Transcultural Health Care: A Culturally Competent Approach, 4th Edition American Indians Alaskan Natives (AI/ANs) Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Amount of Indian blood necessary to be considered a tribal member varies among the tribes—¼ to be a Navajo, which is the largest tribe in United States and live in the Southwest ▪ 556 different tribes in the United States and Canada ▪ Each tribe unique but share similar views regarding cosmology, medicine, and family organization Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Heritage ▪ Forced migration by United States government ▪ Life on MOST reservations is hard with high poverty and high unemployment although a few have significant money due to oil, land leases, gambling casinos, etc. ▪ Children were taken from them and placed in “White Man’s Schools” Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Group, clan, or tribal emphasis Present oriented Time is always with us Age Cooperation Harmony with nature Giving/sharing Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Pragmatic Mythology Patience Mystical Shame Permissiveness Extended family and clan Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Non-aggressiveness Modesty Silence Respect other’s religion Religion is a way of life Land, water, forest belong to all Beneficial, reasonable use of resources Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Low educational levels for most tribes, preferring children to remain at home and learn Indian ways ▪ For the traditional, health care is an undesirable profession because one should not work with the dead or ill ▪ Navajo sometimes have a special cleansing ceremony to allow them to work in a hospital Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Language and dialect vary by tribe, but most speak English and in the southwest many speak Spanish instead of English ▪ Minor variations in pronunciation can change the meaning of the word ▪ Talking loudly or interrupting someone is considered rude Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Navajos generally do not share thoughts and feelings easily outside family and friends, making it difficult to obtain trust in the healthcare setting ▪ Comfortable with long periods of silence ▪ Touch is unacceptable unless you know the person very well Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ No set pattern for willingness to share tribal ceremonies ▪ Pueblo groups usually do not share any tribal ceremonies ▪ Light passing of the hands for a handshake ▪ Considered rude to point with the finger; instead shift your lips in the desired direction Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Direct eye contact is rude and confrontational—deadpan facial expression ▪ Proximity for conversations usually greater than 24 inches ▪ Time sequence is present, past, and future Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ The future is out of one’s control. ▪ Very few are future oriented and for the Navajo there is no future verb tense ▪ Time is not something that can be controlled, nor should time control the person; events start when the people arrive Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Navajo, like most Native Indian tribes, is matrilineal in decision-making and land rights ▪ Relationship between brother and sister is more important than that between husband and wife ▪ Children's names are not revealed at birth Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Older people are addressed as grandmother, grandfather, mother, father, or a nickname. ▪ Algonquin are egalitarian society ▪ Dene and Athabascan are patriarchal ▪ Navajo, Iroquois, Pueblos, and Haida are matriarchial societies Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ AI/AN naming traditions vary greatly from tribe to tribe and are frequently determined by nature, animals, or character. ▪ In the past, AI/AN women practiced breastfeeding exclusively. ▪ Since the early to mid-1980s, the use of formula has become popular. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ A primary social premise is that no person has the right to speak for another. ▪ Parents are permissive in childrearing practices and may allow a child decide whether if not go to school or take medicine. ▪ Ceremony plays a vital, essential role in AI/ANs everyday life. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ When a couple marries in the Pueblo tribes, the man goes to live in the woman’s house. ▪ In Navajo tradition, families have separate dwellings but are grouped by familial relationships. ▪ The Navajo family unit consists of the nuclear family and relatives such as sisters, aunts, and their female descendants. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ In all American Indian and Alaska Natives extended family members play an important role in the infants’ life. ▪ Older adults are looked on with clear deference ▪ Elders play an important role in keeping rituals and in instructing children and grandchildren. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Social status is determined by age and life experiences. ▪ Among the Pueblos governors are chosen from a particular clan; unless one is born in the clan they cannot run for tribal governor. Generally, individuals are discouraged from having more possessions than their peers, and those who display more material wealth are ignored. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Standing out is not encouraged among the different tribal groups. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Many AI/ANs remain traditional in their practice of religious activities. Family matters are more important than work, resulting in high rates of absenteeism. ▪ In addition, tribal ceremonies are seen as necessary and they often must take time from work or school. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Tribal members in the community function informally as cultural brokers and assist by helping non– American Indian staff to understand important cultural issues. ▪ Conflict is addressed indirectly through third parties in some tribes Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Group activities are an important norm in AI/AN cultures. ▪ One individual should not be singled out to answer a question because the student’s mistakes are generally not forgotten by the group. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Issues of superior-subordinate roles exist and are related to age. ▪ IHS is the only organization allowed to discriminate in hiring practices; it is required to hire an AI/AN when possible. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck AI/AN tribes and clans are a. Patriarchal. b.Matriarchal. c. Egalitarian. d.Depends on the tribe and clan. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: D Some tribes and clans are patriarchal, some are matriarchal, and some are more egalitarian. Variations exist within the tribe and clan as well. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Skin color among AI/ANs varies from light to very dark brown, depending on the tribe. ▪ Each of the American Indian tribes vary in terms of facial features and height. ▪ Never assume that an AI/AN patient is from a particular tribe, if wrong, he or she will be offended. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Historically, most diseases affecting AI/ANs were infectious such as tuberculosis, smallpox, and influenza. ▪ Diseases of the heart, malignant neoplasm, unintentional injuries, diabetes mellitus, and cerebrovascular disease are the top five leading causes of AI/AN deaths Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Type 1 diabetes mellitus is almost nonexistent in AI/ANs but type 2 diabetes mellitus is the third most prevalent chronic disease affecting all AI/AN tribes. ▪ The incidence of diabetes varies among tribes has steadily increased and is approaching 30 percent. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Albinism occurs in the Navajo and Pueblo tribes. ▪ Navajos who lived in Rainbow Grand Canyon are genetically prone to blindness that develops in individuals during their late teens and early 20s. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ The Zunis have an incidence of cystic fibrosis seven and one-half times that found for Caucasians. ▪ Methamphetamine (meth) abuse and suicide are two top concerns in Indian country. ▪ Suicide rates among American Indians and Alaska Natives (AI/ANs) are 1.7 times higher than the national average. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Alcohol use is more prevalent than any other form of chemical misuse. ▪ Many accidents are attributed to driving while under the influence of alcohol. ▪ Spousal abuse is common and frequently related to alcohol use. The wife is the usual recipient of the abuse, but occasionally, the husband is abused. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Food has major significance beyond nourishment in AI/AN populations. ▪ Food is offered to family and friends or may be burned to feed higher powers and those who have died. ▪ Life events, dances, healing, and religious ceremonies evolve around food. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Corn is an important staple in the diet of American Indians. ▪ Rituals such as the green corn dance of the Cherokees and harvest-time rituals for the Zuni surround the use of corn. ▪ Corn pollen is used in the Blessingway and many other ceremonies by the Navajo. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Each tribe has its own version of fry bread. ▪ Access to fresh fruits and vegetables is minimal during wintertime. ▪ AI/AN diets may be deficient in vitamin D because many members suffer from lactose intolerance or do not drink milk. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Traditional AI/ANs do not practice birth control and often do not limit family size. ▪ In Apache and Navajo tribes, twins are not looked on favorably and are frequently believed to be the work of a witch. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Some want their blood and urine specimens returned to them upon discharge. ▪ Many use herbs during labor and delivery. ▪ A ceremony may be performed by the medicine man during labor and delivery. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Be flexible with positioning for delivery. ▪ Some may want the umbilical cord, meconium, and afterbirth. ▪ Some may use peyote during labor and delivery. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The most common form of substance abuse among AI/ANs is a. Alcohol. b.Peyote. c. Marijuana. d.Methamphetamine. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer The most common substance abuse among AI/AN tribes is alcohol which is 1.7 times higher than other groups who have been studied. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Most AI/AN tribes believe that the souls of the dead pass into a spirit world and became part of the spiritual forces that influenced every aspect of their lives. ▪ Today some tribes maintain their traditional practices but use a mortuary or use the IHS morgue to prepare their dead. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The Pueblo tribes prepare their own dead and only certain family members are allowed to prepare the body. ▪ Hopis bury their dead before the next setting of the sun and bury them in upright sitting positions with food and goods in the grave with the person. ▪ After the Zuni burial, the members must take off three days from work for a cleansing ceremony. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The body must go into the afterlife as whole as possible. ▪ In some tribes, amputated limbs are given to the family for a separate burial and later the limb is buried with the body. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ In some tribes, family members are reluctant to deal with the body because those who work with the dead must have a ceremony to protect them from the deceased’s spirit. ▪ In the Navajo, if the person dies at home, the body must be taken out of the north side of the hogan and a ceremony conducted to cleanse the Hogan or it must be abandoned. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Older adults are reluctant to discuss advance directives once they discover what it means. ▪ Effective discussions require that the issue be discussed in the third person, as if the illness or disorder is happening to someone else. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ If a provider makes a statement such as “if you don’t get medical care, you will die,” this implies that the provider wishes the client dead. ▪ If the patient does die or is extremely ill, the provider might be considered a witch. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The Navajo are not generally open in their expression of grief; they often will not touch or pick up the body or prepare the body for burial. ▪ Grief among the Pueblo and Plains Tribes are expressed openly and involves much crying among extended family members Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ AI/AN religion predominates in many tribes. ▪ When illnesses are severe, consultations with appropriate religious organizations are sought. ▪ Sometimes, hospital admissions are accompanied by traditional ceremonies and consultation with a pastor. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ AI/AN tribal traditional members start the day with prayer, meditation, and corn pollen. ▪ Prayers ask for harmony with nature and for health and invite blessings to help the person exist in harmony with the earth and sky. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ The meaning of life for AI/ANs is derived from being in harmony with nature. ▪ The individual’s source of strength comes from the inner self and depends on being in harmony with one’s surroundings. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Spirituality cannot be separated from the healing process in ceremonies. ▪ Illnesses, especially mental illnesses, result from not being in harmony with nature, from the spirits of evil persons such as a witch, or through violation of taboos. ▪ Healing ceremonies restore an individual’s balance mentally, physically, and spiritually. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Traditional AI/AN beliefs influence biomedical healthcare decisions. ▪ asking patients questions to make a diagnosis fosters mistrust. ▪ This approach is in conflict with the practice of traditional medicine men, who tell people their problem without their having to say anything. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ IHS has attempted to shift its focus from acute care to health promotion, disease prevention, and chronic health conditions. ▪ Wellness-promotion activities include a return to past traditions such as running for health, avoiding alcohol, and using purification ceremonies. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Medicine men, diagnosticians, crystal gazers, and shamans tell them how to restore harmony. ▪ Many families do not have adequate transportation and must wait for others to transport them to their appointments. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Frequently, pain control is ineffective because the intensity of their pain is not obvious to the health-care provider because patients do not request pain medication. ▪ Herbal medicines may be preferred and used without the knowledge of the health-care provider. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Mental illness is perceived as resulting from witches or witching (placing a curse) on a person. ▪ In these instances, a healer who deals with dreams or a crystal gazer is consulted. Individuals may wear turquoise or other items such as a medicine bag to ward off evil. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ The concept of rehabilitation is relatively new to AI/ANs because, in years past, they did not survive to old age to which chronic diseases became an issue. ▪ Autopsy and organ donation are becoming a little more accepted among traditional AI/ANs. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ AI/AN healers are divided primarily into three categories: those working with the power of good, the power of evil, or both. ▪ Some are endowed with supernatural powers, whereas others have knowledge of herbs and specific manipulations to “suck” out the evil spirits. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ Health-care providers must be careful not to open medicine bags or remove them from the patient. ▪ These objects contribute to patients’ mental well-being, and their removal creates undue stress. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ Treatment regimens prescribed by a medicine man not only cure the body but also restore the mind. ▪ Individuals living off reservations frequently return to participate in this ceremony, which returns them to harmony and restores a sense of well-being. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Vietnamese Americans Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Vietnam is a long narrow country that would stretch from Minneapolis to New Orleans ▪ Majority are closely related to the Chinese ▪ Over 1,200,000 Vietnamese in the United States Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ 1975 Vietnamese War brought 130,000 to the US and mainly came from urban areas and had some familiarity with Western lifestyles and thus adjusted well in the United States ▪ A quarter million more left in 1978–1979 because of the communist regime in Vietnam and became the “boat people” for the next 10 years Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Many remained in squalid concentration camps for years ▪ Later immigrants were less educated, poorer, and came from rural areas of Vietnam and came without their families intact Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Third wave—Orderly Departure Program– provided safe and legal family repatriation in the United States ▪ Fourth wave in 1987—Amerasian Homecoming Act brought military families, political detainees, children of American servicemen, and more women Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Place high value on education and the teacher is well respected ▪ Educational system in Vietnam emphasizes observation, memorization, and repetitive learning ▪ Some continue to experience discrimination in the United States Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications ▪ Vietnamese has several dialects, all of which are understandable to each other but not with other Indochinese countries ▪ Similar in structure to Chinese with borrowed words, polytonal, and one syllable ▪ Only Asian language that uses the English alphabet Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Language translations are not easily and directly translatable—in any language ▪ Blue and green are the same work ▪ No way to say “no,” only “yes” ▪ Hot and cold are not related to temperature but to perceived bodily imbalances that are called am and duong Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Words used in the affective domain are always difficult to translate in any language ▪ Expressing emotions is considered a weakness, and thus may revert to physical symptoms to describe emotional stress ▪ Caution on touching the head, do not put your feet up and bare the soles of your feet, and do not point or beckon with the upturned finger Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Men greet each other with a handshake, but not women or men and women ▪ Men can walk hand in hand as can women without a sexual connotation ▪ Direct eye contact, especially with those in a perceived higher status position, is deemed disrespectful Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Most are present oriented with many becoming more futuristic as they acculturate ▪ Punctuality depends on occupation and educational level and language ability ▪ Age is not so important as in the European American culture, age is calculated at time of conception, not birth; use the 10-month calendar, resulting in many given Jan. 1 as a birth date Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Use a family name, middle name, and first name and written in that order ▪ Relatively few family and middle names, with first name having some meaning ▪ Naming procedure can be confusing for Americans so many Vietnamese give the American order of names; thus adding more confusion—just ask if you are unsure. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles ▪ Traditional families are patriarchal and extended resulting in difficulty for some when women are in authority positions ▪ Women make most of the healthcare decisions; otherwise roles are divided by gender ▪ Reversal of roles in the United States may cause family disharmony until adjustment Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Children are an extension of parents and are expected to be obedient and respectful of elders ▪ Grandparents take a significant role in rearing the grandchildren ▪ Permissive US lifestyle with teenagers and dating can cause family disharmony Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Eldest male has the responsibility for parents to the extent that it is more supreme than his responsibility to his wife and children ▪ Elders may feel alone and be depressed with clash of values from their home country and the United States culture ▪ To smile in the face of diversity is demonstrative of strong moral character Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Lesbian and gay relationships are not discussed —carry a significant stigma for most ▪ Pseudofamilies are formed by gender groups in the United States in order to share resources and improve economic status Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Variations in skin color requiring different assessment techniques than for white-skinned people ▪ Small in stature compared with European Americans with narrower shoulders and wider pelvic structure ▪ Published growth charts are not accurate for Vietnamese—and other groups Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology Continued ▪ Sparse body hair, few apocrine glands, 40% have palatine tori, flat nose bridge causing more difficulty in fitting eye glasses ▪ Betel nut pigmentation among older women from chewing betel leaves ▪ High rates of depression and anxiety-related disorders—especially post-traumatic stress syndrome Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology Continued ▪ High rates of malaria, Tbc, parasitosis, hepatitis B related to the tropics, refugee camps, and crowded living conditions ▪ New arrivals should also be screened for round worm, whipworm, liver flukes, trichinosis, scabies, lice, and impetigo Transcultural Health Care: A Culturally Competent Approach, 4th Edition Drug Metabolism ▪ More sensitive than other groups to propranolol, atropine, diazepam, and psychotropics—beyond body size ▪ More sensitive to the effects of alcohol ▪ Many adults and some children have lactose intolerance Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-Risk Behaviors ▪ Lower socioeconomic rural immigrants may not be aware of tobacco causing cancer or aware for the need of health screening and breast exams and pap smears ▪ High rates of liver and gastrointestinal cancer and “sudden unexplained death syndrome” ▪ Low use of alcohol, tobacco, and recreational drugs Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-Risk Behaviors Continued ▪ Reliance on family for healthcare may mean the illness is more severe when seeking health care ▪ Some may not trust healthcare providers based on situations in refugee camps ▪ Usually have great respect for all healthcare providers Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ ▪ ▪ ▪ ▪ Meal time is a family affair Holidays usually have special foods and dishes Smaller body size means few calories required White rice is the main staple Wide variety of fruits, vegetables, and meats Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Ascribe to the hot (duong) and cold (am) theory of foods requiring different foods for certain illnesses—varies by region of migration so just ask and they will tell you. ▪ Traditional diet may be high in sodium and in the United States low in calcium and high in fat Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Women have children over a longer period of time than European Americans ▪ Abortions common in Vietnam—great stigma to have a child out of wedlock ▪ Many are not familiar with birth control methods in the United States ▪ Women over the age of 40 have an average of 6 abortions and 4 pregnancies Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Specific food practices to have a healthy pregnancy and baby and to balance equilibrium in each trimester of pregnancy ▪ Maintain non-strenuous physical activity to prevent miscarriage, have a healthy and small baby, and quick delivery ▪ Prolonged labor if idle, afternoon napping can cause a large baby Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Invasive procedures during labor are disliked and feared ▪ Many prefer squatting position for birthing ▪ Touching the head can cause distress because the soul resides here ▪ Specific postpartum rituals that vary among rural and urban Vietnamese Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Older women assume responsibility for the baby’s care ▪ Caution on praising the child because jealous spirits will steal the child ▪ Cutting child’s hair or nails can cause an illness Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Death is a normal part of life ▪ Reincarnation and ancestral spirits support the sometimes stoicism seen with death ▪ Prefer to die at home without extensive lifeprolonging measures ▪ May buy casket in advance Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck A Vietnamese friend tells you she balances her food choices according to hot and cold properties. In Vietnamese, the words for hot and cold are a. Yin and yang. b. Am and duong. c. Fret and cho. d. Garm and sard. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: B The Vietnamese words for hot and cold for balancing foods are am and duong. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals Continued ▪ Gather around dying person and express great emotion ▪ Call religious leader only at the request of the family ▪ Flowers are reserved for the rites of the dead ▪ Family wears white for 14 days after death, followed by black arm bands for men and white headbands for women Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Buddhism, Confucianism, and Taoism are the majority ▪ Animism by a few from highland areas of Vietnam ▪ Some may maintain a religious altar in the home ▪ Family is the main reference point throughout life Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices ▪ Good health is achieved by having harmony and balance with the am and duong—an excess of either one may lead to discomfort or illness ▪ Illness can be naturalistic or supernaturalistic ▪ Traditional medicine depends on northern or southern Vietnamese ancestry Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Many fear any invasive procedure ▪ Believe that body fluids cannot be replaced ▪ May discontinue any medicine that causes side effects ▪ Most are reluctant to take medicine on a longterm basis Transcultural Health Care: A Culturally Competent Approach, 4th Edition Responsibility for Health Care ▪ Family care for ill member in the hospital in Vietnam and may wish to do so in the United States ▪ Crisis-oriented care in Vietnam ▪ Many believe Western medicine is too powerful for Vietnamese and therefore say they will take the medicine and then either do not or only take part of it Transcultural Health Care: A Culturally Competent Approach, 4th Edition Common Vietnamese Treatments ▪ ▪ ▪ ▪ ▪ ▪ ▪ Cai gio Be bao or bar gio Giac Zong Moxibustion Acupuncture, acupressure, acumassage Multiple herbal therapies Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cai gio ▪ “Rubbing out the wind” is used for colds, sore throats, flu, sinusitis, etc. ▪ Ointment or hot balm is spread across the back, chest, and/or shoulders and rubbed with the edge of a coin ▪ Dermabrasion procedure to let out bad wind as the blood is brought to the surface Transcultural Health Care: A Culturally Competent Approach, 4th Edition Be bao or bar gio ▪ “Skin pinching” for headaches or sore throat ▪ Produce ecchymosis and petechiae ▪ Very specific technique Transcultural Health Care: A Culturally Competent Approach, 4th Edition Giac ▪ Cupping or cup suction ▪ Dermabrasion procedure to relieve stress, headaches, joint and muscle pain ▪ Small metal or glass cup is heated by placing wormwood or cotton saturated with alcohol and set afire ▪ Cup forms a suction as it is turned upside down on the skin and then removed, leaving large ecchymotic round areas Transcultural Health Care: A Culturally Competent Approach, 4th Edition Zong ▪ An herbal preparation relieves motion sickness or cold-related symptoms ▪ Ointment or herbs are put in boiling water and then inhaled. Can be purchased commercially. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Moxibustion ▪ Used to counter conditions associated with excess cold, including labor and delivery ▪ Pulverized wormwood or incense is heated and placed directly on the skin along certain meridians Transcultural Health Care: A Culturally Competent Approach, 4th Edition Acupuncture, Acupressure, Acumassage ▪ Used for a wide variety of conditions and illnesses—some of which have been proven scientifically—especially for some pain conditions ▪ Needles, pressure, or massage along the Qi channels of energy flow Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The parents of a two year old bring her to the ER because of a persistent productive cough. The nurse finds several quarter-sized ecchymotic area on the child’s back. The nurse recognizes these marks as a. Cai gio b. Be bao or bar gio c. Giac d. Zong Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C Giac, cupping, leave round ecchymotic areas when the cup is removed. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Turkish Culture Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Türkiye, as it is written in Turkish, means “land of Turks.” Referred to as a geographic, religious, and cultural crossroads, the Republic of Türkiye is situated at the geographic intersection of Europe, Asia, the Middle East, and Africa. ▪ While Turks have emigrated throughout the world, many live in Western Europe, largely as a result of “guest worker” programs. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Today, the Republic of Türkiye is politically stable and continues to adapt economically to reforms. ▪ Türkiye remains strategically important to the West and is a strong ally of the United States. ▪ The Turkish immigrant population in the US differs significantly from most of the Turkish population in Europe, both in terms of demographic makeup and socioeconomic status and integration. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Over 202,000 people of Turkish descent live in the United States. ▪ They live in 42 states, with over half living in New York, California, New Jersey, and Florida. ▪ Just over half of the individuals in this group were born outside the United States. ▪ Most arrived in the US before 1980. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ A high proportion of Turks in the United States come from the elite and upper-middle classes, interspersed with smaller groups of middle-class students and skilled laborers who are supported privately or by the government. ▪ Many Turks sought advanced American education in highly technical fields, leading to more abundant employment opportunities in the United States upon completion of their studies. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ A Uralic-Altaic language, Turkish is spoken by 90% of the population and has approximately 20 dialects. ▪ Differences in some of the dialects are so great that they are considered different languages. ▪ The Turkish alphabet is much like the English alphabet, although it does not have a “w” or an “x” and additional sounds are symbolized by an diacritical mark over vowels. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ The Turkish language does not distinguish gender pronouns (ie, “he” from “she” or “her” from “his.”) Therefore, Turks when learning English may inadvertently confuse these pronouns. ▪ Turkish distinguishes a formal from an informal “you,” signifying the importance of status in Turkish society. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Speaking in loud voices is common; this does not always signify anger but rather excitement or deep involvement in a discussion. ▪ More than one person may speak at the same time or interrupt another person; this is not necessarily considered rude. ▪ However, someone of lower status should not interrupt someone of higher status. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Group affiliation is valued over individualism in Turkish society. In fact, identity may be determined by family membership or group, school, and work associations. ▪ Turks generally do not desire much privacy and tend to rely on cooperation between family and friends, although competition between groups can be fierce. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turks value harmony over confrontation. ▪ The outward show of feelings is less restrained. ▪ For women, expressions of anger are usually acceptable only within same-sex friendships and kinship networks or toward those of lower social status. ▪ Generally, women are not free to vent their anger toward their husbands or other powerful men. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Touching, holding hands, and patting one another on the back are acceptable behaviors between same-sex friends and opposite-sex partners. ▪ Same-sex friends, especially among the older generations, are commonly seen holding hands or linking arms while walking. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Very strict Muslims may not shake hands or touch members of the opposite sex, especially if they are not related. ▪ When interacting with someone of higher status, one is expected to maintain occasional eye contact to show attention; however, prolonged eye contact may be considered rude, or may be interpreted as flirting. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turkish people tend to dress formally; men wear suits rather than sports jackets and slacks on social occasions. ▪ Women tend to dress modestly, wearing skirts and dresses rather than slacks. More traditional Muslim women may wear very modest clothing and cover their heads with a scarf, either black or a colorful print. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ However, styles continue to change, and denim jeans and casual dress are becoming common among young people for less formal occasions. ▪ Turks openly display emotions such as happiness, disgust, approval, disapproval, and sadness through facial expressions and gestures. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ No” is indicated by raising the eyebrows or lifting the chin slightly, while making a snapping or “tsk” sound with the mouth. ▪ Appreciation may be expressed by holding the tips of the fingers and thumb together and kissing them and is commonly used to express appreciation for food. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turkish people take pride in keeping their homes immaculately clean, and one is expected to remove one’s shoes inside the home. ▪ Most Turkish hosts in Türkiye and many in the United States offer slippers to their guests. ▪ Whether wearing shoes or not, showing the sole of one’s foot is considered to be offensive in Turkish culture. ▪ Women are expected to sit modestly with knees together and not crossed. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turks tend to have a relaxed attitude about time; social visits can begin late and continue well into the night. ▪ While punctuality in social engagements is not highly important, in business relationships, punctuality among Turkish Americans is gaining in importance. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turks value status and hierarchy. Demonstrating respect for those of higher status is mandatory and determines the quality of interactions with a person. ▪ Strangers are always greeted with their title, such as Bey (Mr.), Hanim (Mrs., Miss, or Ms.), Doktor, or Profesör. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ When friends or family members greet, it is customary for each to shake hands and to kiss one another on each cheek. ▪ Traditionally, when greeting someone of very high status or an elderly person, one might grasp his or her hand and kiss it, and then bring it to touch one’s forehead in a gesture of respect. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ In a very traditional Turkish home, the father is considered the absolute ruler. ▪ The concept of izin (permission or leave to do something specific) captures this significance. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Less traditional families show more equality between spouses, especially in nuclear families in which the wife is well educated. ▪ Yet, remnants of traditional family structure prevail; the husband often acts as the ultimate decision maker, especially in financial matters. ▪ Women may work full time outside the home in addition to assuming full responsibility for running the daily activities inside the home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Legal marriage in Türkiye does not permit polygamy, although some may practice it outside. ▪ A woman’s age, and the number, age, and gender of her children influence her status in the family and the community. A young “gelin” (woman age 15 to 30) has the lowest status. The “middle-aged” woman (30 to 45) has medium status while the “mature” woman (45 to 65) has the highest status. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ In “old age” (65 or older), a woman is highly respected but is not powerful. ▪ However, this status varies according to education, religious practice, socioeconomic level, urbanization, and professional achievement. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Children are held very dear in the Turkish family and they are expected to act as young children, not small adults. ▪ They are accustomed to receiving attention from family, friends, and visitors. ▪ Kissing children and pinching their cheeks is quite common. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Once children enter school, they are expected to study hard, show respect, and obey their elders, including older siblings. ▪ Girls are expected to help care for younger siblings, to help at mealtimes, and to learn to cook. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Traditionally, children are not allowed to act out or talk back to their superiors. ▪ Light corporal punishment is generally acceptable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Male circumcision is a major rite of passage. ▪ This is a time of celebration within the extended family, and newly circumcised boys are honored with gifts. ▪ Traditionally, boys can be circumcised up to the age of about 12, although the modern trend is to perform the circumcision in the hospital shortly after birth. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Urban adolescents are beginning to date in pairs in addition to the more traditionally accepted practice of group outings. ▪ However, sexual interaction is strongly discouraged among youth and the unmarried, especially for young women. ▪ Virginity in unmarried women is a strong cultural value. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ A key objective among Turks is socioeconomic advancement, including education, better professional opportunities, and material success. ▪ Although financial independence is valued in Turkish culture, independence from the family is not encouraged. ▪ Adult children, especially men, remain an integral part of their parents’ lives, and parents expect their children to care for them in their old age. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Because respect is highly valued in Turkish society, maintaining or improving status in the community is of key importance. ▪ Individuals must always consider what impact their actions will have on the family and often they consult parents or other family members before making major decisions. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Young people living in Türkiye generally live in their parents’ home until they are married, unless school or work necessitates other arrangements. ▪ Family-initiated marriages range from rare contractual agreements between parents to the relatively common introduction and gentle encouragement of a newly formed couple. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Elders in Turkish culture are attributed authority and respect until they become weak or retired, at which time their authoritative roles diminish. ▪ Individuals are socialized to take care of elderly parents, regarding it as normal and not as an added burden. ▪ Grandparents play a significant role in raising their grandchildren, especially if they live in the same home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ The extended family is very important in Turkish culture. ▪ Even the apparent increase in nuclear households does not rule out the networks among closely related families. ▪ Whether or not they live under the same roof, a young family may still live under the supervision of the husband’s parents or at least maintain an interdependent relationship. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Divorce is becoming more common in Turkish society, but remains socially undesirable. ▪ Widows, however, are generally taken care of by their late husband’s family and, depending on their age and socioeconomic background, may have the option to remarry. ▪ Premarital cohabitation and unwed motherhood is strongly discouraged. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Homosexuality is only beginning to be received “at a distance.” In fact, one of the most popular entertainers in Türkiye is a homosexual and a transvestite and is accepted as such. ▪ However, most Turks would be hesitant to associate themselves with the gay community. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Because Türkiye is a group-oriented culture, the Turkish workplace may be more team oriented. ▪ Turkish relationship orientation may lead to dependence on personal contacts and networks to accomplish tasks. ▪ Developing these relationships and networks may appear as nepotism or as too much socializing from the American perspective. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Hierarchical structure is highly pervasive throughout Turkish culture, and the workplace is no exception. ▪ Turkish employees expect an authoritative relationship between superior and subordinates. ▪ However, indirect criticism is expected and appreciated to “save face.” Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ A Turk may be highly offended if openly criticized, especially if done in front of other people. ▪ They may be reticent about asking questions for fear of exposing a lack of knowledge. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Turks perceive that aggressive face-to-face confrontation may cause relationships to deteriorate. ▪ The dominant means of conflict resolution is collaboration reinforced by compromise and forcing. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues Many women do not work because it interferes with child care, the order of the home, and it requires them to be together with men from outside the immediate family. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Turkish population is a mosaic in terms of appearance, complexion, and coloration. ▪ Appearances range from light-skinned with blue or green eyes to olive or darker skin tones with brown eyes. ▪ Mongolian spots, usually found at or near the sacrum, are common among Turkish babies and should not be confused with bruising. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Malaria has not been fully eradicated in Türkiye, especially in the southeast. ▪ Endemic goiter associated with iodine deficiency is a major health problem in Türkiye. ▪ Behçet’s disease, a syndrome of unknown etiology, is prevalent in Mediterranean countries, the Middle East, and Japan and primarily affects males between the ages of 20 and 40. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Common health conditions among Turks are lactose intolerance, thalassemia, cardiovascular diseases, cancer, obesity, hypertension, diabetes, tuberculosis, and conditions related to high smoking rates among men and women. ▪ The most prevalent food- and water-borne diseases are infectious hepatitis and sporadic cases of salmonellosis and dysentery. Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-risk Health Behaviors ▪ Cigarette smoking is widespread in Türkiye and tends to start at an early age. Türkiye, a major producer of tobacco in the world, has instituted very limited anti-tobacco activities. ▪ Turks tend to consume less alcohol than Americans or Europeans, perhaps as a result of the Muslim culture that discourages more than moderate alcohol use. Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-risk Health Behaviors ▪ The tendency of Turkish men to view themselves as strong/immune to disease and the traditional cultural view condoning male promiscuity increases the danger for both the man and his wife. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Turkish cuisine is influenced by the many civilizations encountered by nomadic Turks over the centuries, as well as by a mixture of delicacies from different regions of the vast Ottoman Empire. Therefore, food choices are varied and tend to provide a healthy, balanced diet. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck A common genetic/hereditary condition among Turks is a. Hemophilia. b. Thalassemia. c. Anemia. d. Sickle cell anemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: B A common genetic/hereditary condition among Turks is thalassemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Tea and a snack is always on hand for visitors, and dinner guests may have difficulty finishing everything on their plates ▪ Turkish hostesses may relentlessly offer to replace what has been eaten. ▪ Polite guests refuse the first offer, but the hungry need not worry; offers are made again and again. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Turkish cooking is not terribly spicy and is prepared artfully and fastidiously, as Turkish appetites tend to be discriminating. ▪ Breakfast is typically a simple meal of white feta cheese (beyaz peynir), olives, tomatoes, eggs, cucumbers, toast, jam, honey, and Turkish tea. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Hot midday or evening meals may include any of the foods described below: ▪ Çorba (soups) range from light to substantial. ▪ Meze (hors d’oeuvres) include a great variety of small dishes, either hot or cold, such as yaprak dolma (stuffed grape leaves in olive oil), olives, circassian or çerkez tavuğu (chicken with walnut sauce), çiroz (dried mackerel), leblebi (roasted chick peas), or sigara böreği (a savory cheese pastry fried until crispy). Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Salads include lettuce, tomatoes, cucumbers, onions, and other raw vegetables with a dressing of olive oil and lemon juice or vinegar. ▪ Olive oil and lemon are staples in Turkish culinary preparation. ▪ Turks generally prepare meat in small pieces in combination with other vegetables, potatoes, or rice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Famous Turkish cuisine includes köfte, small spicy meatballs, and kebab, skewered beef or lamb and vegetables. ▪ While poultry is less common, fish has a special place in Turkish cuisine. ▪ Türkiye is the birthplace of yogurt, which is an essential part of the Turkish diet and is generally served with hot meals rather than as cold breakfast food. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Vegetables are served cooked or raw, hot or cold, as part of a stew or casserole, or stuffed (dolma) with meat, rice, and currants. ▪ Rice and börek are important parts of Turkish culinary tradition. Börek is made by wrapping yufka (thin sheets of flour-based dough) around meat, cheese, or spinach and then frying or baking until the dough is flaky. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Turkish desserts fall into 4 categories: 1. 2. 3. 4. Rich and sweet pastry, such as baklava Puddings Komposto (cooked fruits) Fresh fruits. In fact, most meals are concluded with fresh fruit and coffee or tea. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Turkish kahve, from which the English word coffee is derived, is famous for its dark, thick, sweet taste. ▪ The Muslim religion requires abstinence from eating pork and drinking alcohol, but not all Muslims abstain, depending on their degree of religious practice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ The Islamic tradition of Ramazan, or Ramadan in Arabic countries, is a month of fasting (oruç tutmak) observed by practicing Muslims throughout the world. ▪ During Ramazan, one is not allowed to eat or drink anything from sunrise to sunset as a test of willpower and as a reminder of the preciousness of the food provided by a gracious Allah (God). Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Generally, pregnant and postpartum women, travelers, and those who are ill are excused from fasting but may be required to make up lost time at a later date. ▪ The evening meal, iftar, is something to which all look forward with great anticipation, and Turkish women, who almost invariably do all the cooking, create veritable feasts each night. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Motherhood is accorded great respect, and pregnant women are usually made comfortable in any way possible, including satisfying their cravings. ▪ Pregnant women may continue their daily activities or work as long as they are comfortable. ▪ In traditional Turkish culture one of the most important desires of a married woman is to have a child. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ A woman who has not had a child is faced with social pressure and accusations and thus may try to use some traditional practices to increase fertility. ▪ Some women damage their bodies by using these traditional practices and sometimes the damage is permanent. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ The pregnant woman is always encouraged to keep up her strength by eating foods that are rich in nutrients. ▪ Many pregnant women take prenatal vitamins, drink a lot of milk, and apply salves such as Vaseline to avoid stretch marks. ▪ Light exercise, such as walking, is encouraged. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ It is acceptable, though not common, for the husband and the birth mother’s father to be present during the birthing process. ▪ Expressions of discomfort and pain are quite acceptable. ▪ However, Laz women from the Black Sea area tend to be stoic. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ The postpartum period can last up to 40 days. ▪ Light exercise is encouraged during this period and bathing, an important part of the Muslim tradition, is strongly encouraged. ▪ A special food called log˘usalik is served to the postpartum woman to increase milk production. ▪ Breastfeeding women drink hot soups and other fluids such as milk. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ At birth, a small blue bead called a nazar boncuk, believed to protect the child from the “evil eye,” is usually placed on the child’s left shoulder. ▪ Other traditional practices include placing iron under the baby’s mattress to protect against anemia, tying a yellow ribbon to the crib to ward against jaundice, and placing a red bow on the crib to distract any envy or negativity. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Practices used to make childbirth easier include unlocking places that are open, untying the woman's hair ribbons, unbuttoning buttons, standing straight and turning so the child will move, drinking water that has been prayed over by religious leaders, enclosing the woman around her waist and rocking her three times, and putting her in a blanket and rocking her three times. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Water is not given to a newborn infant until the call to prayer has been announced three times; otherwise, the infant will have bad breath. ▪ At the end of the 40 days, she returns to normal life. ▪ She is bathed with abundant water and prayers are read. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The home health nurse found an iron under the mattress of a two month old baby. The iron prevents the baby from a. The evil eye. b. Thalassemia. c. Anemia. d. Jaundice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C Placing an iron under the baby’s mattress prevents anemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ When death occurs, the deceased individual's next of kin cry in the most natural manner. ▪ Neighbors who hear about the death gather at the home of the deceased to share in the suffering of the next of kin, to console them, and to help with the initial preparations. ▪ Having prayers said is a common practice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Turkish Muslims do not generally practice cremation because the body must remain whole. ▪ Frequently, the body is displayed in the home for a day or two; it is then placed in a coffin and taken to the cami (mosque) to be visited primarily by men. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Preparations for burial include three important procedures: bathing, wrapping in a shroud, and funeral prayers said outside a mosque. ▪ If someone dies in the morning, they are buried after the mid-afternoon prayers; those who die during the night are buried in the morning. ▪ The funeral may be delayed for distant relatives. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Common rituals after death are closing the eyes of the deceased, tying the chin, turning the head towards Mecca, putting the feet next to each other, putting the hands together on the abdomen, and removing clothing. ▪ In some places the bed is changed; a knife, iron or other metal object is placed on the abdomen of the deceased; the Koran is read at the head of the deceased. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ After the burial, a meal honors the deceased, which signifies moving the deceased into the afterlife. ▪ If these rituals are not completed, the spirit of the deceased will be left behind. ▪ The traditional mourning period is 40 days, during which time traditional women may wear black clothes or a black scarf. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Although Muslim Turks believe in the afterlife, death is always an occasion of great mourning. ▪ An expression of sympathy to one who has just lost someone to death is Basiniz sag˘ olsun (may your head be healthy), hoping that one is not overwhelmed with grief. ▪ Mourning is the most important and careful behavior after a death occurs. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Ninety-eight percent of Turks are Muslim, but freedom of religion is mandated by the Turkish secular state. ▪ Most are Sunni Muslims, with a minority from the Alevi Muslim group. ▪ Other religious minority groups include Jews (mostly Sephardic) and Christians. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Traditional prayer is practiced five times each day and can take place anywhere, as long as one is facing the holy city of Mecca. ▪ A special small rug, called seccade, is used for praying. ▪ When entering the cami, shoes are always removed and women must cover their heads. ▪ Men and women go to separate parts of the cami for prayer. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ One prepares for prayer by ritual cleansing called abdest, which, at minimum, includes washing the face, ears, nostrils, neck, hands to the elbow, and feet and legs to the knee, three times each. ▪ A woman does not enter into a religious activity unless she is ritually pure: women who are menstruating or who have recently given birth are excluded. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Turks rely on their religious beliefs and practices and their family and friends for strength and meaning in life. ▪ Spiritual leaders or healers are sought most often for assistance with relationship or emotional problems and, less frequently, for physical problems. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Most Turks rely on Western medicine and highly trained professionals for health and curative care. However, remnants of traditional beliefs continue to have an impact on health-care practices. ▪ A common explanation for the cause of illness is an imbalance of hot and cold. For example, diarrhea is thought to come from too much cold or heat; pneumonia results from extreme cold. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Terminally ill clients are generally not told the severity of their conditions. ▪ Informing a client of a terminal illness may take away the hope, motivation, and energy that should be directed toward healing, or it may cause the client additional anxiety related to the fear of dying and concern about those being left behind. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ In general, women are responsible for the actual care taking of the ill and the elderly in the home. ▪ In traditional households, the mother-in-law or father-in-law, depending on who controls the finances in the family, makes decisions about going to the physician. ▪ The person who is respected as the most educated has primary input into decisions about health care. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Türkiye has one of the highest rates of consumption of over-the-counter antibiotics and painkillers; aspirin is commonly used as a panacea for a variety of ailments, including gastric upset. ▪ Turks commonly consult a pharmacist before visiting a physician. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Using rubbing alcohol or a wet cloth to bring down a fever and warming the back to treat coughing. ▪ Türkiye encourages health tourism at their 1500 thermal spas, which are frequented for treating conditions, such as rheumatism, respiratory and digestive problems, diabetes, skin conditions, gallstones, female diseases, kidney and heart conditions, nerves, obesity, and hyperlipidemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ The concept of the “evil eye” is prevalent. ▪ Speaking too well of one’s health may incur misfortune through others’ envy or nazar. ▪ Cologne is sprinkled on the hands of guests before and after eating to provide cleanliness and a fresh lemon scent. ▪ Inhaling from a cloth or handkerchief doused with cologne may be used for relief from motion sickness. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Turkish culture allows freedom to express pain, either through emotional outbursts or through verbal complaints. ▪ Although stigma is attached to mental illness, many families seek treatment or care for the client at home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Seriously ill people are expected to conserve their energy to allow their minds and bodies to fight their illnesses; thus, reducing their energy expenditure. ▪ During hospitalization, refakatçí refers to the person who stays overnight with the client, providing emotional and physical support and comfort. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Turkish people usually prefer to receive blood from family members. ▪ Muslims traditionally prefer that the body remain intact after death; thus, organ donation and transplantation remains controversial among some Turks. However, former Prime Minister and President Turgut Ozal and his wife promoted organ donation by publicly signing donor cards to encourage others to do so too. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Mr. Oktay, age 66 years, is alert and oriented and has terminal heart failure. His wife does notwant him to know. The nurse should a. Abide my the wife’s wishes. b. Directly tell Mr. Oktay. c. Consult his children. d. Ask Mr. Oktay what he knows about his condition. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer D The first step is to determine what Mr. Oktay knows about his condition. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ When modern medicine is not available, accessible, or affordable, or when it has not worked, Turks may seek the care of a traditional healer. ▪ Physicians, and to a lesser extent nurses and midwives, have historically been held in very high esteem. 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 1 Chapter 38 People of Vietnamese Heritage Susan Mattson and Larry D. Purnell Overview, Inhabited Localities, and Topography Overview Vietnam is located at the extreme southeastern corner of the Asian mainland, bordering the Gulf of Thailand, Gulf of Tonkin, and South China Sea, alongside China, Laos, and Cambodia. With a population of over 90 million in a land mass of 127,330 square miles (CIA World Factbook, 2011), it is relatively narrow in width, but its north–south length equals the distance from Minneapolis to New Orleans. Vietnam consists largely of a remarkable blend of rugged mountains and the broad, flat Mekong and Red River deltas, which mainly produce rice. Other features are a long, narrow coastal plain and other riverine lowlands, where most ethnic Vietnamese live. Much of the rest of the country is covered with tropical forests. Longevity for females is 74.92 years, and for males, 69.72 years. The fertility rate is a low 1.91 children per female (CIA World Factbook, 2011). Heritage and Residence The Vietnamese are a Mongolian racial group closely related to the Chinese. The population shares some characteristics with other Asian and Pacific Islander groups, yet many aspects of its history and culture are unique. Vietnam was under Chinese control from 111 BC to AD 939 (Huer, Saenz, & Doan, 2001). At that time, a variety of Chinese beliefs and traditions were introduced to Vietnam, including the religions and philosophies of Confucianism, Buddhism, and Taoism. In addition, the system of Chinese medicine was adopted widely. European merchants and missionaries arrived in Vietnam during the 16th century, and the French established a political foothold and instituted changes in government and education, including Western medical practices (Huer et al., 2001). The terms Indochinese and Vietnamese are not synonymous. Indochina is a supranational region that includes the countries of Vietnam, Laos, and Cambodia. Vietnam alone has eight different ethnic groups, the majority (86 percent) of whom are Viet (CIA World Factbook, 2011). One factor in providing proper health care to Vietnamese in America is understanding that they differ substantially between and among themselves, depending on the variant cultural characteristics of culture (see Chapter 1in this book). Clear differences exist among Vietnamese, Cambodians, and Laotians with respect to premigration experiences, which influence subsequent manifestations of psychological distress. Along with Asian Indians, Vietnamese immigrants have the highest proportion of children under the age of 18, with a median age of 33, yet the poverty rate is highest for Koreans, Vietnamese, and Chinese (13 percent). Within this population, Vietnamese immigrants have the highest proportion of naturalized citizens (50 percent), with the smallest proportion of those who were foreign born and not U.S. citizens at 21 percent; 30 percent are native born Americans. Forty-nine percent of the immigrants arrived before 1990, and 42 percent came between 1990 and 1999 (Office of Minority Health, 2007). Initial Vietnamese immigrants confronted a unique set of problems, including dissimilarity of culture, no family or relatives to offer initial support, and a negative identification with the unpopular Vietnam War. Many Vietnamese were involuntary immigrants, with their expatriation unexpected and unplanned; their departures were often precipitous and tragic. Escape attempts were long, harrowing, and for many, fatal. Survivors were often placed in squalid refugee camps for years. The first wave of Vietnamese immigration began in April 1975, when South Vietnam fell under the Communist control of North Vietnam and the Viet Cong. At that time, many South Vietnamese businessmen, military officers, professionals, and others closely involved with America or the South Vietnamese government feared persecution by the new regime and sought to escape. American ships and aircraft rescued some; many were temporarily located in refugee camps in Southeast Asia, and then sent to relocation camps in the United States. The 130,000 Vietnamese refugees who arrived in the United States in 1975 came mainly 1 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 2 2 Aggregate Data for Cultural-Specific Groups from urban areas, especially Saigon, and consequently had some prior orientation to Western culture. Many spoke English or soon learned English in relocation centers. More than half were Christian. Sixty-two percent consisted of family units of at least five people, and nearly half were female. They were dispersed over much of the United States, often in the care of sponsoring American families. One year after arrival, 90 percent were employed, and by the mid-1980s, their average income matched that of the overall American population. These first-wave immigrants adjusted well in comparison to the subsequent wave. By the 1970s,further events in Vietnam triggered a second wave of immigration. Many Vietnamese grew disenchanted with Communism and their decreased living standard. Great numbers had been forced into labor in new countryside settlements, and young men were often fearful of being called to fight against China or in the new war with Cambodia. Some left by land across Cambodia or Laos, commonly joining refugees from those countries in an effort to reach Thailand. For more than a decade, many others, known as the “boat people,” departed Vietnam in small, often unseaworthy and overcrowded vessels in hopes of reaching Malaysia, Hong Kong, the Philippines, or another non-Communist port. Half died during their journey. Many were forcibly repatriated to Vietnam or eventually returned voluntarily; others continued to languish in camps for years. Most of the second-wave refugees represented lower socioeconomic groups and had less education and little exposure to Western cultures. Most did not speak English. This wave of Vietnamese included far more young men than women, children, or older people, which disrupted intact families and normal gender ratios. Many spent months or years in refugee camps under deplorable and regimented conditions. The United States passed the Refugee Act of 1980 in response to this second wave and widened the scope of resources available to assist refugees or individuals who fled their native country and could not returen for fear of persecution and physical harm (Huer et al., 2001).When they finally arrived in the United States and Canada, many did not fit into American communities, did not learn English effectively, and remained unemployed or obtained menial jobs. These hardships contributed to physical problems, psychological stress, and depression. The contiuing persecution of individuals in Vietnam led to a third wave of immigration, beginning in 1979 with the creation of the Orderly Departure Program, which provided safe and legal exit for Vietnamese seeking to reunite with family members already in America. Former military officers and soldiers in prison or reeducation camps were allowed to come the United States with their families, resulting in the immigration of 200,000 individuals by the mid-1990s. The Humanitarian Operation Program of 1989 also permitted more than 70,000 current and former political prisoners to immigrate. Finally, the Amerasian Homecoming Act of 1988 allowed the children of Vietnamese civilians and American soldiers to immigrate to the United States. Many of the Amerasian children were orphans who had lived on the street, received no formal education, and had been subjected to prejudice and discrimination in Vietnam (Huer et al., 2001). Reasons for Migration and Associated Economic Factors Vietnamese, whether as immigrants or sojourners, have fled their country to escape war, persecution, or possible loss of life. Better-educated, first-wave immigrants from urban areas had professional, technical, or managerial backgrounds. Less-educated, second-wave immigrants from more rural areas were fishermen, farmers, and soldiers and had only minimal exposure to Western culture. Factors influencing the ability of displaced Vietnamese to obtain employment included a higher level of education and the ability to speak English on arrival. Thus, the second-wave immigrants were significantly more disadvantaged. Educational Status and Occupations Vietnamese place a high value on education and accord scholars an honored place in society. The teacher is highly respected as a symbol of learning and culture. In contrast to American schools’ emphasis on experimentation and critical thinking, Vietnamese schools emphasize observation, memorization, and repetitive learning. This style of learning is still predominant in Vietnam, including the universities with schools of medicine and nursing. Most Vietnamese men and women in America are very educationally oriented and take full advantage of educational opportunities when possible. Educational level and occupation continue to vary by the time of arrival in the United States, as described earlier in the discussion of the four waves of immigration. Communication Dominant Languages and Dialects The official language of Vietnam is Vietnamese, with English increasingly being favored as a second language, followed by French and Chinese (CIA World Factbook, 2011). Ethnic Vietnamese speak a single distinctive language, with northern, central, and southern dialects, all of which can be understood by anyone speaking any of these dialects. The Vietnamese language resembles Chinese and contains many borrowed words, but someone speaking one of these languages cannot necessarily understand the other. All words in Vietnamese consist of a single syllable, although two words are commonly joined with a hyphen to form a new word. Verbs do not change 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 3 People of Vietnamese Heritage forms, articles are not used, nouns do not have plural endings, and there are no prefixes, suffixes, definitives, or distinctions among pronouns. Contextually, the Vietnamese language is musical, flowing, and polytonal, with each tone of a vowel conveying a different meaning to the word. The language is spoken softly, and its monosyllabic structure lends itself to rapidity, but spoken pace varies according to the situation. Whereas grammar is mostly simple, pronunciation can be difficult for Westerners, mainly because each vowel can be spoken in five or six tones that may completely change the meaning of the word. Vietnamese is the only language of the Asian mainland that, like English, is regularly written in the Roman alphabet since it was introduced by the French in the 17th century. Although the letters are the same, pronunciation of vowels may vary radically depending on associated marks indicating tone and accent, and certain consonant combinations take on unusual sounds. When speaking Vietnamese, Westerners in particular will often use “hand signals” to indicate an upward inflection or a mark that should appear with the letter being spoken (personal observation, Mattson, 2005, 2007–2009). Even if someone learns how to pronounce and translate Vietnamese, problems may remain with respect to intended meaning of various words. One minor but perennial stumbling point with potential medical connotations is that the words for “blue” and “green” are the same. More important, the word for “yes,” rather than expressing a positive answer or agreement, may simply reflect an avoidance of confrontation or a desire to please the other person. The terms “hot” and “cold,” rather than expressing physical feelings associated with fever and chills, may actually relate to other conditions associated with perceived bodily imbalances. Various medical problems might be described differently from what a Westerner might expect; for example, a “weak heart” may refer to palpitations or dizziness, a “weak kidney” to sexual dysfunction, a “weak nervous system” to headaches, and a “weak stomach or liver” to indigestion (Muecke, 1983b). Most Vietnamese refugees, even those who have been in the United States for many years, do not feel competent in English. Although many refugees eventually learn English, their skills may not be adequate in certain situations. The important subtleties in describing medical conditions and symptoms, or the more abstract presentation of ideas during psychiatric interviews may be particularly difficult. Health-care providers may need to watch patients for behavioral cues, use simple sentences, paraphrase words with multiple meanings, avoid metaphors and idiomatic expressions, ask for correction of understanding, and explain all points carefully. Approaching Vietnamese patients in a quiet, unhurried manner, opening discussions with small talk, and directing 3 the initial conversation to the oldest member of the group facilitate communication. Cultural Communication Patterns Traditional Vietnamese religious beliefs transmitted through generations produce an attitude toward life that may be perceived as passive. For example, whenever confronted with a direct but delicate question, many Vietnamese cannot easily give a blunt “no” as an answer because they feel that such an answer may create disharmony. Self-control, another traditional value, encourages keeping to oneself, whereas expressions of disagreement that may irritate or offend another person are avoided. Individuals may be in pain, distraught, or unhappy, yet they rarely complain except perhaps to friends or relatives. Expressing emotions is considered a weakness and interferes with self-control. Vietnamese are unaccustomed to discussing their personal feelings openly with others. Instead, at times of distress or loss, they often complain of physical discomforts such as headaches, backaches, or insomnia. Vietnamese tend to be very polite and guarded. Sparing one’s feelings is considered more important than factual truth. The strong influence of the Confucian code of ethics means that proper form and appearance are important to Vietnamese people and provide the foundation for nonverbal communication patterns. For example, the head is a sacred part of the body and should not be touched. Similarly, the feet are the lowest part of the body and to place one’s feet on a desk is considered offensive to a Vietnamese person. To signal for someone to come by using an upturned finger is a provocation, usually done to a dog; waving the hand is considered more proper. Hugging and kissing are not seen outside the privacy of the home. Men greet one another with a handshake but do not shake hands with a woman unless she offers her hand first. Women do not usually shake hands. Two men or two women can walk hand in hand without implying sexual connotations. However, for a man to touch a woman in the presence of others is insulting. Looking another person directly in the eyes may be deemed disrespectful. Women may be reluctant to discuss sex, childbearing, or contraception when men are present and demonstrate this unwillingness by giggling, shrugging their shoulders, or averting their eyes. Negative emotions and expressions may be conveyed by silence or a reluctant smile. A smile may express joy, convey stoicism in the face of difficulty, indicate an apology for a minor social offense, or be a response to a scolding to show sincere acknowledgment for the wrongdoing or to convey the absence of ill feelings. Vietnamese prefer more physical distance during personal and social relationships than some other cultures, but extended Vietnamese families of 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 4 4 Aggregate Data for Cultural-Specific Groups many individuals live comfortably together in close quarters. Temporal Relationships Vietnamese religion and tradition place emphasis on continuity, cycles, and worship of ancestors. Traditional Vietnamese may be less concerned about the precise schedules than are European Americans. To cope with their changed situation, many Southeast Asian refugees concentrate on the present and, to some extent, on the future. Asians frequently arrive late for appointments. Noncompliance in keeping appointments may relate to not understanding oral or written instructions or to not knowing how to use the telephone. One other aspect of time involves the concept of age. Vietnamese people pay much less attention to people’s precise ages than do Americans. Actual dates of birth may pass unnoticed, with everyone celebrating their birthdays together during the Lunar New Year (Tet) in January or February. In addition, a person’s age is calculated roughly from the time of conception; most children are considered to be already a year old at birth and gain a year each Tet. A child born just before Tet could be regarded as 2 years old when only a few days old by American standards. Because the practice of determining age is so different in Vietnam, many immigrants who do not know their exact birth date are often assigned January 1 for official records. When a friend is invited on an outing, the bill is paid for by the person offering the invitation. When giving gifts, the giver often discounts the item, even though it may be of great value. The recipient of a gift is expected to display significant gratitude, which sometimes lasts a lifetime. Some may be reluctant to accept a gift because of the burden of gratitude. Vietnamese may refuse a gift on the first offer, even if they intend to accept it eventually, so as not to appear greedy. Format for Names Most Vietnamese names consist of a family name, a middle name, and a given name of one or two words, always written in that order. There are relatively few family names, with Nguyen (pronounced “nwin”) and Tran accounting for more than half of all Vietnamese names. Other common family names are Cao, Dinh, Hoang, Le, Ly, Ngo, Phan, and Pho. Additionally, there is little diversity in middle names, with Van being used regularly for men and Thi (pronounced “tee”) for women. Given names frequently have a direct meaning, such as a season of the year or an object of admiration. Family members often refer to offspring by a numerical nickname indicating their order of birth. This practice may increase the difficulty of modern record-keeping and identification of specific individuals. Therefore, use the family name in combination with the given name. Indeed, Vietnamese refer to one another by given name in both formal and informal situations. For example, a typical woman’s name is Tran Thi Thu, which is how she would write or give her name if requested. She would expect to be called simply Thu or sometimes Chi (sister) Thu by friends and family. In other situations, she would expect to be addressed as Cô (Miss) or Ba (Mrs.) Thu. If married to a man named Nguyen Van Kha, the proper way to address her would be as Mrs. Kha, but she would retain her full three-part maiden name for formal purposes. The man would always be known as Kha or Ong (Mr.) Kha. Some Vietnamese American women have adopted their husband’s family name. Children always take the father’s family name. Family Roles and Organization Head of Household and Gender Roles The traditional Vietnamese family is strictly patriarchal and is almost always an extended family structure, with the man having the duty of carrying on the family name through his progeny. Some families who are not accustomed to female authority figures may have difficulty relating to women as professional health-care providers, although this is changing in Vietnam. Today there are many physicians, dentists, and pharmcists who are women, with an increasing number of men choosing nursing as a career (personal observation, Mattson, 2007–2009). With the move into Western society, the father may no longer be the undisputed head of the household, and the parents’ authority may be undermined. Immigrant Vietnamese families frequently experience role reversals, with wives or children adapting more easily than men. A Vietnamese woman lives with her husband’s family after marriage but retains her own identity. Within the traditional family, the division of labor is gender related: the husband deals with matters outside the home, and the wife is responsible for the actual care of the home, and often makes health-care decisions for the family. While many Vietnamese and Vietnamese American women work outside the home, they also continue as the primary caretaker of the home. Although her role in family affairs increases with time, a Vietnamese wife is expected to be dutiful and respectful toward her husband and his parents throughout the marriage. Vietnamese refugees of all subgroups have experienced degrees of reversal of the provider and recipient roles that existed among family members in Vietnam. “Women’s jobs,” such as hotel maid, sewing machine operator, and food-service worker, are more readily available than male-oriented unskilled occupations; today more men are employed in these jobs. Role reversals between parents and children are also common because children often learn the English language and American customs more rapidly than their parents 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 5 People of Vietnamese Heritage and therefore, may be able to find employment more quickly. Vietnamese families in the United States experience a greater tendency toward nuclearization, growth in spousal interaction and interdependency, more-egalitarian spousal relations, and shared decision making than their traditional counterparts. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Traditionally, children are expected to be obedient and devoted to their parents, their identity being an extension of the parents. Children are obliged to do everything possible to please their parents while they are alive and to worship their memory after death. The eldest son is usually responsible for rituals honoring the memory and invoking the blessings of departed ancestors. This pattern may be ingrained from early childhood. Vietnamese children are prized and valued because they carry the family lineage. For the first 2 years, their mothers primarily care for them; thereafter, their grandmothers and others take on much of the responsibility. Parents usually do not discipline or place extensive limits on their children at a young age. Generally, Vietnamese do not use corporal punishment such as spanking; rather, they speak to the children in a quiet, controlled manner. Young people are expected to continue to respect their elders and to avoid behavior that might dishonor the family. As a result of their exposure to Western cultures, a disproportionate share of young people have difficulty adapting to this expectation. A conflict often develops between the traditional notion of filial piety, with its requisite subordination of self and unquestioning obedience to parental authority, and the pressures and needs associated with adaptation to American life. Ironically, successful relationships with Americans at school have placed Vietnamese adolescents at risk for conflicts with their parents. Conversely, failure to form such relationships with their American peers has sometimes appeared to be a precursor of emotional distress. Parents do, however, show relative approval for adolescent freedom of choice regarding dating, marriage, and career choices. The extreme bipolarities of the adaptation of Vietnamese youth are sometimes overemphasized. Members of one group, usually the children of the first-wave refugees, are often portrayed as academic superstars. At the other end of the social spectrum are the criminal and gang elements, who often direct their activities against other Asian immigrants. Most Vietnamese adolescents, however, fall between these two extremes and have the same pressures and concerns as other youths. Family Goals and Priorities The traditional Vietnamese family is perhaps the most basic, enduring, and self-consciously acknowledged 5 form of national culture among refugees, providing lifelong protection and guidance to the individual. The family, usually large, patriarchal, and extended, includes minor children, married sons, daughtersin-law, unmarried grown daughters, and grandchildren under the same roof. Other close relatives may be included within the extended family structure. The family is explicitly structured with assigned priorities, identifying parental ties as paramount. A son’s obligations and duties to his parents may assume a higher value than those to his wife, children, or siblings. Sibling relationships are considered permanent. Vietnamese self is defined more along the lines of family roles and responsibilities and less along individual lines. These mutual family tasks provide a framework for individual behavior, promoting a sense of interdependence, belonging, and support. The traditional family has been altered as a consequence of Western influence, urbanization, and the war-induced absence of men. Nevertheless, many Vietnamese continue to uphold this social form as the preferable basis of social organization in the United States. As mentioned in the previous section, exposure of the younger generation to American culture can become a source of conflict with considerable family strain as adolescents are influenced by the perceived American values of individuality, independence, self-assertion, and egalitarian relationships. Traditionally, older people are honored and have a key role in transmitting guidelines related to social behavior, preparing younger people for handling stressful life events, and serving as sources of support in coping with life crises. Older people are usually consulted for important decisions. Addressing a client in the presence of an older person, whether they speak E...
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