Caution: These are broad generalizations and should not be used to stereotype any individuals.

Prejudice and Discrimination
Due to the history of slavery followed by racial discrimination, African American patients may not trust “white” institutions such as hospitals. This may be compounded by both the current studies documenting racial disparities and the memory of such horrors as the infamous Tuskegee syphilis experiment, where African American men with syphilis were left untreated, even after a cure had been discovered.

African Americans may be very sensitive to discrimination, even when it is unintended. For example, do not use the term “gal” to refer to a woman. It has the same connotations as “boy” for an African American male. Address the patient as Mr., Mrs., or Ms., or by professional title and last name. As with all patients, be sure to apologize and explain if a patient is kept waiting. It may be interpreted as a sign of disrespect or discrimination.

World View
Religion is important to many African Americans. Clergy should be allowed to participate when appropriate. Privacy for prayer is important and quiet time should be allowed for it. Health care practitioners may offer to pray with a patient if all parties are comfortable. It is customary for clergy and acquaintances from the patient’s place of worship to visit the sick on Sundays, often directly from church.

Time Orientation
Those of lower socioeconomic status may be present time oriented, which may impede preventive medicine and follow-up care. Explain the need for preventive medication (such as for hypertension) or to finish antibiotics even when symptoms disappear. Explanations may be important. Due to time orientation and/or economic factors, some may delay seeing a physician until symptoms are severe.

Pain
Expression of pain varies widely. It is equally acceptable to be expressive or stoic.

Family & Gender Issues
Family structure may be nuclear, extended, or matriarchal. Close friends or church members may be part of a kin support system and even referred to by terms like “sister” or “brother.” Households headed by women are common. In such cases a grandmother or aunt may be the patient’s spokesperson. Often, the father or eldest male may take this role. Decisions may be made by the patient.

Generally, women are considered equal to men. Many women achieve higher socioeconomic status and educational levels than men.

Pregnancy & Birth
Prenatal care is common. Traditionally, only females attended birth, but this now varies. Today, a male partner often assists the delivery.

End of Life
The incidence and death rates for some types of cancer, including prostate and cervical, are particularly high among African Americans. This may be due in part to the fact that lack of trust for the healthcare system leads to delays in screening.

They may be reluctant to sign a DNR for fear that physicians will withhold beneficial treatment. This can be addressed directly by saying, “Some patients don’t like to talk about these issues because they’re afraid their doctors may withhold treatment that might be beneficial to them. Is this something that you’re concerned about?”

Reluctance to remove life support may be due to a belief that miracles are always possible. The thought may be that only God knows for sure if a situation is hopeless.  In addition, patients and caregivers may not trust the medical community, again due to historical experiences with racism. Some consider it taboo to donate organs or blood except to a family member, for fear it will hasten one’s own death.

Health & Belief Practices
Beliefs about the cause of disease include biomedical beliefs and divine punishment. If lack of adherence stems from a belief that disease is due to punishment for sin, it may be helpful to involve clergy or to have the patient pray for God to guide the physicians.

In rural areas of the South, rich foods (red) may be thought to cause “high” blood, which may be confused with high blood pressure. Attempts may be made to treat “high” blood with clear, white foods to “lower” the blood. Since white foods can include things high in sodium, this should be discussed with the patient. “Low” blood is thought to result from too much vinegar, lemon juice, and garlic, and not enough red meat. Be sure to clarify the difference among “low” blood, low blood count, and low blood pressure.

The African American culture has a rich tradition of herbal remedies. Be sure to discuss the use of home or herbal remedies to prevent potential drug interactions. Expression of pain varies widely. It is equally acceptable to be expressive or stoic.

Note: Material is drawn from the work of Loudell Snow on lower SES African Americans in rural South, as well as Waters, C.M. and S. Locks (2005) African Americans. In JG Lipson and SL Dibble (Eds.), Culture and Clinical Care (pp.14-26). San Francisco: UCSF Nursing Press; and National Cancer Institute Fact Sheet on Cancer Disparities, http://www.cancer.gov/about-nci/organization/crchd/cancer-health-disparities-fact-sheet.

Caution: These are broad generalizations and should not be used to stereotype any individuals.

Values and Communication
Individuals often expect to know the details of their condition.

Privacy is important, although patients and their family members may want/expect nurses to provide psychosocial care.

Direct eye contact and emotional control are expected. But try to avoid excessive direct eye contact with members of the opposite sex to avoid any hint of sexual impropriety.

Independence is valued; self-care will generally be accepted.

Time Orientation
Time orientation often depends on socioeconomic class. Poor people tend to be present-oriented; middle & upper class individuals tend to be future oriented.

Pain
Patients will generally tend to be stoic, although most will want pain medication.

Family & Gender Issues
Generally, family size is small. The term “immediate family” refers to spouse, siblings, parents, children. Families are often spread out geographically, and the patient may have fewer visitors than do other ethnic groups.

Among GLBT patients, friends may take on the role of family.

Husbands and wives usually have equal authority, and either may make decisions for a child.

Pregnancy & Birth

Prenatal care is generally sought.

The husband is usually the preferred labor partner.

Hospital births are generally preferred, even if an alternative birthing center is used. This may be related to a cultural desire to control events.

There are no post-partum rituals, other than those associated with various religions.

Breastfeeding may be practiced for 3-6 months.

Pediatric
Some upper-middle-class parents believe there is a link between childhood vaccines and autism and refuse to get their children vaccinated.

End of Life
Patient will generally want to know their diagnosis and prognosis.

Although many want “everything done,” hospice is increasingly an acceptable alternative. Often, however, it is not seriously pursued until the last few days before death.

Stoicism is valued when someone dies.

Organ donations & autopsies are acceptable, as are cremation or burial, unless forbidden by religion.

Health & Belief Practices
Independence is valued and self-care will generally be accepted.

Patients generally prefer an aggressive approach to treating illness.

Biomedicine preferred, although many may also use complementary and alternative medicine. Be sure to inquire about the use of herbal medications.

They may prefer to be left alone when sick.

Germs are thought to be the cause of disease; treatment aimed at destroying germs. Antibiotics are often requested, even for viral illnesses. Be sure to explain the difference between treating viral and bacterial conditions. Explain why antibiotics must be finished, even after symptoms subside.

Middle-class patients often use the Internet to obtain information and may want to dictate specific treatment based on what they learned from that source.

Caution: These are broad generalizations and should not be used to stereotype any individuals. They are most applicable to the least acculturated members. Individuals from China, Japan, Korea, and the Philippines are included in this group.

Values and Communication

Harmony and conflict avoidance are highly valued, as is respect. Thus, Asian patients may agree to what the healthcare provider says, without having any intention of following through. Make sure the reasons for adherence to recommendations are explained and stressed.

They may avoid direct eye contact as a way of showing respect. Do not assign other meaning to this.

Filial piety (respect for and duty to one’s parents) is an important value.

Avoid asking questions which require a “yes” or “no” response. Have the patient demonstrate understanding of any patient teaching.

Avoid using hand gestures; some, such as beckoning with the index finger, is insulting to Filipinos & Koreans.

Offer things several times; patients may refuse at first in order to be polite.

Anticipate patients’ needs when possible. Do not wait for a request for pain medication or assistance since patients may feel it is inappropriate to take a health care provider away from other patients in order to attend to their personal needs.

Since pronouns do not exist in most Asian languages, they may confuse “he” or “she”.

Time Orientation
Traditional Chinese patients may be past-oriented, placing a heavy value on tradition. Filipinos may be both past-and present-oriented, and may not always adhere to “clock” time. Many Koreans are future-oriented and adhere to clock time for appointments, but not social events.

Pain
Stoicism is highly valued. Pain may be expressed only by a clenched jaw. Offer pain medication when the condition warrants it, even if patient does not request it. When it is medically necessary, explain why and insist on giving it.

Filipinos may be particularly concerned about addiction to pain medication.

Family & Gender Issues
Most Asian cultures are hierarchical; tremendous respect is often accorded to the elderly. Males are often accorded more respect than females, and wives may defer to husbands in decision making.

Allow family members to fulfill their familial duty by spending as much time with the patient as possible and by providing nontechnical care. Involve the family in decision-making.

Pregnancy & Birth
The traditional birth partner may be the mother-in-law or other female relative.

Women are generally stoic while giving birth.

Since pregnancy is thought to be a “hot” condition within traditional Chinese medicine, birth is believed to deplete the body of heat. Restoration of warmth is important. Offer new mothers liquids other than ice water, which may be deemed too “cold”.

Traditionally, new mothers avoid cold, bathing & exercise for one month post partum (“Doing the Month”). Respect post-partum prescriptions for rest. Sponge baths may be preferred.

Parents may avoid naming baby for up to 30 days. Traditionally, a child is given an unattractive nickname before then so as to avoid attracting the attention of spirits who might want to “steal” the child.

Pediatrics
A great deal of pressure is often put on children to succeed in school.

“Mongolian spots” are common and should not be misinterpreted as bruises. This congenital birthmark, not uncommon in Asian births, usually fades as the infant grows into childhood.

End of Life
Family members may wish to shield a terminal diagnosis from the patient. Ask the patient upon admission (or before the need arises, if possible) whom should be given information about his/her condition. If the patient requests that all information be given to a family member, be sure to investigate the legal implications of doing so.

Patients and their families may not want to discuss end-of-life issues in advance. One approach is to say, “Some (Chinese) families do not like to discuss these issues in advance. Is this something that you feel comfortable discussing with me?”

Cancer is both highly feared and stigmatized. If it has been agreed that the patient not be informed of a cancer diagnosis, subsequent discussions should involve terms such as “growth” or “lesion” rather than “cancer,” and “medication” rather than “chemotherapy.”

Due to the high level of respect for parents and the elderly, some adult children may be reluctant to withdraw life support for fear of giving the appearance of not honoring their parents.

Health Related Issues
Coining & cupping are traditional medical practices in China, Korea & Viet Nam, not forms of abuse, despite the marks these may leave on the patient’s body.

Fevers are often treated by wrapping in warm blankets and drinking warm liquids.

Avoid giving ice water, without asking whether the patient prefers it to water at room temperature. They may prefer hot liquids, such as tea.

The use of herbs is common. Be aware that if patients have only used traditional Chinese herbs, they may not know how to take Western medications, since the herbs are usually boiled in water and then drunk. Be sure to instruct on the use of western medication if that is the case.

Avoid the number “4.” Because the character for the number 4 is pronounced the same as the character for the word “death” in several Asian languages, patients may be uncomfortable in rooms with the number 4.

Mental illness is often highly stigmatized. Patients with emotional problems are likely to somaticize them and present with physical complaints. Patients may be reluctant to discuss emotional problems with anyone outside the family, including health care providers.

Caution: These are broad generalizations and should not be used to stereotype any individuals. They are most applicable to the least acculturated members. The information here is primarily relevant to Mexicans.

Values, World View and Communication
Personal relationships are valued. Asking about the patient’s family and interests before focusing on health issues will generally increase rapport and trust.

Patients may have a fatalistic view of the world, which can interfere with adherence to preventive health care.

Time Orientation
Many have a present time orientation, which may impede use of preventive medicine and follow-up care. Explain the need for preventive medication (such as for hypertension) and to finish antibiotics even after symptoms have disappeared. Tie adherence to something they care about (e.g., dancing at a daughter’s wedding or seeing a grandchild).

Pain
Patients may tend to be expressive (loud) when in pain, although it varies with the audience (males may be more expressive around family members than around health care professionals). However, remember that just because it is acceptable to be expressive, it doesn’t mean there is not a real medical problem. Always investigate.

Family & Gender Issues
Large families are common and all may visit the patient. Allow family members to express their love and concern by spending as much time with the patient as possible. Allow them to assist patient with activities of daily living if the patient is reluctant to do self-care.

Patients may be reluctant to discuss emotional problems outside the family.

Modesty may be important, especially among older women. Try to keep them covered whenever possible.

Older, more traditional wives may defer to husbands in decision-making, both for their own health and that of their children. When patients come in, find out with whom they may want to consult before making decisions. They may want to involve family members.

Pregnancy & Birth
The traditional birth partner may be the mother-in-law or other female relative.

Women are generally stoic while giving birth.

Pregnancy is seen as a normal condition, so prenatal care may not be sought.

The woman’s mother may be the preferred birthing partner.

Laboring women often yell out “aye yie yie” — a loud form of controlled breathing. Others will be stoic.

Traditionally, new mothers avoid cold, bathing & exercise for 6 weeks post partum. Respect post-partum prescriptions for rest. Sponge baths may be preferred.

Since pregnancy is traditionally thought to be a “hot” condition, birth is thought to deplete the body of heat. Restoration of warmth is important. Offer liquids other than ice water, which may be deemed too “cold.”

Pediatric
There are a number of folk diseases that affect children, including mal de ojo (evil eye), caída de la mollera (fallen fontanelle, often cause by dehydration), and empacho (stomach pain).

 “Evil eye” is generally believed to be caused by envy when someone compliments a child. Be sure to touch the child when complimenting him or her to prevent this. The child may be wearing a red string or “deer’s eye” (a large brown seed with red string) to prevent it.

Herbal remedies are often used. Be sure to ask about them. Chamomile tea (manzanilla), used to treat colic, is generally safe and sometimes helpful. However, greta, a yellow to grayish-yellow powder, and azarcón, a bright reddish-orange powder, both used to treat empacho (stomach pain), contain lead and can be dangerous.

A chubby baby is seen as a healthy baby, so additional teaching regarding diet and diabetes may be warranted.

A baby with a fever will often be bundled up, which may run counter to the use of cooling measures that may have been instructed. It is important to include the grandmother in patient teaching since she may have the most say in terms of day-to-day health care issues, especially if she lives with the family.

Belly button binders may be used to prevent an “outie.” Your concerns should be with the cleanliness of the coin and the tightness of the binder. Instead of advising caregivers not to use a binder, teach them to make sure the coin is clean and that the binder is not too tight.

End of Life Issues
Since family members may want to withhold a fatal diagnosis from the patient, ask patient upon admission (or before the need arises, if possible) how much information they want to be given regarding their condition, or to whom the information should be provided.

Family members may resist hospice for fear it will emphasize the fact that their loved one is dying and thus encourage the individual to give up hope and the will to live.

The family of a terminal patient may be reluctant to remove life support lest it be seen as encouraging death. If the illness determined to be “punishment by God,” life support may be considered interfering with the opportunity for the patient to redeem his or her sins through suffering. At the same time, however, traditional respect and courtesy toward physicians may lead the patient or the patient’s family to agree with a doctor who suggests removing life support, even when they are opposed to it.

Health Related Practices
A predominant theory of illness is that it results from an upset in body balance. Patients may refuse certain foods or medications that upset the hot/cold body balance, even if they don’t verbalize it as such. With this in mind, offer alternative foods & liquids. Ask if they prefer water with ice or at room temperature.

Among those following more traditional practices, “fat” is seen as healthy. Many Mexican foods are high in fat and salt. Thus, nutritional counseling may be necessary for diabetics and individuals with high blood pressure.

Ask what remedies, if any, the patient has tried before coming in. Ask in a way that implies that all of your patients attempt self-treatment before coming in, and that you need to know what those attempts were to avoid prescribing something that could result in a bad interaction. Do not let patients believe you are criticizing them for trying home remedies or seeing other healers. Doing so may lessen their trust in you.

Caution: These are broad generalizations and should not be used to stereotype any individuals. They are most applicable to the least acculturated members. Note: The following includes Arabs and Iranians (Persians). Although most Middle Easterners are Muslim, there is a large population of Jewish Iranians who fled Iran after the Islamic revolution in 1979. Most live in greater Los Angeles and Great Neck, New York.

Communication
Effective communication with Middle Eastern patients is often assumed to be two-way. You many need to share information about yourself in order for them to share information about themselves. Healthcare providers may be expected to take a personal interest in their patients.

Direct eye contact with members of the opposite sex may be interpreted as a sign of sexual interest, particularly from female to male. Thus, female patients may avoid direct eye contact with maleproviders.

Repetition of demands is often made to show emphasis, as is a loud tone of voice.

For many Iranians, “thumbs up” is a rude gesture and should be avoided.

World View
Islam is a dominant force in the lives of many Middle Easterners. Give patients the opportunity to pray privately several times a day, facing east toward Mecca. Many have a fatalistic attitude regarding health (it is all in Allah’s hands), so they may see their health-related behavior as being of little consequence. Inshallah means “God willing.”

Time Orientation
Arabs tend to have a past and present time orientation. Human interaction is given higher priority than clock time, so if being on time is important, emphasize it.

Iranians tend to be more future oriented, although a fatalistic attitude can interfere with adherence to preventive medicine. Social time can be flexible.

Pain
Patients tend to be very expressive about pain, particularly in front of family. Pain is feared and should be minimized. Explaining the source of pain and the prognosis may improve these patients’ ability to cope with it.

Family & Gender Issues

Middle Easterners are very family oriented. The family is seen as more important than the individual. Expect many familial visitors to see the patient.

Be patient with “demanding” family members; they may see it as their job to make sure that the patient gets the best care possible.

Personal problems are usually taken care of within the family; they may not be receptive to counseling.

Traditionally, the eldest male is the decision maker. Even among the more acculturated, the entire family (including extended family) may participate in decision-making.

Sexual segregation can be extremely important. Assign same-sex caregivers whenever possible, and maintain a woman’s modesty at all time. Offer a gown that provides maximum coverage if possible.

Women may defer to husbands for decision-making regarding their own and their children’s health. In fact, the husband may answer questions addressed to his wife.

Pregnancy & Birth
Arab women may delay prenatal care because pregnancy is seen as a normal condition.

They may not make many preparations for birth because planning can be seen as challenging the will of Allah.

It is acceptable for women to be very loud & expressive during labor and delivery. Iranian women often receive a gift of expensive jewelr to compensate for their “suffering.”

A female relative may be the birth attendant; Arab men are not expected to participate. However, acculturated Persian men are more likely to participate.

Colostrum is believed to be harmful to the baby, so breastfeeding is often delayed for the first few days.

End of Life Issues
When offering chemotherapy, offer all options for administration. While a ventricular assist device may seem the most convenient, it may be determined that it has rendered a Muslim “unclean,” thus preventing him or her from praying.

When a patient is diagnosed as terminal, family members may wish to shield him or her from that fact. On admission (or before the need arises, if possible) ask patients to identify how much information they want to be given regarding their condition, or to whom the information should be provided.

They may not want to plan for death, since doing so can be seen as challenging the will of Allah. You might approach them by saying, “Some [Muslim] families feel that making such decisions is interfering with the will of Allah. Is this a belief you share, or do you want to begin discussing the decisions that need to be made?”

Avoidance of planning for death may also interfere with acceptance of hospice care. Another factor contributing to lower use of hospice is the belief that the family should be the one to care for the patient. When discussing hospice, be sure to explain that it can be done at home.

Muslims may not allow organ donation, since according to Islam, the body should be returned to Allah in the condition in which it was given: whole. Those who are in favor of it say that because organ donation can save a life, it falls under the Islamic doctrine that “necessity allows the prohibited.” For the same reason, they may be reluctant to allow an autopsy, but will if required by law.

Health Related Practices
Muslims may not take medications, eat, or drink from sunrise to sunset during the month of Ramadan. This period of fasting, self-sacrifice, and introspection is based on the Islamic calendar and thus occurs at a different time each year. Although they may be exempt during illness or pregnancy, Muslims may have to make up for it later on, which is much more difficult since no one else will be doing so at that time.

They may see the expectation of self-care as a lack of caring. Family members and caregivers are often expected to take care of them. Because of this, include family members in any patient education.

Injections may be preferable to pills based on the belief that injections are more effective. Offer options when possible.

Damp, cold, drafts, and strong emotions may be thought to lead to illness. For example, the “evil eye” (envy) may be thought to cause illness or misfortune. Amulets to prevent this may be worn and should not be removed. Such amulets include the hamsa, which looks like a hand with a blue stone in the palm, and a round blue stone with a blue and white “eye” in the center.

They may be used to heavy use of medications & may feel slighted if not given prescription.

When providing meals, be aware that observant Muslims and Jews do not eat pork. Muslims are also expected to abstain from alcohol, which may be found in cough medicine. Medications that contain geletin may also be a problem.

If a patient offers you food, it may be perceived as rude to refuse it. The second time it is offered, it is best to accept it.

Note: Some of this information is based on material from Meleis, A. I. (2005) Arabs. In J. G. Lipson and S. L. Dibble, eds. Culture and Clinical Care, 42-57. San Francisco: UCSF Nursing Press; and Hafizi, H. (2005) Iranians. In J. G. Lipson and S. L. Dibble, eds. Culture and Clinical Care, 246-276. San Francisco: UCSF Nursing Press.

Caution: These are broad generalizations and should not be used to stereotype any individuals. They are most applicable to the least acculturated members.There are more than 550 different Native American tribes, with much variation among them.

Communication
Native Americans often use anecdotes and metaphors to describe their own health status. A story about an ill neighbor may be a way of saying that the individual is experiencing the same symptoms. The names of deceased relatives may be avoided, although a relationship term such as “brother” or “mother” may be used instead.

Long pauses generally indicate that careful consideration is being given to a question. Do not rush the patient.

Direct eye contact may be avoided out of respect and/or concern for soul loss/theft. Do not misinterpret it as a lack of interest or evasiveness.

Due to a history of misuse of signed documents, some may be unwilling to sign informed consent or advanced directives. Some may display hostility toward healthcare providers due to the history of treatment of Native Americans by whites.

Older adults may prefer the term “American Indians” over “Native Americans.”

Time Orientation
A present time orientation is common. Individuals are often oriented to activities, rather than the clock. “Indian time” may run very late.

Pain
Stoicism is highly valued, and patients may not express their pain, other than by mentioning, “I don’t feel so good” or “Something doesn’t feel right.” If the patient reports feeling “uncomfortable” and is not given pain relief, s/he generally won’t ask again. Offer pain medication when the condition warrants it, even if patient does not appear to be in pain.

Family & Gender Issues
Extended family is important, and any illness concerns the entire family.

Decision making varies with kinship structure. Patients will generally make their own decisions about their health.

Pregnancy & Birth
A female relative may be the birth attendant.

Stoicism is encouraged during labor & delivery. Mother & infant may stay inside and rest for 20 days post partum, or until the umbilical cord falls off, depending upon custom. Some may want to save the umbilical cord, because it may be seen as having spiritual value.

Pediatric
In some tribes, long, thick hair is the sign of a healthy child; cutting it is taboo and believed to lead to illness or even death. Check with the family before cutting a child’s hair.

Teen pregnancy rates are high and may be more culturally acceptable than in other populations.

End of Life Issues
Some tribes may prefer to avoid discussion of a terminal prognosis or DNR since negative thoughts are believed to hasten death. Others will use the information to make appropriate preparations.

Some tribes may avoid contact with the dying, while others will want to be at the bedside 24 hours a day. Visitors may display a jovial attitude so as not to demoralize patient. Mourning is done in private, away from the patient.

After death, wailing and shrieking may occur.

Some may want to leave a window open for the soul to leave at death; others may orient the patient’s body to a cardinal direction before death.

Health Related Practices
Before cutting or shaving hair, check to see if the patient or family wants to keep it. Realize that in some tribes, cutting hair is associated with mourning.

A medicine bag may be worn. Do not treat it casually or remove it without discussing it with the patient. If it is absolutely necessary to remove it, allow a family member to do so, keep it as close to the patient as possible, and return it as soon as possible.

Food which is blessed (via traditional religion or Christianity) may be thought to be devoid of harm. Nutritional guidance should take this into account. Many traditional foods are high in fat.

Similarly, tobacco is seen as sacred and has important ceremonial use in some tribes. This can be challenging when trying to provide counseling against smoking.

Traditional healers may be combined with the use of Western medicine. Allow traditional healers to perform rituals whenever possible. Do not touch or casually admire ritual objects.

Note: the material contained in this profile is adapted from Kramer, J. (1996) American Indians. In JG Lipson, SL Dibble, and PA Minarik (Eds.), Culture and Nursing Care: A Pocket Guide (pp. 11-22). San Francisco: UCSF Nursing Press.

Caution: These are broad generalizations and should not be used to stereotype any individuals. They are most applicable to the least acculturated members.

Communication
Provide frequent updates on patient treatments and progress to help allay the anxiety of family members. They may expect nurses to be friendly, warm, caring, and to “feel” for them.

They may speak loudly and seem abrasive. This was likely necessary in Russia to get attention in the healthcare system.

Make direct eye contact, be firm, and be respectful. Address patients as “Mr.,” “Mrs.,” or “Ms.”

Time Orientation
Most are future-oriented and punctuality is valued. They may arrive early to appointments in an effort to be seen first, or late so as not to waste time waiting.

Pain
Russian patients tend to have a high pain threshold and stoic attitude regarding pain. Coupled with fear of drug addiction, it may be necessary to discuss with them the importance of pain medication. Pre-medicate for dressing changes or daily care that causes discomfort.

Family & Gender Issues
Family members and friends are expected to visit patients in the hospital; they may participate in providing care. Family may want to stay overnight.

The sex of the provider is usually not an issue, but they may prefer to have a family member of the same gender present when performing personal care.

Pregnancy & Birth
Exercise & lifting heavy objects often avoided during pregnancy for fear of harming the unborn child.

A female relative is often the preferred labor & delivery partner.

End of Life
Since family members may want to withhold a fatal diagnosis from the patient, ask patient upon admission (or before the need arises, if possible) how much information they want to be given regarding their condition, or to whom the information should be provided.

Hospice care is generally accepted.

Autopsies and organ donations may be refused due to what may be considered the sacredness of the body.

Health Related Practices
Many, especially the elderly, believe that illness results from cold. Therefore, keep them covered, close windows, keep the room warm, and avoid iced drinks, especially if they have a fever. They may prefer sponge baths to showers.

They may not like taking large numbers of pills. Space medication administration so that as few pills as possible are given at one time.

They may prefer non-pharmacologic interventions for nausea, including lemon slices, ginger ale, mineral water, or weak tea with lemon.

They may practice cupping; resulting marks should not be misinterpreted as abuse or a symptom.

Choosing among various treatment options may be challenging since some patients may be used to a system that offered no choices.

Patients and their families may frequently offer small gifts of food or chocolate. Accept them, as it may be perceived as rude to turn them down.

Note: Information for this profile is based on the work of Peter Anderson, R.N. and from Evanikoff del Puerto, L. and E. Sigal (2005), Russians in J. G. Lipson and S .L. Dibble, eds. Culture & Clinical Care, 415-430. San Francisco: UCSF Nursing Press.

Caution: These are broad generalizations and should not be used to stereotype any individuals. They are most applicable to the least acculturated members. Hindus, Sikhs, and Muslims from India, Pakistan, Bangladesh, Sri Lanka, and Nepal are included in this group.

Values, World View and Communication
Hindus and Sikhs may believe illness is the result of karma, due to actions in a past life. Those who follow Ayurvedic medicine may see it as resulting from an imbalance in bodily humors.

Patients may not express feelings openly, so observe facial expressions closely.

Direct eye contact may be considered rude or disrespectful, especially among the elderly.

Silence often indicates acceptance or approval. With some South Asians, a side-to-side head bob may indicate agreement or uncertainty. An up-and-down nod may indicate disagreement, while acknowledging what the speaker is saying.

Some patients may not want to sign consents, as they may consider health care professionals to be the authorities and thus may prefer to have them make the decisions.

Time Orientation
This group is generally future-oriented. Some, including some Pakistanis, may not be oriented to “clock time.”

Pain
These patients generally tend to be stoic, except during childbirth.

There is a great concern regarding drug addiction and thus there may be a reluctance to take pain medication. When pain medication is necessary, explain why. Muslims may not want narcotics for anything other than severe pain.

Some Pakistani Muslims may prefer injections to pills.

Family & Gender Issues
Women are often modest and may prefer a gown that provides better coverage. Many may prefer female caregivers as well.

Male health care providers should not shake hands with a female unless she offers her hand first.

Close female family members may insist on remaining with the patient. Family members may take over the activities of daily living for the patient, such as feeding, grooming, etc. Because of this, do not insist the patient practice self-care unless medically necessary.

The father or eldest son usually has decision-making power, but generally family members are consulted before decisions are made. Husbands may answer questions addressed to the wife.

Pregnancy & Birth
Pregnant Hindu women are often encouraged to eat nuts, raisins, coconuts, and fruits in the belief that doing so will lead to a healthy, beautiful baby. Dried ginger powder, celery seeds, nuts, and puffed lotus seeds may be given to a new Hindu mother in an effort to cleanse her system and restore her strength.

Moaning and screaming are acceptable during childbirth.

Traditionally, female relatives served as labor partners, though it is becoming more common for the husband to assist.

South Asian women may practice a post-partum lying-in period. While they are expected to feed the baby, everything else is done for them. Traditionally, female relatives take over. If none are around, the patient may expect nurses to do this.

Baby naming may be delayed for a week among Hindu Indians. It should not be misinterpreted as a lack of bonding.

End of Life
When a patient is diagnosed as terminal, family members may wish to shield him or her from that fact. On admission (or before the need arises, if possible) ask patients to identify how much information they want to be given regarding their condition, or to whom the information should be provided.

Most family members will not allow autopsy unless absolutely necessary.

Health Related Practices
Use of home and folk remedies is common, but may not be disclosed to physicians. Explain in a nonjudgmental way that most patients try home remedies first and why it is important you know what self-treatment regimens they have tried.

Sikhs are required not to cut their hair or shave their beards. Their hair will usually be worn in a turban. Consider this before cutting or shaving any hair in preparation for surgery.

Observant Hindus will generally not eat meat or fish; some may not eat eggs. Observant Muslims will not eat pork.

Muslims may not take medications, eat, or drink from sunrise to sunset during the month of Ramadan. This period of fasting, self-sacrifice, and introspection is based on the Islamic calendar, and thus occurs at a different time each year.

Those who practice Ayurvedic medicine (Hindus, Sikhs, and some Muslims) classify food in terms of hot or cold, based on qualities inherent in the food rather than on its temperature. “Hot” foods, including meat, fish, eggs, yogurt, honey, and nuts, are encouraged for “cold” conditions, such as fever or in anticipation of surgery, especially in winter. “Cold” foods like milk, butter, cheese, fruits, and vegetables are encouraged during the summer and for “hot” conditions, including pregnancy.

Note: Some material adapted from Zachariah, R. (2005) East Indians. In J. G. Lipson and S .L. Dibble, eds., Culture and Clinical Care, 146-62. San Francisco: UCSF Nursing Press; Hashwani, S.S. (2005) Pakistanis, in J. G. Lipson and S. L. Dibble, eds, Culture & Clinical Care, 360-374. San Francisco: UCSF Nursing Press; and Rajwani, R. J. (1996) South Asians. In J. G. Lipson, S .L. Dibble, and P. A. Minarik, eds., Culture and Nursing Care: A Pocket Guide, 264-79. San Francisco: UCSF Nursing Press.

Caution: These are broad generalizations and should not be used to stereotype any individuals. They are most applicable to the least acculturated members. People from Cambodia, Laos, and Vietnam are included in this group.

Values, World View and Communication
Keep in mind that many Southeast Asians are refugees who fled to the United States to save their lives rather than simply to improve them.

Many Southeast Asians are Buddhist and believe in reincarnation. Many traditionalists are animists, believing that spirits inhabit objects and places, and that ancestors must be worshipped so their spirits do not harm their descendants. It is not unusual for members of this cultural group to practice Christianity, however.

Modesty is highly valued, and this value may interfere with some screening procedures, such as pap smears and colonoscopies. Clinicians may need to take extra time to explain procedures and to accommodate modesty concerns as best as possible.

Giggling at “inappropriate” times usually indicates nervousness or discomfort.

It may be difficult to obtain an accurate health history from older individuals, as patients were rarely told the name of illnesses, medicines given, or procedures performed.

Time Orientation
A present-time orientation is common, though emphasis on remembering ancestors reflects a past-time orientation as well.

Older, less acculturated members may not be oriented to “clock” time and may thus arrive early or late for appointments.

Pain
This group is generally stoic. Pay attention to nonverbal indications, such as a clenched jaw. Anticipate the need for pain medication, even if a patient does not ask for it, and explain that the doctor ordered it.

Family & Gender Issues
Great respect for elders is common. Adult children are expected to care for their parents.

Among older generations, men are the decision-makers, and either the husband or eldest son (if his father is deceased) may take on the role. Note that the family spokesperson may not be the decision-maker, but merely the one who speaks English.

When a patient is accompanied by relatives, address the eldest person present first—especially if male.

Pregnancy & Birth
Either the mother or the husband may be the preferred labor partner. When asked, they may not give an accurate count of pregnancies because many count only live births.

Some Hmong new mothers may want to take home the placenta for burial.

Pediatric
A baby may not be seen as “human” until several days old—a tradition that probably developed to discourage mothers from bonding too closely in an environment with high infant mortality rates.

The head is the seat of life and is thus considered very personal, vulnerable, honorable, and untouchable (except by close intimates), so avoid putting intravenous lines in an infant’s scalp unless necessary, and then only with explanation.

Some Vietnamese mothers may appear to have difficulty bonding; this is an illusion. If they pay little attention to their newborn, it is probably out of fear that if they call attention to how attractive their infant is, spirits may want to steal the child, which could result in the child’s death.

Children may wear “spirit-strings” around their wrists or “neck rings.” Neither should be cut or removed as some consider these to carry the children’s life-souls.

End of Life
When a patient is diagnosed as terminal, family members may wish to shield him or her from that fact. On admission (or before the need arises, if possible) ask patients to identify how much information they want to be given regarding their condition, or to whom the information should be provided. Be aware that in most parts of Southeast Asia, diagnoses are usually given to the family, who decide whether or not to tell the patient.

Some may believe that at death parents and grandparents become ancestors who should be worshipped and obeyed. Since these ancestors shape the well-being of living descendants, a child (regardless of age) may have trouble agreeing to terminate the care of a parent.

Family may want to wash the body at death and some may want to place a coin in the deceased’s mouth, according to custom.

Hmong may refuse autopsies and organ donations because they believe that whatever is removed from the body will be missing when they are reincarnated.

Health Related Practices
Patients (especially rural non-Christians) may fear surgery because many believe that souls are attached to different parts of the body. They may feel that a surgical procedure might sever this connection, thus causing illness or death. Some may believe that if the body is cut or disfigured or parts are amputated, the patient will remain in a state of imbalance for life. This may be thought to trigger frequent illnesses and render the person physically incomplete in his or her next incarnation.

Some Hmong believe that when people are unconscious their souls can wander, so anesthesia is dangerous.

Some believe that verbal statements in and of themselves can cause illness or death, and for this reason may not want to discuss potential risks and dangers. Less acculturated patients may want to consult a shaman.

Therapies like cupping and coining (or “coin rubbing”) are traditional remedies, not forms of abuse. So ascertain how and why any observed markings on a patient’s body were made before reporting them.

Some patients may have concerns about blood being drawn. They may fear it will sap their strength, cause illness, force their souls to leave their bodies, or that it will not be replenished. If a patient is anxious, ask about his or her concerns so they can be addressed.

Note: Information for this profile was adapted from several sources, including Kulig, J.S. and S. Prak (2005) Cambodians (Khmer), in J. G. Lipson and S. L. Dibble, eds, Culture & Clinical Care, 63-84. San Francisco: UCSF Nursing Press; Johnson, S. K. and A.L. Hang (2005) Hmong, in J. G. Lipson and S. L. Dibble, eds, Culture & Clinical Care, 250-263. San Francisco: UCSF Nursing Press; and Muecke, M. A. (1983) In search of healers: Southeast Asian refugees in the American health care system. WJM 129: 835-40. Additional information on Hmong beliefs was taken from Fadiman, A. (1997) The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York: Farrar, Straus, and Giroux.