial. Salty seasonings and the use of many preserved foods means that many Koreans eat high amounts of sodium.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 81 South Korea. Koreans tend to use job titles rather than first names in addressing co-workers or superiors. A special rice dumpling soup with beef broth. some kind of soup (kuk). many are lactose intolerant and avoid milk products. The traditional Korean costume for both men and women is called the hanbok. The concept of kibun. especially in the presence of an elder. when they are expected to behave and not bring shame on their families. called tubu in Korean. Korean society is rigidly ordered based on age or station. is eaten to celebrate the Lunar New Year. bean paste. the South Korean work-week included Saturday mornings. Koreans eat rice with a spoon. as it is not considered appropriate to speak while dining. South Koreans were noted for having the longest work-week of any nation—up to 60 hours a week for the average worker. Friendship is a close relationship within the same age group. soy sauce. . No dietary taboos as such. is a source of protein. In contrast to custom in China and Japan. cucumber. Foods and Eating Habits Dietary Practices: Everyday Diet: Popular Foods: Many Koreans hold to the hot-cold theory of balance that requires certain foods to be eaten to treat various illnesses and conditions. skewered boiled beef (chok). Meals are generally eaten in silence. popular foods include a variety of rice cakes (p’yon). green onion.” is important in relating to Korean people. and pickled fish. as it faces U. this was necessary due to low wages. For men. and halfmoon shaped rice cakes (songp’yon). and as much as 84 hours for unskilled laborers. cold bean soup (k’ongguk). The sex trade is a continuing problem for the South Korean government. Employment: Traditions: they are old.7 hours each week. Koreans generally do not like iced beverages. Koreans are a homogeneous people. the average Korean worked 54. Korean people generally do not participate in small talk and are comfortable with long periods of silence. the individual’s identity is related to his or her position in the organization. In the work environment. according to their mythology. Kimchee is served at most meals. In addition to kimchee. Expression of feelings may be discouraged. Popular seasonings include garlic. pepper. it consists of trousers with a jacket and perhaps a vest and over-jacket. The woman’s hanbok consists of a long. A typical meal includes rice (pap). People may address one another as “brother” or “sister. Elementary education was made free and compulsory for children ages 6 to 11 in 1953. and beans. Protestants outnumber Roman Catholics about three to one. Relations among various religions groups are generally peaceful. A punch made with honey. in 1997 there were more than 9. Beverages: Koreans may drink a hot or cold tea made by boiling roasted corn or barley and straining the liquid. English is widely taught in schools because of the country’s close relationship to the United States. pine nuts. Among practicing Christians. that is served as a special dessert. fine arts. three grades each of middle and high school. with six grades of elementary school. but all are supervised by the Ministry of Education. The Korean school system is organized in a 6-3-3-4 ladder pattern. dried persimmons. and miscellaneous colleges such as seminaries. Elective subjects include technical and vocational courses. arithmetic. Small specialized schools for subjects such as music. barley. Roman Catholics have 15 dioceses and six missionary groups. Education Status: Elementary School: Secondary School: Higher Education: South Korea has one of the highest literacy rates in the world—nearly 98 percent. white. Koreans in the United States find support in Korean congregations of many denominations. Prior to 1969. Korean language. azalea. About 80 percent are private. and four years of higher education. music. Wines are made from a wide variety of fruits and flowers. pine tree. It is not free and is based at least partly on an entrance examination but may also include middle school activities records. and practical arts. The basic curricula consists of moral education. In 1997. shik’ye. admission has been through a lottery system by zones in an attempt to ease distinctions between schools of differing quality. math. High school education provides advanced general and specific training based on middle school work. . strawberry. junior colleges. Bachelor’s degrees are offered in 26 areas of study. natural science. including cherry. While kindergarten is not included in the formal educational structure. Christianity was introduced to Korea in the 18th century by Jesuit missionaries. Higher education institutions include four-year colleges and universities. universities and colleges of education. nearly all students continued on after graduating from elementary school. Some 83 Protestant denominations are active in South Korea. electives. and chrysanthemum. Middle school enrollment has been steadily growing as more children ages 12 to 14 attend grades 7 to 9. cont. Junior vocational colleges work with industry and play a major role in graduating mid-level technicians and preparing graduates for certification in many areas. In recent years. as is a sweet rice drink. and science are being established. and cinnamon (sujonggwa) is popular. and extracurricular activities. physical education. The country is homogeneous. Celebrating Diversity: South Korea. The Ministry of Education is working to increase availability. so virtually everyone speaks Korean. Wines and grain alcohol are produced from rice. Private high schools can select students by whatever methods they choose and decide on appropriate tuition. millet. and that about identical percentages practice Christianity and Buddhism: 26 percent. students were required to pass an entrance exam to advance to middle school. Religion Status: Christianity: The most recent estimate shows that 46 percent of Koreans have no religious affiliation. Chinese has been increasingly popular as the South Koreans rediscover their ancient ties to China and the importance of China as a trading partner. and 17 Protestant missionary groups operate in the country.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 82 Respecting Differences. Since that time. social studies. Curricula includes 11 required subjects.000 kindergartens in the country enrolling more than 27 percent of children ages 3 to 5. and friends. Acupuncture and herbal remedies are popular. Those who practice shamanism may use a practice known as hanyak to heal both body and soul. justice. Abortion is legal and accepted. which contributes to their longevity. shamanist rituals still take place and there are well over 50. hot spices. Religious surveys typically fail to include the shamanist population. high blood pressure. the life force of the body. so the exact number of practicing shamanists is unknown. Many U. Mormons. family. and Vietnam. and ginseng is widely used. and it is a powerful underpinning for Korean social order. Some Koreans are adherents of Taoism. which may be diminished by such things as blood withdrawal. Employers deduct a small amount from the employee’s wages to cover costs. Tips for Health Care Providers Attitudes: Koreans view physicians as powerful and trustworthy members of society. Koreans generally eat a diet low in fat and processed food and high in vegetables. Each family has a health insurance card. In July 2000 South Korea completed a five-year restructuring of its health care system. and other conditions are common. Health and Health Care Health Status: Traditional Practices: Medical System: Because of the high sodium content of traditional Korean diets. Confucianism emphasizes devotion to parents.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 83 South Korea.000 fee-paying members of shamanist organizations throughout the country. the National Health Insurance Corporation. This involves the use of herbal medicine to create personal harmony. Korean folk beliefs. cont. Many traditional practices are used and accepted in South Korea. practical examples of their search for human ideals. Japan. prescription medications are available over the counter in South Korea. Alcoholism is a significant problem. Koreans may use cupping techniques as well as moxibustion. Thus a cold would be treated with hot bean sprout soup laced with garlic. the country’s oldest religion. and ethical living are central tenets of Confucianism. the country has the highest alcohol consumption rate in the world. According to the Korean Embassy. Illnesses seen as “hot” or “cold” are treated by opposing forces to restore balance. sweating. Many traditional practices are used and accepted in South Korea. Muslims. and dental care is covered as well. that serves all citizens. Illness is sometimes seen as the result of a disruption of the body’s balance. Jehovah’s Witnesses. and the worship of ancestors. and sex. merging many private insurance companies into one national provider. and members of such organizations as the Jesus Morning Star Church and the All People’s Holiness Church are part of the Korean religious landscape. the burning of a soft material at specified spots corresponding to internal energy channels. Contraception is widely used in South Korea to limit family size to two children. Koreans who are Buddhists view illness as a natural part of life to be accepted.S. including shamanism. Like other Asian cultures. Buddhism: Confucianism: Shamanism: Other: Most Korean Buddhists are members of the Mahayana (greater vehicle) school also practiced in China. Illness is sometimes seen as the result of a disruption of the body’s balance. Confucianism was the official Korean religion from the 14th to the 20th centuries. Koreans may also be concerned about kior chi force. harmony. Buddhist and Confucian thinkers left a legacy of refined philosophical works as well as beautiful. still exist in many diverse forms and have a strong influence on everyday life. Peace. From the Three Kingdoms through the Choson period. The influence of Confucianism is seen throughout Korean social life. . More a philosophy than a religion. and dried anchovies to clear congestion. diabetes. particularly in the rules governing human relationships and ancestor worship. especially in the business community. Parents’ Day: Children give their parents gifts of carnations and letters of appreciation. Show respect. They often do not like to use pain medication for fear of addiction or complications. The family will want to spend time with the individual following death. as is kite flying. Do not address an older person by his or her first name. Ch’usok: Harvest Moon Festival. Shamanism is still a strong force. is played on a board with 29 circles and four sticks. When handing something to an elderly person. father. but a husband. Special foods include a rice dumpling soup in beef broth. Organ donation and transplantation are thought to disturb the body’s integrity. Arbor Day Buddha’s Birthday Children’s Day: Parents give gifts to their children and take them on family outings. . use both hands. Touching among strangers is considered disrespectful except for medical examination purposes. celebrates Korea’s independence from all foreign powers. Koreans wear traditional clothing and travel to be with family. As in many Asian cultures. The Korean expression for “much pain” is ah-poom nida. tkokkuk. and burn incense. National Foundation Day (Gaecheonjeol Day): Date on which Dangun. Most South Korean immigrants are Christian and would follow Christian religious practices such as requesting a minister or priest. including the United States. Cremation is viewed as destroying the soul or spirit. Lunar New Year: Celebration varies from January 21 to February 19. See-sawing is popular. one of the most important holidays. or eldest son may be the final authority.000 years ago. family and friends may chant. Independence Movement Day: Commemorates the beginning of the Samil Independence Movement against the Japanese colonists in 1919. particularly the reduction of sodium in the daily diet. two to four days off work. this is the date Japan surrendered to the United States. Gifts of cash in red envelopes are given to young people for correctly executing a traditional bow in front of elders. When a patient dies. the term chegesso or chegetta. Constitution Day: Celebrates the establishment of the first Korean constitution in 1948 and the establishment of the Republic of Korea shortly thereafter. A traditional game. Emphasize prevention. Celebrations and Holidays January 1 January/February March 1 April 5 April/May May 5 May 8 July 17 August 15 September/October October 3 December 25 Western New Year: Most Koreans count themselves one year older on this date.” may be used for dramatic effect in describing pain. One of them or the eldest daughter may act as spokesperson for the client. Yut-Nori.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 84 Respecting Differences. which may make pain assessment difficult. pray. founded the Korean nation more than 4. Spiritual healers may be used. Korean patients may be seen as overly dramatic in expressing pain. the mythical first Korean. This is often resisted. Allow the family to share in patient care as appropriate. cont. Koreans dress in traditional clothing and travel to be with family and to honor the ancestors and older living family members in a ceremony called sebae. Be careful in discussing terminal illness. and may request cleansing of the body. pointing the sole of the foot toward another person is considered rude. Celebrating Diversity: South Korea. Provide teaching instruction in as many ways as necessary to insure understanding. be aware that in Korea patients are generally not hospitalized for long periods but are cared for at home by relatives. Christmas Day: Official holiday as many Koreans are Christian. although prolonging life is seen as unacceptable and DNR orders are common. When hospitalization is needed. Liberation Day: Celebrated as the official end of Japanese colonial rule and the beginning of the modern era. especially to elders. which literally means “I could die. and it is not uncommon for several religious traditions to be intermingled. date varies. Family Authority: Addressing Clients: Nonverbal Exchange: Verbal Exchange: Hospitalization: Religious Practices: Death and Dying: Decisions are becoming more family-focused. from which half of its vocabulary came.” Good morning/day/night. Among immigrants.000 Koreans came to the United States.” Sentences tend to be longer and more complicated in Korean than in English. about 92 percent are non-English speakers. the learner can hear words pronounced at http:// www. and Lee are the most common Korean family names. and Texas. Korean Christian church attendance is estimated to be about 80 percent. Language. The second wave of Korean immigrants was from the middle class. Kim.” and “l” is pronounced like a combination of “r” and “l. Han-gul.000 Korean residents identified in the 2000 census. The naturalization rate for Korean Americans is about 60 percent. Chawn mahn neh yoh. New York. More than a quarter of all Koreans in the United States live in the Los Angeles. California.” Korean names are usually three syllables with the one-syllable last name first. In 1992. The 1965 Immigration Act opened the gates to a large influx of immigrants from throughout Asia. Yes/No Yeh/Neh/Ah nee yoh . Please/Thank you Ship shee yo/Kam sahm nee da You’re welcome. Ahn yawng hah seh yoh. Yaw boh sey yoh. The Korean population of the United States increased by 53. San Bernardino. Korean women came to the United States as “picture brides. and many 1. Riverside. Ahn yawng hee kyeh seh yoh (said when speaker is leaving).5 and second-generation Korean Americans are becoming involved in politics. Several Web sites provide Korean words and phrases. and Ventura county area. military personnel to enter on non-quota status.com/kintro. foreign-born Koreans show the highest percentage of persons with difficulty in English as compared with other Asians. cont. Most Americans know the Korean word tae-kwon-do.8 percent from 1990 to 2000.500 Korean businesses were damaged or destroyed. which literally translates as “leg-to raiseway of life. Nice to meet you.5. most under the War Brides Act of 1947 that allowed Asian wives and children of U. Beginning in 1903. 43 percent of Koreans have difficulty with English. so a Korean word order would be “I breakfast eat” or “She sick is. and has similarities to other languages including Japanese and Turkish. about 8. In July 2005 authorities broke up a sex-trafficking ring operating brothels in the San Francisco and Los Angeles areas using women brought to California illegally from poor areas of South Korea. The following words and phrases are rendered phonetically.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 85 South Korea.S. There are large Korean settlements in Fullerton. Orange. Glendale.000 Koreans settled in Hawaii to work on plantations. the Korean community in Los Angeles suffered devastating losses following four days of rioting in response to the Rodney King verdict. According to information from the Korean American Coalition Los Angeles–Census Information Center. Park. many with college degrees.langintro. During the period of 1965 to 1977. Los Angeles County has the largest population of Korean immigrants in the nation. many health care professionals emigrated from Korea to the United States. with more than 95. Goodbye. Han-gul was influenced by Chinese. the percentage increase was 44. escaping Japanese control. and Torrance.” From 1950 to 1965 some 17. Koreans in the United States Koreans have been migrating to the United States for more than one hundred years. Pronunciation helps include tips that the accent is usually on the first syllable of the word. Nearly 2. Useful Words and Phrases The Korean spoken language. that “si” is pronounced “shi. Koreans in the United States are concentrated primarily in Hawaii. In the Los Angeles area. Despite the fact that there are five major dialects spoken in the northern and southern parts of the peninsula. La Cañada. in California. The language consists of 14 consonants and 10 vowels. originated in the 15th century with King Sea Jong and is thought to be the first phonetic alphabet in East Asia. Korean is relatively homogeneous and people throughout the country can understand one another. In Los Angeles County. Sentence structure is subject-object-verb. Illinois. How are you? Ahn hawng hah seh yoh? Hello. Mahna beh bahn gahp sum nee dah. Background Note: South Korea. 2005). Toronto. Center for International Rehabilitation Research Information and Exchange (CIRRIE). Ltd. n. 3 Feb. Weol Soon. 18 July. Family Structure and Relatives.com/south-korea.S. Republic of Korea. 2005). 2005).settlement. 2005). Celebrating Diversity: South Korea.kr/enghome/culture/living. ———. Boardroom Minutes. cont. Korean Words and Phrases. http://www.asianinfo. eds.” San Francisco Chronicle.co. Buffalo. http://www.html (22 Mar. http://www. 2005). Library of Congress.. South Korea. Asia-Pacific Connections.gov/g/drl/rls/irf/2002/13877pf. ———. Multiculturalism and Native Issues Centre. Buffalo.asianinfo. Korean Holidays.” Press release. 2005). http://www.seoulsearching. 2005). http://www3.org/asianinfo/korea/cel/annual_customs. 2003. 2005). http://www. Jane N. Korean-American Health Care Beliefs and Practices. http://theseoultimes. http://www. 2005). Sam Chu.com/korean_national_holidays. http://www.gov/r/pa/ei/bgn/2800. 2005). 2000. Education/Literacy in Korea. (22 Mar. Charles. Canada: University of Toronto Anti-Racism. Neely. Cecilia. 2005. Nov. “Alleged Sex-Trade Ring Broken Up in Bay Area. “Sex Life Active.asia-pacific-connections.ktnet. http:// www.org (3 Mar.co.htm (28 Feb. 2 July. 2005). “Local Koreans Mark the Lunar New Year Traditionally. David. http://www.html (8 May 2005).com/ST/db/ read. 2002. 2005). Language Use.com/kintro/ (28 Feb.gov/cia/publications/factbook/geos/ ks. http://www. 10 Jan.com/language/phrases. TravelBlog. Housing. “Scattered But Strong: Korean American Results from the 2000 Census. Lin. Van Derbeken.travelblog. Purcell.prt (9 Feb. 2005). http://www.html (28 Feb. An Introduction to Korean Culture for Rehabilitation Service Providers.htm (14 Feb.baylor.kr/enghome/culture/family. http:///www.” Asian Week. 2005). bed pain hungry hot cold Chim dae A pu Bae kop pa Deu ku wu Choo wu toilet food rice stomachache headache Pyun so Um sik Pap Bae a pa Khol a pa References Annual Customs.com/Language. Korean Words.state. 2004).com/articles/2005/02/03/newws/news01. 2005). http://www. Korean American Coalition Los Angeles Census Information Center. and Ryan Kim. 2005). 2005. Sex Trade Thriving in Korea. Linguistically Isolated Language Environment.country-studies. 2005). Country Studies: South Korea. 2005.asia-pacific-connections. 2005). 2003. http://www. . The World Factbook: South Korea. NY: State University of New York. 2005).htm (22 Mar.html (22 Mar. Eisenberg. 1997. Clothing.edu/~Charles_Kemp/korean.htm (22 Mar.html (3 Mar. U. Kemp. http://www. Smart IT Choices Keep a National Health System Humming.. et al.htm (3 Mar.html (22 Mar.sun.asianweek. http://www. Seoul Searching. Kim-Rupnow. Lipson. http://cirrie.edu (28 Feb.lovethechildren.d. http://www.” La Cañada Valley Sun. San Francisco: University of California San Francisco Nursing Press. Department of State. 2001. Love the Children. Juliene G.lacanadaonline.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 86 Respecting Differences. KTNET. Culture and Nursing Care: A Pocket Guide. International Religious Freedom Report 2002.htm.com (9 Jul.com/2003_01_10/feature_scattered. Lee.htm (22 Mar.html (28 Feb. Sun Microsystems.php?idx=260 (1 Mar.org/World/korean-language. Food. Conor.” The Seoul Times. 2005).htm (3 Mar. “Socio-economic Indicators. http://www. About Korean.sfgate.-Dec. http://atwork. 2004.com/br/1204_ezine/hc_nhic.cia.state.com/words.org/asianinfo/korea/education. Central Intelligence Agency.langintro. Korean Language. An Introduction to Korean. Jaxon. J. ed.html (1 Mar.buffalo.ktnet. ———. electronic equipment. textiles. semiconductors. capital is Tokyo.3%. chemicals.539 (1.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 87 Japan Census Figures (2000) United States Residents Born in Japan: California Residents Born in Japan: 347. steel and nonferrous metals. about 1. ships. vegetables. miles (slightly smaller than California).500 seismic occurrences (mostly tremors) per year.212 (1. machine tools. tsunamis.1%) 112. electrical machinery. pork. services 70% . industry 25%.2%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 145. Christianity 0. sugar beets. country divided into 47 prefectures varies from tropical in south to cool temperate in north many dormant and some active volcanoes. Brazilian. poultry.417. Shikoku. fish 12. Buddhism 44. Japan comprises four main islands: Hokkaido.7%. Filipino.1%. typhoons negligible mineral resources. New Religions 4. eggs. Chinese. Honshu. and Kyushu 127. Other) Japanese Shintoism 50.8% constitutional monarchy with a parliamentary government. dairy products. fish motor vehicles.05% 81.15 years Unknown 99% yen ( JPY ) Japanese 99%. chemicals among world’s largest and most advanced producers of motor vehicles. Others 1% (Korean.244 42.898 sq.19% rice. fruit.64 years 0. processed foods agriculture 5%. which is characterized by solidarity and mutual helpfulness. . They are set back from the street and entered through a gate and a garden. traders from Spain and Portugal reached Japan. banning European books and missionaries. The Japanese defeated the Chinese in a war during 1894–95. it became the national religion by the 7th century. and the influence of the imperial court was undermined by Buddhist monks.S. Japan fought against Germany. establishing a military capital at Kamakura. and in 1904–5 Japan defeated Russia to take power over Korea. is currently in control. gained importance. Many have to wait years to find a house or apartment. In the 5th century. but offensive military forces and nuclear weapons are forbidden. Housing. Jimmu was the first emperor. Zen. In December 1941 Japan bombed Pearl Harbor and entered World War II on the side of Germany. In World War I. generally living with their parents before marriage because of the severe housing shortage.S. The emperor retains his throne. as grown children are required to care for their parents. Celebrating Diversity: Japan. the country was occupied by the U. In the 17th century. Most people live in modern housing. The Fujiwara family took power in 858 and kept it for 300 years. perhaps through an arranged meeting or miai. In 1868 power returned to the emperor in Kyoto. The Japanese governing body is a prime minister and the National Diet. A new Buddhist sect. The Yamato clan came to power in the 4th century AD. Work. The modern Japanese nuclear family is usually small. Buddhism came to Japan from Korea about 552. The Liberal Democratic party. Junichiro Koizumi has been prime minister since April 2001. This was the beginning of the shogunate and the rule of the samurai class as well as the beginning of the Japanese feudal era. but traditional Japanese houses can still be found. Michinaga. Some Japanese families choose to live in the suburbs and must commute several hours each day to jobs in the city. Traditionally. primarily as a symbol of national unity. well-known Japanese practices such as ikebana (flower arranging). and to carry out the formal behaviors required in polite Japanese society. The Japanese sleep on futons which are placed on the floor and then folded and put away during waking hours. Since the 1950s. Tokyo became the capital and Japan closed itself off from Western influence. Elders my assist with household chores and childcare if they are able. Men and women meet at work or while studying at a university. and Jesuit missionaries introduced Christianity. emperors retreated into the background. Warrior families controlled villages and agriculture. and the tea ceremony were established. in 794 the capital was moved to Kyoto. in 1185 the Minamoto under Yorimoto assumed power. Early Japanese tribal culture was greatly influenced by both Korea and China. it resembles the U.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 88 Respecting Differences. Traditions Housing: Family: About three-quarters of the Japanese people live in cities. actually a very conservative group. Family. warriors from the Taira and Minamoto clans engaged in a power struggle that ended with the Taira taking control of the country from the Fujiwara in 1160. Under the greatest Fujiwara leader. and that maintaining harmony is a value. the Noh drama.S. Japan has experienced tremendous economic growth. In the 9th century. Nara became the capital in 710. Near the end of the 12th century. Elderly relatives are often part of the household. During this time. historiographers were appointed to keep records. feudal institutions were abolished. military from 1945 to 1952. where it remained until 1868. The house is divided into rooms by sliding screens made of wood and rice paper. Constitution. The father is head of the family. They learn to behave in public by being polite and shy. The constitution was rewritten in 1946. to respect and obey age and authority. leaving the affairs of government to their subordinates. Young people tend to marry in their late 20s or even after. Congress. much like the U. Japan’s government changed from centralized to a system where the country was divided into great estates. cont. Yorimoto separated the military from the government. In the 16th century. Brief History Japan is thought to have been founded in 660 BC. then through a sliding door where occupants remove their outdoor shoes. children have been taught that the group is more important than the individual. The nuclear bombing of Hiroshima and Nagasaki in 1945 by the United States forced Japan to surrender. which are very expensive. When the stock market crashed in 1992. Although women make up about 40 percent of the workforce. cont. Saving face is important.” Foods and Eating Habits Dietary Practices: Everyday Diet: Some older Japanese hold beliefs that certain combinations of food may cause illness (e. vegetables. Many Japanese are lactose-intolerant and do not handle alcohol well. Traditionally. and haji (shame) are key to Japanese culture. Work: Traditions: Leisure: The Japanese work environment is known to be highly stressful and exhausting.. Traditional Japanese leisure pursuits include horse racing (and gambling). Japanese are traditionally quiet and polite. A wellknown Japanese tradition. eating certain foods is thought to bring good luck and health for the coming year. cholesterol. Many Japanese now eat a Western-style breakfast. Local horse racing is held at 30 regional tracks throughout the country. When greeting others. animal protein. but the traditional breakfast is white rice. including medical personnel. The traditional Japanese diet is low in fat. “The numbers of those who have become completly preoccupied with and dependent upon pachinko have been on the rise. Go and shogi are traditional indoor games. . The 40-hour work week was implemented in 1997. including rice. They tend not to make direct eye contact. death from overwork.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 89 Japan. especially dinner. soba. Brown buckwheat noodles. women put their hands on the front of their legs. are treated with respect. might be a packed lunch. may be eaten instead of rice at times. and touching is not common. a single event runs for eight days at ten racing tracks throughout the country. tofu (beancurd). vegetables. incorporating special rules of etiquette designed to achieve a feeling of peace. Japanese tend to be formal and may use a smile or small bow to acknowledge the other person. and miso (soy paste used in soups). Fish and soybeans are traditional sources of protein. the Japanese nod their heads to show agreement or concentration. During the Lunar New Year celebration. a negative is indicated by holding a hand in front of the face and waving it back and forth sideways. During conversation. and sugar. Most people have to commute to work. The concepts of enryo (selfrestraint). miso soup. is when parents and children eat together. Dinner. The depth of the bow is related to the occasion and the social status of the individuals involved. they are generally paid less than men and hold subordinate positions. they control their facial expressions and are not given to emotional outbursts. Lunch. When bowing. Elders and authority figures. According to the Japanese Embassy. The Japanese eat three meals a day and may have snacks such as rice cakes between meals. o-hiru. the Japanese economy went into a recession from which it continues to recover. but may be high in salt. yu shoku. Rice (gohan) is eaten with most meals. cooked fish. many using the crowded bullet train or shinkansen that travels between major city centers at speeds of over 180 miles per hour. Other popular noodles are ramen and udon. gaman (self-control. and umeboshi. endurance). Soybeans are used in sauces. giving rise to the problem of karoshi. the Japanese keep their feet together and their backs straight. the tea ceremony (cha no yu) has been observed for 600 years.g. This is becoming less common as young people devote more time to leisure pursuits. and many Japanese enjoy traveling to see cherry blossoms in spring and colored leaves in the fall. Pachinko (pinball) is wildly popular. bento. the Japanese would say Itadokimasu (I receive) before a meal and Gochisosama-deshita (It was a magnificent feast) after a meal. watermelon and crabs). especially with superiors. Robots are used extensively in factories to do work such as welding and painting. Japanese traditionally make an effort to prepare and serve food in a manner that is visually appealing. Japanese women traditionally put a hand in front of their mouth when laughing to avoid showing their teeth. Handshaking is becoming more common. and men hold their hands at their sides. and umeboshi (salty pickled plums). This caused considerable stress among workers. as is karaoke. Other mainstays of the everyday diet are vegetables and seaweed. Terms are April through July. Types of Japanese foods and cooking include: Sukiyaki—thinly sliced beef with vegetables. a fiery green horseradish paste. fine arts. and “allergies to school” as early as elementary school. Tempura—prawns. and Japanese children study harder than students in many Western nations. Popular Foods: Beverages: Japanese food is probably quite familiar to most Californians. and those who want to get into the most highly regarded universities need to be accepted by the better high schools. children attend kindergartens and day-care centers. possibly with vegetables and meat. so that all students throughout Japan study the same thing in a grade. sake. The curriculum includes Japanese language. local breweries produce different varieties. children are required to learn a minimum of 1.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 90 Respecting Differences. the school year begins April 1. private cram school. High school attendance (three years) is not required and can be extremely competitive. and industrial arts or homemaking. there are weekly extracurricular activities and an hour of moral education. Japanese rice wine. The atmosphere surrounding both high school and college entrance examinations is called. Yakisoba—fried noodles. social studies. science. the students eat in their classrooms. art. but some have classes on Saturday mornings. and vegetables dipped in egg batter and deep-fat fried. civics. Classes are generally large in both primary and secondary education. . tofu. according to the Japanese Embassy. Three years of junior high school are compulsory. fish. without cream or sugar. Most students attend five days a week. Prior to elementary school. Sushi—small pieces of raw seafood such as tuna. Sashimi—sliced raw fish eaten with soy sauce. mathematics. violence. Japanese “fast food. foreign languages. elementary and junior high students may attend juku. is a popular accompaniment. may include cucumber. science. music. and coffee is also popular. Yakitori—small pieces of chicken and vegetables skewered on bamboo and grilled over hot coals.” Wasabi. Kobe beef is a very expensive delicacy throughout Japan. Education is funded by the federal government together with local and regional governments. “examination hell. and January through March. Ramen—popular and very inexpensive noodle soup. Students must pass entrance examinations. stir-fried in a wok and eaten like spaghetti. Celebrating Diversity: Japan. often English. and home economics. mathematics. Curriculum includes Japanese language. arts and craft. One hour each week is devoted to moral education and extracurricular activities. September through December. arithmetic. on top.. but some include essays or performance tests. music. The Ministry of Education defines the curriculum for the six elementary grades. The Japanese drink green tea. physical education. life environmental studies. and homemaking. and other ingredients. Most schools have three terms each year. Bullying and violence have been blamed for suicides among schoolchildren across the country. It comes from cattle that are specially bred and raised to produce very tender meat with a high fat content. pickled radish. social studies. Both parents and the system itself have been blamed for this unhealthy situation. geography and history. The standard junior high curriculum requires Japanese language. The Ministry of Education specifies the subjects to be taught. health and physical education.” Most of the exams are multiple choice questions. squid. Most children wear uniforms to school. Donburi—bowl of rice with a hot entree. Education Status: Elementary School: Junior High School: High School: Elementary and junior high school attendance (nine years) is compulsory. where they receive individual help with their schoolwork so that they will do well and be prepared for the high school entrance exam. Students may take electives in foreign language. like stir-fried vegetables or deepfried chicken. The severe stress caused by this emphasis on performance has resulted in a pervasive school climate of bullying. cont. After school.006 Chinese characters in addition to Japanese. By the end of the sixth grade. is consumed both cold and warmed. but teachers have latitude in defining the topics they cover. health and physical education. science. and vermicelli prepared right at the table. Lunch is provided. or prawn placed on a ball of vinegared rice and wrapped in seaweed. The Japanese people are generally very healthy and live on average to 81 years of age. It is estimated that about a fourth of the population will be over age 65 by the year 2025. is used in Japan as in many other Asian countries. is a holistic approach designed to strengthen the body while treating an illness. Japan has a comprehensive health care system funded by national and local governments as well as employer and individual contributions.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 91 Japan. Tendai. Many Japanese practice both Shinto and Buddhism. Shintoism. or Shinto. Each shrine has several major festivals each year. Shiingon. Zen. According to Shinto belief. regular participation in formal religious activities is low. the median age is more than 40. all of which was believed to be imbued by supernatural beings or kami. in contrast to Buddhism. as are shiatsu and amma massage. responsible for the sarin gas atttack on the Tokyo subway system in 1995. Competition for schools considered most prestigious is fierce. cont. Jehovah’s Witnesses. The lay organization Soka Gakkai has more than 8 million members. Department of State’s International Religious Freedom Report of 2002. Everyone is covered by the public health insurance plan. Shinto has no official sacred scriptures or fixed dogma. Buddhism was introduced to Japan in the sixth century from Korea. the Church of Scientology. fractures. . and dislocations. there are no weekly religious services. Some 28 different schools of Buddhism are recognized under the 1951 Religious Corporation Law. Japanese Christians are both Roman Catholic and Protestant. making it difficult to determine numbers for particular groups. Believers visit shrines as they desire. and Nara. kampo. becomes a kami and continues to participate in the life of the community. Moxibustion. The Aum Shinrikyo group. with the numbers of Protestant and Catholic churches roughly equal as of 1994. Kampo practitioners are both medical doctors and pharmacists trained in Eastern medicine. Sekkotsu therapy is the use of touch to diagnose sprains. regardless of the quality of his or her earthly life. Shinto grew out of respect and awe for nature. Spanish Jesuit missionaries introduced Christianity to Japan in 1549. Religion Status: Shintoism/Shinto: Buddhism: Christianity: New Religions: According to the U. Practitioners strive for peaceful relations with other religions. Acupuncture is frequently used. as attending a big-name school is thought to increase the graduate’s chances of getting a good job. the birth rate is well below one percent. All other religions practiced in Japan are grouped in this category. major schools include Jodo Shinshu. and native religions such as Perfect Liberty and Risho Koseikai. Customarily. There are both public and private institutions. Joudo. Nichiren.S. the Japanese use Shinto rites to celebrate birth and marriage and Buddhist ceremonies for funerals and memorial services. the burning of small amounts of a plant called mogusa or moxa on the skin to stimulate the immune system and prevent illness. Practitioners erected shrines in sacred places. In addition. One traditional Japanese practice. Japanese may eat rice porridge with pickled vegetables when they are ill and use pickled plums and hot tea to avoid constipation. is the indigenous Japanese folk religion that embodies native Japanese religious and philosophical beliefs. Many companies recruit from only the top universities. it was banned from 1612 until 1873. Health and Health Care Health Status: Traditional Practices: Medical System: The Japanese population is overall much older than that of many neighboring countries. Higher Education: About half the graduates of Japanese high schools attend either a two-year junior college or a four-year university. has been renamed Aleph and is under government surveillance. which are then treated with massage. after death every person. They include the Unification Church of Japan. introduced to Japan in the sixth century. The father. especially with superiors. Japanese Americans. Placing a parent in a nursing home is a difficult decision that may cause guilt. Japanese may be very stoic in expressing pain.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 92 Respecting Differences. may not speak or understand English. and touching is not common. this may not indicate agreement. . The gates of the house are decorated with kadomatsu made of pine branches. Isei. a tradition called hatsumode. and straw. Japanese begin by soaping and scrubbing before entering the tub. Families visit Shinto shrines or Buddhist temples to pray for good health and good fortune in the new year. In situations of terminal illness.S. born and educated in the United States. or Nisei. Terminal patients may prefer to die at home with care from the family. tend not to ask many questions about medical treatment and leave decisions to health care professionals. Tips for Health Care Providers Attitudes: Family Authority: Addressing Clients: Nonverbal Exchange: Verbal Exchange: Hospitalization: Death and Dying: First-generation Japanese Americans. the mother often has more authority than the son or daughter. bamboo. Handshakes are common in younger generations. is used only for soaking—the most relaxing part of the bathing ritual. It is considered polite to speak in a soft voice and avoid expressions of conflict or disagreement. Red and white foods are eaten. attitudes and culture. bells ring 108 times to drive away the evil spirits of the past year. Older Japanese may nod during conversation. discuss the situation with family members including spouse and eldest children. Facial expressions are generally controlled. Daily tub baths before bedtime are generally preferred. Cleanliness is very important as part of a belief in the need to purify the body to restore health. Older Japanes may not agree to organ donation or autopsy due to belief that the body should remain intact. Some Japanese companies operate hospitals for their employees. immunization. The system includes small neighborhood clinics and large hospitals. although potted plants are frowned upon because their roots are considered an omen of a long hospitalization. The second generation. Many people write resolutions for the new year. and children receive otoshidama. eldest son. The bath. Celebrations and Holidays January 1–3 Shogatsu. DNR is generally decided by the entire family. Chrysanthemums and white flowers are generally not given because of their association with death and funerals. They may be hesitant to disclose bad news to the patient. and a straw rope called shimenawa hangs at the entrance to the house. or ofuro. Oral medication may be preferred to injections. especially older individuals. They use little direct eye contact. may still retain Japanese attitudes. Third generation Sansei and fourth generation Yonsei generally reflect U. Greet clients formally by using the last name. as these are the colors of good fortune. decorated envelopes of money. cont. and older Japanese may refuse medication for fear of addiction. and private plans are also available. Self-disclosure depends on establishing a relationship of trust. Saving face is important. and settle conflicts. and both prenatal and post-natal care. Public health centers in urban areas provide health education. Sick elders are primarily cared for by the eldest son’s family. Japanese tend to be very modest and prefer caregivers of the same gender. Visitors will bring gifts of food and flowers. These decorations welcome the gods and spirits of ancestors who protect the families living there. Japanese Americans who follow Shinto or Buddhist beliefs may have the body cremated. or eldest daughter is traditionally the family authority. Family members may wish to stay with the patient during hospitalization. Family and patient may avoid discussing death. preventive health care. In younger generation families. Celebrating Diversity: Japan. and the health care professional may need to ask pointed questions to elicit desired information. At midnight on New Year’s Eve. New Year: The most important Japanese celebration before which people clean their houses. pay debts. Buddhist priests perform sutra readings to honor the ancestors. Autumn Equinox: Includes custom of making special dumplings to offer to the moon along with samples of crops from the autumn harvest. In 1942.038 Japanese lived in the United States. and smoke. The National Origins Act of 1924 banned Japanese and other Asians from entering the United States.000 years of happiness to the child. July O Bon. May 3 Constitution Day May 5 Children’s Day: Celebrated during Golden Week. and dry rice cake pellets with peach blossoms are made. reaching a peak between 1900 and 1910. Vernal Equinox Day: People visit family graves to pay respect to ancestors. 5. discrimination against Asian Americans was a fact of life on the West Coast. the beginning of the school year and the time employees begin new jobs. April 29 Green Day begins Golden Week. Respect for the Aged Day: Celebrates the elderly and long life. Adults’ Day: All young people turning 20 during the coming year are honored in a coming-of-age ceremony. According to a history Web site prepared by the National Park Service. traditionally honored boys but now includes girls as well. Festival of the Dead: Many people take holidays from work for this observance of welcoming and consoling the spirits of ancestors. one of the first groups of settlers from Japan arrived at Gold Hill in El Dorado County in June 1869. November 23 Labor Day December 23 Emperor’s Birthday Japanese in the United States Immigration to Hawaii and the West Coast of the United States began in the late 19th century. cont. with media reinforcing negative stereotypes. September 15 Keiro no hi. Many people take a holiday of a week or more to enjoy spring travel. were interned in temporary detention camps for two to seven months and then moved to permanent concentration camps where they were held without charges. In 1890. Red-and-white candy sticks called chitose-ame (thousand year candy) are sold at the shrine to bring 1. fun activities and special foods include rice dumplings wrapped in bamboo leaves. opens with fires and lanterns to guide the spirits home and concludes with fires to see the ancestors back to the spirit world. September 23 Tsukimi. and Washington in relocation camps in remote locations. and other agricultural products. More than 90. Assembly Bill 781. and 7 are considered lucky by the Japanese. after which they are eligible to vote. 2. January (2nd Monday) Seijin no hi. the Gospel Society. United States citizens and legal permanent residents. more than 1. Doll Festival: Families pray for the health and happiness of their daughters and display doll collections with dolls wearing traditional Japanese court attire. after the bombing of Pearl Harbor by Japan and the entry of the United States into World War II. . In October 1877 the first Japanese American community organization of record in the United States. evidence. Oregon. Special food includes rice boiled with beans and a saltwater fish. Even prior to World War II. The book Return to Manzanar tells the story of one such camp. drink. October 10 Sports Day November 3 Culture Day November 15 Shichigosan. March 21 Haru no Higan. Seven-Five-Three Day: Boys ages 3 and 5 and girls ages 3 and 7 are taken to Shinto shrines wearing traditional costumes to pray for health and safety.100 in California. Offerings of white sake. silk cocoons. rice cakes. February 11 National Foundation Day March 3 Hina-matsuri. The numbers 3. Moon Viewing. which became law in California in 2004.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 93 Japan. Executive Order 9066 directed the forcible resettling of all persons of Japanese descent living in California. tea plants. or trial. was established in San Francisco to provide English classes and offer boarding services and a gathering place for Japanese immigrants.000 Californians of Japanese descent. Japanese were again allowed to immigrate to the United States. bringing mulberry trees. Beginning in the 1950s. bamboo roots. retroactively issues a high school diploma to any person of Japanese descent whose education was interrupted due to forced removal and incarceration during World War II. Yes/No. Japanese books are read from what we would consider the back to the front. not the heart. Shiri-masen. such as sensei.or. Konbanwa. and adjectives.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 94 Respecting Differences. There are many local dialects. Oyasumi/Oyasuminasia. Please. Language. Wakari-masen. Konnichiwa. Good night. Japanese contains many loan words from other languages. I don’t think so. Titles are added after the family name. Konnichiwa. An interesting note is that the Japanese consider the stomach. Ii-desu/Ii-desu-yo. I don’t know. Arigato/Arigato gozaimasu (polite). Good evening. Sou omoi-masu. . to indicate honor and respect that includes factors such as age. In California. but standard Japanese. How are you? Ogenki desu-ka? I’m fine. the center of emotions. Names in Japanese. Good afternoon. another set of characters. I don’t understand. Japanese are found throughout the state with the largest concentration in Los Angeles. Good-bye. Japanese are the only immigrant group to identify themselves by the generation in which they were born. as in most other Asian cultures.and fourth-generation Japanese Americans. Of course. cont.000 are used regularly. Useful Words and Phrases Written Japanese has three sets of characters. Sansei and Yonsei are third. Good morning. called keijo in Japanese. Hello. One of these is found at http://www2. are often added when the person addressed is a doctor or teacher. The firstgeneration Issei maintain a strong sense of Japanese identity. I think so. Ohayo/Ohayo-gozaimasu (polite). Katagana characters are used to make foreign words pronounceable in Japanese. begin with the family name followed by the given name.” and other titles of respect. Kanji contains 50. As in other cultures. Onegai shimasu (used when asking for something).htm. is most widely used. Mochiron-desu. A number of excellent Web sites provide pronunciation of words to aid those who wish to speak elementary Japanese to their Japanese American patients. Please. the owing of a favor—with the result that a simple sentence might be uttered 20 different ways. The following words and phrases may be helpful to the health care provider. To show verb tense. Genki-desu. Dozo (used when offering something). so a traditional Japanese person would “open the stomach” for a conversation. gender. hiragana. verbs. Thank you. often Chinese but sometimes English and European languages.000 Chinese characters for nouns.tokai. based on the language as spoken in Tokyo. Wakari-masita. Recent immigrants tend to be well educated and to settle in urban areas with Japanese American communities.jp/yuki/greetings. but only about 3. Wakatte-imasu. I understand. Sayonara. are added to the kanji. with lines of characters printed vertically and read from right to left. Sou omoi-masen. Hai/Iie. The suffix “chan” may be used for a child or close friend. I know. OK. particularly in Kyoto and Osaka. The Nisei are those born and educated in the United States who retain significant vestiges of Japanese culture. the Japanese have a special manner of speaking. The word “san” is the equivalent of “Mr” or “Mrs. social status. Celebrating Diversity: Japan. npt. ———. http://www.cr. 2005).asianinfo. 2000. Encyclopaedia Britannica Premium Service. eds.” 2005.asianinfo. Canada: University of Toronto Anti-Racism. 2005).org/asianinfo/japan/pro-religion. International Religious Freedom Report 2002. Japan. http://www. General Information about Japan. http://www.asianinfo. 2005).jp/yuki/ (24 Mar. 2005).org/asianinfo/japan/pro-family_customs. History of Japanese Americans in California: Organizations and Religious Practices. Japanese Words and Phrases. Japan.gov/g/drl/rls/irf/2002/ 13874pf. History of Japanese Americans in California: Immigration. 2005). “Saint.html (8 May 2005).htm (22 Mar. http://atwork.gov/history/online_books/5views/ 5views4a.gov/history/online_books/5views/5views4e. http://www. http://www.settlement.htm (22 Mar.asianinfo.com/teaching/asia/html/about_japan.htm (24 Mar.cia. http://www.Org. Japan’s History and Background. Lipson. 1997. National Park Service.html (25 Mar. http://www. . The World Factbook: Japan. The Language of Japan.htm (24 Mar. Japan’s Society Celebrations. Japan’s Family Customs.org/asianinfo/japan/pro-history. Department of State.gov/cia/publications/factbook/geos/ja.asianinfo.htm (24 Mar. et al. References AsianInfo. http://www.cr.or. History of Japanese Americans in California: Incarceration of Japanese Americans During World War II. 2005). ———.npt. Japan’s Religion and Philosophy.htm (22 Mar. http://www.org/asianinfo/japan/japanese_language..htm (22 Mar.britannica.htm (28 Feb. ———.org (23 Mar. ———.gov/history/ online_books/5views/5views4c. 2005. 2005).jobmonkey.asianinfo. ———. Culture and Nursing Care: A Pocket Guide. ed. 2005).asianinfo. JobMonkey.state. 2004).htm (22 Mar.npt.tokai. Toronto. Campsie.org/asianinfo/japan/cuisine_sushi. 2005). http://www.htm (22 Mar. ———. U. Yuki’s Page.org/asianinfo/japan/education_literacy. http://www. 2005). Eating in Japan.com/eb/ article?tocid+34111 (24 Mar. http://www. 2005). http://www2. Juliene G.cr. Encyclopaedia Britannica. cont. Japanese Education and Literacy.. http://www.org/asianinfo/japan/society_celebrations. 2005). ———. 2005). Multiculturalism and Native Issues Centre.S. Central Intelligence Agency. San Francisco: University of California San Francisco Nursing Press. ———. Philippa. http://www.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 95 Japan.htm (22 Mar. 2005). ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 96 Respecting Differences. Celebrating Diversity: . Southeast Asia Philippines Vietnam Laos Thailand Cambodia . Celebrating Diversity: .○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 98 Respecting Differences. Muslim 5%. floods petroleum. 15 regions and Metro Manila.5%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 115. sugarcane. pineapples.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 99 Philippines Census Figures (2000) United States Residents Born in Philippines: California Residents Born in Philippines: 1. earthquakes. miles (7.107 islands. fish. hydropower 18. Buddhist/Other 5% Republic of the Philippines: president directly elected for six-year term. to April). electronics. mangoes.473 22. slightly larger than Arizona) 87. wood products. chemicals. clothing.6% Philippine peso (PHP) Christian Malay 91. beef. Protestant 9%.830 sq. typhoons. fish coconut products. services 48% . fishing agriculture 36%. Chinese 1. corn.4 million (4. chicle. food processing. textiles.95% rice. northeast monsoon (Nov. pork. southwest monsoon (May to Oct. 76 indigenous languages Roman Catholic 81%. rare woods.27 years 1. Other 3% Pilipino/Filipino (based on Tagalog) and English official languages. Muslim Malay 4%.4%) 664. coconuts. nickel. wiring sets.) volcanoes. 79 provinces. pharmaceuticals. eight major dialects.5%.84% 69. woodcraft and furniture electronics assembly. industry 16%. Senate and House.5%. bananas. 115 chartered cities tropical marine.857.935 (7.91 years 40% 92. eggs. petroleum refining. with one percent of the population controlling most of the land and means of production. caring for children. Fossilized human bones on Palawan indicate habitation as long ago as 22. in the May 2004 presidential election. Godmothers (comadres) and godfathers (compadres) are important. Relatives often live close to one another or together in extended family settings. governor of the Philippines. In 1965 Ferdinand Marcos was elected president. the Filipinos began guerilla war against the United States. population growth and migration from rural areas to cities has resulted in housing shortages. The basic problem is inequitable distribution of resources. Many people in rural areas live on land with no water or sanitation. arrived on the island of Palawan over a land bridge from mainland Asia as long as 200. but opposition to Arroyo and political turmoil. Brief History The first inhabitants of what we now call the Philippines. stone tool remains date to 30. Children start learning household chores at a young age and may assist the family financially by selling small items on the streets or at markets. Gloria Macapagal-Arroyo assumed the presidency in 2001. Manuel Roxas y Acuña was elected president.S. 1991. Women retain their private property following marriage. Work. which provides personal. In 1996. Celebrating Diversity: Philippines. In 1998. he was forced to step down in 2000 over corruption charges and was later indicted.000 BC. as many as 10 pairs may be involved in a wedding or baptism. who was executed by the Spanish in 1896 for instigating insurrection. Under terms of the Treaty of Paris in 1898 the Philippines. formally ending a 24-year struggle by Islamic separatist Moro National Liberation Front for autonomy. and slum conditions in parts of the Philippines. military presence ended.S. In 2500 BC. including street protests and rumors of a coup. the middle class comprises only about one-tenth of the population. William Howard Taft took over as the first U. former movie star Joseph Estrada was elected president.S. destroying U. the country was named for King Philip II. continued. Manila was established in 1571. Nearly everything revolves around the family. In 1901 the United States captured Aguinaldo.2 million Filipino families lacked adequate shelter. the hunter-gatherer Aeta. and managing finances. overcrowding. The Philippines became an independent nation in 1946. under Aguinaldo. with wealthier people having Western-style houses. The entire country except the Sulu archipelago was soon under Spanish control. turmoil continues in the area. Traditions Housing: Family: As in many countries. Nearly half the people are below the poverty line with another third just above it. In 1935 a constitution created the Commonwealth of the Philipines. the father is head of the household and responsible for financial security. impeachment charges were dismissed in September. . Guam. Quezon established a government in exile. Filipinos under General Emilio Aguinaldo declared their independence in 1898. In 2002 an estimated 4. Most people live in simple houses or apartments. Traditionally. Arroyo narrowly defeated film star Fernando Poe. Manuel Quezon y Molina became the first president. In July 2005 Arroyo was accused of election fraud and corruption.000 BC. and Puerto Rico were sold to the United States for $20 million. especially the capital city of Manila. Clark Airbase. The independence movement began in 1886 with publication of an anti-Spanish novel by Jose Rizal. Family. Jr. the Philippine government granted greater freedom to the southernmost island of Mindanao. Austronesians (precursors of the Malay people) arrived by sea from Taiwan.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 100 Respecting Differences. cont. Fidel Ramos was elected president in 1992 and U. Many women work outside the home in addition to running their households. Housing. he was killed by a local chief. A military coup attempt in 2003 failed. Mount Pinatubo erupted on June 15. Older family members make decisions by consensus. he declared martial law in 1972 and ruled as dictator until 1986 when Corazon Aquino was elected president. social. In 1565 there was a permanent Spanish settlement at Cebu under royal governor Miguel Lopez de Legazpi.000 years ago. and often economic solidarity. They are raised to respect their elders and to be achievers and make their families proud. Ferdinand Magellan landed on Cebu in 1521 and claimed it for Charles I of Spain. In 1380 AD the Makdum people brought Islam to the Sulu archipelago. Japan invaded the Philippines in 1941. Filipinos fought with the Americans against the Spanish in the Spanish-American War. Adobo refers to the spice mixture used in the dish. Lengthy eye contact is considered rude. a Filipino national dish of braised chicken and pork with coconut milk. an embroidered shirt worn outside the slacks. and do not like cold or acidic foods at breakfast. About 40 percent of the Philippines workforce is involved in agriculture. Many Filipino nurses have emigrated to the United States. and Western Europe and send back remittances that support their families and strengthen the Philippine economy. chiles. Filipinos primarily wear Western-style clothing. bay leaf. Foods and Eating Habits Dietary Practices: Everyday Diet: Popular Foods: Beverages: Filipinos who are Muslims do not eat pork or pork products or consume alcohol. a salty liquid made from fish. Some Filipinos may be lactose-intolerant and/or wheat-intolerant. completion rates are high in major cities and low in some outlying areas. Fish is abundant and prepared many ways. include rice cakes. filled buns. a third party may be enlisted to mediate a solution that saves face for those in conflict. It is often seasoned with garlic. Rice is the basic element of the Filipino diet. Women make up about 35 percent of the labor force. soy sauce. and siomai. vinegar. However. Fruit juices. One popular dish. Meriendas. sinigang. Traditions: Employment: Recreation: Filipinos greet each other by bowing and shaking hands. preferably at room temperature or warmer. and patis. snacks served mid-morning and mid-afternoon. for example). . cont. for men. coconut milk. Overall. Filipino foods reflect the diverse history and settlement of the islands. and soy sauce. They prefer drinks without ice. a terno— long dress with flared skirt and butterfly sleeves. Filipinos are noted for combining several meats and/or seafoods in one dish. There are more than 1. peppercorns. Cockfighting is popular among men. but on special occasions they may don national costumes: for women. and sugarcane wine are popular beverages. slacks and a barong tagalog. 97 percent of children are enrolled in elementary school and 66 percent in secondary school. forestry. Teenagers in the Philippines form same-sex peer groups or friendship clubs known as barkadas which develop their own slang and spend many hours together. or fishing. Filipinos prefer soft and warm foods when they are ill.500 Islamic schools in the Philippines. ginataan (fruit cooked in coconut milk). and many Filipinos shy away from calling attention to themselves in public. steamed. about two-thirds of all children fail to complete primary education. Education Status: In 1995 the Philippines ranked after Brunei and Korea as a leader in school enrollment. vegetables and meats rolled in edible wrappers. Adobo. buko (coconut flesh). and/or ginger may be cooked with the rice. In cases of conflict. relleno. Salty and sour flavors are very popular. In some areas. Basketball is the country’s most popular sport. Popular Chinese dishes include lumpia. Rice is eaten for every meal in combination with such things as salted or smoked fish and vegetables. gelatin. The Spanish influence is seen in such dishes as paealla. called pancit and featured in popular restaurants called panciterias. reflects the Spanish influence. and a Filipino version of tamales. garlic. which in the Philippines most often includes vinegar. siopao. fruit shakes. and caramel custard topped with shaved ice and coconut milk or ice cream). ginger tea. the Tagalog language has several different words for rice depending on its condition (kanin is rice that is ready to eat. and efforts are under way to integrate them into the national education system.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 101 Philippines. is fish lightly boiled in a sour stock with vegetables and fish sauce. Filipinos drink lots of water. Canada. The Chinese influence is seen in noodle dishes. They try to avoid confrontation and do not make direct critical remarks. the Filipino version of spring rolls. dumplings. and halo halo (a dessert of layered fruit. coconut wine. music. social studies. attendance rate is about 97 percent. Protestant organizations include the National Council of Churches of the Philippines and the Council of Evangelical Churches of the Philippines. Roman Catholic. The Roman Catholic Church claims about 68 million members. Compulsory high school subjects include English. government. but the area is still subject to violent uprisings. Instruction in Grade 1 is in the language spoken in the homes of children in the area. the Autonomous Region in Muslim Mindanao (ARMM) was established to ensure Muslim autonomy in areas of Mindanao where they are in the majority. instruction is in English. claims 5 million active members. Celebrating Diversity: Philippines. and other subjects. Ethnic and cultural discrimination by the Christian majority is a continuing problem. sewing. social science. founded in 1902. A 1996 peace agreement with the Moro National Liberation Front (MLNF) concluded a 20-year struggle. gardening. Most Muslims in the Philippines belong to the Sunni branch of Islam. with about 66 percent of Filipino children attending. Protestant. The practice of Catholicism in the Philippines retains strong roots in the animism practiced both before and after Spanish priests converted the natives. Islam was introduced to the Philippines during the 14th century. Students take examinations to receive a high school diploma. established in 1914. Less than one percent of the 1. as Christians try to settle in Muslim areas and Christian missionaries proselytize in Muslim communities. Four-year high schools are free but not compulsory. Muslims are treated as second-class citizens throughout the country. Filipino. The Philippine Independent Church (Aglipayan). . to 5 p. and Islamic groups. such as teacher education and engineering. Muslims are concentrated primarily in the Sulu archipelago and on Mindanao.m. with more than 50 icons said to be responsible for miracles. Both academic and vocational high schools are available. Higher education institutions include both public and private universities and colleges. and Islamic representatives work together with the Interfaith Group to support peace in Mindanao. and citizen army training. Most children attend public schools. School is free and compulsory for children ages 7 through 12. Both English and Filipino are taught along with math. they must pass the National Secondary Aptitude Test to enter a university. science. Primary school comprises grades 1 through 6. Religion Status: Roman Catholicism: Protestantism: Islam: The National Ecumenical Commission fosters interfaith dialogue among Protestant.S. and the Church of Christ (Iglesia ni Cristo). In Grades 2 through 6.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 102 Respecting Differences. with 72 percent of students attending private institutions. cont. which includes cooking. A monthly meeting of Roman Catholic bishops and Muslim leaders works to deepen understanding and further the peace process. some fields. soldiers during the Spanish-American War introduced Protestantism. history. but there are many private schools run by religious orders that charge tuition and often include a year or two of preschool as well as a Grade 7. Students receive a bachelor’s degree after accumulating from 120 to 190 credits. with little influence in either the government or the economy. civics. In 1990. A growing charismatic lay movement. Ferdinand Magellan introduced Christianity to the islands comprising the Philippines on his arrival in 1521. require a semester of work experience. where about 19 percent of the population is Muslim and Muslim extremist groups have been active. The school day generally lasts from 8 a. Many Filipinos are devoted to the Virgin Mary. youth development training. mathematics.m. are two prominent independent Filipino churches. science. Children also study home economics. Many health-related degrees require a one-year internship. Presbyterian and Methodist missionaries who came to the Philippines with U.4 million 2004 primary school graduates passed the aptitude test given in June. Currently about 9 percent of Filipinos are affiliated with a Protestant denomination. Primary School: Secondary School: Higher Education: The school year in the Philippines runs from June through March with a Christmas holiday break. practical arts. El Shaddai. and physical education. and there are cults devoted to the worship of the Child Jesus. Catholic. Health care providers should explain procedures clearly and encourage feedback and questions. receiving transfusions is more readily accepted. The family is very solicitous of a sick member. psychic healing. Medical doctors in the Philippines earn about $400 a month. Smiling is common as a greeting or acknowledgement. . with little justification.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 103 Philippines. GTZ is working with Filipinos on issues including family planning. with illness representing an imbalance. Many nurses are leaving the Philippines for the United States. providing poor quality service and poor implementation of health programs and disease control. Tips for Health Care Providers When working with Filipino patients who are Muslim. They point to a lack of coordination among the various health facilities including private clinics and hospitals and advocate for participation in inter-local health zones. Many Filipinos maintain their belief in spirits and the role of spirits in health and illness. refer to page 22 for information on the influence of Muslim beliefs and practices on health care. GTZ. this would be appropriate. which means inequality in health care delivery among population groups and regions. Traditional folk healers in the Philippines practice centuries-old treatments including herbalism. notes on its Web site that the country faces an increasing burden from chronic diseases such as diabetes due to urbanization. Faith healers claim. inadequate personnel. Some Filipinos may refuse pain medication for fear of addiction or because they are stoic or have a high pain threshold. and the laying on of hands. They make little direct eye contact. cont. massage. Health and Health Care Health Status: Traditional Practices: Medical System: Malnutrition is a major health concern in the Philippines. especially with authority figures and superiors. changing lifestyles. They typically speak softly and avoid expressing disagreement. Nonverbal Exchange: Filipinos are typically shy and awkward in unfamiliar surroundings. but the health care provider should speak slowly and clearly. to perform surgery without instruments or bloodshed. and strengthening local health systems. and environmental health problems. Filipinos use tone of voice to convey meaning and may talk loudly or get emotional. Donating blood is thought to upset the balance of the body. Health care is a matter of location and ability to pay. and insufficient drugs. According to the Philippines Department of Health. A German government organization assisting with social and economic development in the Philippines. and the entire family may visit. The health care delivery system is highly fragmented. Handshakes are not commonly used. Family Authority: The father or eldest son often acts as the family spokesperson. Verbal Exchange: Speaking in their own language. Few doctors want to practice in remote rural areas. The department notes that rural health units are often ineffective. expanding social health insurance coverage. Most Filipinos understand English. District hospitals suffer from poor facilities. Filipino physicians are retraining as nurses to be eligible for these jobs as well. Attitudes: Filipinos may see health as a matter of balance (timbang). Some will use herbal medicine prior to seeking Western medical help. Addressing Clients: Greet clients formally by using the last name. Provincial hospitals do not have enough money and have high patient loads. Female family members may expect to stay at the patient’s bedside at all times. Filipinos may be sensitive to shame and/or saving face. Filipinos generally hold medical professionals in high regard and tend to follow their directions. 13 percent of the national budget is spent on public health. Canada. and Western Europe where they can make up to $40 an hour as opposed to $108 a month. but decisions are generally made by the entire family. Hospitalization: Filipinos prefer soft and warm foods and drinks without ice when they are ill. If an Asian or Chinese menu is available. Patients prefer to die at home with hospice care except in cases of acute illness. New Jersey. Mass and eat a breakfast of native treats following the service.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 104 Respecting Differences. Bataan Day. Epiphany or Feast of the Three Kings People’s Power Day A very somber season in this mostly Roman Catholic country. Filipinos in the United States Filipinos. Rizal Day: Anniversary of the death of hero Jose Rizal. Celebrations and Holidays January 1 January 6 February 22 Lent. the family. In cases of terminal illness. at least the eldest son or daughter. should be told and allowed to convey the information to the patient. Three-day feast at the end of Ramadan. Most speak English. and they account for 7.4 million foreign-born Filipinos living in California. Death and Dying: In cases of serious or terminal illness. some featuring people suspending themselves from crosses or flagellantes beating themselves raw. Increasing numbers of . Nativity scenes or belens. From December 16 to 23. a DNR order will be decided upon by the family. according to Census 2000. visiting the cemetery and perhaps staying overnight. are the second largest immigrant group in the United States. with nearly half of the 1. The family may ask to wash the body and say good-bye. cleaning and decorating graves. Date varies according to the lunar calendar. and Illinois. Customs include banging on pots and pans to frighten away evil spirits. Some 46 percent of recent Filipino immigrants to the United States have a college degree or more. Holy Week April 9 May 1 June 12 June 24 August 31 November 1 November 30 December 25 December 30 Eid-al-Fitr New Year’s Day: Celebration begins with fireworks and media noche (midnight snack) on New Year’s Eve. where they account for nearly half of all foreign-born residents. They have been immigrating to the United States since they served as seahands on Spanish galleons that began trading with America in 1587. and they have a very low poverty rate (less than 1 percent in 2000). Holiday customs include caroling in exchange for food and money. some featuring elaborate figurines and added to year after year. From 1906 to 1946 the first major wave of immigrants came as farm laborers to Hawaii. Other states with sizeable numbers of Filipino immigrants are New York. Cremation is not usually practiced.m. opening doors and windows to bring in good luck. Filipino immigrants make up 8 percent of the population of Hawaii. Holy Week includes the blessing of palm fronds woven in intricate designs.5 percent of the state’s population. They are symbols of hope that bring blessings and luck to the home. Day of Valor Labor Day Independence Day (celebrates independence from Spain) Manila Day National Heroes Day All Saints Day: A time for remembering the dead. The body after death is given high regard. processions with flower-decked carts carrying scenes of the events of the Passion. and decoration of homes with the Filipino Christmas symbol. are a common feature of homes at Christmas. 6. also called Pinoys. and organ donation and autopsy may not be welcome. Christmas Day is the high point of a long celebration that concludes on Jan. A Catholic hospitalized patient should see a priest if terminally ill. the last day is now an official holiday. families attend 4 a. the month-long Muslim fast. Celebrating Diversity: Philippines. cont. enactments of the Passion. five-pointed star-shaped lanterns made of bamboo sticks covered with rice paper or colored cellophane. Filipinos are sometimes spoken of as “invisible” due to being mistaken for other Asian groups or for Latinos. elaborate parols. Filipinos make up 23 percent of the population of Daly City. Bonifacio Day: Anniversary of the death of hero Andres Bonifacio. sfgate.buffalo. Don’t mention it. nurses. Some analysts suggest that availability of nurses from the Philippines may have the effect of lowering overall wages for U. http://www. 25. Magandang gabi.S. The basis for Filipino is Tagalog. were interviewed. Buffalo. “Philippine Schoolkids Learn the Wrong Things. . It is an official language of the Philippines.globalization101.ucla. 14 Oct.” The Straits Times. Useful Words and Phrases English is taught in Philippines schools from elementary grades. It is somehow more considerate to refer to Filipino. Baguioro. Happy Birthday. as the immigrants are willing to work for less. According to the Web site Tagalog Lang. Understanding Persons of Philippine Origin: A Primer for Rehabilitation Service Providers. citizens. “Case of the Philippine Nurses. there are close to 300 nursing schools in the Philippines. “Filipino is Tagalog Plus—it is supposed to be more inclusive of languages other than Tagalog. Maligayang Pasko. Mabuti. Yes/No Oo/Hindi Merry Christmas. Remittances from Filipinos working in the United States and other foreign countries totaled $7.edu/ eloisa.com. Magandang umaga. Most spoke English well. In December of 1995. Good evening. http://cirrie. Filipino was named the national language. Chronology of Filipinos in America Pre-1898. 2004). . Language. http://www.6 billion in 2003. 2004). Hello/Goodbye Kumasta/Paalam How are you? Kumusta po kayo? (polite) Kumusta ka? (casual) Where does it hurt? Saan po masakit? Fine. Buffalo. and two-thirds said they sent money—remittances—to the Philippines.html? (15 Oct. “The most common sort of first-time migrant is a 25-year-old female college graduate going abroad to work as a domestic helper on a two-year contract. the Philippines sends some 3. 74 percent were naturalized U.000 nurses left the Philippines for the United States and other countries.000 female migrants abroad each day to work.” according to the organization’s Web site.org/issue/migration/4b. .anderson. Luz.” Globalization. not Tagalog.00. Manigong Bagong Taon. 2004. According to Migration News from UC Davis. as the Philippine national language. More than 90 percent said they were happy living in the United States. Borah. Thank you.” San Francisco Chronicle. which was spoken only in Manila when the 1930 Commonwealth constitution provided for a national language but did not specify one.pdf. 5 Nov. Maligayang Bati. Walang anuman. 2002.asia1. Eloisa Gomez. some 750 California Filipinos. Center for International Rehabilitation Research Information and Exchange (CIRRIE). some Tagalog words and phrases for health care providers and teachers to learn include: Good morning. (1997–2001) http://personal.” While many Filipino immigrants can communicate in English. In 2003. who perform more than 250 different jobs in more than 150 countries. “Doctors Leaving Philippines to Become Nurses—for the Money.com (10 Oct. Prosperous New Year. 2003. Melissa. NY: State University of New York. .sg/storyprintfriendly/0. Filipino nurses and physicians retrained as nurses are coming to the United States to meet the ongoing nursing shortage.S.277866. Salamat.1887.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 105 Philippines. References Alipalo. if only to recognize Filipinos who do not regard Tagalog as their first language. 2004). 85 percent of whom were born abroad. which is the third-largest English-speaking country in the world.edu (28 Feb.borah/chronology. 2005). cont. de Torres. hkttp:// straitstimes. The Philippine Overseas Employment Administration assists and tracks overseas workers. Good afternoon. Magandang hapon.Org. During the 1980s under Ferdinand Marcos a new constitution was adopted. Sheila.asp (9 Feb. html (15 Oct.com/ news/nationworld (14 Apr. and Edward Cody.gov. http://www.ph/discover (7 Oct. Vemuri. 2003.tradeport. Thomas. “International Religious Freedom Report 2002: Philippines. and D. 2004). 2004). U. Department of State Bureau of Democracy.asp (9 Feb. 2003. Lily. 2004). Philippines Country Portfolio.com/filipinoheritage/religion/ folk_christianity. 2003.gov/cgi-bin (14 Oct. Library of Congress Country Studies: Philippines. cont.com/destinations/south_east_asia/philippines/ index.britannica. 2005). Indonesia. Culture and Nursing Care: A Pocket Guide. Timeline: Philippines History. 2004). Habitat for Humanity..html (8 May 2005). Odete.htm (9 Oct. Laura. http://www. India. “Philippines. UNESCO.htm (7 Feb.org/countries/philippines/01grw. 2004). Juliene G. 2004). and Labor.lingnet. 2004).unesco.org/areaStudies/ perspectives/philippines/phil_011. 2004).fm (24 Mar.com/filipinoheritage/customs_traditions/fiesta/ fiesta_philippines.koleksyon. Lipson. 2004.org (5 Feb.koleksyon. 2004) Vieira. Tagalog Lang. Ellen. http://www. World Bank Group.state. 2004).com/ATINYROCK/page 21. http://migration. 2004). http://www. 2003. Department of State.htm (9 Oct. ———. Philippines.lonelyplanet. “Bridging Philippines’ Islands of Faith. . 2004). http://lcweb2.migrationinformation.tourism. 1997. “Daly City among Top 5 in Nation for Foreign-Born. World Trade Press.html (7 Feb.” San Francisco Chronicle. 20 Dec.ucdavis. 2004). http://www. http://www. Nick. http:// www. 30 May http://www. et al.gov/r/pa/ei/bgn/2794. Philippines by Rochelle. Celebrating Diversity: Philippines. U.com/ATINYROCK/page 18.” Los Angeles Times.htm (9 Oct. 2004). Nancy. and S. “Maligayang pasko: Filipinos savor old and new holiday traditions.aol.gtz.com (10 Oct.de/philippines/priority/family. The Philippines in Perspective. Richard C.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 106 Respecting Differences. “Troubling Exodus of the Philippines’ Best and Brightest. Joaquin.doh. 1 Nov.com Tope. http://www. Richard. Grieco.gov/cia/publications/factbook/geos/rp. http://www.html (14 Oct. Filipino and Korean Integration in the US.com/food/ethnic_cuisine/philippines. Local Health Systems.ph/hsra/tsk/link%20sites/local%20health.infoplease. Lonely Planet World Guide: Destination Philippines. Multiculturalism and Native Issues Centre.htm (15 Oct.P. Philippines. http://migration.com (10 Oct. The Philippines: A Manifold Land. http://www. Philippines Country Profile.sfgate. Freeman. eds. WOW Philippines.latimes. Philippine Festive Isles. Infoplease. 2004). 2004).cia. Encyclopaedia Britannica Premium Service. Dolan. ed. http://www. Estrella. http://sfgate. Human Rights. 2004). Background Notes: Philippines.gov. Toronto.habitat. 2004). Holidays and Fiestas.com/eb/article?tocid=23752.” Washington Post.” Migration Policy Institute. http://members.S. GTZ Philippines.” Encyclopaedia Britannica. 2004). Philippines. Nakashima. ———. http:// www. Philippines Department of Health. Cicero.ucdavis. http://www.com (10 Oct.loc.edu/mn/comments/php?id=873_0_2_0 (6 Oct.aol. 2004). “The Foreign Born from the Philippines in the United States. 2004).org/intl/countryprofiles.” San Francisco Chronicle. 2004). Migration News. 13 Dec. Paddock.S.edu/mn/comments/php?id=3009_0_3_0 (6 Oct. 2005. 14 Apr. “Parol Brings Blessings at Christmas. 2004. Education in The Philippines. http://www.gov/g/drl/rls/irf/2002 (28 Feb.sallys-place.org/eapsocial/countries/phil/educ1.. The World Factbook: Philippines. 2004). Philippines Education System.htm (9 Oct. 2004). Philippines. http://www. Defense Language Institute Foreign Language Center. 2004. Noonan-Mercado. 13 Dec. http://www. 9 Oct.htm (11 Oct. http://www2. http://www. Elizabeth.” San Francisco Chronicle. http://www.html (15 Oct. Education. 2004). 2002.asp (9 Feb. http://tagaloglang. San Francisco: University of California San Francisco Nursing Press.sfgate.rtf (9 Oct. 2002. http://sfgate.worldbank.state. http://www.com/sppot/philippinestime1.com (11 Oct. Canada: University of Toronto Anti-Racism.org/iau/cd-data/ph. http://members. 97% paddy rice. shoes food processing. garments. corn. tea. rubber.535. oil. chromate. miles (slightly larger than New Mexico) 83. Ho Chi Minh City is largest city in country. Cao Dai.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 107 Vietnam Census Figures (2000) United States Residents Born in Vietnam: California Residents Born in Vietnam: 988.7%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Agricultural Exports: Industries: Labor Force: 127. and Khmer. monsoonal in north with hot. coal. Cham. hydropower 19. paper agriculture 63%. poultry. Muslim Socialist Republic of Vietnam: capital Hanoi is economic and political center of the north. Christian.04% 70. English (increasingly favored as a second language). Hmong. chemical fertilizer. machine-building. Chinese.576 25. mountain area languages (Mon-Khmer and Malayo-Polynesian) Buddhist. Hoa Hao. pigs. potatoes. forests. glass. Khmer. especially in the Mekong River delta phosphates.) with flooding. Indigenous Beliefs. marine products. Thai. dry season (mid-October to mid-March) occasional typhoons (May to Jan. steel. fish rice.249 (4. manganese. rubber. economic center of south tropical in south.174 (3. cement.61 years 28. offshore oil/gas. sugar.51 years 1. industry and services 37% . coffee.3% dong (VND) Vietnamese 85–90%. garments. tires. Mountain Groups Vietnamese (official). some French. coffee. soybeans.2%) 418. bauxite. mining. tea.9% 90.800 sq. Chinese. shoes. coal. bananas. rainy season (mid-May to mid-September) and warm. crude oil. This has resulted in stress for both urban and rural women. In both Hanoi and Ho Chi Minh City. a long.N. In the southern part of the country. women may wear the traditional ao dai. this conflict officially ended as a result of U.000 foreign troops. following the killing of several missionaries. the woman of the house is called the “general of the interior. the Chinese conquered the Red River Delta and ruled it until 938 AD when Ngo Quyen defeated Chinese armies at the Bach Dang River. Vietnam fought off repeated invasions by China and expanded its territory southward. high-necked tunic with a slit in the side. Legal age for marriage is 18 for women and 20 for men.” noi tuong. In the 2nd century BC. refined speech. absorbing a variety of groups including the Champa and Khmer. and his wife and children look to him for guidance. Housing. the two pledged greater cooperation. Rural housing varies depending on materials available. were defeated at Dien Bien Phu in 1954. killed some 60. According to one source. forests. and excellent conduct. During the following centuries. Work. manpower. a post office. Houses are typically made of brick. peasants lost their land and there were many uprisings.S. including more freedom for women but also increased burdens as they have been forced to assume more economic responsibility in addition to their traditional chores. Under the Geneva Accords of May 1954. In general. Traditional values for Vietnamese women are hard work. Brief History The early history of Vietnam is anything but clear. this ushered in the Vietnam War which ultimately cost more than 4 million Vietnamese lives. a clinic. The father is the provider. and devastated the jungles. Communism and war have brought many changes to the Vietnamese family structure. 90 percent of rural housing in the Mekong River Delta is made of non-permanent materials. Vietnamese Prime Minister Phan Van Khai met with President Bush at the White House in June 2005. A Bilateral Trade Agreement was signed in July 2000. Northern forces supported by Russia and China sought to liberate the south. Vietnam became embroiled in conflicts with the Khmer Rouge in neighboring Cambodia. The traditional Vietnamese family is strongly influenced by ancestor worship. Spanish and French troops stormed Danang. Celebrating Diversity: Vietnam. intervention in 1989. Both Buddhism and Confucianism stress the importance of respecting and venerating ancestors. with responsibilities for in-laws as well as husband and children. Vietnamese men and women wear Western-style clothing.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 108 Respecting Differences. Each commune includes primary and secondary schools. Traditions Housing: Family: Traditions: Rural areas are divided into communes of 4.000 people. France controlled all of southern Vietnam as a colony called Cochinchina. The United States resumed diplomatic relations with Vietnam in 1994. For special occasions. In 1858. Ngo Dinh Diem consolidated power with the support of Western governments. According to some sources.” From the 1st to the 6th centuries AD. movements began between Vietnam and Western nations to re-establish diplomatic and trade relations. Oxfam Netherlands (Novib) has been engaged in a project to help the growing urban population acquire affordable housing through creating savings groups and providing low-cost housing models. Following the end of the Vietnam War. beauty. integrated urban development projects are under way. and cultivated land. tile.000 to 8. Family. the southern part of what is now Vietnam was part of the kingdom of Funan. or wood. culminating with a declaration of independence by Ho Chi Minh in 1945. Vietnam north of the 17th Parallel became an independent communist state. By 1867. which means “country of cultured people. and service facilities for the activities of daily life and work. and construction material supply services. When the Cold War ended with the collapse of the Soviet Union in 1991. According to one source. Under French rule. it originated with the Dong Son culture in what is now the far northern part of the country in about the 3rd century BC and spread south through the Red River Delta to form Van Lang. cont. forces. Children learn early to respect elders and ancestors and to work hard and achieve to bring honor to the family. In 1976 Vietnam was reunified under communist rule as the Socialist Republic of Vietnam. The Hindu kingdom of Champa arose in the area of Danang in the late 2nd century and spread southward. aided by U. with silk pants and . but girls in rural areas may marry as young as 13. The French. nuoc cham. Foods and Eating Habits Dietary Practices: Everyday Diet: Popular Foods: Beverages: Vietnamese cuisine has three distinct regional flavors: northern. many leafy green vegetables are part of the daily diet. especially with ice.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 109 Vietnam. a spicy beef noodle soup. as the Vietnamese often use hot peppers as well as coriander. Vietnamese prefer warm. in Hanoi thousands of people support themselves by making shoes. and steamed shrimp. This was believed to be more attractive and to prevent tooth decay. Freshly pressed sugarcane juice and coconut juice are popular. mint. a thick noodle soup with beef. is made of sweet rice and coconut milk. Blending nuoc mam with sugar. with lotus tea a specialty. Many Vietnamese dishes are very hot. For many centuries. leading to a practice called ho where people pool resources and bid for the right to take out loans. cha gao. the government introduced doi moi. and most meals include soup and a stir-fry in addition to rice. star anise. Vietnamese in the United States may change their names to reflect the order popular here. Vietnamese names begin with the family name. and bun bo hue. and spices. the controlled transition of the communist economy to a market-based system including private enterprise and competition. Fish is a main ingredient. garlic. banh trang. xoi nuoc dua. One popular dessert. or fresh rice wrappers. which are often dyed red. . Hugging is acceptable only between relatives. lime juice. It looks like tea and is quite mild. The national dish is a soup of rice noodles. In 1986. and carrots creates a popular sauce. lemon grass. the non la. and do not like to eat anything cold. is woven of palm leaves and goes back to the 13th century. and other spices to flavor their food. grilled meatballs. Obtaining bank credit has been difficult. Vietnamese cuisine tends to be lighter than some other countries in the region. and Vietnamese beer is reputed to be good. Tea is grown in the Dalat region of the country. Employment: sandals called guoc. followed by the middle name. Women traditionally keep their maiden name when they marry. The majority of Vietnamese. and other things from discarded materials. favorites include pho. The conical hat worn by farmers to shade their faces from the sun. including lemongrass beef. they do not like extremely cold beverages. The typical diet includes few dairy products. and southern. until the French stopped the practice in 1954. cooked in banana leaves. banh uot. Vietnamese are very fond of soups and may eat them at any meal. Strong emotions are generally not expressed except in the presence of family and close friends. thit bo nuong. Rice paper wrappers. Rice is the staple food of the Vietnamese diet. vinegar. basil. chopped shallots. According to one source. Vegetables are often served raw. Tea is the most popular beverage at all times of the day. cont. they are dipped in fish sauce. as high as 80 percent. are very light and made of ground pork or shrimp and vegetables. work in agriculture. tom. Vietnamese traditionally greet each other by joining hands and bowing slightly. The Vietnamese prefer long-grain rice. Fermented fish sauce. Vietnamese seek to avoid conflict and to draw attention to themselves. are used for wrapping a variety of tasty ingredients. Vietnamese spring rolls. central. meat. tools. Making direct eye contact may be considered impolite. they may be lactose-intolerant. they drink warm tea or room temperature water when sick. upper-class Vietnamese girls’ teeth were blackened with Betel nuts at puberty. The Vietnamese enjoy iced tea without sugar or lemon. soft foods such as rice porridge and lots of fruits and vegetables when sick. In the northern part of the country. is used in many dishes. noodles are more commonly used than rice. nuoc mam. Popular snacks include peanuts and watermelon seeds. and sensitive topics are often discussed indirectly. with what we know as the “first” name in the last position. In general. nem nuong. . and Confucian traditions. and literature as well as morality. Founded in 1919 by Le Van Trung. according to the 2002 International Religious Freedom Report compiled by the U. Department of State. Due to economic constraints. sometimes called a “triple religion. Hoa Hao emphasizes private acts of worship and devotion. Most Buddhists are members of the ethnic Minh majority found throughout the country. about 45 percent of young men and 33 percent of young women are in school. the largest. Siddharta. Many students do not pursue higher education because of the expense. contains more than half of all adherents. founded in south Vietnam in 1939 by Huynh Phu So. 5. A Khmer ethnic minority in the Mekong Delta practice Theravada Buddhism. estimated to be between 1 and 3 million. Curricula includes Vietnamese history. is considered by some a reform branch of Buddhism. all students are required to do manual labor at their schools each week. government. Religion Buddhism: Cao Dai: Hoa Hao: Roman Catholicism: About 50 percent of Vietnamese are Buddhist. when many northern Catholics moved to the Saigon (now Ho Chi Minh City) area in the south prior to the partition of the country. Nearly three times as many urban as rural men are enrolled in universities. Celebrating Diversity: Vietnam. Confucius. Large universities are very competitive. Lao Tse. language. and teacher salaries are low. Children are supposed to attend school half days six days a week. where it was a political and military force before 1975.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 110 Respecting Differences. The basic belief system was influenced by Mahayana Buddhism. According to one source.” According to one estimate. concentrated in the Mekong Delta. Primary education is compulsory and lasts from ages 6 to 10. Following secondary school.S. Christianity was introduced in the 17th century by French missionaries. Boys and girls are equally represented at this age. Cao Dai includes 13 different sects. education is no longer subsidized and has become expensive. compared with 62 and 58 percent in cities. Students are expected to work hard. there is no priesthood and few ceremonial elements. do a great deal of homework. Many Vietnamese visit Buddhist temples even though they may not practice Buddhism. and succeed in school to bring honor to their families. headquartered in Tay Ninh Province. According to a 2003 report. many children drop out of school to help support their families. colleges. There is a substantial gender and attendance gap between urban and rural areas as students reach the later teens. This religion. Taoism. about 30 percent of those considered Buddhist practice their faith regularly. and nearly five times as many urban as compared to rural women. students have opportunities to attend vocational schools. women at this level are entering the marriage market and contributing to their families economically rather than pursuing higher education. or universities. Many schools are overcrowded and short of supplies. Roman Catholics account for perhaps 9 percent of the population or about 7 million Vietnamese. and parents do not question their decisions. In rural areas. Education Status: Primary School: Secondary School: Higher Education: Both public and private schools are contolled by the Department of National Education. cont.4 percent of men and 3. In rural areas. Secondary school lasts for seven years. Teachers are greatly respected. and Vietnamese customs. but adherents recognize Jesus. and Moses as among those through whom divine revelation has come.3 and 3 million Vietnamese. Overall. Roman Catholics fought against Communist guerrillas until 1954. Cao Dai combines elements of many religious traditions.9 percent of women ages 20 to 29 were attending universities in 2000. That report states that many Buddhists actually practice a religion containing elements of Mahayana Buddhism. Believers comprise between 1. It may also produce marks suggestive of abuse. Vietnamese both in their own country and in the United States may consult traditional medical practitioners. Two-thirds of Protestants today are members of ethnic minorities in the northwest provinces and Central Highlands. Protestantism: Islam: Protestants comprise about 1. Dr. he was very impressed with the emphasis on prevention that has produced dramatic results compared with similarly developed nations. . and Hanoi. Incense may be burned on a home altar to appease ancestors. Pinching (bat gio)—Like coining and cupping.” All districts reportedly have health centers and hospitals. perhaps to exorcise an evil spirit. leaving a red mark.000. “catching the wind”)—This involves dipping a coin in mentholated oil and rubbing it across the skin in a prescribed manner to release excess force or “wind” from the body. forming suction that draws out the bad force. this practice involves pinching the skin to release the bad force. and the use of powdered patent medicines that are acquired from China and Thailand. Cupping (giac)—A series of small. Ho Chi Minh City. which is unique to the ethnic Cham people who live on the central coast. more than half of these are affiliated with Pentecostal evangelical house churches. acupressure or massage. Quality health care has been provided nationwide. who visited the country in 2002. Through iodizing the country’s salt supply.baylor. Vietnamese commonly believe the maintenance of health is a matter of keeping a balance between opposing forces—am and duong (yin and yang in Chinese). A California public health physician. “Vietnam’s community health care network is well developed compared to other countries in the region.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 111 Vietnam. A variety of dietary. An imbalance of these forces is thought to cause illness.htm). Mark Horton. Other traditional practices include the use of balms. the others practice Bani Islam. These are described on the Baylor University site (http://www3. and more than 95 percent of children under one year have been vaccinated against six common diseases. and nearly all communes have health centers. an amulet of cloth containing a Buddhist verse that is blessed by a monk and worn on a string around the wrist or neck of a baby or child. cont. goiter has been significantly reduced. About half are Sunni Muslims. and Buddhists monks may be consulted for prayer. Horton noted after his 2002 visit that hospital facilities are inadequate and lack nearly all modern diagnostic and therapeutic technology. Like people in many other Asian cultures. Steaming (xong)—Medicinal herbs are boiled and the steam inhaled or used for bathing. acupuncture.edu/~Charles_Kemp/vietnamese_health. with medical workers providing health care in villages. traditional medical. However. especially in remote and mountainous areas. The Muslim population of Vietnam is estimated at about 65. MD. which are frequently translated as “hot” and “cold” when applied to health. They use an abridged Koran and participate in some traditional Cham festivals. Health and Health Care Health Status: Traditional Practices: Medical System: The Vietnamese government reports great strides in reducing infant mortality and childhood diseases. and Western medical practices are used to bring about the proper balance and restore health. Some sources have noted that these marks may be mistaken for evidence of child or spousal abuse. Polio has been eradicated. and are. briefly: Coining (cao gio.2 percent of the population. According to the government of Vietnam on its tourism Web site. heated glasses are placed on the skin. Missionaries from the Christian and Missionary Alliance introduced Protestantism in 1911. was impressed with the way the government is working with UNICEF and the World Health Organization. primarily located in western An Giang province. the country is producing its own hepatitis B vaccine. Many Vietnamese use amulets and other forms of spiritual protection such as the bua. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 112 Respecting Differences, Celebrating Diversity: Vietnam, cont. Tips for Health Care Providers Refugees from Vietnam and other Asian countries may be suffering from such things as nutritional deficits, hepatitis B, tuberculosis, parasites, malaria, HIV, and post-traumatic stress disorder.According to an excellent source from Baylor University, most Vietnamese follow Buddhist concepts that affect their health care beliefs and practices. Consult the section on Buddhism, page 22, for additional information. Patient education materials in the Vietnamese language can be found on the EthnoMed Web site, http://ethnomed.org, as well as the California Health Department and other sites. Attitudes: The Buddhist respect for authority means that Vietnamese will be reluctant to challenge those in positions of authority. In cases of disagreement, saving face by appearing to go along with a doctor’s advice is preferable to confrontation. The Buddhist approach to life stresses acceptance of the cycle of suffering and rebirth, enduring pain and perhaps delaying seeking medical attention. Preventive health care is not part of this world view. When a Vietnamese person visits a Western medical professional, he or she may expect a medicine to be prescribed immediately, without tests, and for that medicine to work immediately to relieve symptoms. The patient will often discontinue a medication when symptoms have disappeared rather than completing the prescription. According to the Baylor site, “it is quite common for Vietnamese patients to amass large quantities of halfused prescription drugs, even antibiotics, many of which are shared with friends and even make their way back to family in Vietnam.” When a physician does not prescribe medicine, a Vietnamese person may go to a traditional practitioner or obtain medicine from a specialized “injectionist” or a relative in a country where antibiotics and other drugs are available without prescription. Family Authority: The father or eldest son is the family spokesperson. Addressing Clients: Greet clients formally by using the last name. Show respect to elderly clients by making a gentle bow. The typical Vietnamese greeting is a smile and bow. Do not shake a woman client’s hand unless she offers it. Nonverbal Exchange: Respect is demonstrated by avoiding direct eye contact, bowing the head slightly, and using both hands in giving something to another person. Vietnamese prefer to keep a good distance between themselves and others. As in other cultures, the head may be considered sacred and the feet profane. Gentle touch may be appropriate during conversation. A smile may mean many things, including apology, embarrassment, or appreciation. Verbal Exchange: Vietnamese are generally soft-spoken. Raising the voice and pointing are considered signs of disrespect. Open expression of emotions may be considered inappropriate. Explain procedures carefully. The client may nod to indicate that he or she has heard, but this does not indicate understanding or agreement. The Vietnamese client may be reluctant to ask questions or disagree. Hospitalization: Vietnamese may fear lab procedures that require drawing blood, and surgery might be considered a last resort because of its potential for upsetting the balance of the body. They may not request pain medication for fear of addiction or side effects. Death and Dying: Discuss a diagnosis of terminal illness with the family spokesperson, who may not want to reveal it to the patient. DNR is a sensitive issue that will probably be decided by the whole family. Vietnamese Catholics may request the presence of a priest, and Buddhists may want to have incense and a monk at the time of death. The body is highly regarded, and family members may want to wash it themselves. Cremation is preferred by Buddhists. Many Vietnamese are opposed to organ donation and autopsy because of respect for the body. Celebrations and Holidays January–February Tet, the New Year: Celebrated on the first new moon of the year; considered everyone’s birthday, a time for starting over, paying debts, being on best behavior. People visit their parents on the first day of the celebration, and the season includes much socializing and eating, firecrackers, drums, ○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 113 Vietnam, cont. February 3 February March April April 30 May 1 May 7 May 19 May 28 July 28 August September 2 September 3 September and the dragon dance. Children receive gifts of li xi, lucky money, in red envelopes. People decorate their homes and streets with flowers and may display the cay neu, signal tree, a bamboo pole with a basket on top containing areca nuts, betel, and woven bamboo. Founding Day of the Communist Party of Vietnam Lantern Festival Hai-Ba-Trung Day: Celebrates the anniversary of the death of the Trung Sisters, who led a revolt against the ruling Chinese and won freedom for Vietnam in AD 41. The two sisters made MeLing in North Vietnam their capital. When the Chinese recaptured Vietnam after three years, the sisters drowned themselves in the Hat-Ciang River. Thanh Minh (Ancestors) Day: Vietnamese clean and whitewash graves to please the ancestors. Throughout the year, deceased relatives are remembered with special meals and rituals on the anniversaries of their deaths. Liberation Day: Celebrates anniversary of the liberation of Saigon in 1975. Labor Day Defeat of the French at Dien Bien Phu Ho Chi Minh’s birthday National holiday commemorating the birth, enlightenment, and death of the Buddha War Invalids and Martyrs Day Trung Nguyen, Day of the Wandering Souls: Souls of the dead believed to wander to their descendents’ homes. Celebrations are held in Buddhist temples; food is spread on house altars and fake money is burned. Independence/National Day Death of Ho Chi Minh Trung Thu, autumn celebration where children parade through the streets with lanterns; moon cakes are featured. Date varies according to the lunar calendar. Vietnamese in the United States According to tne Web site for Migration Information Source, there were nearly 1 million foreign born people from Vietnam living in the United States at the time of the 2000 census. This makes them the fifth-largest immigrant group in this country, accounting for just over three percent of the total foreign-born population. The number of foreign born from Vietnam increased by 82 percent between 1990 and 2000. They make up 1.2 percent of the population of California, some 418,249 people in the 2000 census. Most of the Vietnamese living in the United States came here as refugees beginning in 1975 when the country was reunified. The first group to arrive were educated and urban professionals and their families airlifted from Saigon in 1975. Most of these people were closely associated with American interests, spoke English, and were familiar with American culture. The second group of immigrants, arriving from the late 1970s through the mid 1980s, included many “boat people” who escaped Communist Vietnam in small boats, often landing in refugee camps where they spent many years before eventually making it to the United States. With rural backgrounds and/or limited education, these refugees had a more difficult time adjusting than the first group. The third refugee group, which includes Vietnamese still arriving in this country, comes as Vietnamese political prisoners or the children of Vietnamese women and American fathers. Language; Useful Words and Phrases Vietnamese is the official language of Vietnam, although there are many dialects and other languages; many older people know French and/or English. Vietnamese uses the Roman alphabet, but the language structure is very different from English. Each word has only one syllable (so that Viet Nam is the correct rendering of the country’s name), and meaning is based on up to six tones which give words that look the same entirely different meanings. The word ma, for example, has six ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 114 Respecting Differences, Celebrating Diversity: Vietnam, cont. different meanings, depending on the tone in which it is pronounced: with a high falling tone it means “mother;” a high flat tone signifies “ghost;” a low to rising tone indicates “grave.” When the word ma or any other word is written, the presence of one of five accents or no accent above or below a word’s vowel indicates the tone and therefore the meaning of the word. The following words and phrases might be helpful for the health-care provider: Hello. Chao (pronounced “chow”). Please. Xin/Lam on. How are you? Ong khoe khong (“own khway-eh kown”). Thank you. Cam on (pronounced “cam un”). You’re welcome. Khong co chi/Khong dam. I don’t understand. Khong hieu (“kowm hee-you”). Yes/No Da/Khong What is your name? Ten (ba, co, ong, em) la gi? My name is . . . Ten toi la (“tain toy la”) . . . Friend Ban References Grieco, Elizabeth. 2004. “The Foreign Born from Vietnam in the United States.” Migration Information Source. http:// www.migrationinformation.org/USfocus/print.cfm?ID=197 (5 Feb. 2004). Habitat for Humanity Vietnam. http://www2.habitat.org/intl/countryprofiles.fm (24 Mar. 2004). Hong, Khuat Thu. 2003. Adolescent Reproductive Health in Vietnam. January. http://www.policyproject.com/pubs/ countryreports/ARH_Vietnam.pdf (18 Nov. 2004). Horton, Mark. 2002. “Vietnam: Progress Through Prevention.” Community Health Beat. http://www.ochealthinfo.com/ public/healthbeat/2002/2002_07.htm. Hunt, Peter Cody. 2002. An Introduction to Vietnamese Culture for Rehabilitation Service Providers in the U.S. Buffalo, NY: State University of New York, Buffalo, Center for International Rehabilitation Research Information and Exchange (CIRRIE). http://cirrie.buffalo.edu (11 Jul. 2005). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. National Institute for Urban and Rural Planning. Rural Infrastructure Planning. http://www.apo-tokyo.org/icd/ act_inti_stm.lib/ICD-OS1-00/Study/Mission/Country%20Papers/Vietnam(1)final.dlc (19 Nov. 2004). “Public Holidays.” http://www.hanoitravel.com/index.cfm?menuid=8 (6 Dec. 2004). Schiffer-Graham, Beate, and S. Vemuri. 2002. Vietnam. Anti-Racism, Multiculturalism and Native Issues Centre, Faculty of Social Work, University of Toronto, Canada. http://www.settlement.org/cp/english/vietnam (18 Nov. 2004). Tick, Edward. 2005. “Fallen Leaves, Broken Lives.” Utne Reader. Jan-Feb. U.S. Department of State Bureau of Democracy, Human Rights, and Labor. “International Religious Freedom Report 2002: Vietnam. http://www.state.gov/g/drl/rls/irf/2002/13916pf.htm (28 Feb. 2004). Useful Vietnamese Phrases. http://www.worldroom.com/pages/wrnhcm/customs/hcm_lang.phtml (6 Dec. 2004). “Vietnam.” Encyclopaedia Britannica. 2004. Encyclopaedia Britannica Premium Service. http://www.britannica.com/eb/ article?tocid=52700 (18 Nov. 2004). “Vietnam Aims to Provide Health Care Services for All.” http://www.vietnam-tourism.com/vietnam_gov/e_pages/Xahoi/ yt-bh_service03.htm (6 Dec. 2004). “Vietnamese Cuisine.” http://www.vietnamsaigontourist.com/vietnamcuisines.htm (6 Dec. 2004). Vietnamese Health. http://www3.baylor.edu/~Charles_Kemp/vietnamese_health.htm (18 Nov. 2004). Vietnamese Patient Education Materials. EthnoMed. http://ethnomed.org/ethnomed/patient_ed/viet/index.html (6 Dec. 2004). Wamsley, Laurel. 2005. “The Fog of Peace.” Utne Reader. Jan-Feb. The World Factbook: Vietnam. http://www.cia.gov/cia/publications/factbook/geos/vm.html (8 May 2005). garments. agricultural processing. Mien. pigs. droughts timber.306 (0. hydropower.08 years 40% 66. and various ethnic languages Buddhist 60%. tourism agriculture 80% . electric power. and Yao 9%. electricity. and 1 special zone tropical monsoon. capital is Vientiane. poultry coffee. tin tin and gypsum mining. cattle.74 years 2. English. corn.4% kip (LAK) Lao Loum (lowland) 68%. gemstones 3. sugarcane. gypsum. 1 municipality. construction.400 sq.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 115 Laos Census Figures (2000) United States Residents Born in Laos: California Residents Born in Laos: 204. ethnic Vietnamese/Chinese 1%.217. tobacco. cotton. rice. Lao Theung (upland) 22%. wood products. Animist and Other 40% (including Christian denominations 1.5%) Lao People’s Democratic Republic: communist state. rainy season (May to November). coffee. timber. vegetables.8% sweet potatoes. garments. (49 ethnic groups) Lao (official).8%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 91.42% 55. country divided into 16 provinces. gold. Lao Soung (highland) including the Hmong. water buffalo. peanuts.7%) 68.284 (0. dry season (December to April) floods. tea. tin. French.141 18. miles (slightly larger than Utah) 6. with the effect of weakening the culture and allowing foreign aggressors to invade. the kingdom of a million elephants. International teams are still clearing unexploded ordnance from that war. Luang Prabang.000 Hmong troops were reportedly involved in the Vietnam War on the side of the United States.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 116 Respecting Differences. who ruled from 1548 to 1571. The height of the Lane Xang Kingdom came during the 17th century under the reign of King Souliyavongsa. Houses include a kitchen hearth and are open on at least one end. France.S. Most houses include an altar mounted on a wall and used for ceremonies associated with ancestral spirits. The French took control of the country in 1893. resulting in a mass exodus of hundreds of thousands of Hmong to refugee camps in Thailand. abandoning earlier efforts at establishing collective farms. They were later replaced by a secret U. moved the capital from Luang Prabang to Vientiane. In 1353 King FaNgum established Lane Xang.” despite the Geneva Accord of 1962 recognizing the neutrality of Laos and forbidding the presence of military personnel. founded in 1930. The Siamese (Thai) attacked and virtually destroyed Vientiane.000 years ago. forces dropped more bombs on Laos than they did over the entire world during World War II. the Emerald Buddha. support from the Hmong troops and made them vulnerable to retribution from their countrymen who had sided with Communist North Vietnam. settlement began along the Mekong River. Brief History Artifacts discovered in the Huaphan and Luang Prabang provinces indicate the presence of hunter-gatherer groups in present-day Laos about 40. During the Vietnam War. which ended with a 1973 Paris agreement. The Lao Sung or highland Lao. A Dutch merchant and later Italian missionaries visited the country and described Vientiane as the most magnificent city of Southeast Asia. . which also recognized the independence of Cambodia. in what is known as the “Secret War. including the Hmong. the new government destroyed Hmong villages. Work. military mission in Vientiane. which was recognized in the Geneva Agreement on Indochina of 1954. with about 50. Between 300 and 700 AD. live at the highest elevations along mountain ridges. In 1992. many to California. cont. with the remaining Hmong taking refuge in Wat Tham Krabok. Celebrating Diversity: Laos. where they were hunted down by Pathet Lao troops. private investment and decentralization of the economy. and eventually to the United States. a key supply route that crossed the country. A 1991 constitution allowed citizens more freedom of movement and participation and reduced the influence of Vietnam. and international organizations for assistance. Fresno County will have received about 2.S. Per capita. LPDR leaders introduced market incentives. Sweden. After 1986. where he built an elaborate religious shrine and temple for the Phra Keo. Traditions Housing: Lao Theung (midland) and Lao Loum (lowland) Lao houses are raised off the ground on wooden or bamboo piles. The breakup of the Soviet Union has caused Laos to turn to other countries including Japan. the Communist Lao People (Pathet Lao) gained control of their country and established the Lao People’s Democratic Republic (LPDR) on December 2. King Setthathirat. and bronze tools date to 1500 BC. Hmong houses are built on the ground with dirt floors and walls constructed of vertical wooden planks and gabled roofs of thatch or split bamboo. Canada. With the aid of North Vietnamese troops.000 killed between 1975 and 1978. the Thai government closed that camp and most of the 14. By the end of September 2005.000 of these refugees. Family. enlisted and supported by the CIA. led the fight to regain the country’s independence. U. Infighting led to the division of the Lane Xang Kingdom into three kingdoms: Vientiane. Evidence of agriculture dates to 4000 BC. as many as 40. Laos has the dubious distinction of being the most heavily bombed nation in history. Many Hmong immigrated to the mountains of Laos from China in the early 1800s.400 residents were able to emigrate to the United States. and Champassack. Hmong who were not able to leave hid in the jungle. The Communist Party of Indochina. The bombing was justified as being directed at a portion of the Ho Chi Minh trail. In 1966. the last officially sanctioned refugee camp in Thailand closed. and Australia. the European Community.S. Houses have woven bamboo or sawn lumber floors and walls with grass thatch or bamboo shingle roofing. In 2004. Austraila. Many of the people from Laos now living in California are members of the Hmong people. taking the Emerald Buddha to Bangkok. Houses include a kitchen alcove at one end and sleeping quarters at the other. The cease-fire that formally ended the war removed U. with raised beds or sleeping benches. The Hmong were declared enemies of the state. Housing. In 1975. the Nop. the soles of the feet the lowliest. Khang. and wives and children of married sons living together. often in consultation with others. In Laos. Xiong. Family: Traditions: Hmong society is organized into 18 clans. which are constituted by last name. Hmong women retain their clan name for identification purposes when they marry. including parents. or Pandau (flower cloth). Lee. one should inquire as to whether visitors are appropriate. Vue. Shoes and handbags are often left ouside the house. A visitor should accept any food or drink offered. the greater the sign of respect (but hands should never be held higher than the nose). After the marriage the couple traditionally lives with the wife’s household for several years before moving to their own home near the husband’s parents. with women responsible for all household chores and child care plus farming tasks. as they believe that if a bad spirit hears positive comments it may take away the child’s soul. The higher the hands. children. when a law required the use of surnames. and individuals are designed as clanmates (kwv tij) and in-laws (neej tsa). Traditional Hmong households are generally large. each with its particular religious rituals. Vang. and often other relatives. The traditional form of Laotian greeting. Kue. although this is discouraged by the government. called Paj Ntaub. Thao. They are consulted on decisions and take part in raising children. one should watch for a taboo sign on a stick in front of the outside door. and Yang. even if one does not consume all of it. Clan leaders are selected for their honesty and ability to make wise decisions. involves placing the palms together in a position of prayer at chest level. Americanized Hmong clan names are: Chang. The head is considered the most sacred part of the body. usually referring to a natural object. When visiting a Hmong household. Traditional families are headed by males who make most of the decisions. Laotians went by first names only until 1943.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 117 Laos. and may need to be consulted by health care providers. One of the Hmong traditions with which most Californians will be familiar is the unique handwork. one should not touch another person’s head or use one’s foot to point at a person or object. The elders are the most respected members of the family. Kong. Hmong people are often humble and may be hesitant to express their true emotions in the company of others. Looking directly into the face or making eye contact when speaking to a person is considered inappropriate. Therefore. Men and women generally keep some distance between them in an encounter. The male-headed household is a powerful force in Laotian society. thought to have originally symbolized the knowledge required for passage from this world into the next world. The handshake is not a common greeting among the Hmong. Hmong girls as young as three years of age begin learning ths intricate embroidered and quilted work using tiny . cont. Men and women rarely show affection in public. Lor. children. perhaps saying “yes” when they do not mean it. Before entering. Marriage is traditionally arranged by go-betweens who approach the girl’s family on behalf of the boy’s family. which warns the visitor not to disturb the family as the house is being protected from evil spirits. Pa Ndau. but they become part of the husband’s clan and children take the name of the father’s clan. with sub-lineages. some traditional Hmong practice polygamy. Fang. something seen frequently in California. Direct comments about children are generally not welcome by Hmong who hold traditional beliefs in spirits. Chue. Removing one’s shoes upon entering a temple or private house is customary. People who have the same clan name are considered brothers and sisters and forbidden to marry. Gender roles are strict. even if they have been born and raised in different countries. accompanied by a slight bow to show respect to persons of higher status or age. Moua. Clan members take responsibility to support one another. Her. A naming or soul-calling ceremony on the third day after the birth of a child traditionally involves an astrologer or bonze selecting a meaningful name. Pha. particularly women. or of saying goodbye. Hang. Cheng. This gestures serves also as a means of expressing thanks or regret. Hmong clans. not touching the body. are determined by ancestral lineage through the great-great grandfather and according to which ancestral traditions they practice. Families include parents. Popular fruits are papaya. and cucumber.” is made of meat or fish with lime juice. Two popular soups are keng no may. buffalo. cassava. applique. rice. and is often displayed and sold at craft fairs and art exhibits. fish with coconut cream. glutinous.” Swidden or slash-and-burn agriculture is traditionally practiced in the hilly midland and highland areas. Popular seasonings include lemon grass. lao lao. Aside from ice cream. and sugar may also be added. This colorful work is found on everything from slippers to wall hangings. When the French took control of the country. because it has a high starch content. A typical meal would include rice. a dish from Luang Prabang. Other popular main dishes include stir-fried chicken with mushrooms (aioan chua noeung phset kretni). and chiles. Celebrating Diversity: Laos. and chiles are added to many foods. Pa daek. and keng het bot. and wine. formal education was available through Buddhist temples to a select number of males. or sticky rice. secular schooling was established but limited to a minority of children. seasoned with lemon grass. It is eaten with the fingers. oranges. chile sauce. Employment: cross stitches. is created from dried buffalo meat and skin along with eggplant. The manufacturing sector is located primarily in and around the capital city. mint. sweet potato. and reverse applique. and fresh coriander (cilantro). rolled into balls and dipped into soup or a vegetable or meat dish. Refrigeration is uncommon. is a kind of rice vermicelli served cold with raw chopped vegetables and coconut milk flavored with meat and chiles. chiles and pa daek. It illustrates a young girl’s qualities of discipline and creativity. ducks. agriculture is the occupation of the majority of people. fermented fish sauce. is a common ingredient. In traditional villages in all parts of Laos. A popular salad. A popular Lao meal. and sousi pa. Fish sauce. or game (including snake). the Lao People’s Democratic Republic planned to implement universal pri- . contains shredded green papaya seasoned with padek and chiles. oxen. Laap. Klao poun. a popular Lao dish whose name means “good fortune. vegetables. highlighted with crisp-fried pork skin and sweet basil. Fermented rice is used to make a type of whiskey. is the staple food throughout Laos. a mushroom soup. corn. Hmong people may eat plain boiled rice soup with a small amount of chicken. made of bamboo shoots. Education Status: Prior to the 1850s. and chiles. Livestock include chickens. and berries. bananas. khao kam. According to the Library of Congress study. “Everyone is first and foremost a subsistence farmer. Midland and highland crops include rice. so meals must be prepared from fresh ingredients. mint. ginger. Peanuts are a common ingredient. Vegetables include corn. Foods and Eating Habits Dietary Practices: Everyday Diet: Popular Dishes: Beverages: When ill. white radish. klao. In the lowland area. The government made secular education compulsory in 1951. and vegetables as well as opium and forest products. garlic. comes from Vietnam and is a combination of vermicelli in hot meatball soup served with vegetable leaves that are stirred into the soup as desired. pigs. they prefer to kill their own chickens to guard against unhealthful chemicals. it must be steamed rather than boiled. but relatively few children graduated from secondary school. klao niaw. fish. According to the Library of Congress Country Study on Laos. beef. Rice. with the hotness of the chiles varying among ethnic groups. is most common. feu. Vientiane. and horses. Or lam. lime juice. with paddy rice cultivation more common in the flatter lowlands. Both tea and coffee are grown and drunk in Laos. cont. coconut milk. tam som. poultry. dairy products are rarely eaten. a popular dish at weddings and other celebrations. Festive meals might include eggs.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 118 Respecting Differences. usually eaten at every meal. green onions. 160 students attending secondary schools. Ceremonies associated with the practice of animism often involve an offering of a chicken and rice liquor. and that illness occurs when one or more of these spirits leaves the body. some wat include small spirit huts associated with the phi khoun wat. Theravada Buddhism is tolerant of other religions. School quality and student performance vary widely between urban and rural areas and among different ethnic groups. Baha’i. Small numbers of Laotians practice Islam. This belief in spirits. technical studies. cont. forestry. and teachers are paid irregularly and often must spend most of their time doing other jobs to earn a living. is the common religion of midland and highland Lao ethnic groups. and many Laotians combine Buddhism with other religious practices. Proselytizing is prohibited by the government. with approximately 300 congregations throughout the country. which discourages rural students from pursuing their education. Animist beliefs are widespread even among practicing Buddhists. with much repetition of grades and dropping out. and well-being. Pali. Spirits are everywhere and involved in all aspects of life. and expanding education to remote areas. Buddhism was introduced in the eighth century and was widespread by the fourteenth century. Students who do not live in such a place must board away from home. Two groups are officially recognized: the Lao Evangelical Church. According to the Library of Congress. Sisavangvong University offers courses in education. Secondary education is concentrated in the provincial capitals and district centers. Balance can be restored by a ceremony called the soukhkwan or baci that calls back the spirits to bestow health. The school year lasts for nine months. Confucianism. The LPDR replaced the French system with a Laotian curriculum and conducted an extensive adult literacy campaign in 1983–84.000 adherents in Laos.851 students and 7. there were 4. Primary education begins at age six and lasts for five years. as opposed to Mahayana Buddhists. This goal was later extended to 2000. Many schools offer only one or two grades. practice Theravada Buddhism. who believe that nirvana will come only when all people are prepared for salvation. but schools are poorly constructed and teaching materials are scarce. an umbrella group that includes most Protestant denominations. Roman Catholicism claims perhaps 40. a National Polytechnic Institute. the spirit of the monastery. called neeb by the Hmong. In 1996–97.335 students. Cotton strings are tied around the wrists to keep the spirits in place. Religion Buddhism: Animism: Christianity: Other: The majority of lowland Lao. prosperity.507 university students reported in Laos. In 1996–97 there were 695 kindergartens with 37. The lack of educational materials continues to be a serious problem. Protestantism is growing. who comprise two-thirds of the population. wat. Many Lao people believe that they are protected by khwan. Secondary school begins at age eleven and lasts for six years. there were 180. and Taoism. and a Medical Sciences University. The temple. Theravada Buddhists believe that each individual is responsible for his or her own nirvana. Primary School: Secondary School: Higher Education: mary education by 1985. primarily ethnic Vietnamese who live in major urban areas along the Mekong River. and the arts. in the late 1980s the average student took 11 to 12 years to complete the primary course. . thirty-two spirits. three years of lower and three years of upper secondary.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 119 Laos. Other institutions of higher education include regional technical colleges. Education reforms initiated in 1986 focused on improving science training. Some students go from three years of lower secondary to a vocational course such as agriculture or teacher training.896 primary schools serving 786. recruiting minority teachers. a Pedagogical University. agriculture. and the SeventhDay Adventist Church. In 1994–95. is a focal point of village life and provides a location for ceremonies and festivals as well as a symbol of village identity. Sanskrit. although beliefs and practices differ widely among tribes. Most villages have a school. and 542 dispensaries in Laos. Tips for Health Care Providers Most of the Laotian immigrants U. Herbal remedies are widely used. 131 health centers. traditional animist Hmong believe in three souls: one that goes to heaven. They will generally try traditional remedies first and even after consulting a Western practitioner. Illness is believed to be a matter of imbalance between the body and the spirit. The Ministry of Public Health includes an Institute of Traditional Medicine which formulates and markets preparations from medicinal plants. health care providers will deal with are members of Hmong or other highland groups that hold animistic beliefs and whose daily lives are heavily influenced by the spirit world. techniques. and women traditionally handle childbirth themselves or turn to female relatives or midwives for assistance. when drinking water is contaminated by human and animal waste washed down from higher locations. Briefly. Herbs may be made into drinks. Several excellent Web sites provide health information materials in the Hmong language as well as information for health care providers on working with Hmong patients. Surgery is often not acceptable to and feared by the Hmong . The Spirit Catches You and You Fall Down. the Hmong will engage a shaman (tix neeb). some things to keep in mind when working with foreign-born Hmong and many other Laotians in the health care setting: Attitudes: Hmong respect authority but may be suspicious that U. Most health care personnel are concentrated around the capital. In 1995. cont.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 120 Respecting Differences. often inappropriately. A handbook for health care providers containing words and phrases in both Hmong and English as well as extensive information on working with Hmong patients and clients will soon be available. especially in the upland ethnic groups. All health care providers who work with Lao (especially Hmong) people would do well to read Anne Fadiman’s book. This is the story of a Hmong family’s experience with the health care establishment in Central California during the birth and subsequent diagnosis of epilepsy and death of their fourteenth child. especially in the matter of health and illness. most Lao people believe in the power of spirits in their lives. learning the chants. to climb a ladder to heaven on a magical horse to consult the spirits for a cure. and a wide variety of useful resources. It contains a health dictionary. and one that is reincarnated. As indicated above. Unregulated pharmacies sell drugs. Children’s deaths are primarily the result of such communicable diseases as malaria and acute respiratory infections as well as diarrhea. Celebrating Diversity: Laos. and it contains valuable information about Hmong beliefs and practices. Poor sanitation throughout the country contributes to the spread of disease. The Hmong recognize both spiritual and physical causes of illness. vitamins. Health care workers are not well paid and are held in low esteem by the public.S.hmonghealth. Death is viewed as a passage from one phase of existence to the next. can be found at http://www. in the early 1990s the condition of the health care facilities was poor and supplies were limited. Spiritual causes of illness include evil spirits or one’s own spirit leaving the body. Lia. which could be a man or a woman specially called to this role. Health and Health Care Health Status: Traditional Practices: Medical System: Chronic vitamin and protein deficiencies are common. rubbed into the skin. one that remains with the body. Diarrheal diseases are especially prevalent at the onset of the rainy season. In cases of serious illness. for insight into the beliefs that cause these clients to have difficulty with Western medical practices. funded by the National Library of Medicine. Immunization efforts are increasing. information on traditional healing.S.org. Shamans study for several years with a master. and procedures of healing rituals as well as the names and natures of the spirits responsible for good fortune or illness. there were 25 hospitals. According to the Library of Congress study.100 physicians. page 111. and fever suppressants. and in rural areas vendors may sell small packets of assorted drugs such as antibiotics. The Hmong Health Education Network. Hmong use the same kind of cupping and pinching treatments described in the earlier section on Vietnam. doctors take advantage of their unfamiliarity with Western medicine. which claimed 3. or used for soaking baths. people fire bamboo rockets filled with gunpowder. or offer to boil the water. Processions with elephants are held in Luang Prabang. Many Hmong and other Laotians see a spiritual component to illness and believe that healing requires the work of a shaman (acharn) to communicate with the spirit world. Dancing.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 121 Laos. Traditional Hmong do not accept autopsy or organ donation. They consider prolonged direct eye contact rude. or Mrs. Immunizations are traditionally not acceptable. but the family spokesperson may be another person who speaks better English. Most respect firmness and politeness. rocket judging takes place in Vientiane. Offer tea or juice as an alternative. Physical privacy is important and should be protected by using curtains and not requiring patients to undress more than is strictly necessary. This ancient festival was to remind the gods that rain is needed. . Encourage and support a visit from the shaman if the patient desires one. most will allow the procedure. Boun Bang Fai. singing. arrange for a portion to be analyzed for chemicals that might interact negatively with prescribed medications. and do not pat children on the head. Explain procedures and recommendations clearly in simple language. Vixakha Bouxa: Celebrates the birth. Greet clients using Mr. New Year: Celebrated by Lowland Lao. If the family wants to bring an herbal drink. cont. If possible in this kind of situation. refrain from touching the head without permission. Rocket Festival: Celebrates start of the rainy season. Try to determine what herbal medicines the Hmong patient is using at home in order to check for negative drug interactions. and their last name. A Hmong patient may be hesitant to ask questions. and puppet shows. Disease prevention and health promotion are not highly valued or widely practiced. In the hospital setting. Because the Hmong believe the soul resides in the head. particularly those needed following childbirth. Like surgery or organ donation. or spiritual leader. Discuss a diagnosis of terminal illness with the family spokesperson. processions. Patients may be unwilling to drink water unless it has been boiled. lasts up to a week. Festival of the Dead Boun Nam. Do not remove jewelry or amulets without the permission and understanding of the patient. Encourage family members to bring in special foods. Touching between members of the opposite sex is considered disrespectful. try to serve plain foods without spices to Hmong patients. and death of the Buddha. Work with the dietician to ensure that foods are consistent with dietary practices to the extent possible. Celebrations and Holidays April 15 May August Fall Boun Pee Mai. Be aware that “yes” may not mean assent. Personal questions should be deferred until a comfortable relationship has been established. Water Festival: Celebrated with boat races on the rivers. enlightenment. It is considered inappropriate to talk about impending death. and ask the patient to repeat or interpret the information to ensure understanding. Hmong are very polite and reticent. Houses are cleaned to expel bad spirits. and Hmong people often present a positive attitude even when they know the person is dying. the idea of removing something from or putting something into the body means that the person will be reincarnated with less than a complete body or something foreign included in it. The father or eldest son is the primary decision-maker. Family Authority: Addressing Clients: Nonverbal Exchange: Verbal Exchange: Hospitalization: Death and Dying: unless tests have identified a disease that requires surgery for a cure. oldest male family member. observed at the full moon of the sixth lunar month. When Hmong parents understand that their children need to be immunized to attend school. Haw Khao Padap Din. get a list of common herb treatments from an herbalist and give it to the hospital pharmacist to check for possible drug interactions. Handshakes and smiles are appropriate. National Day Hmong New Year Festival: The only formal Hmong holiday. November-December December 2 Dec. and Burma. Hmong in the United States Because the majority of people from Laos living in California are members of the Hmong ethnic group. Gary Yia Lee made this comment about the Hmong language: A Hmong is expected to be able to speak the Hmong language which is distinctly different from all other languages. Language. 2005. and the remainder distributed among more than a dozen other states. The national language. Great Stupa. in addition to the Hmong. one or more of the local or national foreign languages. .133 in California. and the Lao language shares many characteristics with the Thai language. About 5. These could be Mandarin for those in China. The Lao are Buddhist. a tower built in Vientiane in 1566. they are animists rather than Buddhists. Paul area had the largest concentration of foreign-born Hmong. . discussion will be limited to Hmong in the United States and California. in addition to their mother tongue.284 foreign-born from Laos were living in the United States. Sacramento. . Vietnamese for those in Vietnam and Northern or Central Thai for those in Thailand. and their language is completely different from Lao. There are songs and ball tossing games and competitions. supposedly on the site of an earlier building housing relics of the Buddha. The more educated a Hmong is in another language. Speaking at a 1995 symposium in St. Vietnam. and Merced. 1–Jan. Being members of a minority and living among many other ethnic groups. Like the Hmong. Some of the Mien people have also fled Laos for the United States and other countries and can be found in California. Useful Words and Phrases There are as many as 70 distinct ethnic groups in Laos. Lao for those in Laos.773. the more words from that language the person is likely to use in everyday conversations. According to the 2000 census. prior to the arrival of the latest group of refugees. 204. Thailand. approximately 315. the Minneapolis-St. 15 Boun That Luang. is the language of the majority lowland Lao people who live in the valleys along the Mekong River and grow irrigated rice. Both use the alphabetic script used in India. like their neighbors in Thailand. Handbook for Teaching Hmong-Speaking Students. most Hmong need to learn. another 5. which consists . they have also borrowed foreign words from these languages. and 68. This was traditionally a time to honor all beings both living and dead and to show gratitude to and/or placate the spirits. with the largest number. 41. That figure increased during 2004 as the illegal refugee settlement at Wat Tham Krabok monastery in Thailand was closed in June and the United States agreed to take 15. According to the Migration Information Source. Foreign-born Hmong living in the United States that year numbered 102.000 of these refugees were to be resettled in California. As of January 1. The valuable reference produced by Bruce Bliatout and others in the Folsom Cordova Unified School District in 1988. most of these refugees had passed up earlier opportunities for resettlement in the United States in hopes that they would be able to return to their homes in Laos. boys and girls to get acquainted and courtships begin. In the process. Harvest festival: Celebrated by Lowland Lao on the full moon of the twelfth lunar month. week-long event also celebrates the country’s greatest national monument. All official refugee camps in Thailand were closed in the 1990s. The Khmu people who live in the midlands are descendants of the original inhabitants of Laos. In the highlands. and several million Hmong lived in China. followed by Fresno.000 in Minnesota. Lao.000 refugees by the end of 2004. celebrated for up to a week beginning the first day of the waxing moon of the twelfth month with a “Calling of the Spirit of the New Year” ritual. each with its own traditions and language. More than 200. Celebrating Diversity: Laos. includes some helpful basics about the Hmong language.000 Hmong still lived in the highlands of Laos. people wear their finest traditional costumes. Minn. cont.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 122 Respecting Differences. Paul.306 were in California. the Pha That Luang. some of which become assimilated as Hmong. Village elders have the responsibility of calling the spirits home for the new year. the Mien or Yao people live and speak a language related to but distinct from Hmong.000 Hmong have fled Laos since the Pathet Lao took power in 1975. In the United States. Milwaukee-Racine. Use of noun classifiers. et al. Burma.org. 2005). http://www. Vietnam. Nyob zoo. Use of multiple verbs in one sentence. CA: Folsom Cordova Unified School District. although the letters do not represent the same sounds in English and Hmong. Hmong words have only one form. The White Hmong dialect uses the Romanized Practical Alphabet (RPA). the Hmong speaker would say “I go arrive his house. When deciding how to pronounce the Hmong words. Handbook for Teaching Hmong-Speaking Students. I am fine. cont. 2000. These two dialects are mutually intelligible.org/cp/english/laos (30 Jan. which uses consonant letters at the ends of syllables to represent the different tones on which the preceding vowel may be pronounced. mid (no consonant). Bliatout. Hmong nouns are divided into different classes.pdf (1 Feb. Thailand. Hello. When there is no consonant. high falling (j). without any connection between them. etc. University of Toronto. Hmong is spoken in Laos. The alphabet was created in the 1950s by missionary linguists. The Hmong language is one of the group called the Miao-Yao languages spoken in Southeast Asia and Southern China. including: ■ ■ ■ ■ ■ A preference for one-syllable words. Laos.” for example. The Hmong language shares several characteristics with other languages of the region.org/media/pdfiles/HmongBk. Minneapolis. Elsa. Multiculturalism and Native Issues Centre. different genders. What is your telephone number? Koj nus naj npawb xov tooj yog li cas? Where do you live? Koj nyob qhov twg? References Batica. The use of tone to indicate word meaning. low falling (m). with number. Minnesota school district. Community Partners in Children’s Care: the Hmong Americans. http://xpedio02. http://www.childrenshc. low (s).” Useful Words and Phrases Words and phrases helpful to health care providers are being compiled in a separate handbook to be available from www. Southeast Asia Community Resource Center. with words possibly taking on different meanings depending on the classifier used. Sacramento. Canada. Ua koj tsaug. Where does it hurt? Koj mob qhov twg? What is your name? Koj lub npe hu li cas? I am glad to meet you.org/stellent/groups/public/@web/@healthprof/documents/ policyreferenceprocedure/038697. Kuv nyob zoo.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 123 Laos.settlement.pdf (1 Feb. Paul. Faculty of Social Work. 2004. Bruce. Minn. tense. . 2005). Hmong contains eight different tones: high (indicated in the RPA by the consonant b). Both are spoken by Hmong living in California. or verb tenses. It uses the ordinary letters of the Roman alphabet. 2005). Kuv zoo siab tau ntsib koj. the voice’s natural speaking tone is indicated. of two major dialects: White Hmong and Green (or Blue) Hmong. case. Teachers and health care professionals who wish to speak to Hmong students and clients would do well to make use of the speaking dictionaries available from the St. mid-rising (v). Sib ntsib dua. Anti-Racism. with the colors referring to the colors traditionally used in women’s garments of the two groups and reflecting somewhat different cultures and residential distribution in distinct regions of China. Bello. keep in mind the use of the consonant following a vowel to indicate the tone. How are you? Koj puas nyob zoo? Thank you.seacrc. Children’s Hospitals and Clinics. and by the Miao minority in Southern China.healthcareers. with differences in pronunciation being similar to those found between various regions of the United States. the Hmong language allows the use of two or more main verbs in a single clause. 1988. made clear by the order and combination of words used. Goodbye. Like Mandarin. as described above. Instead of saying “I go to his house. breathy mid-low (g). Sheila. and low falling and rising (d). Lack of inflections indicating different forms of words such as possessive. com/laoculture. “History of Laos. http://countrystudies. Barry. 2002.org/ prsentation/index_files/frame.saturn. Encyclopaedia Britannica Premium Service. http://www.hmongcenter. New York: Farrar.” http://www.hndlink.edu/~Charles_Kemp/laotian_health. Children’s Hospitals and Clinics.html (2 Feb.” http://asiarecipe. Gannett News Service. 2005). Kemp. http://www. 2005).asia-discovery. Yau. “Laos.state. 2004). 2001.org/ etforinwitle. Country Studies: Laos. 1997. 2004). http://ww2. http://www. ———. Laotians.laoembassy.hmongstudies.org/hmonhisandpa. Xiong.us/laos/ (31 Jan. http:// www. 2005). 2000. Building Bridges: Teaching about the Hmong in our Communities. eds.org/culture/culture_info5..baylor.html (2 Feb.html (8 May 2005). ed. Department of State Bureau of Democracy.” Hmong Studies Internet Resource Center.htm Hmong Cultural Center.org/30feast. 2003.” Migration Information Source.org/ hmongjourforf.S. 2005). 2005). 1998. 2005).k12.gov/g/drl/rls/irf/2002/13878pf. and Labor.berkeley.S. Lao Family Community of Minnesota.html (2 Feb. and the Collision of Two Cultures.” http:// xpedio02. 1995.org/thintowatfor.htm (1 Feb. 2005.hmongcenter.html (2 Feb. Turner.learnabouthmong.cia.html (2 Feb. “Hmong Journey for Freedom.” http://www. http://www. ‘Etiquette for Interacting with the Hmong. cont. San Francisco: University of California San Francisco Nursing Press.org/hmongclans.” 2004.learnabouthmong. 2004). Celebrating Diversity: Laos. “Cultural Identity in Post-Modern Society: Reflections on What Is a Hmong?” http:// www. 2005). Lipson. Charles. Straus and Giroux.com/discover/intro/society. Lao Embassy.org/ (1 Feb.childrenshc. Paul. 2000. Evans. http://www. “History of Laos. Hmong Dictionary.” http://www. 2002. 2005). Human Rights. 2005).migrationinformation. “Starting Anew. 2005). U.mn.org/stellent/groups/public/@xcp/@web/@clinicsanddepts/documents (1 Feb. 2005). ———.html (31 Jan.html (14 Feb. http://www.britannica. 2005).htm (28 Feb.wisinfo. “Information for Visitors to a Hmong Home.” http://www. 2005). Learn About Hmong.” http://www.clm/Laos/travel-guide/history. Culture and Nursing Care: A Pocket Guide. The World Factbook: Laos. http://www3. http:// www.cfm?id=281 (1 Feb.hmongcenter.hmongcenter.” http://www.htm (7 Dec. 2004.org (1 Feb. “Hmong History and Paj Ntaub. “The Hmong Language.stpaul. 2003. 2005). Mai.htm (7 Dec. 2005).hmonghealth.us/Hmong/Dictionary/Hmongeng/ (1 Feb. Laos Travel Guide. 2005).htm (1 Feb.hmongcenter. Part II.ocf.laofamily. New York: Palgrave MacMillan. 2005).edu/~kongsab/h_laopdr.” http://www. Jennifer.” Encyclopaedia Britannica. Fadiman. Grant.” http://www.” Gannett Wisconsin Newspapers Special Report. http://www.gov/cia/publications/factbook/geos/la. ———. 2004). 2005. http://www.com/thailand/ (2 Feb. ———. Minn. “Homng Culture and Medical Traditions.htm (7 Dec. Her American Doctors.html (2 Feb. “Cultural Competency.com/mld/twincities/news/special_packages/hmong_journey/ 8042147. 2005). Slide Presentation. “Hmong Clans. Cultures and Economies of the World.htm (1 Feb.hmongcenter. et al. Anne. 2005).twincities. “The Hmong New Years in Perspective. Juliene G. Hmong Health Website. “The Foreign Born Hmong in the United States. . Minneapolis/St.” Laos Infosite. Lee.” http://www. “Lao Cuisine: The Raw and the Cooked.org/culidinposso. (Excerpt from Hmonguniverse).org/hmonglanguage2.com/eb/ article?tocid=52522 (30 Jan. Gary Yia. The Spirit Catches You and You Fall Down: A Hmong Child. Library of Congress. “International Religious Freedom Report 2002: Laos.. U.org/Feature/display. Hmong National Development. The Statesman’s Yearbook: the Politics. 1997.html (2 May 2004). “Social Overview.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 124 Respecting Differences. “Recent History of the Hmong. http://www. transistors. cement. tin agriculture 49%. lead. capital Bangkok. light manufacturing. fish. arable land 29.3%.5%) 62. Christian 1.3%.114 (0. soybeans rubber. ethnic and regional dialects Buddhist 92. plastic. gypsum. cassava (tapioca). Chinese 14%.36% rice. Other 0. office machine parts.5%. warm. plastics. miles (slightly more than twice the size of Wyoming) 65.444. corn.6% baht (THB) Thai 75%.87% 71. seafood tourism. industry 14%. 76 provinces. cloudy southwest monsoon (mid-May to September). English (secondary language of elite). sugarcane. textiles/garments. dry. Muslim 5. rainy. prime minister designated from among members of the House of Representatives. services 37% . Other 11% Thai. lignite. motor vehicles.7% Kingdom of Thailand: constitutional monarchy.7%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 198. furniture.371 30. agricultural processing. leader of party that can organize majority coalition usually appointed prime minister by the king tropical.88 years 0. cool northeast monsoon (November to mid-March).1%.801 (0. computers. humid tsunamis tin.57 years 10% 92. rubber. Hindu 0. fluorite. beverages. tobacco. southern isthmus always hot. rubber.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 125 Thailand Census Figures (2000) United States Residents Born in Thailand: California Residents Born in Thailand: 169.114 sq. natural gas. timber. tungsten. coconuts. King Rama Thibodi. Phya Tak Sin established a new capital called Thonburi on the Chao Phraya River. with a growth rate averaging about 9 percent annually. 8. Work. According to some stories. It is the only country in South and Southeast Asia not to have been colonized by Western nations.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 126 Respecting Differences. Banharn Silpa-archa became Prime Minister and formed a coalition government. its current form of government. extended families may live together under one roof. establishing the Chakri dynasty that still rules Thailand (called Siam until 1939). 2004. which is essentially a free enterprise system. 2005. had been the fastest-growing in Asia between 1985 and 1995. has been ruler since 1950. It is unclear whether these innovations came from China to Thailand or vice versa. and 3. such as concrete blocks and steel roofing.066 were still listed as missing. The Thai currency virtually collapsed in 1997. from 1932 until 1992. Field Marshal Pibul Songgram followed a pro-Japanese policy that put Thailand on the side of Japan in World War II. a series of military dictators ruled the country. 26. Celebrating Diversity: Thailand. Many Thais build a spirit house for spirits that might have been disturbed during construction of a house. The Siamese signed a treaty with the United Kingdom in 1826 and began diplomatic relations with the United States in 1833. As of Jan. aunts. a new Thai kingdom grew up about 1350 on the Chao Phraya River. In 1767. in a location where the shadow of the main house never falls upon it. established the Kingdom of Ayutthaya. due to the shortage of timber. In rural areas.392 people were known to have been killed in Thailand (including a grandson of the king). He moved his capital across the river to Bangkok. this area may be used for creating handicrafts. and compiled a legal code based on Hindu sources and Thai customs. building houses on the outskirts of Bangkok using affordable housing technology. Traditions Housing: Family: Houses in rural areas are often raised. Houses in the central plain are noted for their high gabled roofs. legislative. some 5. Compared to other countries such as Indonesia and Sri Lanka. cont. and Thong Duang was chosen as King Rama I. Different parts of the country have slightly different styles of houses. A bloodless coup during the reign of King Rama VII in 1932 transformed the country into a constitutional monarchy. In addition to serving as a storage space for equipment or livestock. allowing for the separation of the executive. A typical family unit would include grandparents. The kingdom established contact with Portugal in the 16th century. wide eaves. who controlled it for 14 months. often a single room. A new constitution was drafted after the 1996 election. The first Thai ruler. and judicial branches of government. Mon. Thailand’s tsunami losses were relatively modest. In fact. Until the SARS epidemic in 2003 (Thailand had no outbreaks) and the devastating tsunami of Dec. Cultivation of wet rice and metallurgy formed the basis for early civilization in the region. the Thai economy was continuing to rebound. Tourism is a major industry. made Theravada Buddhism the official religion. and many of those killed in the tsunami were tourists. Evidence suggests that the Thais migrated to present-day Thailand from Nan Chao in the Yunnan area of China in the 8th and 9th centuries. The current king. when elections were held. but assistance from the International Monetary Fund helped turn things around. the kingdom was defeated and destroyed by invading Burmese armies.457 were injured. The Thai are related linguistically to various groups originating in southern China. cousins. The economy. He was deposed in 1782. and Khmer civilizations had migrated from China to Southeast Asia by the 7th century. and ample space underneath the house. and perhaps distant relatives. Habitat for Humanity has been active in Thailand since 1998. This small house is placed on a pole for the spirits to live in. Housing. Family. Bhumibol Adulyadej. When this kingdom declined. The Thai Rak Thai Party led by Thhaksin Shinawatra was victorious in 2001 elections. The inhabitants offer food and flowers to keep the spirits happy. 31. In the 1996 elections. Malay. Corruption and the subsequent Asian financial crisis forced him to hand over power to Chuan Leekpai in November 1997. Children are raised to . through a series of 17 coups. when one considers that some 290. with domestic livestock living underneath the family living quarters.000 people were killed in this epic disaster. uncles. Brief History Research suggests that Bronze Age peoples were living in what is now Thailand by 4000 BC. in 1238 Thai chieftains overthrew Khmer overlords and established a Thai kingdom at Sukhothai (Dawn of Happiness). Ceremonies and family gatherings mark a baby’s first haircut at one month and again at puberty. and many Thais are employed in the thriving tourist industry.” The royal family is greatly revered by the Thai people. processing. Men and women generally do not show affection in public. It is considered rude to put the fork into one’s mouth. phasin in the north. Interestingly. Foods and Eating Habits Dietary Practices: Everyday Diet: No known food taboos. Respect must be shown to Buddhist objects and sites. and visitors are advised not to criticize the monarchy and always to stand during the national anthem. Thai food is highly spiced. with a distinctive sweet smell. Thai people avoid crossing their feet. kin khao. The youngest daughter inherits the house and is responsible for caring for her parents in their old age. Chopsticks are not generally used in Thailand except for eating noodles. and transporting rice. with seasonings and cooking methods introduced from China (stir-frying and deep-frying of meat). Crossing the legs is OK for men when seated on the floor. The head is considered sacred and not to be touched except for parents patting their children’s heads. Only the right hand is used to pass and receive items such as gifts. Thais address one another by their first names preceded by Khun. In the north and northeast. The feet are the least sacred part of the body and should not be pointed at anyone or used to touch a person or object. marketing. Fishing is a large industry. the country’s major crop—grown in Thailand for more than 700 years. accompanied by a slight bow. The eldest male is generally the family patriarch. Thailand has an extensive food processing industry. a traditional family holds a ceremony to ward off evil spirits. Automobile assembly factories and textile production plants provide employment. khao niaw. and phathung in central Thailand. ta kiap. is the finest Thai rice. Shoes are removed when entering a temple and often a house.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 127 Thailand. The traditional Thai greeting. Women are not supposed to touch images of the Buddha. India (curries). Traditions: Employment: respect their elders and to avoid conflict. “it’s nothing. and they prefer to be called by a single name or nickname rather than the required surname. involves placing the palms together at chest level with the fingers extended. Thais use a fork held in the left hand and a tablespoon in the right hand from which the food is eaten. Rivers and canals provide a major means for transportation of people and products within the country. but domestic violence is common. still worn in some rural areas. often using the phrase mai pen rai. Most Californians are familiar with Thai food as a result of having eaten at some of the many Thai restaurants in the state. Thais were known by only a single name. The Thai people are very patient and not aggressive. A typical meal would include rice with several meat and/or vegetable dishes. In the northeastern part of the country. About half the Thai people are employed in agriculture. Jasmine rice. khao hawm mali. silk worms are raised and silk is processed and woven. For the most part. most in cultivating. and they are not allowed to touch Buddhists monks or hand anything directly to them. means “to eat rice. As in other Asian countries. Boys are often given greater freedom than girls. which is generally played in schools and other public places at 8 a. Until 1913. Muslim Thais would not eat pork or drink alcohol. The status of women is improving. is common. every day.m.m. sticky rice is rolled into a ball and eaten with the hands. Deeper bows and higher placement of the fingers (but not above the eyebrows) signifies deeper respect. and 6 p. “to eat” in the Thai language. women generally bend their knees and tuck their feet under and to one side of the body. sticky rice. Traditional dress for both men and women. called the wai. an old law permits husbands to beat their wives. but overfishing of the Gulf of Thailand is a serious problem. When seated. When a baby is three days old. Divorce is allowed and requires only mutual consent or proof of desertion. called a sarong in the south.” This staple of the Thai diet is eaten at most meals. cont. Western-style clothing is common. is an ankle-length piece of cloth wrapped around the waist. and by Portuguese . neua phat bai ka prao. Thai literature. Many schools were destroyed by the Dec. lime. gai phat met ma-muang. the second term runs from November to March. basil. After six years. Perhaps the best-known Thai dish in Western restaurants is phat tai. ice. four technology institutes. often spelled pad thai. with summer vacation until May. beef stir-fried with vegetables and Thai basil. deep-fried fish. Pre-school is provided for children from age three. Education Status: Primary School: Secondary School: Higher Education: Public education is free and compulsory for children ages 6 through 12. which consists of fried noodles with bean sprouts. fried rice. Other popular Thai dishes include phat pak lai yang. The first school term lasts from May to October. beef balls or pork. green curry with beef and tiny eggplants. One Product” initiative schools at all levels are encouraged to use locally available raw materials to produce products. Beginning in 2000. salty shrimp paste (kapi). Many schools have uniforms and begin the day with a prayer service. religious instruction. not just listen and agree. and the state subsidizes the activities of the . lemon grass. or fish) with rice is also commonly served. and lime juice. and khao phat. ginger (khing). One can even find fried locusts and other delicacies. and condensed milk. Following a three-week break. two open universities for distance learning. Curry (chicken. The Constitution requires the Thai government to patronize and protect Buddhism and other religions. wide noodles with seafood. cha yen. and upper secondary. Military service is compulsory for men at age 21: service varies from two months to two years depending on education and prior military training. 2004 tsunami. the private sector had nine universities and a technology institute. ages 12 to 15. science.” Primary education lasts from ages 6 to 12. Religion Status: According to the International Religious Freedom Report 2002. history. Night markets are especially popular. students receive the Higher Secondary School Certificate. The curriculum includes math. Popular Dishes: Beverages: missionaries (chiles). green papaya salad. chicken soup flavored with coconut milk and lemon grass. chicken stir-fried with vegetables and cashews. Seasonings frequently found in Thai cuisine include lime juice. Stewing and grilling are traditional methods used for preparing food. tamarind juice. raat naa taleh. and one institute of development administration in the public sector. is a popular drink made with black tea. and English. a favorite in northeastern Thailand made with chiles.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 128 Respecting Differences. Secondary school is divided into lower secondary. In 1996 there were 13 universities. coconut milk (kati) and fresh coriander. close to 100 percent of the Thai people claim some type of religious faith. and both children and their parents were killed. The Ministry of Education maintains a Web site indicating statistics and reconstruction efforts. ages 16 to 18. through which they learn budgeting skills as well as production know-how. the ministry instituted a free school lunch program to improve nutrition. tom khaa gai. An interview with Education Minister Pongpol Adkreksarn featured on the ministry’s Web site discusses the role of educational institutions in boosting the country’s economy through free enterprise and the creation of small businesses. garlic. fish sauce (naam pla). stir-fried vegetables. beef. black pepper. plaa thawd. chicken. Classes meet for six hours a day Monday through Friday. Thai iced tea. peanuts. Students may take vocational subjects or academic courses if they plan to attend university. Another popular Thai dish found in many California restaurants is som tam. kaeng khiaw waan. In the 1999 education act. peanuts. ground peanuts. geography. teachers are directed to “teach students to think. or noodles with duck. In Thailand. Celebrating Diversity: Thailand. and a special sauce. fresh fast food is available day and night in open market street kitchens. Through the “One School. The most common dishes at street kitchens are soups. cont. relax the patient. including the Church of Christ in Thailand. Other groups combine practices of Buddhism. Buddhist temples in Thailand are known as wat. has been used since ancient times and is related to Chinese acupuncture and Indian yoga. Christianity. millions of poultry birds in the region have been exterminated. and spirit worship. Most Muslims are ethnic Malay. . In the Muslim south. halls for public ceremonies.000 mosques in 59 provinces. China. witchcraft. Nuat Boraan. who have more than 650 shrines and temples throughout Thailand. Theravada Buddhists believe each individual is responsible for his or her own nirvana. Many traditional herbal remedies are used to treat illness and maintain health in Thailand. The wat is a focal point of village life and provides a venue for ceremonies and festivals as well as a symbol of village identity. The Thai government reports that 0. Islamic. with more than 700 people killed since violence began escalating in January 2004. traditional Thai massage. which is the dominant religion in four of the five southernmost provinces that border Malaysia. and the Evangelical Foundation of Thailand as well as organizations of Baptists and Seventh-Day Adventists. and Christian communities. Some Thai people wear amulets to protect them from diseases. but new cases continue to crop up in these countries as well as China. with the largest number in Pattani province. libraries. There are more than 3. Taoism. Health and Health Care Health Status: Traditional Practices: The 8th National Economic and Social Development Plan contained major strategies for reforming the health system by improving access and efficiency. Air pollution in Bangkok causes many health problems. Recent estimates suggest that 85 to 90 percent of the population practices Theravada Buddhism. as opposed to Mahayana Buddhists. Up to 10 percent of Thais practice Islam. Most Protestant churches belong to one of four umbrella organizations. Because many people living in poverty in the region are reluctant to kill their flocks without compensation. Buddhists practice the daily ritual of bintabat. South Asian immigrants have established Hindu and Sikh communities. Cambodia. to gain spiritual merit. In 2004. soothe tired muscles. giving alms to monks. Members of the Mien hill tribe practice a form of Taoism. among other things. but they also include descendants of immigrants from South Asia. They may offer monks the first portion of their morning meal and receive a blessing. government-run schools and teachers have been the targets of terrorism. 32 people in Thailand and Vietnam died of bird flu. Theravada Buddhism is tolerant of other religions. Religious instruction in Buddhism and Islam is required in both primary and secondary public schools. developing a consumer protection system. and balance the four elements: earth.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 129 Thailand. and Indonesia. Six tribal groups are officially recognized as practicing animism. water. and housing for hundreds of monks. and encouraging health behaviors to promote health and prevent disease. Most Thai Muslims are affiliated with the Sunni branch of Islam. who believe that nirvana will come only when all people are prepared for salvation. some experts see the threat of a flu pandemic caused by combination of a severe strain of bird flu virus with the human flu virus. they range from tiny spaces sheltering one or two monks and a statue of the Buddha to huge complexes with schools. fire. This type of massage is believed to release channels of energy. HIV/AIDS is a serious health threat in Thailand as in many other countries. About 25 percent of the Christian population is Roman Catholic. Laws proscribe speech likely to insult Buddhism. formed in the 1930s. and air. Mahayana Buddhism is practiced by a small number of Chinese and Vietnamese immigrants. half of this group lives in Chiang Mai province and the remainder in the Bangkok area and the northeastern provinces. and accidents. Buddhism: Islam: Christianity: Other: Buddhist. cont.7 percent of the population is Christian. interfaith dialogue is also encouraged and funded by the government. Tips for Health Care Providers Nearly all the Thai people practice Buddhism. Thais believe the food selected by the bulls from this assortment will be plentiful in the coming year. a midwife. corn. up to 500. for information on how the Buddhist faith may impact the health care encounter. and rice wine. which provide sleeping space for at least one companion for each patient. Secondary care at the district level comprises services provided by medical and health personnel and includes community hospitals serving populations of 10. singing. page 22. traditional medicine. Various public sector ministries and agencies oversee health promotion activities and services. celebrated with candlelight processions at Buddhist temples. See the section on Buddhism. Medical System: The father of Thailand’s current king introduced Western medicine to Thailand following his education at Harvard Medical School. When it came to power in 2001. especially in private hospitals. In cities. young people offering gifts to elders and asking for their blessing. General or regional hospitals have more beds. The first modern hospital was established in 1886. sesame seed. water. general hospitals. Songkhran. The public health care system is organized into three levels. No suggestions specific to working with clients from Thailand could be located. Private hospitals are operated as businesses and require fees for service. . Dancing. hay. including dental care. and care for the disabled. Royal Plowing Ceremony marks the beginning of the rice planting season. people fire bamboo rockets filled with gunpowder. and employ medical specialists in all fields. Visakhapucha: Celebrates the birth. HIV/AIDS prevention and treatment. Boun Bang Fai. and puppet shows are part of the festivities. and large private hospitals. Chakri Day: Celebrates the Chakri dynasty. The Ministry of Public Health has overall responsibility for all physical and mental health activities. family members or friends stay with the hospitalized individual. health centers staffed by physicians and other health professionals provide outpatient care.000 and include a health worker. Tips in profiles for other countries where the majority of people are Buddhist will probably be helpful in working with patients from Thailand. Community Primary Health Care Centers provide care in rural areas. university hospitals. Rocket Festival: Celebrates start of the rainy season. At the conclusion of the ceremony. processions. Thai New Year: Celebration involves cleaning houses. Health centers serve populations up to 5. sacred red-and-gold plow pulled by two decorated oxen who plow three furrows accompanied by a procession of drummers. Rice is planted in the furrows. hill tribes celebrate for eight days. This ancient festival was to remind the gods that rain is needed. Celebrating Diversity: Thailand.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 130 Respecting Differences.000 or more. On the primary level. cont. the Thai Rak Thai party introduced universal healthcare for some treatments and services. and a technical nurse. Tertiary care at the province level includes regional hospitals. Celebrations and Holidays February April 6 April 12–14 May May May Maghapucha: Buddhist festival commemorating an occasion when more than a thousand disciples gathered to hear the Buddha speak. enlightenment. and the bulls are offered bowls of rice. perhaps releasing caged birds or putting live fish into rivers. participants rush into the field to collect rice to take home to add to their own rice to ensure a good crop.000 in remote villages. Thailand has both public and private hospitals. observed at the full moon of the sixth lunar month and observed with candlelight processions at Buddhist temples. In most cases. About 375 health-related private non-profit organizations receive government and outside funding to work in areas including disease prevention. at a cost of 30 bhat/THB per visit. and death of the Buddha. Community health posts staffed by a single community health worker provide simple curative care as well as health promotion and disease prevention assistance to populations of up to 1. 801 (0. followed by San Francisco and San Diego. For example. participants ask the goddess Mae khongkha (Mother Water) to wash away their sins and grant them a wish. Language. The first Thai alphabet was created in the thirteenth century by King Ramkamhaeng of the Sukhothai Kingdom. involves fishing boat racing. July August 12 September November December 5 December 11 Asalhapucha: Festival marking the beginning of the period that young men spend in a monastery beginning at age 20. both marrying and fathering 22 children in all. and they never returned. the word sua (rising) means “tiger. . Loy Krathong: Festival held at the full moon involving a krathong. and English is required in public schools and spoken widely in Bangkok and other major cities. Chinese is widely spoken in Thailand. The Grand Palace and other buildings are decorated with colored lights. My name is . North Carolina. speaks French and English.” The alphabet contains 44 consonants and 32 vowels. Sawadee ka (from a woman). Sawadee khrap (from a man). The Thai people revere their ruler. object. They came to the United States in 1830 and settled in White Plans. Like many Asian languages.114 of those in California. and falling. with adjectives following nouns. and the basic sentence structure is similar to English: subject. verb. low. which will come true if the candle continues to burn as their krathong floats out of sight. who was educated in Switzerland. My name is . rising. Excuse me. The largest number of Thais live in Los Angeles. .5%) native-born Thais lived in the United States.” sua (falling) means “shirt. khopkhun. parades. . King Bhumibol’s Birthday. How are you? Sabai deerue? Very well. Thai depends on pitch to differentiate the meanings of words that are otherwise pronounced alike. Dee chan chew (girl) . Queen’s Birthday Narathlwat Festival in southern Thailand. . thank you. The following are some transliterated words and phrases: Hello. Pom chew (boy) . the conjoined (Siamese) twins born in 1811 and discovered by an English trader in 1824. Sabai di. Thai does not use punctuation or capital letters. Hello. According to the 2000 Census. with 62. and is an accomplished jazz saxophonist and yachtsman. and movies on giant screens. Yes/No Chai/Mai chai . 169. There is no widely accepted method for translating Thai into the Roman alphabet. placed in a river or stream. Thai is written from left to right. . Useful Words and Phrases Thai is the official language of the country.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 131 Thailand.” and sua (low) means “mat. small cup made of banana leaves containing a lighted candle and incense sticks. high. The five Thai tones are mid.2 percent between 1990 and 2000. He took the twins from Thailand in 1829. . . . fireworks. cont. and participants enjoy stage shows. Kaw toht. Pronouns are used to indicate social standing and familiarity. The number of Thais in California increased by 46. Constitution Day Thais in the United States The first Thai immigrants to the United States may have been Chang and Eng. “The Thai Language. 2005. “Schools in Thailand under Ethnic Siege.asp?countryid= 237&countryname=Thailand (4 Feb. ———.” New York Times.intersolinc. http://www.ethnicityonline. 2005). Vanichkorn. Wibulpolprasert.” http://www. 2004). “Thai Language. 2005).nytimes. Suwit. 2005).” http://www.reliefweb.”http://www.gay-thailand.org/cp/english/thailand (4 Feb.org/greetings. 2001. ThailandLife. “Thai Church Tackles Domestic Violence. . Rajendra. The Statesman’s Yearbook: the Politics.htm (4 Feb.net/language.” http://www. Habitat for Humanity Thailand.” http://en. Multiculturalism and Native Issues Centre.asp?countryid=237&countryname=Thailand (4 Feb. National Catholic Reporter. 2002. http://www.fm (24 Mar. 3.lonelyplanet.com. 2005). 2005). 101. 6 July. Lonely Planet World Guide.thailandlife. ———. Wikipedia.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 132 Respecting Differences.com (7 Jul. Inc. 2005). Cultures and Economies of the World.” ThailandLife.html (8 May 2005). ———. 2005). “International Religious Freedom Report 2002: Thailand. Mydans.com/siamese_twins. Barry. “Traditional House of the Central Plain.cia.org/wiki/Thai_immigration_to-the_United_States (6 Feb. 2005). 2004).”CountryReports.” http://www. ed.net/customs. 2002.com/thailandoutlook1/about+thailand/health/ (5 Feb. 2003.org. Beena. ———.wikipedia. ed. “ Thailand: General Over view.htm (6 Feb.moe. 1999–2000.countryreports. World Health Organization. Seth. U. Country Reports.jobmonkey.htm (28 Feb. 2005).” http://www.” http://www.” http://www.htm (4 Feb.net/buddhism_summary. Turner.thailandlife. 2005).html (4 Feb. 2005).” http://www. ———.asp?countryid= 237&countryname=Thailand (4 Feb. “Thai Health System. Thailand Health Profile.NSF/db900SID/MHII-6994EF?OpenDocument (3 Feb.com/newsletters/newsletter_24htm (6 Feb.com/teaching/asia/html/thailand_customs. “Spirit Houses.int/rw/ RWB. 2005).htm (3 Feb. New York: Palgrave MacMillan.S.th/main2/article/article_pongpol/SMEs_ENG.” http://www.gov/cia/publications/factbook/geos/th.html (4 Feb. 2002. 2005. “Thailand: Culture and Customs. ———. http://www. ThailandOutlook. The World Factbook: Thailand. http://www.html (4 Feb.com/destinations/south_east_asia/thailand/history.com/teaching/asia/html/food_in_thailand.countryreports.com/spirithouses.gov/g/drl/rls/irf/2002/13911pf. http://www2. 2003. http://www. p. Ethnicity Online. JobMonkey. 2005.com/thaihouse_central.org/customs. GayThailand. Canada. “Thailand Tsunami Situation Report 01 Feb. “The Original Siamese Twins.state. 2005). and Labor. 2005). Thailand. 8 April.com. Anti-Racism. Thailand. http://www.habitat.” 2005.htm (4 Feb. Department of State Bureau of Democracy. Pongpol. Faculty of Social Work.” http://www.com/ expandedprofile. http://www. Kathy.htm (4 Feb. “Thai Customs and Social Mores.settlement. 2005). 2005). 2005). “Thai Immigration to the United States. “Enjoying Thai Food. “Universities and Colleges as the Foundations for SMEs.jobmonkey.emulateme. http://www. Human Rights. Ministry of Public Health.org/intl/countryprofiles. References Adireksarn. Bangkok: Bureau of Policy and Strategy. 2005). University of Toronto.com. Celebrating Diversity: Thailand.go.” http://www. “Thailand: In Their Language. “Common Customs of Thailand.html (4 Feb.gay-thailand. cont.” InterSol. 2005).com.thailandlife.thailandoutlook. Cultural Awareness in Healthcare: Buddhists. textiles agriculture 75% . rubber. fish.4% riel (KHR) Khmer (pronounced “Kami”) 90%. timber. occasional droughts oil.4%) 53. 20 provinces. Vietnamese 5%.898 sq. wood and wood products.069 19. rainy. French.978 (0. footwear tourism. tapioca rice. rubber. gem mining. rubber. capital Phnom Penh tropical. English Theravada Buddhist 95%. dry season (December to April). phosphates. monsoon season (May to November). vegetables. Other 4% Khmer (official) 95%. cement. garments. timber.91 years 1. iron ore.6%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 69. corn. clothing. cashews. rice milling. flooding. gas. Other 5% Kingdom of Cambodia: multiparty democracy under a constitutional monarchy established in September 1993.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 133 Cambodia Census Figures (2000) United States Residents Born in Cambodia: California Residents Born in Cambodia: 139.87 years 40% 69. miles (slightly smaller than Oklahoma) 13. gemstones. manganese.607.544 (0.81% 58. Chinese 1%. hydropower potential 20. tobacco. little seasonal temperature variation monsoonal rains ( June to November). fishing.96% rice. and violence in refugee camps in Thailand and Malaysia. often after spending time in acculturation programs in the Philippines. The People’s Republic of Kampuchea was established and much of life returned to its pre-Khmer Rouge patterns. That same year. The area underneath the house is used for storage or for animals.000 Cambodians were able to find asylum in the United States. disease. and volunteers. Cambodia won independence from France in 1953 and became the Kingdom of Cambodia under King Sihanouk. in 1887. about one-fourth of the city’s million residents live in shantytowns and other informal settlements on public land on the outskirts of the city. he renamed the country the State of Cambodia in 1989 and Buddhism was reestablished as the state religion. Brief History Present-day Cambodia had its beginnings in the Angkor Empire of the Khmers. medical supplies. the Cambodian People’s Party won but did not establish a governing coalition of rival parties until 2004. and more than 180. In Phnom Penh. established in 802. In 1863. Factional fighting ended the first coalition government. basic freedoms were curtailed. In 1985 Hun Sen became prime minister. King Sihanouk briefly resumed power. 1113–1150.-backed government of South Vietnam. the United States began a secret bombing campaign against North Vietnamese forces in Cambodia. which covered much of Southeast Asia and reached its height between the 9th and 14th centuries. for protection against monsoon flooding. those who made it often found starvation. The temple-mountain known as Angkor Wat was constructed during the reign of Suryavarman II. The Khmer Rouge sought to create a communist rice-growing dynasty combining Maoist ideology with Cambodian nationalist beliefs. Anti-French guerilla activities. In 1967 the Khmer Rouge supported peasants in an uprising to protest a tax on rice. In the 2003 elections. cont. sending the army to fight the North Vietnamese in Cambodia. beginning in 1946 when France re-imposed its protectorate. Celebrating Diversity: Cambodia. Family. led by Pol Pot. Sihanouk resigned in 1976 and Khieu Samphan became head of state.S. Hundreds of thousands of Cambodians were driven from their homes into labor camps. The international community assisted with food. with Pol Pot serving as prime minister. . with ladders or stairs. money became worthless. A 1991 peace agreement signed in Paris between various rival factions brought King Sihanouk back as symbolic head of state. making his capital at Angkor. Cambodia became part of French Indochina. Prince Norodom Sihanouk became king in 1941. Sihanouk broke off relations with the United States and allowed North Vietnamese guerillas to set up bases in Cambodia to combat the U. Yasovarman I ruled Cambodia in the late 9th century. thousands of Khmer Rouge surrendered in a government amnesty in 1994. Urban housing is generally of brick or wood. government officials. and the country was renamed Kampuchea. Floors are made of wood. and Cambodians with Western educations were among the first to be killed. or were tortured and executed in what is now called the Killing Fields period as the Khmer Rouge sought to build a new society with no trace of the past. People sleep on the floor on mats and eat sitting on the floor on a mat. and thatched roofs are constructed of palm leaves. nearly 2 million Cambodians had been executed or died of disease or starvation. At this time the Cambodian army was facing two enemies: the North Vietnamese and its own communist Khmer Rouge guerillas. King Sihanouk was deposed in a coup in 1970. Housing. City dwellers were forcibly evacuated to the countryside to become agricultural workers. when the French submitted to Japanese demands for bases in that country. and the practice of religion was banned. Lon Nol was overthrown by the Khmer Rouge. Thailand took control of Angkor in 1431 and moved the capital to Phnom Penh. Traditions Housing: Rural houses are generally built on stilts. with Vietnam and Laos. city dwellers. In 1993 the monarchy was restored and the country renamed the Kingdom of Cambodia. the King of Cambodia put his empire under the protection of France. Work. Buddhist monks. in 1975. gave rise to the communist-led revolution. The Japanese occupied Cambodia during World War II. Sihanouk formed a guerilla movement while exiled in China. Many tried to escape across the Thai border. 1n 1969. Fighting broke out with Vietnam in 1977. Prime Minister General Lon Nol assumed power and proclaimed the Khmer Republic. while he was out of the country. walls are woven bamboo. By the time the Vietnamese took over Phnom Penh in January 1979. 1998 elections brought a new coalition and political stability.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 134 Respecting Differences. when people were sent into the countryside to live in collectives. husbands were allowed to have extramarital affairs. a spicy fish paste. generally centered around the local wat or temple. creating employment both on the rubber farms and in rubber-processing plants. Residents of urban areas may have several jobs in various service industries. Cambodian families traditionally eat together. although noodles are eaten with chopsticks. In urban areas. other families live as subfamilies with relatives or other extended family. clothing. the head is considered the place where the spirit dwells and should not be touched. lemon grass. primarily in the growing and processing of rice. Other meals include rice or noodles with fish paste and vegetables. and ginger. The traditional greeting is a slight bow accompanied by hands together in a position of prayer at chest level. Fish is eaten fresh. but women were expected to be faithful. Women wear a blouse and a sarong. Children are treated affectionately and encouraged to be independent. chicken is a hot food. Family: Traditions: Employment: Most Cambodians live in small villages located near roads or water. which is harvested twice a year because of the country’s tropical climate. They believe in the hot/cold properties of foods to cure illness and maintain health. when they were destroyed. Before they sit down to eat. Men often shake hands. Traditional Khmer women were to stay at home raising children. While men have traditionally been the heads of Cambodian households. chiles. and pharmaceuticals provide employment. In formal situations. The combination of ingredients determines whether a food is hot or cold.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 135 Cambodia. or dried. a checked scarf worn on the head or around the neck. they cut a bunch of fresh hot chili . years of war and genocide have resulted in a situation where only 20 to 30 percent of adult Cambodians are male. which is used for activities and religious ceremonies. Rice is considered neutral. they do not use ice in beverages. economic and political framework of Khmer life and traditions. According to Elizabeth Chey: “The Khmer Rouge return to year zero destroyed the social. For working in the fields. Rubber plantations were plentiful prior to the war and genocide years. About 25 percent of households are headed by women. Rice may be steamed. fried. . Eye contact with an older or superior person is considered impolite.” Traditionally. After twenty years. is used to season many dishes. Rice mills and factories producing textiles. Cambodian names are spoken and written last name first. but women may still be reluctant to do so. During the Khmer Rouge period. Some have been revived. As in other Buddhist cultures.000 families along the Tonle Sap (Great Lake) live in floating houses and support themselves by catching and fattening fish for market. Rice and fish form the basis of the everyday diet. Breakfast might be chicken soup or a noodle dish. nearly 40. According to one source. Prahoc. farm people ate together in large halls rather than in family units. Many women were raped in these camps. Foods and Eating Habits Dietary Practices: Everyday Diet: Many Cambodians are lactose intolerant. Western-style clothing is worn. Cottage industries produce woven cloth and clothing sold at local markets. Most Khmer love spicy hot food. food was often given only to women and children. Logging was a source of employment before excessive logging resulted in deforestation and a 1995 ban on timber exports. the feet are the lowest part of the body. salted.) followed by the given name or both given and family names. In refugee camps in the 1980s. They enjoy soy drinks and specially brewed coffee. Like many Asian people. as men and boys were suspected of being guerillas. vegetables are cold. . or made into noodles. Cambodia is emerging again . cont. Khmer women were virtuous and responsible for upholding their families. both men and women wear loose shirts and trousers.) or Lok Srey (Mrs. People eat most foods with their hands. Commonly used spices are mint. Most Cambodians work in agriculture. Traditional Khmer dress includes the krama. people are addressed as Lok (Mr. This has posed a problem for women widowed in fighting or genocide. even after the death of the husband. . 1 percent of seven-year-olds were enrolled in school. Popular Dishes: Beverages: peppers and mix them with fish sauce to dip.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 136 Respecting Differences. much of it due to land mines. Some 19. cont. the ministry reported that 64. Education is controlled primarily by the Ministry of Education. Thai cooks use red chiles a lot. which is thought to aid digestion but which turns the teeth. Many young people use methamphetamine smuggled in from Thailand. Only 14. Khmer. The school year runs from October until June. allowing for individual preference in the hotness of the food. and gums a dark red when used frequently.026 primary schools operating in Cambodia. and coconut water (tekdong) are also popular. num pachok sach ko chagio (cold noodles with lemon grass beef kebab and spring rolls). In addition to academic subjects. As many as six million unexploded mines litter the country. Locally brewed rice wine is a popular drink. upon completion of two years a student receives a diploma called a baccalaureate. Cambodian cooking is often compared to Thai cooking. Education Status: Primary School: Secondary School: Most Cambodians grew up without formal education due to the fighting that has devastated the country. Tea is the most common drink. which is integrated into the curriculum as part of a subject called Lifeskills. jackfruit. palm juice (teknot). Soda water with lemon. and 6. salor kor ko sap (Khmer vegetarian soup): nhoam sach ko tirk krote (crispy sliced spicy fried beef with crisp lettuce orange sauce). which can be made of wood. Sach ko char spee khieu (beef with Chinese broccoli). 72 percent of those have dropped out of or never attended school.3 percent. there were 5. Students are taught to recognize various kinds of mines. and a sweet creamy fruit called the durian. rambutan. where Cambodians prefer to spice up their dishes by hot side servings. mangoes. . students in primary and lower secondary schools learn about agriculture. Some markets and restaurants have special areas set aside for the eating of this fruit. and instruction is conducted in the official language. lips.2 percent of children were enrolled in secondary school.000 Cambodian children between ages 5 and 17 working. oranges. vegetable spring rolls (num cha gio pale). for decades. Upper secondary school lasts three years. Save the Children Norway reports that there are 653. and 31 percent of Cambodians ages 5 to 24 had never attended school. In 1998–99. Youth and Sport. Education is now mandatory for children ages six through twelve. which have injured more than 40. mangosteen. There are many similarities between the two countries. Lower secondary or middle school lasts three years. The repetition rate was 21. but there are significant differences as well. kari krahum saich moan (red chicken curry). or plastic. longan. with a net primary school enrollment of 78. pineapple. Land mines are a serious problem in Cambodia. metal. Fruit is popular and includes bananas. with a second diploma given at completion of the third year. Some Cambodian women chew the betel nut.250 working children were involved in the commercial sex trade. Cambodia has one of the highest rates of disability in the world.9 percent. kari baitongh saich trey (green fish curry). lychee. with students receiving a diploma when they have completed this level. However. Celebrating Diversity: Cambodia.3 percent were enrolled in preschool. causing blindness and death. Primary school lasts six years. papayas. with more than 2 million students.000 Cambodians. in the late 1990s some brewers responded to the demand for a higher alcohol content by spiking the wine with insecticide. Pre-school education lasts three years. one of the poorest in the world. the new constitution mandates nine years of education and calls for a restructuring of the system. An alcoholic drink is made of fermented palm juice. In 1997–98. According to a UNESCO source. many people find the smell so objectionable that airlines and hotels may ban them. Dermal techniques are . Its citizens have a life expectancy of only 58 years. 15 percent have electricity. Many people attribute illness to possession by evil spirits as a result of a spell cast by another person or by the individual’s neglect or errors in performing rituals. diphtheria. Diseases that have been largely controlled in other countries are still rampant in Cambodia. Animism. When Cambodian males are 16 years old. Foreign missionaries operate unhindered. dermal techniques such as cupping. pinching. is considered one of the architectural wonders of the world. More than a third of the wats were destroyed.000 Muslims in Cambodia are mostly ethnic Chams who live mainly on the banks of the Mekong and Tonle Sap rivers and in Kampot province. During the Khmer Rouge period. malaria. and 14 percent have indoor sanitation. gaining merit toward their salvation. and Angkor Wat. Many people rely on folk and herbal medicines. Less than 1 percent of Cambodians are Christian. Land mines injure thousands of Cambodians each year. A formal organization. All religions were banned during the reign of the Khmer Rouge. most enter the wat and live the life of a monk for at least a few days. are widely used in Cambodia. and visiting shrines of the Buddha. kru khmers. smallpox. Hinduism was the main religion. The approximately 700. typhoid fever. The Cambodian Association of Traditional Healers. healers called accha conduct diagnostic and healing activities in the client’s home. cont. Other ways of gaining merit include giving food to the monks. Higher Education: Higher education in Cambodia. dengue fever. lasts from four to seven years. and coining. the largest religious building in the world. called tertiary education. and trachoma. Religion Buddhism: Islam: Christianity: Other: More than 90 percent of Cambodians practice Theravada Buddhism. More than a hundred different Christian organizations and denominations operate freely in the country. Cao Dai. and various rituals. maintenance of the body’s hot-cold balance. Traditional healers. A study by the University of Alabama of the role of traditional healers in TB treatment indicates that Cambodians generally seek Western medicine first but turn to healers for relief from the side effects of drugs. including tuberculosis. Herbs are often grown in the family garden. In 1989 Buddhism was reestablished as the official religion of Cambodia. and many monks and novices were killed or became refugees. Health and Health Care Health Status: Traditional Practices: Cambodia is one of the poorest nations in the world. as compared to 71 years in neighboring Thailand. which are thought to restore balance by releasing excess air from the body and leave marks on the skin that might be mistaken for signs of abuse. many hospitals were destroyed and physicians were killed to stamp out Western influence. is working with Western organizations in a TB project in Phnom Penh. or they may be gathered in the jungle by a kru khmer. Cambodia has nine public institutions of higher education.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 137 Cambodia. Only 29 percent have access to clean water. Malnutrition is common. Specialized secondary schools. The main forms of medical treatment in rural areas comprise herbs. Many Cambodians drink water from streams and rivers and are at risk for a host of diseases including hepatitis and cholera. leprosy. The incidence of AIDS continues to rise. which has more than 1. Before Buddhism was introduced. celebrating holy days. and Bahai’i are all practiced in Cambodia. offer tertiary instruction in various technical areas for upper secondary school graduates. when monks were forced to leave the wats and go to work on collective farms with everyone else. Most practice the Malayinfluenced Shafi variety of Islam. all of which are free to students. called technical and professional training institutions. The wat is a major symbol in villages. although the religion is growing.000 congregations of various kinds. RACHA trains village midwives and traditional birth attendants in Life Saving Skills (LSS) to make home deliveries safer. Medical services are provided through provincial hospitals. Drugs are often shared with family members and friends. In addition. some are afraid to take prescribed anti-depressants for fear of addiction or that they may never awaken if they take them. will be applicable to caring for Cambodian patients who practice Buddhism. colds. Agency for International Development and the Royal Government of Cambodia founded the Reproductive and Child Health Alliance (RACHA) to improve health care by integrating the traditional structures with modern medical practices. This is designed to release excess air and will probably produce a contusion. hepatitis B. chest. mysterious procedures.S. it draws the skin and the excess energy or air into the cup. district clinics.” While many Khmer language patient education materials are available at http://ethnomed. between the eyes. or back. cont. One problem in dealing with these individuals is that the Khmer language contains no comparable terms for describing the conditions. usually at the base of the nose. Tips for Health Care Providers The information on Buddhism. multiple interviews. a Cambodian might go to another practitioner. including Buddhist nuns and village shopkeepers. Pinching: Pressure is applied by pinching the skin firmly between the thumb and index finger. Health care providers often have trouble convincing Cambodian patients of the need to take medications for a chronic condition such as high blood pressure or diabetes. many Cambodians are illiterate. The program trains rural health workers. as described on the EthnoMed Web site. as this makes them feel as though something is being done. or on the neck. Language and cultural barriers. According to EthnoMed: “Western health care is confusing and overwhelming for many Cambodians. EthnoMed. The following information may be helpful for those working with Cambodians in the health care setting. Cambodians expect to be given medications for every illness.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 138 Respecting Differences. and intestinal parasites. As it cools. reports that many are depressed and suffer with PTSD. . If one physician does not prescribe medication. Rubbing or coining: The skin is lubricated and rubbed with a coin or spoon to bring toxic air to the body surface. muscle pain.org/ethnomed/patient_ed/camb/index. sore throat. Techniques. as they often expect instant results from taking a drug. page 22. Some believe that X-rays destroy red blood cells and decrease life expectancy. given their history. due to the horrific conditions many endured in their own country or in refugee camps. the U. and the somewhat abrupt behavior of personnel combine to make obtaining health care an unpleasant experience. Hospitals are often short of equipment and supplies as well as trained staff. Attitudes: Cambodians think drawing blood will make them weaker because blood is taken away and not replaced. Common diseases found in new refugees were tuberculosis. As is the case with many people even in our own culture. The Cambodian Ministry of Health has instituted village feedback committees to encourage community partnerships in the public health decision-making process and build the confidence of the people. to provide health care in rural areas using a holistic approach to capitalize on existing resources.html. Cambodians arrived in the United States in worse health than many other refugee groups. which works with the Cambodian community in Seattle. and village dispensaries. crowded waiting areas. Medical Condition: On the whole. Cambodians are at high risk for post-traumatic stress disorder (PTSD) and other psychiatric problems. In 1996. Celebrating Diversity: Cambodia. medications are often taken only until the symptoms have abated rather than until the prescribed regimen has been completed. and diarrhea. Unsurprisingly. Formal prenatal care may be avoided because of physical examinations. are: Cupping: A heated cup is placed on the skin (usually the forehead or abdomen). Women in general prefer to have a woman health care provider. Medical System: used for such things as headache. Independence Day: Celebrates independence from France in 1953. and entering into nirvana. cont.” or “Mrs. People gather at the temple with offerings of rice which they toss on the ground for their dead ancestors. and may be a very frightening prospect. Pisak Bochea: Celebrates the Buddha’s birth. Cambodians tend to be stoic. as some believe the soul is located in the head. On Day 2. celebrated with parade including floats. Mourners wear white. fruits. and other spectacles in front of the palace. Silence is preferable to aimless chatter. They may use tiger balm. foods chosen by the cows after they have circled the field three times and been blessed is used to make predictions for the coming year. food. inaugurates the new angels who come to take care of the world for the coming year. and clothing are offered to the monks in return for their prayers for the ancestors and deceased relatives. Khmer New Year: Day 1. Speak softly and be polite. Moko Sangkran. . Many are lactose-intolerant. celebrated on the full moon of the sixth lunar month. especially in Phnom Penh. Buddhists believe that if departed souls do not find their families making offerings at the temple. Bonn Chroat Preah Nongkoal. the soul will be cursed and will bother the descendent throughout the year. Royal Plowing Ceremony: The king leads the yoked sacred cows. Touching the head without permission is considered rude. fingers pointed upward. Some Cambodians who have been in this country longer may shake hands. Victory over American Imperialism Day Labor Day Genocide Day: Marks Khmer Rouge atrocities. Celebrations and Holidays January 7 February 18 February February April 14–16 April 17 May 1 May 9 May May 26 August/October November 9 National Day: Celebrates Vietnamese overthrow of the Khmer Rouge. Surgery is traditionally seen as a last resort. older people meditate or chant the dharma. Bonn Pchum Ben (full moon): Spirit Commemoration Festival held for spirits of the dead on the fifteenth day of the tenth month. Cambodians are unlikely to agree to organ donation or autopsy.” and the last name. Cambodian Vietnamese Friendship Day Meak Bochea: Buddhist festival celebrated on the full moon of the third lunar month. Cambodians may prefer dying at home. people clean and decorate their houses. Cambodians are very modest. Greet clients formally by using “Mr. who sows the rice seeds. but polite women lower their eyes. and use cupping to draw out pain. Chinese/Lunar New Year: Many Cambodians. Discuss a diagnosis of serious or terminal illness with the family first. Monks and religioius laypersons. They prefer warm tea or water to ice water. offerings of food and clothing for the monks made for at least 15 days. Very similar to ceremony in Thailand. apply medicated tapes to painful areas. collected on the day of the full moon. Eye contact is acceptable. bands. commemorates the Buddha’s enlightenment and entering nirvana. The family and religious helpers may want to wash the body. Elders are important in the decision-making process. Some clients may be uncomfortable with written consents due to experiences with the Khmer Rouge. may be needed to recite prayers for a dying individual.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 139 Cambodia. This should not be removed without permission. let them talk with the patient. Gifts are given to parents to ask forgiveness. Both adults and children may wear strings or chains around their necks with an amulet containing Buddhist transcription for protection. enlightenment. followed by the queen. The body is cremated. aacha. celebrate. The usual greeting involves bringing the palms together. Family Authority: Addressing Clients: Nonverbal Exchange: Verbal Exchange: Hospitalization: Death and Dying: The father or the eldest son or daughter is the family spokesperson. An article from the June 1. Thousands of people come to the Tonle Sap. Congress approved admission of a large number of rural Cambodians who had fled across the border into Thailand and had been living in refugee camps. Chum reap lir/Lear heouy. California’s Cambodian population grew by 24 percent. Goodbye. Cambodians look to education to help their children become productive members of society. Excuse me. a mixture of rural and urban.” and Phnom Penh from all over the country to participate in and watch the boat races. based on an Indian alphabet. Suom tous. The following words and phrases may be helpful: Hello. Useful Words and Phrases As indicated above. The use of interpreters may be necessary in the health care setting. Historical ties with the Indian culture mean that there are similarities in the language. Lok Mrs. most of the Cambodian refugees arrived in the United States unable to read or write their native Khmer language. October/November Water Festival includes the Boat Race. Some of the educated Cambodians have been able to establish businesses or find employment. Thank you. Baat. Te’. 35 vowel symbols. Celebrating Diversity: Cambodia. and business and professional people—arrived soon after the fall of Phnom Penh to the Khmer Rouge in 1975. many Cambodian refugees and immigrants are illiterate in their own language and might be unable to read patient materials. In 1979. The first group—government officials. How are you? Tau neak sok sapbaiy jea te? Good morning. Good night. military officers. “Great Lake. during that period. Those who have jobs often work in low-wage areas that require more than one job to support a family. Since 1979 the study of Khmer language and literature have been revived. Please. Tivia Surday. and 33 subscripts. Long Beach and Stockton are home to the largest Cambodian communities in the state. Yes (used by men). and Bonn Ork Om Bok (eat the flat rice) events. People educated from 1862 until the defeat of the French in 1953 were educated in French. Mr. three groups of Cambodians have been resettled in the United States since 1975. includes 66 consonant sounds. No. Jas. The complex written language. with stone inscriptions dating back to the seventh century. as discussed in the introductory materials. 33 superscripts. Suom. Language. According to information provided by EthnoMed. cont. Yes (used by women). Chum reap sur/som pas. educated and illiterate refugees. but many are on public assistance.000 in 2000. 2000 Asian Week discusses the situation of Khmer students in Long Beach. Moon Festival.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 140 Respecting Differences. This creates a generation barrier that often causes problems within Cambodian families. Ar kun. Long Beach has the largest Cambodian population in the United States. the U. With the exception of the first group. The Khmer language has the oldest written records of any Southeast Asian language. pointing out that those who were born in this country or arrived here as small children are fluent in English while the older generation is not. Cambodians in the United States The Cambodian population in the United States grew by nearly 40 percent between 1990 and 2000. estimated to be about 55.S. many of which are available through EthnoMed. Lok srey . Readray Surday. The third group comprises Cambodians who have been admitted to the United States since 1980. cambodia/ program_dept. Timeline: Cambodia.” http://bigpond. Antonio. and Ngin Chhay.” Asian Week. 1 June.com/pearls3.settlement.html (9 Feb.org/ia/cbc/cambodia. Department of State Bureau of Democracy. “Country Report: Cambodia. Cambodia. Inbaraj. 2000.mekong. “Country by Country: Cambodia. 2005). Faculty of Social Work. 2005).pdf (8 Feb.ethnicityonline.htm (7 Feb. “EngenderHealth Makes Creative Strategies in Low-Resource Settings. Ethnicity Online.html (8 Feb. 2004). http://ethnomed. http://news. “Language Barriers.html (9 Feb. 2005). 1999. “In Cambodia. eds.htm (7 Feb. Chey.html (8 May 2005). Nuth. Barry. 2005).asianweek. Elizabeth. 2005). 2005).” http://www. ed.gov/cia/publications/factbook/geos/cb. 2005). et al. “Cambodia in Brief. “Cambodia: Programs and Projects 2001. 2005).uab.S. Savy.engenderhealth. Sakhan. 2005).net/cambodia/banyan1.net/buddhism_summary. Sonny.mekong. Alejandra. Save the Children Norway. Bruce. Sharp.frizz-restaurant. EngenderHealth. http://www.htm (28 Feb. Asians in California: 1990 to 2000.” http://www. “International Religious Freedom Report 2002: Cambodia. Canada. 2003. Hope Rises from Squalor. New York: Palgrave MacMillan.cambodia/fact_about_children.” http://bigpond. Lopez. 2005).○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 141 Cambodia.htm (7 Feb. Zimmer. and Labor.kh/users/rb. 2004).” http:// www. CA: Center for Comparative Studies in Race and Ethnicity.net/cambodia/mines. Sophoan.” http://www.net/cambodia/women.” http://www. http://www. 2005). 1997.cia.” http://www. Anti-Racism..org/docs/PAC_2001. The Statesman’s Yearbook: the Politics. Multiculturalism and Native Issues Centre.kh/users/rb.htm (7 Feb.stanford.com. 2005). EthnoMed. (6 Feb. University of Toronto. cont.org/news/in_the_news/020404. Kannitha. “Landmines in Cambodia. Stanford University.stm (23 Feb. “Feeding the Ancestors: The Cambodian Pchum Ben Festival.org/ethnomed/cultures/cambodian/camp_cp.state. http://www.edu/reports/report_8pdf.org/cp/english/cambodia.unescobkk. “Cambodia.communityipm.html (7 Feb.htm (7 Feb. 2002.pdf (8 Feb.” http://www. Culture and Nursing Care: A Pocket Guide. Festivals in Cambodia. Jessica. Cambodia.edu/gorgas/Documents/ TraditionalHealers%Final. Turner. Juliene G. Cambodian Cultural Profile. . Graceffo. San Francisco: University of California San Francisco Nursing Press.mekong.” World Social Forum.co.htm (8 Feb. 2002. Lee. “The Banyan Tree: Untangling Cambodian History.html (9 Feb.htm (6 Feb.” http://www. http://ispnews. 2005). Pich.asp?idnews=27150 (8 Feb. http://www. Kong. 2005). Lipson.engenderhealth.com/2000_06_01/ feature_khmer_longbeach.gov/g/drl/rls/irf/2002/13869pf. 2005). “Traditional Healers and TB Care in Phnom Penh. http:// ccsre.org/education/aceid/higher-edu/Handbook/HB_Cambodia.net/cambodia/ pchum.html (6 Feb. Cultures and Economies of the World. Human Rights. “The Status of Khmer Women.” http://www.mekong. 2005). 2005).net/ print. http://www.com. 2005. ———.htm (7 Feb.uk/go/pr/fr/-/1/hu/asia-pacific/country_profiles/1244006. Bou.” http://www. Stanford.. Cultural Awareness in Healthcare: Buddhists. Cecelia.bbc. 2002. References BBC News. 2004). 2002. U. The World Factbook: Cambodia. Celebrating Diversity: .○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 142 Respecting Differences. Other Countries India Iran Armenia Russia . Celebrating Diversity: .○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 144 Respecting Differences. Kashmiri. Gujarati. jute. services 23%.264. food processing.552(3. mica. English is used nationwide in politics and commerce. petroleum. Kannada. miles (one-third the size of the United States) Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: 1.4% 63. oilseed. Other 3% 15 official languages include Hindi. Urdu. Punjabi. Jain.9%. the national language. titanium ore. Sindhi. earthquakes. cattle.66 years 1. and Sanskrit.5% Republic of India: federal republic.346 sq. limestone 54% rice.201(2. New Delhi is the capital varies from tropical monsoon in south to temperate in north floods. manganese. natural gas. petroleum. diamonds. bauxite.080.2%) Quick Facts Country Area: 1. Sikh 1. gems and jewelry. engineering goods.35 years 25% 59.3%.3%) 198. computer software services agriculture 60%. Dravidian 25%. plus Bengali.022. 28 states. leather goods textiles. poultry. Tamil.3%. wheat. chemicals. Parsi 2. chemicals. 7 union territories. water buffalo. fish textiles. Assamese. sheep. potatoes. chromite. spoken by 30% of people. Malayalam. goats. machinery.5% Indian rupee (INR) Indo-Aryan 72%.269. Christian 2. Hindu 81.388 24. Muslim 12%. mining. other groups including Buddhist. cement. Oriya. steel. cotton. Punjabi. sugarcane. industry 17% Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: . iron ore. droughts. tea. transportation equipment.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 145 India Census Figures (2000) United States Residents Born in India: California Residents Born in India: 1. tsunamis coal. Aryan tribes from the northwest invaded about 1500 BC. more than 5. The subcontinent was divided into the secular state of India and the smaller Muslim state of Pakistan. Celebrating Diversity: India. Housing. 26. his wife determines tasks to be done by other female family members. (4) nuclear family: man. and they introduced the Indus to the caste system..○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 146 Respecting Differences. By the 19th century. Arab incursions started in the 8th century. The Aryans spoke and wrote Sanskrit. Other major concerns are overpopulation. In 1971 India invaded East Pakistan. widespread poverty. Greatest damage was caused to the outlying Andaman and Nicobar Islands in the Bay of Bengal and the mainland southeast coast state of Tamil Nadu. Rural Indians live in simple huts or thatched houses. Males are more highly regarded than females. cont. although many may have other relatives or friends living with them temporarily while they get settled in the United States.000 people in 373 villages perished. was prime minister from 1966 until her assassination in 1984. which became the separate nation of Bangladesh at the end of hostilities. wife.. The senior male is generally the head of the family. Four major kinds of families can be found in India: (1) traditional joint family: head of household (usually male). most notably the British East India Company. which gained control of all European trade in India by 1769. struck the east and southwest coasts of India and left more than 10. and the family of one of his sons. Work. introducing Islam to the largely Hindu culture. his unmarried children. and astrology. the bride’s family traditionally provides a dowry to the groom’s family. Britain had assumed political control of virtually all Indian lands. Middle-class families often live in smaller houses or apartments. Although this practice is now illegal. Most marriages are arranged by family elders on the basis of factors including caste. Indira Gandhi. housing varies greatly. India carried out nuclear tests in 1998.700 people dead. Turkish invasions began in the 11th century. Muslims. and hundreds of thousands homeless. People are generally expected to marry into the same caste and perhaps to follow a . the environment. India became a republic in 1950. and the urban poor—of whom there are millions—live in shacks or slums due to the lack of affordable housing. Children are brought up to obey their fathers without question. where more than 35. (2) patriarchal extended family: male head of household. The Indus had a written language and built complex cities that were home to as many as 30. education. but occupation lasted only about 150 years before the Greeks under Alexander conquered the Persians. and Sikhs was accompanied by widespread violence and death. jati. 2004. The more affluent city-dwellers live in modern houses and have servants and cars. Although caste. This is the basic family unit among immigrant Indian families. his extended family. Persian invasions occurred around 500 BC. his daughter. a major financial burden that is thought to encourage couples to abort female children. his married brothers. their merger with the earlier inhabitants created the classical Indian culture. Mass movement of Hindus.000 have died since uprisings began in 1998. The 2001 movie “Monsoon Wedding” provides insight into this aspect of Indian culture. and unmarried children. Fundamental concerns in India include the ongoing dispute with Pakistan over Kashmir.000 residents. (3) intermediate joint family: male head of household. Traditions Housing: Family: Caste System: As might be expected in such a large and diverse country. Family. and their extended families. Brief History The highly developed urbanized civilization in the Indus Valley goes back to about 3000 BC. Mothers often cater to their sons while treating their daughters more strictly. Nonviolent resistance to the British Raj under Mohandas Gandhi and Jawaharlal Nehru led to independence in 1947. his wife. where some 8. and ongoing ethnic and religious conflict.000 missing. his married sons and their wives and children. Nehru became prime minister in 1951. and were followed in the late 15th century by European traders. is becoming less important in urban areas. The bride traditionally moves to her husband’s village. his wife. India and Pakistan went to war in 1965 over Kashmir. Buddhism was founded in India by Siddhartha Gautama in the 5th century BC. the settlement in 1966 left that region divided between the two nations. The tsunami of Dec. it is still an important aspect of Indian society. Young people often leave the country to seek better employment opportunities. peas. South Indian dishes are more spicy. more food is vegetarian.11 percent. Foods and Eating Habits Dietary Practices: Everyday Diet: Popular Foods: Beverages: Food is highly respected in most South Asian cultures. cauliflower. especially for the non-Hindu and higher-caste Hindu groups. or chicken. Some 33 percent work in the manufacturing sector. dal in the western part of the country sweetened. and rice cooked with a variety of spices. where one enjoys marinated meat. Eating off another person’s plate. and foods tend to be hotter than in the north.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 147 India. although about 83 percent of them are Hindu. it is used to scoop up other foods from the plate and then eaten. and Sambar. Preparation varies. and chicken cooked in very hot earthen ovens. Dress: Employment: hereditary occupation. Throughout the country. In the east and south. Dal (lentils) is a favorite food throughout the country. Untouchability is illegal but still practiced. southern Indians drink more coffee. Hindus do not eat beef. When meat is eaten. Sandals are the preferred footwear. Many Indians are vegetarians. and southern dal cooked with vegetables. People generally eat with reverence and avoid distractions such as watching television or excessive talking while eating. and Muslims do not eat pork. Women wear saris and short blouses. religion. Food preferences vary considerably from north to south due to tradition. 58 percent of the working urban population in India is employed in the services sector—one-fourth of these are involved in retail or wholesale trade. especially those from the south. Strict Muslims do not drink alcoholic beverages. or using dishes or glasses that have been used by others are often taboo. citizens with tech support questions are served by men and women in India who are trained to speak in the appropriate American accent. Traditional dress for most Indians is simple and minimal. the highest class). Western clothing is increasingly common throughout India. The four Hindu castes are Brahmans (priests.S. cont. Dosa. but the technique for wrapping the sari varies from place to place. spinach. and climate. Kshatriyas (warriors). In the Punjab. potatoes. Many Indians prefer to eat with their fingers rather than use utensils. a combination of pajamas and a long-tailed shirt. women commonly wear the shalwar-kamiz. where a staple of the diet is chappati. Curry is said to be a British invention. More meat is eaten in the north and northwest. as cows are considered sacred. developed by returning colonialists who wanted to recreate the spicy flavors they became accustomed to in India. and the survey reports that less than a quarter of the working population is involved in agriculture. and Sudras (workers). Tea is generally the beverage of choice in the northern and eastern parts of the country. lamb. jobs to India provides employment for large numbers of educated Indians. Indians never use the left hand for eating. the diet is based on simple ingredients such as lentils. The unemployment rate in 2004–2005 was 9. unleavened wheat bread fried on a griddle like the tortilla. About 15 percent of Hindus are labeled “untouchables” (Dalit) due to their hereditary occupations such as garbage collector or handling the dead. The majority of Indians in California are Sikhs. Coconut is widely used in southern cooking. Caste is not an important factor among Indians living in the United States. who are opposed to caste distinctions. no food or drink is allowed from sunrise to sunset each day. rice is a staple. Muslims fast during Ramadan. offering somebody a bite of something one has already tasted. with favorites including Idli.S. According to a recent survey. Punjabi tandoori cooking is often available at Indian restaurants in California. . fish. it is generally goat. grains. with Western-style school uniforms seen throughout the country. Vaisyas (traders). Water and buttermilk (lasi) are believed to help the digestive process. Many U. with dal makhni in the north made with butter and cream. the region most California Indians come from. as it is reserved for personal hygiene. The outsourcing of U. Christians. the largest religion in Asia. and they believe that individuals proceed through a series of reincarnations. classes XI and XII. Karma. especially among girls. Religion Hinduism: Islam: Christianity: Sikhism: About 80 percent of Indians practice Hinduism. In addition to public schools. More than 90 percent of children are enrolled in the primary grades.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 148 Respecting Differences. Hindu-Christian tensions are common in many areas of India. with the remainder being Shi’a. About two percent of the Indian population practices Sikhism. and may be offended if offered it. just after noon. although attendance is not regular. classes IX and X. work education. make up about 2. Sikhs believe in one god and the equality of all people. Higher education is very important in India. a word that means action and is related to the Western notion of fate. Instruction is still primarily in English. Hindus have many gods and holy books. the number of universities increased more than sevenfold. Education Status: Primary Level: Upper Primary Level: Secondary Level: Higher Education: The Indian constitution calls for free and compulsory education for all children up to age 14. they wash their hands. Cows are sacred to Hindus. from which the largest number of California Indian immigrants come. a religion founded in the late 15th century. and health and physical education. who do not eat beef of any kind. mathematics. Secondary school is divided into lower secondary. Public schools are free in most states to both boys and girls at least through class IX. teacher absenteeism. art education. but the majority are under the control of individual states. is an accumulation of past actions that influence the present. environmental studies. mathematics. Before praying. classes I through V. Many important universities are controlled by the union government. Curriculum includes three languages. each one taking the person closer to or farther from enlightenment. and English). Education is a joint responsibility of the union and state governments. In India’s first 40 years as an independent nation. students attend upper primary classes VI through VIII. Celebrating Diversity: India. Prayer times are before sunrise. many of whom still abide by the caste system. They form the majority in the state of Punjab. intended to bring together the best of Hinduism and Islam. English-language) are available. are found throughout the country. which is the dominant religion of neighboring Pakistan and Bangladesh. The holy scripture is called the Guru Granth Sahib. cont. More than 100 million Indians are Muslims who practice Islam. Strict Muslims pray five times each day and are not exempted even when hospitalized. and inadequate local supervision. Following primary school. More than 90 percent of India’s Muslims are of the Sunni branch. science and technology. and feet. art education. they form the majority in three small northeastern states. Sikh places of worship are called Gurdwaras. Muslims do not eat pork. both Catholic and Protestant. and art of healthy and productive living. social sciences. A 2005 report found that only 47 percent of students enrolling in Class I reach Class VIII. late afternoon. Hindus. This was due to lack of adequate facilities. modern Indian language. science and tehcnology. but state languages are also used. and health and physical education. after susnset. with a fifteen-fold increase in the number of students. and higher secondary. The national curriculum includes the mother tongue or regional language. Children ages 6 to 11 attend primary school. social sciences.3 percent of the Indian population. face. private and religious schools (mainly Christian. and at bedtime. but they form the majority in Jammu and Kashmir. . mathematics. Muslims are spread across India. work education. Curriculum at this level includes three languages (the mother tongue or regional language. mind. Do not touch an Indian you do not know well. Yoga. stresses the unity of all religions and all humanity. and soul. It is important for Indians to have same-sex providers during medical treatments. California has its own College of Ayurveda in Grass Valley. paying particular attention to individual differences between people that call for different remedies. Ayurveda developed among the Brahmans about 4. The concept of karma may play a role in that Indians may see illness as the result of actions in a previous life. Body odors are not considered offensive. The word “aunty” or “uncle” is often used after the first name even for people who are not related. and many people are blind due to trachoma. Jainists practice strict vegetarianism and nonviolence toward all living creatures. Tips for Health Care Providers Attitudes: Family Authority: Addressing Clients: Nonverbal Exchange: Verbal Exchange: Research indicates that Indians tend to respect medical professionals.000 years ago. stick to formal language and ask how the individual would like to be addressed. Dysentery and other diseases carried by waterborne organisms are common and deadly. People older than you are never addressed by only first names. When working with Indian clients.000 sub-centers in operation. These are operated by the states and generally staffed by trained paramedical personnel. Other: Buddhism was founded in India. Primary Health Centers are the basic unit of health care in India. which may be seen as weakness. cont. B’hai. it is taught at 16 schools in India. originated in the 7th century BC. with weekly visits in some cases from a trained government physician. a system of rigorous mental and physical discipline. especially to children. Indians generally do not use first names. often with government support. When speaking with clients and family members. Yoga. as Indians expect the health-care professional to . If recommended treatment conflicts with family beliefs. Avoid unnecessary physical contact. Clients and families expect medical practitioners to be confident and not give them choices. The traditional all-purpose Indian greeting is “namaste. Unani Tibb is based on Greek medicine and includes some elements of Ayurveda. they may ignore the treatment. Tuberculosis rates are high. Ayurveda stresses establishing and maintaining a balance of life energies rather than dealing with individual symptoms.600. with an estimated 178. and posits three universal energies controlling all of life. and lack of access to pure drinking water is common. Recent figures indicate more than 7. Do not offer a variety of options. and may shower more than once a day. Malaria is still a problem. Private medical practitioners may practice traditional or Western medicine.000 physicians. Indians often prefer showers to baths. which claims about 4 million adherents in India. One of the national goals of health education has been the promotion of small families.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 149 India.” Public displays of affection are not encouraged. as he or she may take offense and be uncomfortable. B’hai has grown in recent years due to extensive evangelism. Indian Buddhists belong to both the Mahayana and Hinayana schools. Ayurveda is taught at some 100 colleges. and Unani Tibb. San Jose.000 rural health centers and 83. dates to the second century BC. Three major systems of indigenous medicine are practiced in India: Ayurveda. with classes in San Francisco. not asking many questions or disputing treatment directions. Health and Health Care Health Status: Traditional Practices: Medical System: Malnutrition is widespread. and Seal Beach for students seeking to become Clinical Ayurvedic Specialists. Jainism. The doctor-population ratio is 1:3. It focuses on the interaction between body. a religion founded in the mid-19th century. Except among their peers. be direct and concise and do not expect them to ask questions. The family’s senior male is the chief decision-maker who must be included in discussions and decisions about the care of family members. the Sikh holy book. surrounded by family members. family members should be called. homes lighted with oil lamps. and they may wish to include a spiritual leader to pray for the dying person and purify the body. Muslims bury the body as soon as possible after death. Diwali. Mahabir Jayanti: Jain festival celebrates the birth of the founder of Jainism. a patient may refuse to eat Western foods. houses are cleaned and cattle decorated. Celebrating Diversity: India. Makar Sankranti: Three-day harvest festival after winter solstice. The only proscription seems to be against eating meat that has been killed as part of a religious ritual. The body is ritually washed. Vaisakhadi Festival: Sikh celebration in Punjab. sacrifice a goat or sheep and share with the poor. Dussehra Festival: 10-day Hindu celebration of the triumph of good over evil. Muslims do not eat pork. Bakrid: Muslim festival honoring the trials of the Prophet Ibrahim. cont. and most families would not agree to an autopsy unless absolutely necessary. particularly the male head of household. When discussing the possible risks of a treatment plan. Expression of grief may be loud and sustained. Discuss a serious or terminal illness with family members before telling the patient. In the case of death in the hospital. Buddha Purnima: Celebrates birth. special cooking. They would prefer to die at home. Hindus and Sikhs cremate their dead. the holy book is read continuously and taken out in procession during celebrations. Milad-Un-Nabi: Muslim celebration of the birth of the Prophet Muhammad. celebrations in state capitals and parade with folk festival in New Delhi. provide positive reassurance. Muslims say special prayers. Some Sikhs are vegetarians. which would not present a problem in the hospital setting. Independence Day: Marks independence from Britain in 1947. In the hospital. goddess of prosperity and wealth. Celebrations and Holidays January 1 January 13 January 14/15 January 26 February March March tApril April/May May May August 15 August/September September/October October 2 October/November Oct–Nov/Dec–Jan English New Year’s Day Lohri: Celebration of fertility and the spark of life. must be consulted if a patient is to be hospitalized. celebrated nationwide with fireworks. Hindu and Sikh patients will accept narcotics for pain. focuses on a bonfire. enlightenment of the Buddha. and purchase of new clothing and jewelry. a time of great merriment and feasting when people throw out grievances and celebrate brotherhood. Muslims. decorating. businesses start new accounting year. Festival of Lights: Five-day Hindu festival of Laxmi. None of these faiths allows organ donation. Hospitalization: Death and Dying: have the correct answer. Guru Nanak in October-November and Guru Gobind Singh in December-January.D. Sikhs celebrate the birthdays of two important gurus. Some Indians may hold to the hot-cold theory which is part of Ayurvedic medicine. celebrated primarily in Punjab state. Family members. others eat meat of all kinds. but Muslims will probably refuse except for severe pain. Republic Day: Celebrates anniversary of adoption of the Indian constitution in 1950. death. feasting and dancing follow reading of the Guru Granth Sahib. . Hindus. Holi: Two-day spring festival known as the color-throwing festival. Gandhi Day: Celebrates birth of Mohandas Gandhi in 1869. Muharram: Muslim (Shi’a) festival marks the beginning of the Muslim year.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 150 Respecting Differences. Janmashtami Festival: Hindu festival celebrates Lord Krishna’s birthday. Serving meat to Indian clients is problematic. as Hindus do not eat beef. and Sikhs all believe in the immortality of the soul. 570 A. and many Indians are vegetarians. The family may not want the patient to know the serious nature of the illness. A separate handbook containing comprehensive Punjabi vocabulary for health care providers is available from the Kern Resource Center.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 151 India.S. November 14 November/December December 25 Children’s Day celebrates the birthday of Jawaharlal Nehru. The majority of Indian immigrants to California are from the state of Punjab in north India. the U. Kirpa karkay or please Thank you. A U. Because most of the Asian Indians living in California are Punjabi-speaking Sikhs from the state of Punjab. Indian culture is steeped in religion and the formal greetings reflect one’s faith. Punjabi. we will focus on Punjabi words and phrases.S. Idu’l Fitr: Muslim festival at the coming of the new moon marking the end of Ramadhan. and Bengali are some of the most common. cont. Some 71 percent held bachelor’s and master’s degrees.000 Punjabis—primarily Sikhs—in the region.000 Punjabis crossed into the United States from Canada. Between 1920 and 1930. The Immigration Act of 1987 made visas easier to obtain. Sat sri akaal.” and Hindus say “Namaste.” Muslims say “Aslam alaikam.” or “What’s up?” To say goodbye the Sikhs say “Rab rakka” and the Muslims “Khudaa haafiz. children participate in rallies and cultural programs. there were more than 6. which roughly translates as “Hello. hierarchy. Peasants’ daily income was under 10 cents per day.5 million desis in the United States the vast majority are Indians. www. a month of fasting in honor of the Koran. and that Punjabi peasants often had to mortgage their small plots of land to pay for taxes for water and land. The article notes that. by 1985 there were more than 500.618). Punjabis soon began moving to the Central Valley to work in agriculture.604).S. U. and many came to this country to advance their professional careers and to ensure better opportunities for their children. During that time they worked on highways and railways in Northern California. . Please. Revised immigration laws in 1965 opened the doors for those with education and technical training to enter the country. to be successful. 3. with the largest concentrations of Asian Indians living in Los Angeles (29.health-careers. Asian Indian population increased by 133 percent. During that same period. Gumarati. the Asian Indian population in California increased by 125. Punjabi does not have a European system of greeting. Goodbye.org. Achaa. Urdu. so the propsect of earning $2 a day in Canada or the United States encouraged many to emigrate. about 1.3 percent. Useful Words and Phrases Of the 15 official languages of India. and status that differ from the values of mainstream U.000 Indians left the United States due to lack of employment. noting that of the 2. Davis Web site notes that British rule had caused economic hardships for India.C. Between 1990 and 2000. Rab rakka.S. whose median household income is nearly 50 percent higher than the national average. which borders Kashmir and Pakistan. according to the 1990 census. Language. about 3.301). advertisers targeting the Indian immigrant market must reflect core Indian values of education. In the Sikh community it is “Sat sri akaal. citizens and to bring relatives to the country (with an annual quota of 100 people!). and Fremont (21.000 Indians to this country. Dhanvad/shukriya OK. consumers.” It is polite for each culture to address each other with that community’s chosen phrase. Between 1903 and 1908. San Jose (28. In 1946. The following words and phrases from that handbook may be helpful. A July 2005 article in Time magazine details the importance of the South Asian or “desi” market in the United States.000 South Asians in the United States. resulting in an annual migration of more than 20. Hindi. Indian immigrants to the United States have the highest level of education of any group.” The informal greetings is “Kiddha” (the respectable one being “Pranaam”). Hello. The National Origins Act of 1924 banned Asians from entering the United States. By 1910.500 remained in the United States and were given the right to become U. Christmas Asian Indians in the United States Foreign-born Indians are the third-largest immigrant group in the United States. S.” Migration Information Source.” 2005.htm (28 Feb. The Economic Times. “Chasing Desi Dollars. 2003.” http://www. http://sallys-place.” http://niam. SikhNet..com/thehindu (15 Apr.naukri.. Barry.com (5 Feb. Barbara. 2005). Show me.html (13 Apr. Dhillon. 2002. Asians in California: 1990 to 2000.” http://www. Stanford University. 2005). New Delhi Edition.com/food/ethnic_cuisine/india. “Fifty-two Percent Dropout in Schools.hoteltravel. U. 2001. References “Basic Principles of Ayurveda.nic..com/india/guides/festivals.com/india/guides/history. “India Holidays and Festivals. 2004). The Statesman’s Yearbook: the Politics. Freeman.hinduonnet. Rupinderpal Singh. Malhotra. 2004). http://www. National Council of Educational Research and Training. 2004). http://www.state. http://www. Kiviat.cia. “Punjabi Migration to United States. 2005). Stanford.ncert. 2005). Where does it hurt? Do you need help? Let me help you. http:// ccsre. “The Foreign Born from India in the United States. http://www. ed. http://www.cfm (25 Mar. The World Factbook: India. Tourism of India. http://www.” Encyclopedia Britannica.in/social/health. “India.nic. “India. 2005).migrationinformation.com/demosection/hr-zone. http:// www. 7 Apr. and Nupur Sahu. 2004. Nancy. 2004). Tuhaada naam ke ha? Tuhada swagatt hai.” http://www.” Discover India.com (13 Apr. 2004). Department of State Bureau of Democracy.buffalo.in/sites/schoolcurriculum/schoolcurriculum. Priya E. “Services Sector Top Employer of Urban Workers. Punjabi Lessons. “India History.pardesiservices. http://www. Tsunami Update: India.com/corp-web/definition.htm (13 Apr. Alejandra. 2002.html (8 May 2005).com/tsunami/india. Human Rights. 1997.com/eb/ article?eu=121166 (12 Apr. (6 Feb.gov/g/drl/rls/irf/2002/4023pf.html (5 Feb. (A22–A24) Lipson. 2004).asp (14 Apr. 2003. Dekhavo menu. cont.com/us/phrasepunjabi. http://www. Culture and Nursing Care: A Pocket Guide. Ki haal nay? Tuhaada haal theek ha? Neinu ni pata. Kang.htm (26 Mar. What is your name? You are welcome. Tuhanu meri samajh aagi? Meri smajhich nahi aanda. 2004). “International Religious Freedom Report 2002: India. Cultures and Economies of the World. Celebrating Diversity: India. 1004).edu/punjab/pacific. Encyclopaedia Britannica Premium Service.com (26 Mar. “Working with Persons with Disabilities: An Indian Perspective.indiantravelportal. 2004). Do you understand me? I don’t understand. “Holidays of India. Organisation of Curriculum at Elementary and Secondary Stages.stanford.britannica.htm (13 Apr.htm (15 Apr. 2005. Pinto.htm (13 Apr.gov/cia/publications/factbook/geos/in. http:// www.5abi. 2004).html (5 Feb. 2004). Elizabeth. http://cirrie.” http://lib. Useful Phrases. . 2004).com/independent/contrib3.” Indian Travel Portal.” Sally’s Place. www. Grieco. New York: Palgrave MacMillan. “Pioneer Asian Indian Immigration to the Pacific Coast. 2004). Lonely Planet.lonelyplanet. Jasbir Sing. San Francisco: University of California San Francisco Nursing Press. “History of Indians in US.hoteltravel. Ajay.htm (13 April 2004).○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 152 Respecting Differences. Juliene G.” http://www.itihaas. Lopez. 2005).” Center for International Rehabilitation Research Information and Exchange (CIRRIE). eds.sikhnet. 22 Feb. Turner.org (5 Feb.” 2002. The Hindu.tourismofindia.” 2005.meadev.edu/reports/report_8pdf. “Health. Ehy kithy dard karda hai? Kee thuhannu madhat chahidee hah? Menu thuhaddi madhat karn dhano. http://www. How are you? I do not know.” Time. “Indian Cuisine. and Labor.edu (5 Feb.ucdavis. http://www. et al.com/tradition/holidays.php (15 Apr. 11 July. 2005). CA: Center for Comparative Studies in Race and Ethnicity. food processing (particularly sugar refining and vegetable oil production). armaments agriculture 30%.9 %) 158. miles (slightly larger than Alaska) 68. country divided into 28 provinces. subtropical along Caspian coast periodic droughts. Turkmen 2%. Turkic and Turkic dialects 26%. earthquakes petroleum. zinc. chemical and petrochemical products. Sunni Muslim 9%. fruits and nuts. petrochemicals. caviar petroleum 80%.86% 69. textiles. copper. dairy products. nuts. Kurd 7%. floods. cement and other construction materials.613 (1. lead. Arabic 1%. Other 2% Shi’a Muslim 89%. chromium. Lur 2%. Christian.017.226 (0.23 years 0. industry 25%. Jewish. natural gas.860 23. carpets petroleum.72% wheat.8%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 636. sugar beets. Gilaki and Mazandarani 8%. Luri 2%. wool. Zoroastrian. rice. cotton. sulfur 8. dust storms. Turkish 1%. iron ore. Other 1% Persian and Persian dialects 58%. metal fabricating. Kurdish 9%. Azeri 24%. Balochi 1%. most political activities conducted by various pressure groups mostly arid or semiarid. services 45% .4% Iranian rial (IRR) Persian/Farsi 51%. Baloch 2%.96 years 40% 79. fruits. coal.300 sq. Arab 3%. sandstorms.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 153 Iran Census Figures (2000) United States Residents Born in Iran: California Residents Born in Iran: 283. other grains. manganese. and Baha’i 2% Islamic Republic of Iran since 1979: capital Tehran. implementing social. In June 2005 the conservative mayor of Tehran. When the Allies occupied western Iran in 1941. Reza Shah was forced from the throne. Celebrating Diversity: Iran. a border dispute with Iraq led to a devastating war that lasted until 1987. During World War II. only to be followed by the Seljuk Turks. Brief History Known to the rest of the world as Persia. led to a revolution in 1978. militant Iranian students took 52 Americans hostage at the American Embassy in Tehran. his son. human rights abuses. Soviet troops refused to withdraw from northwestern Iran. was elected president in 1997 and reelected in 2001.-Iran relations. was elected president. Work. but the building capacity is about 450. its ancient Greek name. Alexander was defeated by the Parthians. along with an increase in building permits and housing loans. Iran’s people comprise a mosaic of different ethnicities. Housing. Premier Mohammed Mossadeq forced the parliament to nationalize the British-owned oil industry. and Pahlavi dynasties followed. a reformist. and the central government exerted power over provinces and tribes. the Shah left the country in 1979 and died in exile. Iran’s location puts it at the center of history. An earthquake in 1987 killed more than 50.” a complex plot orchestrated by British and U. cont.000 BC. holding them for 444 days.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 154 Respecting Differences. economic. Private investment in the construction industry has been growing.000 people. runs the country according to strict Shi’ite Muslim rules. violent opposition to the Middle East peace process. a nationalist uprising against the ruling Shah brought a limited constitution. The Shah’s heavy-handed methods. 1979. Most families are patriarchal. On Feb.000 new families are formed in Iran. with the earliest settled cultures dating from around 16. Bush labled the country part of the “Axis of Evil” for its support of terrorists. the Mongols. In 1951. and France to direct a revolution that resulted in establishment of an Islamic republic. In 1980. most Iranians regard the family or other group as being more important than the individual. President George W. Family. Iraq. killing more than 30. and administrative reforms known as the Shah’s White Revolution—funded in large measure by petroleum. The Safavid dynasty (1502 to 1736) brought a renewed independence to the country. Mahmoud Ahmadinejad.. Iran served as a supply line for lend-lease supplies to the Soviet Union. with authority descending through the male line by age. religions. The domestic construction industry has been expanding to meet increased demand. intelligence agencies. Like many cultures outside the Western world. more than 1 million housing units will need to be constructed by March 2007 to alleviate the shortage.000 housing units in urban areas were privately financed. who were followed by the Sassanians. In 1905.S. however. when he was defeated by the Greeks under Alexander the Great.000 Iranians. ruled as Shah until 1979. 1979. making generalizations about family structure and customs difficult. Islamic Arab forces conquered the country. 4. until 1935. backing revolts that established brief separatist regimes in Azerbaijan and Kurdistan. his commitment to nuclear energy seems likely to worsen U. A fairly sophisticated agricultural society with large population centers existed in the 6th century BC. and alleged efforts to develop nuclear weapons. In the 7th century AD. Mohammad Khatami-Ardakani. . On Nov. and Tamerlane. and social classes.000 units. 1. Under his rule the country began to modernize. Ayatollah Ali Khamenei returned from 15 years of exile in Turkey. Mohammed Reza Pahlavi. 98. According to the country’s Minister of Housing and Urban Development.S. Qajar. the Zand. In December 2003 a major earthquake devastated the city of Bam in southeastern Iran. Khamenei. Reza Kahn seized control of the government in 1921 and named himself Reza Shah Pahlavi in 1925. Relations between the United States and Iran are extremely tense. including systematic torture and other human rights violations. politics became somewhat secularized. The country we now know as Iran was invaded and ruled by a bewildering number of outside groups while developing a unique identity. he was removed from power during “Operation Ajax. Each year some 800. housing is at a premium in Iraq. Oil was discovered in 1908. In 2002. Cyrus the Great ruled an empire stretching from northwestern India to Greece from 559 to 330 BC. The Shah became increasingly dictatorial. He was conquered by Nadir Shah. Traditions Housing: Family: As might be expected in a country where the population has doubled in 25 years. Most new urban housing units are constructed of concrete. the spiritual leader and highest authority of the Islamic Republic of Iran. Following the war. most especially under Shah (king) Abbas. Before the revolution. upper-class women living in cities were beginning to enter the workforce. The rate among women is twice that of men. Warm tea sweetened with hard candy may be used. although traditional robes and turbans are still worn in parts of the country. Snacks include tea. a long black dress. and feta cheese. control virtually every aspect of life. but other clothing is permitted if it fits loosely and only the hands and face are visible. Large families with many sons are preferred. when large families were encouraged. Social gatherings are often segregated by gender. Lamb and chicken are the most popular meats. Clergymen. camel. Men usually wear Western-style clothing. but some women now wear scarves. which has the largest “brain drain” of any nation. Iranians dress conservatively in public. A marriage custom unique to Shi’a Islam is the temporary marriage or sigheh. The official unemployment rate is 13 percent. bread (nan). such as carpets. Iranians may wear loose fitting pajama-type garments. Divorce is rare in Iranian culture. butter. and feta cheese are commonly part of the diet. Many Iranians hold the hot-cold theory of foods and strive for a balance between the two to maintain health. and pistachios. turmeric. Popular spices include dried limes. but polygamy is rare and must also be approved by the government. Young people often marry before the age of 20. Lunch would include plain rice (chelo) or rice mixed with fruits. and tribal groups. village. beef is considered inferior. Foods and Eating Habits Dietary Practices: Everyday Diet: Strict Muslims do not eat pork or consume alcohol. Food combinations play an important role in Iranian life. pomegranate juice. The midday meal is largest. and saffron. Fruit is a popular dessert. . Many jobs are not open to women now. Iranians use a spoon rather than a fork to eat rice. Tea is served after every meal. Traditions: Employment: Children are brought up to be disciplined and to respect their elders. Breakfast might include eggs. goat. vegetables. or meat (polo). mullahs. While many of the jobless are unskilled and uneducated. often rising to positions of leadership. In general. Supper is a large meal in the north. and segregation by gender is an important part of the new order. Meat is often served skewered and grilled (kabab) or chopped into a stew (khoresh). although privatization began in 1991. Merchants and professionals who sided with the Shah lost influence after Khomeini came to power. and buffalo may be part of the diet. Iran is divided into urban. resulting in a doubling of the country’s population in 25 years. Fresh ingredients are preferred. many professionals with college degrees are also out of work. and half of university graduates cannot find work in their own country. while men are protectors and control the outside world. The black head cover or maghan-ea is still widely worn. provided they can support them and the existing wife/wives approve of additional wives. three meals a day are common except during Ramadan. but analysts believe more than 20 percent of Iranians are unemployed. This may extend to alcohol in medications. Wool and wool byproducts. At home. are important exports. many wear the chador. sumac. Shi’ite Muslims are permitted to have as many as four wives. many have left the country. Children of this kind of marriage are legitimate but have fewer rights and privileges than other children. Mothers and other female family members are caregivers.5 million working-age Iranians. honey.000 physicians are among the unemployed. About 10. In rural areas. Official estimates put the unemployed at 3. Most industry is still state-controlled. Iranians generally like to eat with the family. Islamic dress. fruits. The 1979 Islamic revolution brought many changes to Iran. cinnamon. unmarried children live with their parents. market-town. Women over age nine must be covered from head to foot in hejab. pastries. Unemployment is a serious problem and is partly the result of population growth as well as a shortage of raw materials and the debilitating war with Iraq. They avoid cold water during illness. About a third of the people work in agriculture. eggs. mostly on small farms. The crisis dates back to the 1980s. Dairy products including yogurt. but elsewhere it is light and eaten late in the evening. cont. milk.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 155 Iran. those who pass receive the National High School Diploma. and walnuts. dictation. Tea (chai). Most institutions of higher education are run by the government. Persian reading and comprehension. This one-year phase includes 24 semester credits and prepares students to take the university entrance exam. cont. a stew made with poultry. mathematics. khoresh bademijan is stew with eggplant. Teachers discourage discussion and questions. grape leaves stuffed with a variety of meats. usually served sweetend after every meal. social studies. successful students receive the Certificate of Completion.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 156 Respecting Differences. schools have compulsory daily religious instruction. vegetables. This level covers grades 9 through 11. with students ages 14 to 17. About 80 percent of subjects are required. Although five years of primary education are compulsory. If a student’s grade is high enough. arts. The lower secondary level is called the Guidance Cycle and covers grades 6 through 8. Persian composition. Parents pay fees for textbooks and school heating and maintenance. or a four-year technical program designed to train lower-grade technicians and leading to a Second Class Technician’s Certificate. Religion Status: The nation of Iran is a constitutional theocracy whose official religion is Ja’fari Shi’ism. The general academic curriculum includes: the Qur’an. natural sciences. Schools are segregated by gender. Jews. students pursue either an academic or a vocational/technical path. The general or academic track has two stages: the first two years cover general curriculum. Education Status: Primary Level: Lower Secondary: Upper Secondary: Pre-University: Higher Education: The government provides free and compulsory education for children ages 6 through 10. following the Islamic revolution. University education is free to students who have a Certificate of Completion and pass the entrance exams. Students are assigned large amounts of memorization and homework from an early age. Yogurt-based drinks such as sharbat and dug are also popular. and Christians are the only recognized religious minorities allowed to practice their . and physical education. children in rural areas may not have access to schools. Curriculum includes both theoretical and applied knowledge. as is khoresh fesenjan. and Iranians enjoy dolmeh. and the final year allows students to specialize in one of four areas: literature and arts. meat with plain rice. physics and mathematics. Depending on aptitude shown on the exam at the end of grade 8. Applicants also must pass a test in Islamic theology. and several teacher-training colleges. Passing an examination at the end of grade five indicates completion of primary education. Grilled ground meat is called kabab kubideh. or social sciences and economics. pomegranate juice. The government provides course books for each subject to be used nationwide. Koreshe mast is stew with yogurt. Students take a national exam following this three-year cycle. ages 11 through 13. he/she can continue on to the academic or technical/vocational track in upper secondary education. There are 46 universities. Those who fail twice cannot pursue further academic education. Popular Foods: Beverages: Chelo kabab. and urban schools are often overcrowded and operate with two half-day shifts. Celebrating Diversity: Iran. is the national beverage. 200 colleges and professional schools. enrollment is about 60 percent of eligible children. religious teaching. The constitution provides that other denominations of Islam be accorded full respect and that Zoroastrians. There are examinations at the end of each year to determine promotion to the next grade. Secondary school is not compulsory. Students who pass a regional exam at the end of grade 8 receive a Certificate of General Education. and rice. The technical-vocational track is either a two-year vocational or agricultural program leading to a Trade Certificate. is a popular dish. 60 post-secondary technical institutions. Baluchs. Islam: Zoroastrianism: Christianity: Judaism: Baha’i: religion within the limits of the law. the protection of Islamic beliefs. Protestant denominations are also present. The Baha’i religion. About 89 percent are Shi’a and the remainder Sunni. the state religion. particularly in the areas of employment. Most Christians in Iran are ethnic Armenians affiliated with the Armenian Orthodox Church. A news story on April 14. and northwest sections of the country.000 ethnic Persians primarily in the cities of Tehran. and many have been imprisoned. which derived originally from Islam. even executed. Their faith has been declared heretical. This was the state religion of Iran prior to the founding of Islam in the 7th century. Sufi are considered Muslim for government purposes.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 157 Iran. as this would pollute the earth. All Baha’i administrative structures have been banned by the government. Abortion is currently legal only if the woman’s life is in jeopardy. The government is fiercely opposed to Israel. Adherents to the Baha’i faith number about 300. Iranians will generally seek herbal or humoral cures before visiting a physician for Western medical treatment. and even to make house calls. giving alms to the poor. as direct successors of Mohammed. and do not cremate them for fear of polluting the air. play a major role in Iranian life.000 physicians. was founded in Persia about 980 AD. called mullahs. which means that physicians can take the time to establish personal relationships with patients. Shi’ite clergy. In this system. with perhaps 30. and the requirement to do good works and avoid all evil. but the activities of non-Shi’ite schools and other organizations are closely monitored. The government supports anti-Jewish and antiBaha’i sentiment. For this reason they traditionally do not bury their dead. observing the fast of Ramadan. also practiced widely in India and other Asian and Middle Eastern countries. the basic cause of disease is an imbalance in the body’s four humors: blood. “All religious minorities suffer varying degrees of officially sanctioned discrimination. holy leaders.000 throughout the country.000 Christians in Iran. cont. Iran has a surplus of some 10. at least 80. but Sufis have some different practices and secret organizations that set them apart and have led to harassment. deprived of jobs and pensions. 2005 reported a decision by parliament to allow abortions in the first four months if the fetus is mentally or physically handicapped. and making the pilgrimage or hajj to Mecca at least once during a lifetime. is regarded as a political movement loyal to the former Shah.000 illegal and unsafe abortions are performed in Iran each year. Individuals are not required to register with the Ministry of Islamic Culture and Guidance.000 adherents in Iran. a drop from some 80. Sufi sects like Ahl-Haqq and Naqshbandi are popular. education. and Yazd. Shi’ite has two additional pillars: jihad. explain diagnosis and treatment procedures. Shi’ite Muslims practice the five pillars of Islam: professing faith in Allah as the one God and Mohammed as his prophet.” Nearly all Iranians practice Islam. These are the only individuals allowed to interpret the Qur’an (Koran). Health and Health Care Health Status: Traditional Practices: Major causes of illness include parasitic and gastrointestinal diseases caused by lack of clean water and improper sewage disposal. they are leaving the country in large numbers. Kerman. and is still practiced by as many as 60. and Kurds who live in the southwest. one of the three major traditional healing systems. the latter are primarily Turkomen. Zoroastrians believe that all elements are sacred and pure. Unani-Tibb Medicine. Arabs. The United Nations Special Representative in 2001 reported some 300. Iranian Shi’ites recognize 12 imams. they leave the dead on towers of silence to be eaten by vultures. . Non-Muslim owners of grocery shops must post their religious affiliation on the fronts of their stores. praying daily. Judaism is officially recognized. and holy places have been confiscated or destroyed. southeast. According to the International Religious Freedom Report of 2002. and housing.000 prior to the revolution. Some patients may prefer warm compresses to pain medication. and attars. pharmacies. sweet. Silence may have many meanings. and manage public health services. families often prefer to have members with chronic conditions die at home with family care. health posts. Sick Muslims are exempted from the Ramadan fast. as they are very modest and like privacy. Family Authority: The father. facing Mecca. non-Muslim Iranians may also avoid pork. baths. reaching a DNR decision is not difficult as death is seen as a beginning rather than an end. Tastes and aromas—salty.716 beds. fasting. support health delivery facilities.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 158 Respecting Differences. Hospitalization: Iranians are generally more comfortable with care providers of the same gender. Family and friends are an important part of the healing process and should be allowed to stay with the patient if the patient wishes. 4. The family spokesperson may need to assist care providers in controlling noise and number of visitors. Hospital staff should be alert to the possible desire of Muslim patients to observe this ritual. Organ donation and autopsy are generally accepted if explained fully to the family spokesperson. herbs. sour—also play a role. eldest daughter. and at bedtime. bitter. The choice of foods and their manner of preparation is key to maintaining or improving health. Foods may be refused based on the humoral theory. Primary treatment modalities are diet. Before praying. face. About 40 percent of health personnel are women. Tips for Health Care Providers Information on working with Mulsim patients can be found on pages 22 and 23. there were 713 hospitals in Iran with 105. They respect education and authority and so will probably respect the health care provider. Death and Dying: Give a diagnosis of terminal illness to the family spokesperson. . The Ministry of Health and Medical Education is in charge of setting national health policy and supervising activities at the lower levels. and district hospitals. immediately after sunset.000 rural and urban health centers. cupping. In addition. purgation. pungent. the Universities of Medical Sciences and Health Services supervise district activities. Attitudes: Iranians tend to be sensitive and modest in dress and in sharing personal information. and black bile. At the district level. which reveals humoral imbalance in the organ system. or eldest male family member may serve as the family spokesperson and should be included in medical discussion and decisions. The public health system includes several levels.000 health houses. Standing when someone enters the room is a sign of respect. Muslims do not eat pork or drink alcohol. In deciding what information to share. the concept of shame (haya) is a guideline. When a patient has an acute illness. they wash their hands. The foundation diagnosis is the pulse. At the provincial level. Religious Practices: Strict Muslims pray five times each day: just before sunrise. In 2000. Nonverbal Exchange: Eye contact is accepted between equals and those who know one another well. Each ingredient affects the heat or cold balance of the system and may influence the humoral system. Verbal Exchange: Iranians generally speak politely to care providers or strangers but may be loud and emotional with family members and friends. Iranians generally get closer to one another than is common among North Americans and Northern Europeans. late afternoon. yellow bile. eldest son. Medical System: phlegm. at least when first introduced. district health centers. care is provided through some 15. hospital care is preferred. Rural midwives are an important part of the government health system. For most Iranians. Health care is provided by government and the private sector. just after noon. Addressing Clients: Use the client’s last name. In addition. Family and friends often pray or cry softly by the bedside of a dying person. All citizens are entitled to health care. and medical education. cont. health care providers may find the following information helpful when working with clients from Iran. and feet. Handshaking and slight bowing are appropriate. Celebrating Diversity: Iran. month of fasting and prayer: Muslims eat a meal before sunrise. Census estimates the number of Iranian Americans at about 330.000 and 600.469 percent of the population.net.S. More Iranians live in California than in the next 20 states combined.000 Iranians were living in the United States. locally produced Iranian radio and television programs. D. many had come to this country for educational and economic opportunities. Large numbers of immigrants left at the time of the Islamic Revolution in 1979 and the Iran-Iraq War of 1980–1988. their median family income is 38 percent above the national average.000 Iranians in the United States. October 24 Martyrdom of Imam Ali October 28 Quds Day November 3 Eid al Fitr: Feast marking the end of Ramadan.500 Iranians came to the United States seeking assylum from the Islamic Republic of Iran. According to the United Nations High Commission on Refugees. the third Shi’ite imam April 1 Islamic Republic Day April 7 Death of the Prophet/Martyrdom of Imam Hassan April 8 Martyrdom of Imam Reza April 26 Birthday of The Prophet and Imam Sadeq June 4 Death of Imam Khomeini June 5 Anniversary of Overthrow of the Shah July 9 Martyrdom of Fatima August 20 Farsi New Year September 1 The Prophet’s Ascension October 4 Beginning of Ramadan. .S. then break the fast with an evening meal. thanks to the Q++ Studio Diary Publishing System. they represent the full gamut of religious groups found in Iran.000. According to a report prepared in 2003 by the National Iranian American Council. many Iranian restaurants and businesses. the Iranian Interest Section in Washington. special table settings using seven articles beginning with the Farsi letter “s. centered in an area named Little Teheran that stretches from Westwood Blvd.) January 21 Eid al Adha: Feast of Sacrifice February 10 Islamic New Year February 11 Victory of the Islamic Revolution March 20 Day of Oil Industry Nationalization March 21–25 Naw Roz. and bonfires. November 28 Martyrdom of Imam Jafar Sadeq Iranians in the United States Before 1978 about 40.qppstudio. Muslims attend special religious services. cont. average. in each of the years 1987. 200. and 1990.000 Iranian Americans. Most of them are from the educated and wealthier segments of the Iranian population. California is home to some 159.” staying out of the house on the thirteenth day. according to official statistics. Los Angeles has 10 Iranian newspapers. they have six times as many doctoral degrees as their American counterparts. Applications have declined since then but still number several hundred annually. fast until sunset. Iranian Yellow Pages. reports holding passport information for some 900.C. Census 2000 showed that the per capita income of Iranian Americans is 45 percent higher than the U.000. Unofficial estimates put the Iranian American population of Southern California at between 300. Iranian New Year: Celebrations last for 13 days. 1988. March 30 Ashura: Day of the martyrdom of Hossein. representing . http://www. By 1986.000 Iranians were living in the United States. Celebrations and Holidays (Note: Dates are for the year 2005. to south of Santa Monica Blvd.. on average. more than 1. Iranians are concentrated in the Los Angeles-Beverly Hills area. and the largest Persian bookstore outside Iran.. Iranian immigrants are well educated. traditions include spring cleaning. visit family and friends.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 159 Iran. exchange gifts. while the U. but many Iranians do not speak it. Culture and Controversy in Urban Development.iran-daily.htm (6 Apr. Lotfan. 2005). Farsi is an Indo-European language loosely related to English but using Arabic script.com/1383/2141/html/focus. http://www. Golnaz. . 2005). CountryReports. “Iran—In Their Language. “Construction Sector Makes Recovery. http://www. 2003. Farsi includes many words from the Arabic language. Salam.” http://www. Celebrating Diversity: Iran.unani. http:// www.org/customs. Rozbakhair. and other Muslim men.asp? countryid=116&countryName=Iran (5 Apri. Welcome.arizonapersian. Good evening. Shabakhair. Please. Nima. 2005). Good afternoon.” http://www. Most were eventually released. 2001.’” Radio Free Europe. http://www. How are you? Hale shoma chutor ast? Fine. or may speak it as a second language.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 160 Respecting Differences. French. You are welcome. Khushamadatke.countryreports. immigration officials detained hundreds of Iranians.org/profile. Khub. Khahesh mikonam. Language. Ardibili. spoken by 1 percent of Iranians. Thank you.lmu.com (8 Apr.countryreports. Arabic script is read from right to left. and Luri (2%). Goodbye. “Iranians in Westwood. Other languages and dialects include Turkic (spoken by 26%). Good night. 2005). Educated city dwellers may understand English. introduced when the Arabs invaded Iran in the 8th century. ———. Tashaker/Motsha keram/Kelimamnun.edu/csla/community/students-projects/ westwood/ (8 Apr. cont. References American Institute of Unani Medicine. provides many useful links to resources on Iran. http://www. including a number of sites on the Farsi language. 2005). “Iran—Culture and Customs. The following words and phrases may be helpful to the health care professional seeking to establish rapport with a client who speaks Farsi. 2005).html (6 Apr. not a difficult thing to understand.arizonapersian.parstimes. ———. Comparison of Healing Systems.org/greetings. Following the terrorist attacks of Sept. and/or German. 11. Hello.” Loyola Marymount University: The Center for the Study of Los Angeles.” http://www. Rozbakhair. 17 Nov. Useful Words and Phrases Farsi or Persian is the official language of Iran. “Iran—General Overview. some Iranians suffered persecution because of their Middle Eastern ethnicity.asp? countryid=116&countryName=Iran (5 Apri. including Iranian Jews..htm (7 Apr. Esfandiari. “Iran: Unemployment Becoming a ‘National Threat.com/news/archive/2004/rfe/unemployment_threat. Shabakhair. 2004. Iran Daily. The Arizona Persian Web Directory. who reported for a mandatory registration. 2005). 2005).asp? countryid=116&countryName=Iran (5 Apri.com/comparison. http://www.com. Kurdish (9%). 1 May.” 2004. Arizona Persian Web Directory. At the end of 2002.countryreports. Many Iranians responded to the post-9/11 climate by keeping a low profile and not being active in political affairs. Yes/No Bale/Na Good morning. used for all school instruction. Khuda hafez. http://en. “History of Iran. ed. 2005).org/visavis/BTVPages/Iranians_in_US.” Wikipedia. “Iranians in the U.org/wiki/Religious_minorities_in_Iran (5 Apr.org/wiki/Iran (5 Apr.” Medical Women’s International Association. 2005).org/ issues_05_printer_041505WC. 2002.internews. cont. 3. and Labor. “Strengthening Reproductive Health and Safe Motherhood Programs in Iran.” 2005. L.org/DataTools/asylumresults. “Education in Post-Revolutionary Iran. http://en.htm (7 Apr. Masoumeh E. .shtml (7 Apr. Lipson.S.B.org.settlement. 2005). http://qppstudio. Fata. “International Religious Freedom Report 2002: Iran. http://www.org/cp/english/iran. the Iranian Expatriate Capital Abroad.com/Unani. Human Rights. Barry. Sanger. PBS Online: Beyond the Veil—Iranians in the U.” Wikipedia. No. http://www. eds. Public Holidays and Bank Holidays for Iran. http://mwia. 14 Apr. 2005). Khorrami. and Swarnalatha Vernuri. Anti-Racism.regional.” New York Times. 13.shtml (16 Apr. Sedgwick.S.pdf (8 Apr. Vol. 2003.html (8 May 2005).wikipedia.S. U. National Iranian American Council. Grotte. http://www. Juliene G. ed. 2005). http://rawstory. http://www. Culture and Nursing Care: A Pocket Guide. Orr. Iran.state. 2004. 2000. David E. http://www.thruthout. 2005). May/June. The Statesman’s Yearbook: the Politics.gov/cia/publications/factbook/geos/ir. 2004). “Religious Minorities in Iran.” Raw Story.wikipedia. September. Unani Medicine.cia. New York: Palgrave MacMillan.gov/g/drl/rls/irf/2002/13995pf. Williams.wes.nytimes. Feminist Daily News.au/papers/papers/05_tavani2.htm (28 Feb. 2005). 2003. 2005).com (26 Jun.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 161 Iran. et al. “Victory by Hard-Liner Could Widen Rift with U. Department of State Bureau of Democracy. 26 Jun.A. 1997. “Tehrangeles: L.drgrotte. Canada. Heather C.” Islamic Revolution. http://www. University of Toronto.org/ewenr/00may/poractical. Number of Asylum Applicants from Iran. Migration Information Source.niacouncil. Islamic Republic of in the United States.com/exclusives/ orr/tehrangles_iran_capital_expatriates_812. San Francisco: University of California San Francisco Nursing Press. Multiculturalism and Native Issues Centre. Tavani.htm (7 Apr. Turner. Soraya. Q++ Studio. Faculty of Social Work. http://www.S. Cultures and Economies of the World. 2005). Emma. 2005). Mohammad M.. and Raha Rafii. Strength in Numbers: The Relative Concentration of Iranian Americans Across the United States.cfm (8 April 2005).” World Education News and Reviews. 2002. http:// www..html (8 Apr.htm (7 Apr.migrationinformation. 2005). 2005. Robert. 2005).net/worldholidays/iran. The World Factbook: Iran. http://www.org/files/irancensus.htm (8 Apr. “Iran’s Parliament Votes to Liberalize Abortion Laws. 1980 to 2002. http://ww.html (5 Apr. Celebrating Diversity: .○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 162 Respecting Differences. which has status of a province hot. Yezidi (Zoroastrian/animist) 2% Republic of Armenia: country divided into 10 provinces plus the capital. livestock diamonds. droughts copper. copper ore chemicals. petroleum 17. miles (slightly smaller than Maryland) 2. Other Christian 4%. dairy.982. processed food. industry 25%. gold. equipment. Other 2% Armenian Apostolic 94%. synthetic rubber. services 30% . hydroelectric power.482 (0.904 30.07 years -0. Other (mostly Yezidi Kurds) 4% (2002) Armenian 96%. gas.55 years 50% 98. Yerevan. cold. scrap metal. brandy.500 sq. wines. Russian 2%. snowy winters earthquakes.6% dram (AMD) Armenian 93%. zinc.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 163 Armenia Census Figures (2000) United States Residents Born in Armenia: California Residents Born in Armenia: 65.55% fruits. vegetables. machinery. dry summers.25% 71. Azeri 1%.2%) 57.280 (0. machinery.6%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 11. Russian 2%. lead. textiles agriculture 45%. electronic products. Celebrating Diversity: Armenia. when it was annexed by the Soviet Army. During World War I. In that same year. the Ottoman Turks controlled major parts of Armenia. This situation led to a blockade of Armenia by Turkey and Azerbaijan. the history of Armenia has been one of invasion and conquest. and their empire reached its height under Tigrane the Great. Overall. When Turkey was defeated at the end of the war. in 1915. The US Agency for International Development and NGOs including Habitat for Humanity are working to provide adequate housing. Armenia became a constituent republic of the U. brought to Armenia as part of the earthquake relief effort. which continues even though a cease-fire was reached in 1994. Conquering armies include the Greeks. Persians. which Turkey and Turkish sympathizers deny to this day. Armenians call their country Hayastan and refer to themselves as Hai.5 million were murdered or died of starvation in the first genocide of the 20th century. Ottoman Turks. international organizations .S.000 people and leaving more than half a million homeless. In 1936. identified by biblical tradition as the mountain on which Noah’s Ark came to rest. Romans. the independent Republic of Armenia was established on May 28. is visible from the capital city of Yerevan but now officially in Turkish territory and off limits to Armenians. thousands of families still live in metal shipping containers called domiks. sustaining a family is very difficult. An earthquake measuring 6. On the Armenian plateau the domestication of wheat began about 15. Of the estimated 10.R. spear heads and tools. killing some 25. 1991. men are unemployed and depressed or have left the country for employment. Armenia is noted for being the first nation to adopt Christianity as a state religion. which declared its independence from the collapsing Soviet Union on Sept. The devastation of the 1988 earthquake coupled with turmoil following independence from the Soviet Union and economic blockades by Turkey and Azerbaijan have made daily life problematic for many Armenians. The empire stretched from the Caspian to the Mediterranean seas.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 164 Respecting Differences.000 children in Armenian orphanages.9 on the Richter scale struck Armenia on Dec. when St. USAID has provided new homes for 3. 1918. Many people are reluctant to marry. cont. Arabs. 1988. Housing. indicating mankind moved from a hunter-gatherer society to a collective unit much earlier than previously thought. Traces of stored grain were discovered at the site. 16 years after the 1988 earthquake. Armenia became involved in disputes with neighboring Azerbaijan over the region of Nagorno-Karabakh. are thought to be one to two million years old. From the 16th century through World War I. Armenians are spread throughout the world—some 60 percent of the estimated 8 million Armenians worldwide live outside the country.S.000 years ago. According to the United Methodist Committee on Relief. in 301 AD. Work. who ruled from 95 to 55 BC. 90. where as many as 1. Most Californians can make the acquaintance of Armenians whose relatives died during the genocide. Byzantines. 7. and scarce family resources have led to many parents giving their children up to orphanages where they will have adequate food and clothing and receive an education. These two catastrophic situations have had far-reaching economic consequences for Armenia. Traditions Housing: Family: In the earthquake zone. Through its housing purchase certificate program. It survived only until November 29. Ararat. Mt. Family.000 families. Armenia. Brief History Homo sapiens skeletal remains discovered near present-day Bjini. the Ottoman Turks massacred thousands of Armenians between 1894 and 1896. and Russians. which has been working since 1995 with the United Nations and other agencies on development programs. Generalizations about family structure in present-day Armenia are difficult to make. The most brutal of all invaders. the Turks ordered the deportation of the Armenians to the deserts of Syria and Mesopotamia. 23. Other prehistoric sites include a ca. 1920. Gregory the Illuminator baptized King Tiridates III. Habitat is assisting families to complete houses they had started to construct as well as purchasing apartments and reselling them interest-free to families who renovate them.000 BC settlement in Yerevan. Mongols. the first signs of the use of obsidian to make knives. Armenians settled in the kingdom of Ararat in the 6th century BC. whereas for men this index was 75. educating and caring for the children. is a heavy meal generally served between 5 and 7 p. Men take out the majority of bank loans. Fruit and dessert complete the meal along with Armenian coffee. Women bear the burden of the so-called informal sector of the economy. a cousin of William Saroyan. spiced meat and rice wrapped in grape leaves or .” In 1993 women accounted for 49 percent of Armenia’s labor force. is generally a light meal. yogurt. nakhajash. and eggs. Spitak. journalistic. The way of life. which includes assuring the functioning of the family. fish. as a city. The Armenian woman traditionally had an accessory role in the family and in society. The first course would be soup.). or the U. and read his monthly Yerevan Journal at http://road-to-armenia. is still recovering from the effects of the 1988 earthquake. whereas the same index among men was 36 percent. Women’s employment in the newly formed private sector was not high. Foods and Eating Habits Dietary Practices: Everyday Diet: Popular Foods: No dietary taboos. and common mentality have presumed her subordination to her husband. Mostly their activity is in unregistered self-employment (cooking for sale. the capital city. . Although the Constitution provides equal rights for women. jash. abortion has been widespread. cont. more Armenian women are attaining active economic positions in contrast to men. Although the economic situation here is showing some movement.. A full course restaurant meal would begin with appetizers or salads featuring greens. and maintaining the household.m. and sunk. Women have started to make serious contributions to family budgets. For interesting observations on daily life in various parts of Armenia. working as housekeepers.S. . with the bulk of the population out of work and many of the youth having left the country to find employment and a future they don’t see in Spitak. sliced sausage. Lunch. and jam. and bread. The Web site Tour Armenia lists a huge variety of popular Armenian foods: htttp:// www. judicial. In the October 2004 entry he writes: “Far from the bustle of Yerevan. who are confused with loss of their jobs in the state sector because of low wages. efforts are being made to help street children and provide employability skills to young people. Russia.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 165 Armenia. visit the Web site of Californian Andranik Michaelian. Their social and political activity has also increased. bean and vegetable salads.asp.com. etc. Appetizers include lobiov pashtet. thus increasing the amount of money transferred to their relatives in the homeland. Women often remain economically dependent upon men.000 working women were involved in registered small businesses. basturma and sujukh (dried spicy beef ). and other professions. The overwhelming majority of NGO members are women. many now firmly establishing themselves in Europe. and the main course is a meat or fish dish or perhaps both. cheese. available in several consistencies. only 45 out of every 1. engaging in trade outside of Armenia. but might include cold meats. as in most countries women in Armenia remain subordinate to men in many areas. pickled vegetables. unemployment among women reached 64 percent that year. In Yerevan. The overall average salary for women is less than two-thirds that of men because of the low involvement of women in high-paid activity. Breakfast for an Armenian would consist of coffee. a paté of red beans and walnuts. Daily Life: Employment: estimate that 90 percent of them have families who are unable to care for them. People in rural areas enjoy matsun. In 1995 women accounted for 85 percent of schoolteachers and high percentages in medical. social norms. .tacentral. mushrooms that have been pickled and mixed into a spicy paté. Many Californians are familiar with Armenian foods including dolma.com/dining. Since the breakup of the Soviet Union. However. it is known that the lives of many here are made easier due to the money being sent by relatives. sometimes becoming the sole bread providers. Social mobility for women is lower than it is for men. popular rites. Dinner. bread. Greek Orthodox. In 2002. Iranians. Baha’i. Information is somewhat contradictory. Judaism. Non-state institutions are also available. the Mother See.000 Muslims in Yerevan.000 adherents. which is intended to develop communication skills in Armenian and lay the groundwork for learning other languages. Literacy is close to 100 percent. and the conflict with neighboring Azerbaijan. fresh fruits. The state provides day care institutions for children ages 2 to 3 and kindergartens for children ages 3 to 6. Desserts are very popular and include the familiar baklava. This includes grades 4 through 9. including Kurds. and a comparatively large group of practitioners of Yezidi. and rice pudding as well as cakes. Islam. but the most current shows a total of 1.390 state-owned general secondary schools. . One basis for objection has been the sect’s proscription against military service. and other Christian churches in Armenia. A famous Armenian ham-based soup. Armenians eat a a great deal of bread. After many years of being denied recognition as a religion. a Kurdish religion that includes elements of Zoroastrianism. Since achieving independence in 1991. 83 percent of the teachers are women. as well as to lay the foundation for learning in primary school. is cooked all night and served in the morning with quantities of fresh garlic and lavash. is the cathedral and monastery at Echmiadzin. Armenia was home to the first universities in Asia Minor during the Middle Ages. The law requires children to attend school from ages 6 to 17. including California. and ice cream. and the most popular is khorovatz. and pilaf. cabbage. Armenia experienced universal enrollment in basic education from ages 7 to 15. Other religions include Mormonism. Main dishes feature chicken. including the lavash familiar to most Californians. Pentecostal. Hare Krishna. State-run schools at all levels are facing problems of inadequate funding that has caused deteriorating services. khash. Adherents recently celebrated the 1. Leading institutions include Yerevan State University and the Armenian Academy of Agriculture. marinated grilled meat. Grades 10 and 11. and temporary residents of various Middle Eastern countries. Education Status: Preschool: Primary School: Basic/Middle School: High School: Higher Education: When it was part of the Soviet Union. there were about 1. and animism and claims about 40. and pork. His Holiness Karekin II was elected Supreme Patriarch and Catholicos of All Armenians in 1999. The presence of Jehovah’s Witnesses in Armenia has caused considerable strife. As such. Active participation in the church is growing since the breakup of the Soviet Union. Religion Armenian Apostolic: Other Christian: Muslim: Other: The Armenian Apostolic Church is the national church of Armenia and claims about 90 percent of the population as members. Celebrating Diversity: Armenia. The center of the religion. Armenia has faced both political and economic challenges to developing a national school system. Grades 1 through 3 form the first level of what is called the general secondary education. which destroyed much of the nation’s infrastructure. Financial difficulties have been compounded by the 1988 earthquake. Gregory the Illuminator.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 166 Respecting Differences. Children ages 3 through 6 attend preschool. 12 miles west of the capital city of Yerevan. small communities remain. cont. While most Muslims have left Armenia or been deported to Azerbaijan. Baptist. Seventh Day Adventist. There are both Roman and Armenian Catholics. Graduates of basic and high schools can continue their education in two-year vocational schools or universities. he visits Armenian Apostolic churches throughout the world. Armenian Evangelical. halvah.700th anniversary of the conversion of Armenia to Christianity with bishops from all over the world gathering at the new Cathedral of St. beef. they received it in 2004. raisins. Celebrations and Holidays January 1 January 6 January/February February 14 March 8 March/April April 7 April 24 May May 9 May 28 June/July July 5 September September 21 October 12 December 7 New Year (Amanor): Celebrated for an entire week with special foods and gifts. The Transfiguration (Vardavar). no information could be found on things for health care providers to keep in mind when working with Armenian clients. Christmas (Surb Tsnund) Saint Sargis: Festival 63 days before Easter. Independence Day: Celebrates restoration of Republic of Armenia after 70 years as part of USSR. and Lebanon. Health and Health Care Status: The Library of Congress country study for Armenia states: “The social and economic upheavals that followed the earthquake of 1988 combined with the political collapse of the Soviet Union to create a catastrophic public health situation in Armenia. newspapers. honors popular saint who brings luck. Holy Cross (Khachverats): Celebrates the cross and is a memorial to the dead. and San Francisco. A three-year pilot program by the American International Health Alliance in two hospitals in Yerevan focuses on nursing care standards and has resulted in improvements in quality of care. most in Fresno. Purification Day (Trndez) Women’s Day Palm Sunday (Tsaghkazard). There is virtually no up-to-date information available about the health system or use of traditional medicines in Armenia. many of the same crops Armenians grew in their native land thrive here. Armenians first came to Fresno in the 1870s. remember the dead. Many Armenians settled in the Fresno area following the Turkish massacres in the 1890s and in 1915. Holy Translators Day (Targmanchats ton): Dedicated to the creators of the Armenian alphabet and to translators and interpreters of the Bible. The California Armenian community has strong churches.000 live in the Boston area. Ascension Day (Hambartsum): Marks the ascent of Christ into Heaven. gifts from Santa Claus (Dzmer Papik). They started the fig industry and were instrumental in the production of grapes. About half the one million Armenians in the United States live in California. . Los Angeles. Easter (Zatik) Motherhood and Beauty Day Genocide Victims Memorial Day: Armenians worldwide honor the memory of the million or more victims of the 1915 genocide by the Ottoman Turks. 1995. Iraq. Author William Saroyan is one of the best-known Armenians to make California his home. festival of water Constitution Day: Official holiday celebrates adoption of the Constitution of the Republic of Armenia on July 5. Glendale. schools. visiting. decides fate.” The trade blockade imposed by Azerbaijan in response to the conflict in Nagorno-Karabakh meant that basic medical supplies and equipment could not get into the country. and bulgur in California. The greater New York area is home to some 100. Greece.000 Armenians. and more than 50. and various cultural organizations. United Nations intervention in 1993 eased the situation. two years later they were annexed by the USSR. Many came to California after first emigrating to other nations including Egypt. Day of the First Republic: Celebrates the day in 1918 when Armenians gained independence.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 167 Armenia. Likewise. cont. Day of Remembrance of Victims of the 1988 Earthquake Armenians in the United States The geography and climate of California are quite similar to those of Armenia. Victory and Peace Day: A day to celebrate the end of World War II. 2004). Road to Armenia: The Ancient Land in Words. 3 (Mar..” Tour Armenia.” Encyclopedia Britannica. he created the 36-character alphabet specifically to translate the Bible.org/DiscoverArmenia/Index. 2000. http:// www. “UMCOR: Assisting the Armenian People through the Process of Transition.htm (28 Feb. 2004. Vartanian. Useful Armenian Phrases.tacentral. cont. 2004). Celebrating Diversity: Armenia. Bari gisher. Encyclopaedia Britannica Premium Service. Michaelian. I am sick.” Armenian Embassy.gfmer.” Tour Armenia. K’nerek.htm (14 Nov. Music.D. Thank you. Discover Armenia. “Armenia. Reproductive Health in Armenia. 2004). “Education in Armenia. USAID Mission to Armenia: Ten Years of Progress. Bari yereko.” National Geographic.html (17 Nov. Eastern Armenian is the official language of the Republic of Armenia.com/rosen.org/intl/countryprofiles. http://www. . 2004). Please. 2004). Armenian Embassy. Ayo/Ha. Library of Congress.tacentral. 2003. U.gov/g/drl/rls/irf/2002/13919pf. Vochinch.state. 15 Dec.htm (9 Feb. I don’t understand.cilicia. Nicole.stm (15 Nov. The World Factbook: Armenia.us/armenia (16 Nov. Haskanum em.asp (14 Nov.groong. There are at least three different forms of the Armenian language in use today. I want an interpreter. http://www. “The Rebirth of Armenia. Frank. 2004). The following words and phrases may be helpful to health care professionals: Hello (formal) Hello (informal) How are you? (formal) How are you? (informal) Very well. so it is the version most likely to be encountered by U. 2004). I understand. http://www. Matiroysan.” http://www/upenn. Ruth.gov/r/pa/ei/bgn/5275pf. http://www.usaid. Charjhe. Not bad. 2004).com (17 Nov. Country Studies: Armenia. http://www2. Onnik. May.asp (14 Nov. health care providers.com/ index. Bari luis. 2004). Karine.edu/pennnews/article. 2004).org/DiscoverArmenia/armedu. No Kh’ntrem. Vonts ek? Vonts es? Shat lav.” http://gbgm-umc.armeniainfo. Western Armenian is the form commonly spoken by Armenian Diaspora communities in the United States and other countries. Armenia: International Religious Freedom Report 2002. “Partnerships with Hospitals in Armenia and Russia Lead to Improved Patient Care and Opportunities for Nurses. http://www. 2004). and English is becoming increasingly popular along with French and German.” Cobblestone. Good night. Language. Vol. Barev. Ts’tesityun.ch/Endo/Reprod_health/Reprod_Health_Eastern_Eusope/armenia/Armenia (16 Nov.html (14 Nov.com/armo_article_fruitful_legacy.com/eb/article Armenian Holidays. 2004). Yes. Useful Words and Phrases The Armenian alphabet was introduced by scholar and monk Mesrop Mashtots in 405 A.” San Francisco Chronicle. Congratulations. ———.state. University of Pennsylvania.html (8 May 2005).○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 168 Respecting Differences. http://www. Department of State.org/ umcor/caucasus/passingon.cia. “The Hidden Holocaust.gov/cia/publications/factbook/geos/am.cilicia. http://www.fm (24 Mar. 2004). Sh’norhavor lini.com/dining. pp. Hivand em. Chem haskanum. Russian is widely spoken in Armenia. http://countrystudies.html (15 Nov. http://www.am/about/?section=holidays (16 Nov. Pardon me. Viviano. No. Barev dzez.).britannica. 2004). Habitat for Humanity Armenia. 2004).S. Goodbye.S.gov/locations/europe_eurasia/countries/am/video/ 10_years_progress_transcript (14 Nov. http://www. http://www. 205. and Pictures.php?id=687&print=1 (16 Nov. 2004). http://armeniaemb.habitat. Tarkamanich emuzum. http://www. 2004. 2004. http://armeniaemb. Krikorian.com/education. You’re welcome. Good morning. “A Fruitful Legacy. http://road-to-armenia. Sh’norhakal em. Andranik.htm (15 Nov. “Education. Good evening. 2004). Geneva Foundation for Medical Education and Research. 28-49. Che/Voch References “About Armenian Food. Rosen. Background Note: Armenia. 6 krays. subarctic in Siberia to tundra climate in the polar north. electric power generating and transmitting equipment. sunflower seed. sugar beets. Tatar 3.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 169 Russia Census Figures (2000) United States Residents Born in Russia: California Residents Born in Russia: 340. milk petroleum and petroleum products.7%. chemicals.8 times size of U. 21 republics. wood and wood products.177 (1.15 years -0. beef.420. world’s largest country) 143.1% Russian. Belarusian 0. Muslim. Buddhist.660 (0.2%. agricultural machinery. shipbuilding.1 years 25% 99. vegetables.5%. miles (1.8%. Other Russian Orthodox. chemicals. strategic minerals. natural gas.6%) Quick Facts Country Area: Population: Median Age: Population Growth Rate: Life Expectancy at Birth: Below Poverty Line: Literacy Rate: Currency: Population Groups: Languages: Religion: Government: Climate: Natural Hazards: Natural Resources: Arable Land: Agricultural Products: Exports: Industries: Labor Force: 6. medical and scientific instruments agriculture 12. volcanoes.S. 1 autonomous oblast ranges from steppes in the south through humid continental in much of European Russia. Bashkir 0. country includes 49 oblasts.7%. earthquakes oil. services 65% . civilian and military manufactures mining and extractive industries producing coal. machine building. fruits. and metals. Chuvash 1. industry 22. coal. Ukrainian 3%.3% grain.8%.3%. Other Christian. 10 autonomous okrugs. oil. metals. construction equipment. gas. winters vary from cool along Black Sea coast to frigid in Siberia.6% Russian ruble (RUR) Russian 81. natural gas. summers vary from warm in the steppes to cool along Arctic coast permafrost. Other 8. Moldavian 0. 2 federal cities. Other Russian Federation: Moscow is capital.592. communications equipment. timber 7.37% 67.800 sq.1%) 54.309 38.9%. dachas. Prince Vladimir. The Tatars invaded in 1236 and divided the country into small principalities. training. became ruler in the 9th century and established a dynasty. Russians may use the father’s first name as a child’s middle name. with the Bolsheviks led by Lenin. and bathroom. and children are often cared for by grandmothers. Following the war relations between the Soviet Union and the other Allies worsened in a period we know as the Cold War. Public welfare funds supplement the wages of most Russian workers by providing free medical services. Since 1994. Traditions Housing: Family: Employment: About 75 percent of Russians are city-dwellers. Apartments are generally small. . Many children attend nurseries and play schools. established Christianity as the state religion in 988. and construction being paid more than average. made up of several European and Asian republics. of which Moscow was one. Germany invaded the USSR in 1941. with those engaged in such industries as transportation. Housing. In December 1991 the USSR ceased to exist. and the transition to a market economy has been difficult. The Russian Revolution of 1917. women have been part of the workforce for decades. More than 90 percent of Russian women work outside the home. and they are paid less than men in their professional roles. Moscow was strong enough to free itself from Tatar control. His descendant. About 75 percent of Russian physicians are women. the women still bear most of the burden of housework and child care. pensions. In some cases. Russian families have traditionally been very close. government employees such as doctors and teachers may not receive their salaries until months after they are due. sent to gulags. Brief History Today’s Russian people originated in Slavic groups that settled the steppes of European Russia in the 6th century AD. When Josef Stalin came to power in 1929. Organized crime is a serious problem in Russia. In the late 15th century. called czars/tsars. Attempts at restructuring or perestroika began under Gorbachev in the 1980s. when standing in long lines for food and other basic necessities was a fact of life. Daily life includes long commutes to work and lines to purchase food that may take considerable time to prepare.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 170 Respecting Differences. cont. Unemployment is increasing: many people can find only part-time or seasonal work. Family. expanded their empire from the Baltic region of Europe to central and northeastern Asia. Rurik. Ivanevna for a daughter. Beginning in the 1920s. or executed. Work. grandparents played a key role that allowed mothers and fathers to participate in the workforce. the USSR. the common people worked land owned by the aristocracy. characterized by the amassing of nuclear weapons. Relations with the Islamic Chechen Republic are particularly difficult. babushkas. kitchen. most living in large apartment blocks where vacancies are scarce and several generations often share an apartment. Country dwellers may live in houses made of wood or bricks. During World War II 20 million Russians died. Most industries were state-controlled until 1991. While Russian families are traditionally patriarchal. Russia today is a federation of 21 autonomous republics under elected President Vladimir Putin. barter rather than money serves as wages. replaced by 15 independent republics. possibly because due to limited housing several generations usually live in one house. ended this feudal system and the reign of the czars and established the first communist country in the world. doing virtually every job except mining. Russian rulers. According to one source. Under the Soviet Union. Russia became part of the Union of Soviet Socialist Republics. Workers and professionals receive paid vacations. many who opposed him were jailed. A Scandinavian chief. and scholarships. Celebrating Diversity: Russia. and are raised to respect their elders.000 insurgents have been killed in Chechnya. bedroom. Some Russians have summer country homes. industries were turned over to the state and farming was carried out by large collectives. The first name Ivan would be a middle name of Ivanovich for a son. Nevertheless. Within the empire. more than 200. consisting of a living room. mining. Many families have only one child. known as a patronym. Wages depend on the type of work as well as working conditions and the importance of the work to the overall economy. including cold meats. Students may arrive early in the morning and stay after formal classes for supervised homework. and food is relatively expensive. students receive the Certificate of Incomplete Secondary Education. often prepared in a samovar or self-boiling urn. The Russian diet is heavy on carbohydrates. Dessert might be stewed fruit or pancakes filled with jam or cream (blini). smoked fish. soccer. Students attend five or six days a week.ruscuisine. is a non-alcoholic drink made from dark bread or malted rye flour. pickled mushrooms and cucumbers. Basic secondary education takes five years. A typical meal might begin with zakuski. Sausage. pelmeni. as well as information on other aspects of Russian culture. Foods and Eating Habits Dietary Practices: Everyday Diet: Popular Foods: Beverages: Russian Jews. Made from wheat. cont. okroshka. and fishing are popular. potatoes. Making the pelmeni may be a family activity for special occasions. Many Russian children attend kindergartens or creches. Molokan. and Muslims are forbidden to eat pork. Another variety of filled dumplings. Long. The Russian version is often filled with pork and served with sour cream. cold appetizers. vareniki. and perhaps caviar. salt. Upon completion of the 9th grade. is served hot or cold and is probably the most familiar Russian dish. bland foods. or pickled to preserve them. Meats are often dried. . and saturated fats. beet soup. The Soviet Union first participated in the Olympic Games in the summer of 1952 and winter of 1956. with cabbage and various grains used as well. Education Primary Level: Secondary Level: Professional Level: The school year begins in September and concludes at the end of May.com has a wealth of information and recipes for foods and beverages enjoyed by Russian people. Institutions of initial and intermediate professional education train qualified workers and middlelevel specialists including technicians and nurses. The Web site http://www. Kvass. weight lifting. They do not like ice in their beverages. Graduates who continue on to two years of senior high school receive the complete secondary education. Sports: Sports have played an important part in Russian culture since the period following World War II. those who have completed only the five-year basic secondary education can complete the courses in about four years. and plain yogurt. Russians are noted for their high levels of vodka consumption. This beverage is sometimes added to chopped meat and vegetables to create a cold soup. Kulich is a popular bread. and borsch. and hot mustard. Russian vodka runs the gamut from colorless Moskovskaya and Stolichanaya to a variety of bitters with herbs and spices. One popular traditional dish. Primary general education begins at age 6 or 7 and takes four years. Jogging. soy sauce. Russian athletes still excel in these areas. Russians prefer to eat hot soups. and Russian chess players are some of the world’s best. Non-Russian children are taught in their native language. another popular beverage. are filled dumplings resembling pot stickers or pierogies. gymnastics.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 171 Russia. cold winters lead to a shortage of fresh vegetables and fruits. spring onions. are also popular. Zakuski might be followed by a soup such as borsch (beet) or shichi (cabbage). wrestling. When ill. Athletes were supported by the state and won competitions in a variety of individual and team events including ice hockey. salted. which would be followed by meat or fish with potatoes. Students can complete courses in two years if they have completed their secondary education. The Russian language is a required subject. and bread are standard daily fare. fresh meat is not always available. Public education is free and compulsory through the 9th form/grade. Black tea is a favorite beverage. and boxing. with starchy root vegetables and bread serving as mainstays of the daily menu. San Francisco. 20 million Russians were Muslims. Today. and the Central Valley as well as Baja California. Buddhism is being reestablished. When Stalin came to power in the early 20th century. At one point the number of Molokans reached an estimated 500. With the collapse of the Soviet Union. where knowledge of English is more sought-after than an advanced degree. The majority of Russian immigrants to the United States are Jewish. By the 1980s only 3. Courses are taught almost exclusively in the Russian language. Other Christian religious groups in Russia include the Molokans. Molokan communities developed in Caucasus and Central Asia. including the veneration of icons. many Jewish immigrants are cultural rather than religious Jews with little knowledge of their religion. Because Jews were discouraged from practicing their religion in the Soviet Union. Tibetan Buddhism has long been practiced in Russia and was officially recognized by Empress Elizabeth in 1741. Turkey. and (3) postgraduate higher education. During the 19th century. Hundreds of mosques and religious schools were opened with the assistance Muslims in Saudi Arabia.000. Religion Russian Orthodoxy: Other Christian: Islam: Buddhism: Judaism: While the constitution of the former Soviet Union guaranteed religious freedom. which dates to the close of the 10th century when Russian ruler Kievan Rus was converted to Christianity by missionaries from Byzantium. (2) basic higher education (four years) leading to the first university-level degree. the practice of religion was difficult. Molokans maintain strong beliefs in pacifism and communal enterprise. In 2004. Higher Education: Higher education in Russia includes three levels: (1) incomplete higher education (at least two years). Molokans suffered persecution during the Tsarist era.000 Russian Jews emigrated to the United States. Emigration to Israel and other countries has been permitted since the late 1980s. Molokans are found around the world. which experienced growth during the 20th century and now number about 2 million. most mosques and madrasas were destroyed or closed. In 1939 the state relaxed restrictions on religious practice. a group that separated from the Orthodox in the 17th century. the church supported the country’s efforts under Stalin in World War II. with several dozen communities in the United States including Los Angeles. most of them concentrated in two regions of the country—the Volga river basin and the Caucasus. Jews were persecuted in Russia both under Stalin and during the Nazi occupation. Most Russians are members of the Russian Orthodox church. the first wave arrived in the late 19th and early 20th centuries. From 1980 to 1991. cont. about 181. Efforts of Muslims in the Republic of Chechnya to break away from Russia and form an independent Islamic republic have been the source of ongoing terrorism and bloodshed. but this does not necessarily translate to an advantage in the job market. Islam experienced a revival. Celebrating Diversity: Russia. But Kruschev revived restrictions on religious freedom. and about 1. Most Russian Buddhists live in the autonomous Republic of Buryatia in southern Siberia and belong to the Yellow Hat Sect whose spiritual head is the Dalai Lama. During the days of the Soviet Union.000 churches and two monasteries were active. The monastic movement was an important element of economic and social as well as spiritual life during the Middle Ages.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 172 Respecting Differences. and Iran. When the Bolsheviks came to power in 1917. Prince Vladimir made Christianity the state religion in 988.3 million Roman Catholics. With the Soviet Union’s collapse in 1991. more than 8. Baptists and other evangelical groups. More than 40 percent of Russians have a college or university degree. he had most of the temples and monasteries destroyed and many Buddhists killed.000 opened between 1990 and 1995. . With the breakup of the Soviet Union. In rejecting Orthodoxy’s rituals. they nationalized church property and executed or persecuted many priests. Admission to higher education is very competitive. churches began opening. a pattern that may be related to the stigma attached to mental illness in their homeland. Physicians are plentiful but not paid well. and various forms of trauma account for 75 percent of deaths. . Herbal remedies are used widely and include Valerian root and Motherwort for such things as insomnia and headache. Integrating behavioral health services with primary care is one solution. and crowded living conditions in their former homeland. Traditionally. Tips for Health Care Providers Health Status: Attitudes: Hypertension is widespread among Russians.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 173 Russia. used in many Asian cultures. Both life expectancy and the birth rate continue to decline.” It involves heating cups and applying them to the back. . but often they view it as a condition that does not require the regular use of medication. and other services. and limited development of such specialized services as maternity and hospice care. A study published by the American Medical Association reported that Russian-speaking immigrants reported an unusually high frequency of health complaints as compared with other immigrant groups as well as higher than average levels of depression among older immigrants. Rates of infectious disease such as tuberculosis. and researchers note the success of adult day programs that target elderly Russian immigrants with socialization. is called “cupping. high alcohol intake. One source notes that Russian immigrant patients are often seen as loud and complaining. Health and Health Care Health Status: Medical System: Traditional Practices: Malnutrition is a problem due to the shortage of fruits and vegetables. coltsfoot for respiratory ailments. Excessive consumption of alcohol and tobacco cause significant health problems. and leech therapy. patients are not held responsible for participating in their own wellness. Hawthorn berries for blood pressure and cardiac conditions. Many Russian immigrants suffer the effects of heavy cigarette use. . and dysentery are rising sharply. and charcoal in water for stomach acid. Declining food production and increasing environmental pollution have negative health impacts for many Russians. Russian patients may attempt to give the physician monetary or other gifts. Physicians and other health care providers need to guard against categorizing their Russian-speaking patients as hypochondriacs.” Older patients may be suspicious of young health care providers.S. they may report physical symptoms. health care system as a panacea and may use medical services excessively and sometimes inappropriately. environmental pollution. a result of having to go to great lengths to get treatment in their native country. The quality of health care has declined due to poor intensive and emergency care. cont. English-learning. X instructed me to tell you/do . Another source reports that tips or auxiliary payments may be given to ensure good care. hepatitis. massage. insufficient training of medical personnel. Health care is free. Cardiovascular disease. one source suggests accepting other gifts graciously while explaining that they are not necessary. Other commonly used treatments include steam baths. immigrant physicans in the United States report sending money to their Russian counterparts so they can purchase meat and other luxuries. The Soviet medical system was paternalistic and authoritarian and did not encourage patients taking an active role in their health care. These are often short of basic supplies and are staffed not by physicians but by medical aides. as nurses in the Soviet system had no independent authority. a process that often leaves bruises. The Russian health system is organized around regional clinics. Russian patients may not trust care or advice given by nurses. One traditional medical treatment designed to draw evil humors out of the body. . Russian immigrants tend to see the U. with many Russians consuming diets high in carbohydrates. shortages of medicine. While monetary gifts must be refused. as was the custom in their country to augment the low salaries of physicians. One source suggests that nurses say: “Dr. Rather than discuss emotional troubles. cancer. Russian patients may be open to expressions such as touch and humor. hospital stays were often longer than is customary in the United States. minister. According to one source. In medical situations. When greeting one another. family members may want to wash the body or dress it in special clothing. the gender of a provider is not generally a concern. Most do not believe in cremation and are not comfortable with organ donation or autopsy. formerly known as Soviet Army Day International Women’s Day: Women receive flowers and gifts. Depending on religion. and eldest daughter. Russian patients may ask to see a priest. They tend to be stoic and have a high pain threshold. not by first name alone. May Day. they may not ask for pain medication. which corresponds to the first day of the Julian calendar used in Russia until 1918. Direct eye contact is usual. Russians do not like iced drinks. Russian Orthodox Christmas Soldier’s Day. Independence Day: Commemorates the adoption of the Declaration of Sovereignty of the Russian Federation in 1991. Russian patients may speak loudly when attempting to make themselves understood. many Russians may not actively practice their faith and will need no special accommodations. Celebrations and Holidays January 1 January 7 February 23 March 8 May 1 May 9 June 12 August 22 November 7 December 12 New Year’s Day: A popular holiday which some Russians also celebrate on January 13/14. Family members should be notified of a terminal diagnosis and given the choice as to whether or not to tell the patient.○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 174 Respecting Differences. Like most patients. cont. so health care providers should explain the purpose of such tests without going into great detail. flowers and wreaths laid on graves of some of the 20 million Russians who died in the war. mother. Under the Soviet system. Diagnostic tests were not used frequently in the Soviet Union. Russians are very respectful of elders. Family Authority: Addressing Clients: Nonverbal Exchange: Verbal Exchange: Religious Practices: Hospitalization: Death and Dying: Patients will generally want to discuss procedures and matters of consent with family members. and patients may be disturbed by outpatient procedures and shorter hospitalization. Depending on their religion. Celebrating Diversity: Russia. Russians may kiss each other on the cheeks as well as shake hands. Once a relationship of trust has been established. eldest son. rabbi. Due to proscriptions on practicing religion in the former Soviet Union. They may be cautious with a health care provider until a relationship has been established. also called Spring and Labor Day Victory Day: Celebrates victory over the Germans in WWII. Day of the Russian Federation State Flag Day of Accord and Conciliation: Anniversary of the socialist revolution of October 1917. Physicians generally do not reveal a diagnosis of cancer. they look for a caregiver who is competent and sincere. Constitution Day: Celebrates first Constitution of the Russian Federation. . Russians may prefer to care for a dying family member at home rather than use a hospital or nursing home except in cases of acute illness. or other religious leader. Many recent immigrants will speak English. and they may be wary of superficial friendliness. 1993. Decisions makers are the father. They should be addressed by title and family name. Russians consider a diagnosis of cancer a death sentence and tend to respond to it with fear and/or denial. Good afternoon. Dobraye ootro. Glendale has the largest Armenian population outside the capital of Armenia. A 2003 San Francisco Chronicle article notes that about 20 percent of Russian immigrants living in the Bay Area own their own businesses. Dasvidánye.000 Russians emigrated to California. What is your name? Kak vas zavoot? My name is . Zdrástvooyte. making it the tenth-largest immigrant group. Da. Some of the letters look like those in our Roman alphabet. No. Yes. cont. Good evening. Beginning in the late 1980s. Dobriy vyecher. some 14.000 Russian-speaking immigrants lived in the area that year. which has 33 letters. Where does it hurt? Shto oo vas baleet? . Meenya zavoot . I don’t understand. . Pazhhaloosta. Language. Pazhalooysta. Thank you very much. The Russian language uses the Cyrillic alphabet.○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 175 Russia. Spaseeba. but they are pronounced differently. Nyet.000 Russian-speaking immigrants have settled in the United States each year. Good luck! Shchistíva. Russians in the United States Recent Russian immigrants to the United States tend to be older overall than other groups. Most Russian immigrants to the United States have been Jews escaping persecution in their native land. Immigrants from Russia would probably be familiar with the following words and phrases: Hello (informal). A recent survey of Russian immigrants to Minnesota found that 83 percent were over 50 years old. Preevyet. Hello (more formal). preekrasna. 70 percent of these Armenian immigrant speak Russian. and after World War II when Russians displaced by the Nazis came to the United States. Bal’shoye spaseeba. . Spaseeba. about 50. Useful Words and Phrases Russian is the country’s official language. Thank you. . Ya paneemayoo. The first Russians arrived in the United States in the mid-1700s as Russians crossed the Bering Strait into Alaska. Dobriy den. A 1999 Los Angeles Magazine article noted that more than 600. Good morning. Goodbye. Waves of Russians emigrated to this country in the late 19th and early 20th centuries as a result of ethnic and religious persecution. The Cyrillic letter “P” is pronounced “R. In 2003. Many of the immigrants are not from Russia itself. . Ya nee paneemayoo. You’re welcome. thanks. How are you? Kak pazhivayesh? Fine. with 20 percent being over 65 years old. Please. but from other Russian-speaking countries such as Armenia.” for example. Do you speak English? Vi gavareetye pa angleeskee? I understand. but many minority groups speak their own languages. 2004). 1999.php?article=8101 (19 Oct. Traditions.muslimnews.” http://www. Margonelli. “System of Russian Education.russianembassy.com/articles/index. 2005). 2005).com/library/world/KZ/bl_RussiaOrthodoxHistory. http:/ /www.org/USfocus/print. Thomas. 2004). “Working Hard for the Money: Immigrants Carve Out the American Dream.geocities. “Russia and Its Muslim Population: A Balancing Act.unitedwaytwincities. Gareth. 1997.. Master Russian. eds. Robsville.cgi?file=/gate/archive/2003/10/01/moneytales.org. http://www. 1 Nov. References Bendersky.org/ama/pub/category/print/12906. Carney. Rychova.htm (10 Nov.gov/cia/publications/factbook/geos/rs. 2004. Lisa. 2004).htm (10 Nov.uk/news/print_version. http://www. 2004.html (8 May 2005).○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 176 Respecting Differences. Lipson.org/news/ immigrants_russian.ama-assn.htm (10 Nov.migrationinformation.about.hvk/articles/0997/0025. Inc.” The Muslim News. “Moscow 90210: Russian Immigrants in Los Angeles./cp/english/russia (10 Nov. http://masterrussian.” Encyclopaedia Britannica. 2004). http://www.” http://atheism. 2004 http://britannica.org. 1997. 2004). 2003. March 1999. 2004.html (11 Nov. San Francisco: University of California San Francisco Nursing Press.” American Medical Association. 2004). 1 Oct. http:/ /www.com/p/articles/mi_m1346/is_3_44/ai_53980564/print (11 Nov.womenrussia. 2004).co. Elisete. http://www.useic. and Jennifer Yau. http:// www.org/RUSSIA/cuisine. Russian Culture. http://www. http:// www. “Somatic Symptoms among Recent Russian Immigrants. 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Multiculturalism and Native Issues Centre. 2004).htm (10 Nov. ———. Jones.russianembassy. 2004).php?article=34 (16 Apr.migrationinformation. ———.com/scimah/Russia. 18 Oct.” The Asian Age. http://www. 2005). Russia. Diversity Resources. Cheryl. US Immigration Statistics in 2003. “The Temptations of Pelmeni.org?USFocus/ state. 15 Sept.com/bldoctor. Deborah. Faculty of Social Work.hvk. http://sfgate. Religion in Russia.org/RUSSIA/holid. Russian Immigrants in Minnesota.cia. Anti-Racism. 2004). 2004). Sean.ruscuisine.DTL&type=printable (10 Oct. What Language Does Your patient Hurt In?: a Practical Guide to Culturally Competent Care.” http://www.cfm?ID=CA (11 Nov.settlement. Greater Twin Cities United Way.htm (10 Nov. Observed National Holidays. Migration Information Source. 2004). nd. 19 Aug.cfm?ID=263 (11 Nov. Basic Expressions. 2004). Amherst.com/blbasic.htm (19 Oct. ———. University of Toronto.. Family and Daily Life. ○ ○ ○ ○ ○ ○ ○ Understanding and Working with Health Care Clients and Students from Other Cultures 177 . Kern Resource Center 5801 Sundale Avenue Bakersfield.health-careers.org . CA 93309 (661) 827-3266 (661) 827-3304 (fax) www.