129People_of_ChineseHeritageChapter_7YAN_WANG_and_LARRY_D

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People of Chinese Heritage

Chapter 7

YAN WANG and LARRY D. PURNELL

Overview, Inhabited Localities, and Topography OVERVIEW

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

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

Children born to Chinese parents in Western countries tend to adopt the Western culture easily, whereas their parents and grandparents tend to maintain their tradi- tional Chinese culture in varying degrees. Chinese who live in the “Chinatowns” of North America and other places outside of China, maintain many of their cultural and social beliefs and values and insist that health-care

providers respect these values and beliefs with their pre- scribed interventions.

HERITAGE AND RESIDENCE

The Chinese culture is one of the oldest in recorded human history, beginning with the Xia dynasty, dating from 2200 B.C., to the present-day People’s Republic of China (PRC). The Chinese name for their country is Zhong guo, which means “middle kingdom” or “center of the earth.” Many of the current values and beliefs of the Chinese remain grounded in their history; many believe that the Chinese culture is superior to other Asian cultures. Ideals based on the teachings of Confucius (551–479 B.C.) continue to play an important part in the values and beliefs of the Chinese. These ideals emphasize the importance of accountability to family and neighbors and reinforce the idea that all rela- tionships embody power and rule.

During early Communist rule, an attempt was made to break down the values grounded in Confucianism and substitute values consistent with equal social responsibil- ity. This was initially achieved, and rank in society was no longer seen as important. During the People’s Revolution, feudal rank frequently meant loss of social importance, physical punishment, imprisonment, and even death. Later, during the Cultural Revolution, the young were held responsible for the deaths of many previously esteemed elderly and educated Chinese. Today, many of the Confucian values have reasserted themselves. Families, the elderly, and highly educated individuals are again considered important. Research completed by the Chinese Culture Connection, a group of Chinese sociolo- gists, lists 40 important values in modern China, includ- ing filial piety, industry, patriotism, paying deference to those in hierarchal status positions, tolerance of others, loyalty to superiors, respect for rites and social rituals,

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

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

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

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Chinese immigrated to the United States in three different waves: in the 1800s, in the 1950s, and in more recent years. Chinese immigration was initially fueled by economic needs. Over 100,000 male peasants from Guangdong and Fujian came to the United States without their families in the early 1830s to make their fortune on the transcontinen- tal railroad. This immigration continued through the Gold Rush of 1849. Many believed that they could make money in the United States to help their families and later return to China. Unfortunately, most found that opportunities were limited to hard labor and other vocations not desired by European Americans. Their culture and physical features made them readily identifiable in the predominantly white American society. They could not simply change their names and blend in with other, primarily European immi- grant populations. The Chinese had few rights and were barred from becoming U.S. citizens. Racial violence and prejudice against them were common, and the courts did not punish the violators. Compared with other ethnic groups, their immigration numbers were small until 1952, when the McCarran-Walters Bill relaxed immigration laws and permitted more Chinese to enter the country.

The most recent immigrants from Taiwan, Hong Kong, and mainland China are strikingly different from earlier Chinese immigrants in that they are more diverse. In addition, whereas many emigrated to reunite with fami- lies, students, scholars, and professionals flocked to the United States to pursue higher education or research. For their safety and the maintenance of their cultural values, most Chinese settled in closed communities.

EDUCATIONAL STATUS AND OCCUPATIONS

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

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

A university education is highly valued; however, few have the opportunity to achieve this life goal because enrollments in better educational institutions are limited. Because competition for top universities is keen, many families select less valued universities to ensure that their child is accepted into a university rather than slated for a technical school education. After their undergraduate or graduate programs, many young adults come to Western countries to attend universities to seek more advanced education or research. A foreign education is considered prestigious in China.

In the West, initially the Chinese tend to be either highly or poorly educated. This dichotomy may result in health- care providers categorizing clients in a similar manner. Many people believe that Chinese occupations are limited to restaurant work, service employment, and the garment industry. However, this phenomenon has changed since the 1980s. A significant number of Chinese students and scholars from the PRC and Taiwan come to the United States to study every year. Because of the competitive edu- cational system in mainland China and Taiwan, where only the brightest students go to a university, Chinese immi- grants with a college education are often very well edu- cated. Student immigrants are expected to return to China or Taiwan when their education and research are com- pleted. However, many do not return but elect to remain in Western countries, having obtained graduate degrees in the United States, and many find employment in high-tech- nology companies or educational and research institutes.

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

Communication

V I G N E T T E 7 . 1

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

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

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

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

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

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

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

The official language of China is Mandarin (pu tong hua), which is spoken by about 70 percent of the popu- lation, primarily in northern China, but there are 10 major, distinct dialects, including Cantonese, Fujianese, Shanghainese, Toishanese, and Hunanese. For example, pu tong hua is spoken in Beijing, the capital of China in the north, and Shanghainese is spoken in Shanghai. The two cities are only 1462 kilometers (about 665 miles)

apart, but because the dialects are so different, the two groups cannot understand one another verbally. Even though people from one part of China cannot understand those from other regions, the written language is the same throughout the country and consists of over 50,000 characters (about 5000 common ones); thus, most chil- dren are at least 10 to 12 years old before they can read the newspaper.

Although many times Chinese sound loud when talk- ing with other Chinese, they generally speak in a moder- ate to low voice. Americans are considered loud to most Chinese, and health-care providers must be cautious about their voice volume when interacting with Chinese in English so that intentions are not misinterpreted.

When possible, health-care providers should use the Chinese language to communicate (see Table 7–1 for some common phrases), being careful to avoid jargon and use the simplest terms. Many times, verbs can be omitted because the Chinese language has only a limited number of verbs. The Chinese appreciate any attempt to use their language. They do not mind mistakes and will correct speakers when they believe it will not cause embarrass- ment. When asked whether they understand what was just said, the Chinese invariably answer yes, even when they do not understand. Such an admission causes loss of face; thus, it is better to have clients repeat the instruc- tions they have been given.

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

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T A B L E 7.1 Frequently Used Words and Phrases

English Word or Phrase Chinese Pinyin Phonetic Pronunciation

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

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

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

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

1. At 9 o’clock every morning, get the medicine bottle.

2. Take two tablets out of the bottle. 3. Get your hot water. 4. Swallow the pills with the water.

Do not use complex sentences with ands and buts. The Chinese have difficulty deciding what to respond to first when the speaker uses compound or complex sentences.

CULTURAL COMMUNICATION PATTERNS

Chinese have a reputation for not openly displaying emo- tion. Although this may be true among strangers, among family and friends they are open and demonstrative. The Chinese share information freely with health-care providers once a trusting relationship has developed. This is not always easy because Western health-care providers may not have the patience or time to develop such rela- tionships. In situations in which Chinese people perceive that health-care practitioners or other people of authority may lose face or be embarrassed, they may choose not to be totally truthful.

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

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

FORMAT FOR NAMES

Among the Chinese, introductions, either by name card or verbally, are different from those in Western countries. For example, the family name is stated first and then the given name. Calling individuals by any name except their family name is impolite unless they are close friends or relatives. If a person’s family name is Li and the given name is Ruiming, then the proper form of address is Li Ruiming. Men are addressed by their family name, such as Ma, and a title such as Ma xian sheng (“Mister Ma”), lao Ma (“respected older Ma”), or xiao Ma (“young Ma”). Titles are important to Chinese people, so when possible, identify the person’s title and use it.

Women in China do not use their husband’s last name after they get married and retain their own family last name. Therefore, unless the woman is from Hong Kong or

Taiwan, or has lived in a Western country for a long time, do not assume that her last name is the same as her hus- band’s. Her family name comes first, followed by her given names, and finally, by her title. Many Chinese liv- ing in Western counties take an English name as an addi- tional given name because their name is difficult for Westerners to pronounce. Their English name can be used in many settings. Addressing them as “Miss Millie” or “Mr. Jonathan” rather than simply by their English name is better. Even though they have adopted an English name, some Chinese may give permission to use only the English name. In addition, some Chinese switch the order of their names to be the same as Westerners, with their family name last. This practice can be confusing; there- fore, health-care providers should address Chinese clients by their whole name or by their family name and title, and then ask them how they wish to be addressed.

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

Kinship traditionally has been organized around the male lineage. Fathers, sons, and uncles are the important, rec- ognized relationships between and among families in pol- itics and in business. Each family maintains a recognized head who has great authority and assumes all major responsibilities for the family. A common and desirable domestic traditional structure is to have four generations under one roof. However, with the improvement in the standards of living and other changes, families have grad- ually gotten smaller. The first generation of one-child families appeared in the 1970s when China introduced a policy of family planning. This phenomenon led to the nuclear family of three (parents and one child) gradually becoming the mainstream family structure in cities. By the end of 2001, of the 351,234 million households in China, the average number of people in each household was 3.46 (Women of China, 2006c).

Family life takes on various faces and follows new trends. Because young people face greater and greater pressure from work and want a higher standard of living and spiritual life, the traditional concept of raising chil- dren has faded and more couples are choosing the”double income, no kids” (DINK) way of life.

Because increasing numbers of young people leave home to work in other parts of the country or to study abroad, the number of households consisting of older couples is also rising. Improvements in housing condi- tions make it possible for the younger generations to move out of the house and live apart from senior mem- bers of the family. Longer life spans have resulted in more seniors living alone and those who have lost their spouse living by themselves in one-person households. “Empty nests” will become the norm for seniors as parents of the first generation of single-child families get older. That, in turn, means a switch from an old system in which chil- dren looked after their parents to one in which seniors are cared for by society in general through benefits.

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

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the mother-in-law. Many times, the mother-in-law is demanding and hostile to the daughter-in-law and may treat her worse than the servants. This relationship has changed significantly since modern culture was intro- duced to Chinese society. However, such relationships may continue to influence some Chinese families today to some extent, or mothers-in-law and daughters-in-law may simply not get along with each other. Overseas, Chinese are quite different. The involvement of parents, especially the husband’s parents, in the new family’s life may have a great impact on families (Women of China, 2007).

The Chinese view of women is perpetuated to ensure male dominance in a society that has existed for cen- turies. Men still remain in control of the country, largely because of stereotypical roles of men and women. However, since the founding of the PRC, this has been changing somewhat. In 1949, the Communist Party stated that “women hold up half the sky” and are legally equal to men.

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

The traditional gender roles of women are changing, but a sense remains that a woman’s responsibility is to maintain a happy and efficient home life, especially in rural China. In recent times, some Chinese men include housework, cooking, and cleaning as their responsibili- ties when their spouses work. Most Chinese believe that the family is most important, and thus, each family member assumes changes in roles to achieve this harmony.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

Children are highly valued among the Chinese. China’s one-child rule is still in effect (China Turns One Child Policy into Law, 2002). Because of overpopulation in China, the government has mandated that each married couple may have only one child; however, in some rural areas if the first-born child is female, the couple may get permission to have a second child. Families often wait many years, until they are financially secure, to have a child. After the child is born, many family resources are lavished on the child. Families may be able to afford only to live with relatives in a two-room apartment, but if the family believes that the child will benefit by having a piano, then the resources will be found to provide a piano. Children are well dressed and kept clean and well fed.

In China, the child is protected from birth and inde- pendence is not fostered. The entire family makes deci- sions for the child even into young adulthood. Children usually depend on the family for everything. Few teens earn money because they are expected to study hard and

to help the family with daily chores rather than to seek employment. Children are pressured to succeed and improve the future of the family and the country. Their common goal is to score well on the national examina- tions when they reach age 18 years. Most Chinese chil- dren and adolescents value studying over playing and peer relationships. They recognize that they are con- stantly evaluated on having healthy bodies and minds and achieving excellent marks in school.

In rural communities, male children are more valued than female children because they continue the family lineage and provide labor. In urban areas, female children are valued as highly as male children. Children in China are taught to curb their expression of feelings because individuals who do not stand out are successful. However, this is changing. The young in China today frequently think that their parents are too cautious. The children are becoming even more outspoken as they read more and watch more television and movies.

From elementary school to university, students take courses in Marxist politics and learn not to question the doctrine of the country. If they do, they may be interro- gated and ridiculed for their radical thoughts. Nationalism is important to Chinese children, and they want to help their country continue to be the center of the world. Children are also expected to help their par- ents in the home. Many times in the cities when children get home from school before their parents, they are expected to do their homework immediately and then do their household chores. They exhibit their independence not so much by expressing their individual views but by performing chores on their own. However, because of China’s one-child rule and high competition for enroll- ment to colleges, parents and grandparents spoil most children. The children are expected to earn good grades and household chores are not encouraged; this is exhib- ited in overseas Chinese families as well. Lin and Fu (1990) studied 138 children: 44 Chinese, 46 Chinese Americans, and 48 white Americans in kindergarten through second grade and found that both Chinese and Chinese American parents expected increased achieve- ment and parental control over their children. One sur- prising finding was the high expectation for indepen- dence in Chinese and Chinese American children.

Boys and girls play together when they are young, but as they get older, they do not because their roles and the corresponding expectations are predetermined by Chinese society. Girls and boys both study hard. Boys are more active and take pride in physical fitness. Girls are not nearly as interested in fitness as boys, preferring read- ing, art, and music.

Adolescents are expected to determine who they are and what they want to do with their lives. Adolescents maintain their respect for older people even when they disagree with them. Although they may argue with their parents and teachers, they have learned that it seldom does any good. Teens value a strong and happy family life and seldom do things that jeopardize that unanimity. Adolescents question affairs of life and make great efforts to see at least two sides of every issue. They enjoy explor- ing different views with their peers and try to explore them with their parents.

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

FAMILY GOALS AND PRIORITIES

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

Older children who experienced the Cultural Revolution may feel some discomfort with their traditional parents. During the Cultural Revolution, the young were encour- aged to inform on older people and peers who did not espouse the doctrine of the time. Most of those who were reported were sent to “reeducation camps” where they did hard labor and were “taught the correct way to think.” As a result, many families have been permanently separated.

Extended families are important to the Chinese and function by providing ways to get ahead. Often, chil- dren live with their grandparents or aunts and uncles so individual family members can obtain a better educa- tion or reduce financial burdens. Relatives are expected to help each other through connections (guan xi), which are used by Chinese society in a manner similar to the use of money in other cultures. Such connections are perceived as obligations and are placed in a mental bank with deposits and withdrawals. These commit- ments may remain in the “bank” for years or genera- tions until they are used to get jobs, housing, business contacts, gifts, medical care, or anything that demands a payback.

Filial loyalty to the family is extended to other Chinese. When Chinese immigrants need additional assistance, health-care providers may be able to call on local Chinese organizations to obtain help for clients.

Older people in China are venerated just as they were in earlier years. Chinese government leaders are often older and remain in power until they are in their 70s, 80s, and beyond. Traditional Chinese people view older peo- ple as very wise, a view that communism has not changed. Chinese children are expected to care for their parents, and in China, this is mandated by law.

Younger Chinese who adopt Western ideas and values may find that the expectations of older people are too demanding. Even though younger Chinese Americans do not live with their older relatives, they maintain respect and visit them frequently. Older Chinese mothers are viewed as central to family feelings, and older fathers retain their roles as leaders. As generations live in areas removed from China and families become more Westernized, family relationships need to be assessed on an individual basis. An extended-family pattern is com- mon and has existed for over 2000 years. The traditional

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

Kinship relationships are based on the concept of loy- alty, and the young experience pressure to improve the family’s standing. Many parents give up items of daily liv- ing to provide more for their children, thereby increasing opportunities for them to get ahead.

Maintaining reputation is very important to the Chinese and is accomplished by adhering to the rules of society. Because power and control are important to Chinese society, rank is very important. True equality does not exist in the Chinese mind; their history has demonstrated that equality cannot exist. If more than one person is in power, then consensus is important. If the person in power is not present at decision-making meetings, barriers are raised and any decisions made are negated unless the person in power agrees. Even after negotiations have been concluded and contracts signed, the Chinese continue to negotiate.

The Chinese concept of privacy is even more impor- tant than recognized social status, corresponding values, and beliefs. The Chinese word for “privacy” has a nega- tive connotation and means something underhanded, secret, and furtive. People grow up in crowded condi- tions, they live and work in small areas, and their value of group support does not place a high value on privacy. The Chinese may ask many personal questions about salary, life at home, age, and children. Refusal to answer personal questions is accepted as long as it is done with care and feeling. The one subject that is taboo is sex and anything related to sex. This may create a barrier for a Western health-care provider who is trying to assess a Chinese client with sexual concerns. The client may feel uncom- fortable discussing or answering questions about sex with honesty. Privacy is also limited by territorial boundaries. Some Chinese may enter rooms without knocking or invade privacy by not allowing a person to be alone. The need to be alone is viewed as “not good” to some Chinese, and they may not understand when a Westerner wants to be alone. A mutual understanding of these beliefs is nec- essary for harmonious working relationships.

ALTERNATIVE LIFESTYLES

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

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

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

Workforce Issues CULTURE IN THE WORKPLACE

China is becoming more Westernized with high technol- ogy and increased knowledge. The Communist Party is responsible for establishing the dan wei, local Chinese work units, that are responsible for jobs, homes, health, enforcement of governmental regulations, and problem solving for families. Although recent immigrants know that the culture in the workplace is different in the United States, they adapt to it quickly. The Chinese acculturate by learning as much as possible about their new culture in the workplace. They observe people from the culture and listen closely for nuances in language and interpersonal connections. They frequently call on other Chinese peo- ple to teach them and to discuss how to fit into the new culture more quickly. Chinese Americans support one another in new cultures and help each other find resources and learn to live effectively and efficiently in the new culture. They also watch television, listen to music, and go to movies to learn about Western ways of life. They read about the new culture in magazines, books, and newspapers. They love to travel, and when an oppor- tunity arises to see different aspects of the new culture, they do not hesitate to do so.

The Chinese are accustomed to giving coworkers small gifts of appreciation for helping them acculturate and adapt to the American workforce. Often, Americans seek opportunities to reciprocate with a gift, such as at a birth- day party, farewell party, or other occasion. Whereas a wide variety of gifts is appropriate, some gifts are not. For example, giving an umbrella means that one wishes to have the recipient’s family dispersed; giving a gift that is white in color or wrapped in white could be interpreted as meaning the giver wishes the recipient dead; and giving a clock could be interpreted as never wanting to see the per- son again or wishing the person’s life to end (Smith, 2002).

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

Guanxi is a Mandarin term with no exact English trans- lation. This term includes the concept of trust and pre- senting uprightness to build close relationships and con- nections. It definitely helps to build networks. This Guanxi network can be used in the work-related, decision- making process and is also used with family, friends, and community-related issues in the Chinese American community.

ISSUES RELATED TO AUTONOMY

Historically, the Chinese have been autonomous. They had to exhibit this characteristic to survive through diffi- cult times. However, their autonomy is limited and is based on functioning for the good of the group. When a new situation arises that requires independent decision making, many times the Chinese know what should be done but do not take action until the leader or superior gives permission. However, the Western workforce expects independence, and some Chinese may need to be taught that true autonomy is necessary to advance. Health-care providers should be aware, however, that the training might not be successful because it is foreign to Chinese cultural values. A demonstration is the best alter- native, leaving it up to the individuals to determine whether assertiveness can be a part of their lives. After acculturation takes place, Chinese Americans do not dif- fer significantly in assertiveness.

Language may be a barrier for Chinese immigrants seeking assimilation into the Western workforce. Western languages and Chinese have many differences, among them sentence structure and the use of intonation. The Chinese language does not have verbs that denote tense, as in Western languages. Whereas the ordering of the words in a sentence is basically the same, with the subject first and then the verb, the Chinese language places descriptive adjectives in different orders. Intonation in Chinese is in the words themselves, rather than in the sentence. Chinese people who have taken English lessons can usually read and write English competently, but they may have difficulty in understanding and speaking it.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

The skin color of Chinese is varied. Many have skin color similar to that of Westerners with pink undertones. Some have a yellow tone, whereas others are very dark. Mongolian spots, dark bluish spots over the lower back and buttocks, are present in about 80 percent of infants. Bilirubin levels are usually higher in Chinese newborns, with the highest levels occurring on the 5th or 6th day after birth.

Although Chinese are distinctly Mongolian, their Asian characteristics have many variations. China is very large and includes people from many different backgrounds, including Mongols and Tibetans. Generally, men and women are shorter than Westerners, but some Chinese are over 6 feet tall. Differences in bone structure are evidenced in the ulna, which is longer than the radius. Hip measure- ments are significantly smaller: Females are 4.14 cm smaller, and males 7.6 cm smaller than Westerners (Seidel, Ball, Dains, & Benedict, 1994). Not only is overall bone length shorter, but bone density is also less. Chinese have a high hard palate, which may cause them problems with Western dentures. Their hair is generally black and straight, but some have naturally curly hair. Most Chinese men do not have much facial or chest hair. The Rh-nega- tive blood group is rare, and twins are not common in

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Chinese families, but are greatly valued, especially since the emergence of China’s one-child law.

DISEASES AND HEALTH CONDITIONS

Many Chinese who come to the United States settle in large cities like San Francisco and New York, so they are at risk for the same problems and diseases experienced by other inner-city populations. For example, crowding in large cities often results in poor sanitation and increases the inci- dence of infectious diseases, air pollution, and violence.

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

The average life expectancy in China is 72.58 years (CIA, 2007), thanks to improved living conditions and medical facilities, as well as a nationwide fitness cam- paign. In 1949, the average life expectancy was only 35 years (People’s Daily, 2002). Disease incidence has decreased as well, but major problems still exist in rural China, where perinatal deaths and deaths from infectious diseases remain high. Tobacco use is a major problem and results in an increased incidence of lung disease. Health- care providers must screen newer immigrants from China for these health-related conditions and provide interven- tions in a culturally congruent manner.

Many Chinese immigrants have an increased inci- dence of hepatitis B and tuberculosis. Poor living condi- tions and overcrowding in some areas of China enhance the development of these diseases, which persist after immigrants settle in other countries.

According to the Office of Minority Health (2007), Chinese American women have a 20 percent higher rate of pancreatic cancer and higher rates of suicide after the age of 45 years, and all Chinese have higher death rates owing to diabetes. The incidence of different types of can- cer, including cervical, liver, lung, stomach, multiple myeloma, esophageal, pancreatic, and nasopharyngeal cancers, is higher among Chinese Americans (Office of Minority Health, 2007). Overall, the incidence of disease in this population has not been studied sufficiently, and continuing research is desperately needed.

VARIATIONS IN DRUG METABOLISM

Multiple studies outlining problems with drug metabo- lism and sensitivity have been conducted among the Chinese. Results suggest a poor metabolism of mepheny- toin (e.g., diazepam) in 15 to 20 percent of Chinese; sensi- tivity to beta-blockers, such as propranolol, as evidenced by a decrease in the overall blood levels accompanied by a seemingly more profound response; atropine sensitivity, as evidenced by an increased heart rate; and increased responses to antidepressants and neuroleptics given at lower doses. Analgesics have been found to cause increased gastrointestinal side effects, despite a decreased sensitivity to them. In addition, the Chinese have an increased sensitivity to the effects of alcohol (Levy, 1993).

Delineating specific variations in drug metabolism among the Chinese is difficult because various studies

tend to group them in aggregate as Asians. Much more research needs to be completed to determine variations between Westerners and Asians as well as among Asians.

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

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

Nutrition MEANING OF FOOD

Food habits are important to the Chinese, who offer food to their guests at any time of the day or night. Most cele- brations with family and business events focus on food. Foods served at Chinese meals have a specific order, with the focus on a balance for a healthy body. The importance of food is demonstrated daily in its use to promote good health and to combat disease and injury. Traditional Chinese medicine frequently uses food and food deriva- tives to prevent and cure diseases and illnesses and increase the strength of weak and older people.

COMMON FOODS AND FOOD RITUALS

The typical Chinese diet is difficult to describe because each region in China has its own traditional foods. Peanuts and soybeans are popular. Common grains include wheat, sorghum, and maize. Rice is usually steamed but can be fried with eggs, vegetables, and meats. Many Chinese eat beans or noodles instead of rice. The Chinese eat steamed and fried rice noodles, which are usually prepared with a broth base and include vegetables

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and meats. Meat choices include pork (the most com- mon), chicken, beef, duck, shrimp, fish, scallops, and mussels. Tofu, an excellent source of protein, is a staple of the Chinese diet and can be fried or boiled or eaten cold like ice cream. Bean products are another source of pro- tein, and many of the desserts or sweets in Chinese diets are prepared with red beans.

At celebrations, before-dinner toasts are usually made to family and business colleagues. The toasts may be inter- spersed with speeches, or the speeches may be incorpo- rated in the toasts. Cold appetizers often include peanuts and seasonal fruits. Chopsticks, a chopstick holder, a small plate, and a glass are part of the table setting. If the foods are messy, like Beijing duck, then a finger towel may be available. The Chinese use ceramic or porcelain spoons for soup. Knives are unnecessary because the food is usually served in bite-sized pieces. Eating with chopsticks may be difficult for some at first, but the Chinese are good-natured and are pleased by any attempt to use them. Chopsticks should never be stuck in the food upright because that is considered bad luck (Smith, 2002). Westerners soon learn that slurping, burping, and other noises are not considered offensive, but are appreciated. The Chinese are very relaxed at meals and commonly rest their elbows on the table.

Fruits and vegetables may be peeled or eaten raw. Some vegetables commonly eaten raw by Westerners are usually cooked by the Chinese. Unpeeled raw fruits and vegeta- bles are sources of contamination owing to unsanitary conditions in China. The Chinese enjoy their vegetables lightly stir-fried in oil with salt and spice. Salt, oil, and oil products are important parts of the Chinese diet.

Drinks with dinner include tea, soft drinks, juice, and beer. Foreign-born Chinese and older Chinese may not like ice in their drinks. They may just not like cold while eating or may believe that it is damaging to their body and shocks the body systems out of balance. Conversely, hot drinks are enjoyed and believed to be safe for the body. This “goodness” of hot drinks may stem from tradi- tion in which the only safe drinks were made from boiled water. All food is put in the center of the table, arriving all at one time, but usually multiple courses are served. The host either serves the most important guests first or sig- nals everyone to start.

DIETARY PRACTICES FOR HEALTH PROMOTION

For the Chinese, food is important in maintaining their health. Foods that are considered yin and yang prevent sudden imbalances and indigestion. A balanced diet is considered essential for physical and emotional harmony. Health-care providers need to provide special instructions regarding risk factors associated with diets that are high in fats and salt. For example, the Chinese may need educa- tion regarding the use of salty fish and condiments, which increase the risk for nasopharyngeal, esophageal, and stomach cancers.

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

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

enough to suggest that severe dietary deficiencies are not common as long as food is available. Periodically, some deficiencies, such as rickets and goiters, have occurred. The Chinese government added iodine to water supplies, and fish, which is rich in iron, is encour- aged to enhance the diets of people with goiters. Native Chinese generally do not drink milk or eat milk prod- ucts because of a genetic tendency for lactose intoler- ance. Their healthy selection of green vegetables limits the incidence of calcium deficiencies. Health-care providers may need to screen newer Chinese immi- grants for these deficiencies and assist them in planning an adequate diet.

Most Chinese do not eat desserts with a high sugar content. Their desserts are usually peeled or sliced fruits or desserts made of bean and bean curd. The higher death rate from diabetes in Western countries mentioned earlier in this chapter may be due to a change from the typical Chinese diet with few sweets to a Western diet with many sweets.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

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

Most Chinese families see pregnancy as positive and important in the immediate and extended family. Many couples wait a long time to have their first and only child. If a woman does become pregnant before the couple is ready to start a family, she may have an abortion. When the pregnancy is desired, the nuclear and extended family rejoice in the new family member. Overall, pregnancy is seen as a woman’s business, although the Chinese man is beginning to demonstrate an active interest in pregnancy and the welfare of the mother and baby.

China has 80 million one-child families. The gender imbalance has become a serious issue in recent years because many families, especially those in rural areas, prefer boys to girls. China has 119 boys born for every 100 girls, whereas the global ratio is 103 to 107 boys for every 100 girls. In China, the “Care for Girls” program was initiated in 2003 to promote the social status of women, and attempts are being made to decrease gender identification abortions without a medical purpose and the abandonment of newborn girls (XinHua News Agency, 2006)

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Because Chinese women are very modest, many women insist on a female midwife or obstetrician. Some agree to use a male physician only when an emergency arises.

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Pregnant women usually add more meat to their diets because their blood needs to be stronger for the fetus. Many women increase the amount of organ meat in their diet, and even during times of severe food shortages, the Chinese government has tried to ensure that pregnant women receive adequate nutrition. These traditions are also reflected in Chinese families living in the West.

Other dietary restrictions and prescriptions may be practiced by pregnant women, such as avoiding shellfish during the first trimester because it causes allergies. Some mothers may be unwilling to take iron because they believe that it makes the delivery more difficult.

The Chinese government is proud of the fact that since the People’s Revolution in 1949, infant mortality has been significantly reduced. In 2001, the mortality rates for infants and children under age 5 years were reduced to 30 per 1000 and 35.9 per 1000 (Women of China, 2006e). This has been accomplished by providing a three-level system of care for pregnant women in rural and urban populations. Over 90 percent of childbirths take place under sterile conditions by a qualified personnel. This has reduced the maternal mortality rate significantly to 50.2 in 100,000 (Women of China, 2006e). Therefore, most Chinese who have immigrated to Western countries are familiar with modern sterile deliveries.

In China, a woman stays in the hospital for a few days after delivery to recover her strength and body balance. Traditional postpartum care includes 1 month of recov- ery, with the mother eating cooked and warm foods that decrease the yin (cold) energy. The Chinese government supports this 1-month recuperation period through labor laws that entitle the mother from 56 days to 6 months of maternity leave with full pay (Ministry of Public Health, 1992). Women who return to work are allowed time off for breastfeeding, and in many cases, factories provide a special lounge for the women to breastfeed. Families who come to Western societies expect the same importance to be placed on motherhood and may be surprised to find that many Western countries do not provide similar benefits.

Traditional prescriptive and restrictive practices con- tinue among many Chinese women during the postpar- tum period. Drinking and touching cold water are taboo for women in the postpartum period. Raw fruits and veg- etables are avoided because they are considered “cold” foods. They must be cooked and be warm. Mothers eat five to six meals a day with high nutritional ingredients including rice, soups, and seven to eight eggs. Brown sugar is commonly used because it helps rebuild blood loss. Drinking rice wine is encouraged to increase the mother’s breast milk production. But mothers need to be cautioned that it may also prolong the bleeding time. Many mothers do not expose themselves to the cold air and do not go outside or bathe for the first month post- partum because the cold air can enter the body and cause health problems, especially for older women. Some women wear many layers of clothes and are covered from head to toe, even in the summer, to keep the air away from their bodies. However, this practice has changed among some young women who live in Western cultures for a long period of time and when there are no older Chinese parents around during the postpartum period.

Adopted Chinese children display a similar pattern of growth and developmental delays and medical problems as seen in other groups of internationally adopted chil- dren. An exception is the increased incidence of elevated lead levels (overall 14 percent). Although serious medical and developmental issues were found among Chinese children, overall their health was better than expected based on recent publicity about conditions in the Chinese orphanages. The long-term outcome of these children remains unknown (Miller, 2000). Many children adopted from China have antibody titers that do not correlate with those expected from their medical records. These children, unlike children adopted from other countries, have documented evidence of adequate vaccinations. However, they should be tested for antibody concentra- tions and reimmunized as necessary (Schulpen, 2001).

Death Rituals DEATH RITUALS AND EXPECTATIONS

Chinese death and bereavement traditions are centered on ancestor worship. Ancestor worship is frequently mis- understood; it is not a religion, but rather a form of pay- ing respect. Many Chinese believe that their spirits can never rest unless living descendants provide care for the grave and worship the memory of the deceased. These practices were so important to early Chinese that Chinese pioneers to the West had statements written into their work contract that their ashes or bones be returned to China (Halporn, 1992).

The belief that the Chinese greet death with stoicism and fatalism is a myth. In fact, most Chinese fear death, avoid references to it, and teach their children this avoid- ance. The number 4 is considered unlucky by many Chinese because it is pronounced like the Chinese word for death; this is similar to the bad luck associated with the number 13 in many Western societies. Huang (1992) wrote:

At a very young age, a child is taught to be very careful with words that are remotely associated with the “misfortune” of death. The word “death” and its synonyms are strictly forbidden on happy occasions, especially during holidays. People’s uneasiness about death often is reflected in their emphasis on longevity and everlasting life. . . . In daily life, the character “Long Life” appears on almost everything: jewelry, clothing, furniture, and so forth. It would be a terrible mistake to give a clock as a gift, simply because the pronunciation of the word “clock” is the same as that of the word “ending.” Recently, many people in Taiwan decided to avoid using the number “four” because the number has a similar pronunciation to the word “death.” (p. 1)

Many Chinese are hesitant to purchase life insurance because of their fear that it is inviting death. The color white is associated with death and is considered bad luck. Black is also a bad-luck color.

Many Chinese believe in ghosts, and the fear of death is extended to the fear of ghosts. Some ghosts are good and some are bad, but all have great power. Communism discourages this thinking and sees it as a hindrance to future growth and development of the society, but the

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ever-pragmatic Chinese believe it is better not to invite trouble with ghosts just in case they might exist.

The dead may be viewed in the hospital or in the fam- ily home. Extended family members and friends come together to mourn. The dead are honored by placing objects around the coffin that signify the life of the dead: food, money designated for the dead person’s spirit, and other articles made of paper. In China, cremation is pre- ferred by the state because of a lack of wood for coffins and a limited space for burial. The ashes are placed in an urn and then in a vault. As cities grow, even the space for vaults is limited. In rural areas, many families prefer tra- ditional burial and have family burial plots. It is prefer- able to burying an intact body in a coffin.

RESPONSES TO DEATH AND GRIEF

The Chinese react to death in various ways. Death is viewed as a part of the natural cycle of life, and some believe that something good happens to them after they die. These beliefs foster the impression that Chinese are stoic. In fact, they feel similar emotions to Westerners but do not overtly express those emotions to strangers. During bereavement, a person does not have to go to work, but instead can use this mourning time for remem- bering the dead and planning for the future. Bereavement time in the larger cities is 1 day to 1 week, depending on the policy of the government agency and the relationship of family members to the deceased. Mourners are recog- nized by black armbands on their left arm and white strips of cloth tied around their heads.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

In mainland China, the practice of formal religious services is minimal. The ideals and values of the different religions are practiced alone rather than with people coming together to participate in a formal religious service. In recent years, in some parts of China, religion is becoming more popular. The main formal religions in China are Buddhism, Catholicism, Protestantism, Taoism, and Islam.

As immigration from China increases, Chinese people who practice Christian religions have become more visible on the American landscape. Chinese immigrants from the PRC may express perspectives on religious beliefs different from those of the Chinese from other countries, or from Hong Kong and Taiwan, where they have been permitted to practice Christianity. At first, they may go to a church attended by other Chinese people; eventually some are bap- tized, and others continue to attend Bible studies. In cities in the United States, churches are playing a very important role in the local Chinese community in terms of providing support and services to Chinese immigrants, students, scholars, and their families. An understanding of this con- cept is essential when the health-care provider attempts to obtain religious counseling services for Chinese clients.

Prayer is generally a source of comfort. Some Chinese do not acknowledge a religion such as Buddhism, but if they go to a shrine, they burn incense and offer prayers.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

The Chinese view life in terms of cycles and interrelation- ships, believing that life gets meaning from the context in which it is lived. Life cannot be broken into simple parts and examined because the parts are interrelated. When the Chinese attempt to explain life and what it means, they speak about what happened to them, what hap- pened to others, and the importance and interrelatedness of those events. They speak not only of the importance of the current phenomena but also about the importance of what occurred many years, maybe even centuries, before their lives. They live and believe in a true systems frame- work.

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

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

Health-care providers need to understand this multidi- mensional manner of thinking and believing. Assessments, goal setting, interventions, and evaluations may be differ- ent for Chinese clients than for American clients. The con- text of client problems is the emphasis, and the physical, mental, and spiritual aspects of the person’s life are the focal points.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

Health care in China is provided for most citizens. Every work unit and neighborhood has its own clinic and hospi- tal. Traditional Chinese medicine shops abound (Fig. 7–1). Even department stores and supermarkets have Western medicines and traditional Chinese medicines and herbs.

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

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of people infected with HIV rose from 19.4 percent to 28.1 percent (Women of China, 2006b). China now faces a critical period in the fight to curb the spread of, and ulti- mately cure, HIV and AIDS. The World Health Organization (WHO) has predicted that China, if it fails to control the disease’s spread, will have 10 million AIDS sufferers by 2010 (Gu, 2006). A new regulation on AIDS prevention and control (effective January 1, 2007) spells out the plan to administer the free test in areas of the province where the AIDS situation is “grave.” HIV carriers and AIDS patients will be asked to inform their spouses or sex partners of the results, or the local disease prevention authorities will do so (Women of China, 2006b).

Whereas many Chinese have made the transition to Western medicine, others maintain their roots in tradi- tional Chinese medicine, and still others practice both types. The Chinese are similar to other nationalities in seeking the most effective cure available. Younger Chinese people usually do not hesitate to seek health-care providers when necessary. They generally practice Western medicine unless they feel that it does not work for them; then they use traditional Chinese medicine. Conversely, older people may try traditional Chinese medicine first, and only seek Western medicine when tra- ditional medicine does not seem to work.

Among Chinese Americans, these health-seeking beliefs, practices, and patterns remain the same as the ones in China. This results in sicker older people seeking care from Western health-care providers. Even after seek- ing Western medical care, many older Chinese continue to practice traditional Chinese medicine in some form. However, some Chinese clients may not tell health-care providers about other forms of treatment they have been using because they are conscious of saving face. Health- care providers need to understand this practice and include it in their care. Members of the health-care team need to develop a trusting relationship with Chinese clients so that all information can be disclosed. Health- care providers must impress upon clients the importance of disclosing all treatments because some may have antagonistic effects.

RESPONSIBILITY FOR HEALTH CARE

Chinese people often self-medicate when they think that they know what is wrong or if they have been successfully treated by their traditional medicine or herbs in the past. They share their knowledge about treatments and their medicines with friends and family members. This often happens among Chinese Americans as well because of the belief that occasional illness can be ameliorated through the use of nonprescription drugs. Many consider seeing Western health-care providers as a waste of time and money. Health-care providers need to recognize that self- medication and sharing medications are accepted prac- tices among the Chinese. Thus, health-care providers should inquire about this practice when making assess- ments, setting goals, and evaluating the results of treat- ments. A trusting relationship between members of the health-care team and the client and family is necessary to enhance the disclosure of all treatments.

TRADITIONAL CHINESE MEDICINE PRACTICES

Traditional Chinese medicine is practiced widely, with concrete reasons for the preparation of medications, tak- ing medicine, and the expected outcomes. Western medi- cine needs to be explained to Chinese people in equally concrete terms.

Traditional Chinese medicine has many facets, includ- ing the five basic substances (qi, energy; xue, blood; jing, essence; shen, spirit; and jing ye, body fluids); the pulses and vessels for the flow of energetic forces (mai); the energy pathways (jing); the channels and collaterals, including the 14 meridians for acupuncture, moxibus- tion, and massage (jing luo); the organ systems (zang fu); and the tissues of the bones, tendons, flesh, blood vessels, and skin. The scope of traditional Chinese medi- cine is vast and should be studied carefully by profession- als who provide health care to Chinese clients.

Acupuncture and moxibustion are used in many of the treatments. Acupuncture is the insertion of needles into precise points along the channel system of flow of the qi called the 14 meridians. (The system has over 400 points.) Many of the same points can be used in applying pressure and massage to achieve relief from imbalances in the sys- tem. The same systems approach is used to produce local- ized anesthesia.

Moxibustion is the application of heat from different sources to various points. For example, one source, such as garlic, is placed on the distal end of the needle after it is inserted through the skin, and the garlic is set on fire. Sometimes, the substance is burned directly over the point without a needle insertion. Localized erythema occurs with the heat from the burning substance, and the medi- cine is absorbed through the skin. Cupping is another common practice. A heated cup or glass jar is put on the skin, creating a vacuum, which causes the skin to be drawn into the cup. The heat generated is used to treat joint pain.

The Chinese believe that health and a happy life can be maintained if the two forces, the yang and the yin, are balanced. This balance is called the dao. Heaven is yang, and Earth is yin; man is yang, and woman is yin; the sun is

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yang, and the moon is yin; the hollow organs (bladder, intestines, stomach, gallbladder), head, face, back, and lateral parts of the body are yang, and the solid viscera (heart, lung, liver, spleen, kidney, and pericardium), abdomen, chest, and the inner parts of the body are yin. The yang is hot, and the yin is cold. Health-care providers need to be aware that the functions of life and the inter- play of these functions, rather than the structures, are important to Chinese people.

Central to traditional medicine is the concept of the qi. It is considered the vital force of life; includes air, breath, or wind; and is present in all living organisms. Some of the qi is inherited, and other parts come from the environment, such as in food. The qi circulates through the 14 meridians and organs of the body to give the body nourishment. The channels of flow are also responsible for eliminating the bad qi. All channels, the meridians and organs, are interconnected. The results resemble a system in which a change in one part of the system results in a change in other parts, and one part of the system can assist other parts in their total functioning.

Diagnosis is made through close inspection of the out- ward appearance of the body, the vitality of the person, the color of the person, the appearance of the tongue, and the person’s senses. The practitioner uses listening, smelling, and questioning techniques in the assessment. Palpation is used by feeling the 12 pulses and different parts of the body. Treatments are based on the imbal- ances that occur. Many are directly related to the obvious problem, but many more are related through the inter- connectedness of the body systems. Many of the treat- ments not only “cure” the problem but are also used to “strengthen” the entire human being. Traditional Chinese medicine cannot be learned quickly because of the interplay of symptoms and diagnoses. Practitioners take many years to become adept in all phases of diagno- sis and treatment.

T’ai chi, practiced by many Chinese, has its roots in the 12th century. This type of exercise is suitable for all age groups, even the very old. T’ai chi involves different forms of exercise, some of which can be used for self- defense. The major focus of the movements is mind and body control. The concepts of yin and yang are included in the movements, with a yin movement following a yang movement. Total concentration and controlled breathing are necessary to enable the smoothness and rhythmic quality of movement. The movements resemble a slow- motion battle, with the participant both attacking and retreating. Movements are practiced at least twice a day to bring the internal body, the external body, and the environment into balance (T’ai Chi Chen Homepage, 2007). A recent survey in China indicated that 41.3 percent respondents believe that “Yoga” is the most fash- ionable kind of exercise among women (Women of China, 2006c). Yoga incorporates meditation, relaxation, imagery, controlled breathing, stretching, and other physical movements. Yoga has become increasingly pop- ular in Western cultures as a means of exercise and fitness training. Yoga needs to be better recognized by the health-care community as a complement to conventional medical care.

Herbal therapy is integral to traditional Chinese medi- cine and is even more difficult to learn than acupuncture and moxibustion. Herbs fall into four categories of energy (cold, hot, warm, and cool), five categories of taste (sour, bitter, sweet, pungent, and salty), and a neutral category. Different methods are used to administer the herbs, includ- ing drinking and eating, applying topically, and wearing on the body. Each treatment is specific to the underlying problem or a desire to increase strength and resistance.

BARRIERS TO HEALTH CARE

V I G N E T T E 7 . 2

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

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

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

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

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

In China, the government is primarily responsible for pro- viding basic health care within a multilevel system. Native Chinese are accustomed to the neighborhood work units called dan wei, where they get answers to their questions and health-care services are provided. After transition to the United States, Chinese clients face many of the same barriers to health care faced by Westerners, yet they have other special concerns and difficulties that prevent them from accessing health-care services. Ma (2000) summa- rized these barriers as the following:

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

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

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

3. Socioeconomic barriers: Being unable to afford medical expenses is another barrier to accessing health-care services for some Chinese Americans. However, having health insurance does not always assure the utilization of the health-care system or the benefits of health insurance. There may be a sense of distrust between patients and health-care providers or between patients and insurance companies. In addition, many do not know the cost of the service when they enter a clinic or hospital. They are frustrated with being caught in the battle between health insurance companies and the clinic or hospital.

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

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

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

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

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

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

5. The most difficult barrier is frequently the reluc- tance to disclose the diagnosis to the patient or the family.

In recent years, clinics of Chinese medicine and health-care providers who are originally from China have been significantly visible in the United States, especially in the larger cities. These provide opportunity or options for those Chinese Americans who prefer to seek tradi- tional Chinese treatment for certain illness.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

V I G N E T T E 7 . 3

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

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

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

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

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

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

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

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

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

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

Chinese people express their pain in ways similar to those of Americans, but their description of pain differs. A study by Moore (1990) included not only the expression of pain but also common treatments used by Chinese. The Chinese tend to describe their pain in terms of more diverse body symptoms, whereas Westerners tend to describe pain locally. The Western description includes words like “stabbing” and “localized,” whereas the Chinese describe pain as “dull” and more “diffuse.” They tend to use explanations of pain from the traditional Chinese influence of imbalances in the yang and yin com- bined with location and cause. The study determined that the Chinese cope with pain by using externally applied methods, such as oils and massage. They also use warmth, sleeping on the area of pain, relaxation, and aspirin.

The balance between yin and yang is used to explain mental as well as physical health. This belief, coupled with the influence of Russian theorists such as Pavlov, influence the Chinese view of mental illness. Mental ill- ness results more from metabolic imbalances and organic problems. The effect of social situations, such as stress and crises, on a person’s mental well-being is considered inconsequential, but physical imbalances from genetics are the important factors. Because a stigma is associated with having a family member who is mentally ill, many families initially seek the help of a folk healer. Many use a combination of traditional and Western medicine. Many mentally ill clients are treated as outpatients and remain in the home.

Although Chinese do not readily seek assistance for emotional and nervous disorders, a study of 143 Chinese Americans found that younger, lower socioeconomic, and married Chinese with better language ability seek help

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more frequently (Ying & Miller, 1992). The researchers recommended that new immigrants be taught that help is available when needed for mental disorders within the mental health-care system.

Chinese people in larger cities are becoming more sup- portive of the disabled, but for the most part, support ser- vices are popular. Because the focus has been on improv- ing the overall economic growth of the country, the needs of the disabled have not had priority. The son of Deng Xiaoping was crippled in the Cultural Revolution and has been active in making the country more aware of the needs of the disabled. The Beijing Paralympic Games will be held September 6 to 17, 2008, and will open 12 days after the 29th Olympic Games. A successful Paralympics in Beijing will promote the cause of disabled persons in Beijing as well as throughout China. The Games will urge the whole of society to pay more atten- tion to this special segment of our population and will reinforce the importance of building accessible facilities for the disabled and thus enhance efforts to construct a harmonious society in China (Nan, 2006). Overall, the Chinese still view mental and physical disabilities as a part of life that should be hidden.

The expression of the sick role depends on the level of education of the client. Educated Chinese people who have been exposed to Western ideas and culture are more likely to assume a sick role similar to that of Westerners. However, the highly educated and acculturated may exhibit some of the traditional roles associated with ill- ness. Each client needs to be assessed individually for responses to illness and for expectations of care. Traditionally, the Chinese ill person is viewed to be pas- sive and accepting of illness. To the Chinese, illness is expected as a part of the life cycle. However, they do try to avoid danger and to live as healthy a life as possible. To the Chinese, all of life is interconnected; therefore, they seek explanations and connections for illness and injury in all aspects of life. Their explanations to health-care providers may not make sense, but the health-care provider should try to determine those connections so the connections can be incorporated into treatment regi- mens. The Chinese believe that because the illness or injury is caused from an imbalance, there should be a medicine or treatment that can restore the balance. If the medicine or treatment does not seem to do this, they may refuse to use it.

Native Chinese and Chinese Americans like treatments that are comfortable and do not hurt. Treatments that hurt are physically stressful and drain their energy. Health-care providers who have been ill themselves can appreciate this way of thinking, because sometimes the cure seems worse than the illness. Treatments will be more successful if they are explained in ways that are con- sistent with the Chinese way of thinking. The Chinese depend on their families and sometimes on their friends to help them while they are sick. These people provide much of the direct care; health-care providers are expected to manage the care. The family may seem to take over the life of the sick person, and the sick person is very passive in allowing them the control. One or two pri- mary people assume this responsibility, usually a spouse. Health-care providers need to include the family mem-

bers in the plan of care and, in many instances, in the actual delivery of care.

BLOOD TRANSFUSIONS AND ORGAN DONATION

Modern-day Chinese accept blood transfusions, organ donations, and organ transplants when absolutely essen- tial, as long as they are safe and effective. Chinese Americans have the same concerns as Americans about blood transfusion because of the perceived high inci- dence of HIV and hepatitis B. No overall ethnic or reli- gious practices prohibit the use of blood transfusions, organ donations, or organ transplants. Of course, some individuals may have religious or personal reasons for denying their use.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

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

STATUS OF HEALTH-CARE PROVIDERS

Traditional Chinese medicine practitioners are shown great respect by the Chinese. In many instances, they are shown equal, if not more, respect than Western practi- tioners. The Chinese may distrust Western practitioners because of the pain and invasiveness of their treatments. The hierarchy among Chinese health-care providers is similar to that of Chinese society. Older health-care providers receive respect from the younger providers. Men usually receive more respect than women, but that is beginning to change. Physicians receive the highest respect, followed closely by nurses with a university edu- cation. Other nurses with limited education are next in the hierarchy, followed by ancillary personnel.

Health-care practitioners are usually given the same respect as older people in the family. Chinese children recognize them as authority figures. Physicians and nurses are viewed as individuals who can be trusted with the health of a family member. Nurses are generally per- ceived as caring individuals who perform treatments and procedures as ordered by the physician. Nursing assis- tants provide basic care to patients. Adult Chinese respond to practitioners with respect, but if they disagree with the health-care provider, they may not follow instructions. They may not verbally confront the health- care provider because they fear that either they or the provider will suffer a loss of face.

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

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145

People of Guatemalan Heritage

Chapter 8

TINA A. ELLIS and LARRY D. PURNELL

Overview, Inhabited Localities, and Topography OVERVIEW

People of Guatemalan heritage compose a growing num- ber of Hispanic/Latino populations in the United States. Whereas Guatemalans may share a common Spanish language with other Hispanic ethnic groups, they are, nonetheless, a unique cultural group. Health-care providers must be knowledgeable regarding distinct Hispanic cultural characteristics to provide culturally competent care for patients of Guatemalan heritage.

HERITAGE AND RESIDENCE

Guatemala is a Central American country characterized by beautiful landscapes and peoples. This land, referred to as “eternal spring,” has an estimated population of over 12.3 million (CIA, 2007). The northernmost of the Central American nations, Guatemala has 41,700 square miles and is the size of the state of Tennessee in the United States. Its neighbors are Mexico on the north and west, and Belize, Honduras, and El Salvador on the south and east. The country consists of three main regions—the cool highlands with the heaviest population, the tropical area along the Pacific and Caribbean coasts, and the trop- ical jungle in the northern lowlands, known as the Petén (Information Please Almanac, 2007). Guatemala is inhab- ited by Mestizo (mixed Amerindian Spanish—in local Spanish called Ladino) and European 59.4 percent, K’iche 9.1 percent, Kaqchikel 8.4 percent, Mam 7.9 percent, Q’eqchi 6.3 percent, other Mayan 8.6 percent, indigenous non-Mayan 0.2 percent, other 0.1 percent. More than half of Guatemala’s rural population resides in the highlands,

the most populated region of the country. The capital, Guatemala City with a population of 1.1 million, is located within the highland area. Soil in the Pacific low- lands is the most fertile within the country owing to the ash deposited by active volcanoes. Ladinos compose the majority population in this region of Guatemala (Information Please Almanac, 2007).

Guatemala was inhabited for approximately 3000 years by Mayan Indians who lived a simple life based on the culture, customs, and religion of their ancestors. Farming was the primary occupation, although the Maya excelled in architecture, weaving, pottery, and hiero- glyphics. Whereas a few cities (pueblos) were established during Mayan times, the majority of Guatemalans now live in small villages (aldeas).

In the 15th century, the Spaniards came to Guatemala seeking a route to the East Indies. Many remained, estab- lishing a formal government, economy, and way of life based on Spanish culture, traditions, and the Catholic religion (Information Please Almanac, 2007).

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Civil war during the 1960s, 1970s, and 1980s created widespread death, loss of land rights, economic instability, and disruption of the way of life for most Guatemalans. The indigenous population was most adversely affected. As a result, huge numbers fled to Mexico and the United States seeking safety and political asylum. A peace accord signed in 1996 formally ended 36 years of violence in Guatemala. The country continues to be plagued by “abject” poverty. With 56 percent of the population living below the poverty level (CIA, 2007), families with one member earning as little as 14 quetzales a day (equivalent to 2 U.S. dollars) can survive (Walsh, 2006).

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Two distinct types of migration, internal and external, occur among people of Guatemalan heritage. The first occurs within the country of Guatemala. Large company- owned farms (fincas) along the Pacific lowlands grow cof- fee beans, cotton, cardamom, and sugar. During the har- vest season, indigenous people from the highlands migrate to the Pacific lowlands to harvest the crops grown there. Migrants may remain in the fincas for months prior to returning home. Although for many only the male head of household and mature boys migrate, in some cases, the entire family migrates. Another in-country migration is the relocation of indigenous people to Guatemala City. Owing to economic necessity, young women leave their families to work as housekeepers for wealthy Ladino families. Their earnings are sent home to supplement the family income. In some cases, whole fam- ilies relocate to Guatemala City. Some are able to secure adequate income for their needs; however, many cannot and resort to living within the Guatemala City dump.

The second type of migration occurs primarily to the United States. Over 700,000 Guatemalans currently reside in the United States, of whom an estimated 150,000 are undocumented (U.S. Bureau of the Census, 2005).

Approximately 85 percent of America’s farm workers are Hispanic, some of whom are Guatemalan. The average farm worker in the United States averages less than $10,000 a year (National Center for Farmworker Health [NCFH], 2005). These wages provide Guatemalans with sufficient income to send money back home to help sup- port their families. When the opportunity presents itself, many move into nonagricultural jobs, as these generally offer increased stability and higher wages.

EDUCATIONAL STATUS AND OCCUPATIONS

Prior to the Spanish conquest, education in Guatemala was informal. The Mayan languages and cultures were passed down orally from generation to generation. There was no written Mayan language. Children learned lan- guage and culture from their parents, extended family, and community. Ladinos established the first public edu- cation system within the country. Higher education was developed as well. The education system teaches the offi- cial language of the country, Spanish, along with Spanish culture and traditions. High school and university gradu- ates are primarily Ladinos (Shea, 2001).

Within the Mayan culture, boys are permitted to attend school. Parents believe that developing skills in the Spanish language prepares them for additional eco- nomic opportunities. Female children traditionally have not been permitted to attend school. They spent as much time as possible with their mothers to learn homemaking skills. This, however, is changing. More female children are encouraged to attend school. The literacy rate for men is 78 percent, and for women, it is 63 percent (CIA, 2007).

Most Guatemalans are involved in occupations related to farming. Rural families may own a small plot of land passed on by their ancestors; however, many of these plots were confiscated by the government during the civil war. Often, the plot is just large enough for a small adobe brick home with a tin roof and an area to grow corn (maize), beans, and a few other vegetables for family consumption.

Children miss school when needed to help with farm- ing or household duties. Rather than completing high school, many children around the age of 12 years begin working as soon as they are able to do so in order to sup- plement the family income.

Women in rural areas may earn money by selling, at the local marketplace, woven clothing, handmade items, or small animals they have raised. Weavings using a tradi- tional back strap loom contain colors and designs related to the specific indigenous group, village, and family by whom they are made.

Communication

V I G N E T T E 8 . 1

Francisco Salvador Siantz, a 42-year-old Ladino from the Guatemalan Highlands, fell from a ladder and broke his femur while picking apples. Working through an interpreter during his health assessment, he admitted to having a 6-month history of generalized musculoskeletal pain, dizziness, and intermit- tent fevers that he has not revealed to anyone. His laboratory reports return with an elevated blood glucose level. His physi- cian plans to complete a further work-up for diabetes mellitus.

1. This Ladino gentleman has three names. What is the surname of his father? Of his mother? If he were to sign his first and last name, what would they be?

2. What language interpreter was used if he speaks the language of the Ladino Guatemalan population?

3. Identify three possible reasons he did not notify anyone about his history of generalized musculoskeletal pain, dizziness, and intermittent fevers?

4. Besides his diabetes, what might other diagnoses be? 5. If the nutritionist provides him with a diabetic diet,

what “typical” Ladino foods should be included?

DOMINANT LANGUAGE AND DIALECTS

The major languages in Guatemala include the official language, Spanish, which is spoken by 60 percent of the population, and Amerindian languages, which are spoken by the remaining 40 percent. Officially, 23 Amerindian languages are recognized, including Quiche, Cakchiquel, Kekchi, Mam, Garifuna, and Xinca. Ladinos speak Spanish as their primary language. In addition, there are various unofficial Mayan languages (Shea, 2001). Each Mayan ethnic group speaks one dialect as their primary language. If Mayans attend school in Guatemala, they learn Spanish.

Some Mayan men do not have a formal education but are able to speak Spanish because of frequent interactions with Spanish speakers. This occurs most often through business relationships. Mayan men, therefore, may be bilingual, speaking their Mayan dialect and Spanish.

Spanish is the primary language of blacks who attend school in Guatemala. If a black individual immigrated to Guatemala, then her or his primary language is most likely the language of their home country. Most black immigrants to Guatemala speak French as their primary language and learn Spanish after arriving in Guatemala.

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TEMPORAL RELATIONSHIPS

Guatemalan people tend to value the past and live in the present, being more concerned with today than the future because the future is uncertain for many. Some of life’s uncertainties for Guatemalans are related to the daily challenges they face securing adequate employ- ment, housing, food, and other basic necessities such as health care for themselves and their families.

For those in poverty, there is usually not enough money to save for the future and send their children for higher education. Social Security or retirement benefits are not available to the average citizen in Guatemala. Medicare or Medicaid insurance is not available. Most Guatemalans hope that they can work until the time of their death. When an individual is unable to work, it is customary for him or her to be taken care of by the family.

Because work is such a priority in the life of many Guatemalans, they seek health care only when their ill- ness has progressed to the point of preventing them from working or carrying out their duties or roles within the family. Taking time to go to the doctor means time lost from work and loss of pay.

Most Guatemalans live in poverty in rural areas and may not own a watch or clock and may not be able to tell time. Time is related to the natural environment, such as sunrise, sunset, and the rainy season. Businesses in Guatemala are much more relaxed about time. Punctuality is difficult for many because of limited transportation and unexpected family needs.

Future orientation and punctuality are highly valued in the United States. Because these are in direct contrast to Guatemalan values, patient/health-care provider rela- tionships often result in conflict. Guatemalans may be late for appointments or not show up at all. Health-care providers may interpret this behavior as immature or dis- respectful, whereas the reason may actually have to do with a family emergency, lack of transportation, inability to get time off from work, limited finances, or fear of los- ing one’s job. Moreover, health-care providers may expect Guatemalan patients to participate in preventive health screenings and adopt behaviors to reduce their risk of long-term complications of disease. These behaviors require a future orientation that conflicts with the present orientation of many Guatemalans.

FORMAT FOR NAMES

Guatemalans who have a Hispanic heritage use the Spanish format for names. At birth, a child is given a first name (Ovidio) followed by the surname of his father (Garcia), and then the surname of his mother (Salvador), resulting in Ovidio Garcia Salvador. Men’s names remain the same through their lifetime. However, when a woman named Jovita Garcia Salvador marries Francisco Vasquez Gutierrez, she then becomes Jovita Garcia de Vasquez or simply Jovita Garcia Vasquez.

Sometimes, health-care providers incorrectly assume Guatemalan couples are not married because of the for- mat of their names. Guatemalan couples use this format when married in either the church or a civil ceremony.

Couples who live together (unidos) may use this format or choose for the woman to retain her unmarried name.

To convey respect, the health-care providers should address the Guatemalan in a formal manner unless other- wise requested by the patient. Male children and adults are referred to as Mr. (señor). Females are referred to as Ms. (señorita) or Mrs. (señora). Guatemalans are customarily greeted with a handshake. In rural areas, people shake hands softly. To give a firm handshake indicates aggres- sive behavior. In the cities, however, the handshake tends to be more firm. Guatemalans avoid direct eye contact with others, including health-care providers, which is a way of demonstrating respect and should not be misin- terpreted as avoidance, low self-esteem, or disinterest. They speak softly in public. Speaking loud is considered rude.

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

Many Guatemala families follow traditional roles for hus- bands, wives, and children, although this is changing for some. Traditionally, the man has been the head of house- hold and is the primary “breadwinner” and provider for the family. This usually requires men to work outside of the home. Ultimate decision-making power resides with the man of the house.

Women’s roles have traditionally involved raising the children and caring for the home. In rural areas, the wife usually rises around 5:00 a.m. or even earlier. She carries water for drinking and firewood from the nearest sources available. Then she returns home, builds a fire, and begins cooking for the family on a wood-burning stove. Once the family has eaten breakfast, she cleans house by sweep- ing the dirt floors, grinds corn to make tortillas, washes clothes, cares for the young children, breastfeeds as needed, sews, weaves, cares for chickens and other small animals, and prepares for market day (Shea, 2001). Little girls begin fetching water at the age of 3 to 4 years. At age 7 years, they are washing clothes, gathering wood, and caring for younger siblings. At age 9 years, young girls learn to weave and embroider (Glittenberg, 1994).

Guatemalans place a high value on the family and the extended family. Most families are nuclear—comprising a father, mother, and children. Extended family is impor- tant to Guatemalans and may include grandparents, aunts, uncles, and cousins.

A young woman’s 15th birthday (quinceñera) is cele- brated as her passage to womanhood. Coming of age for a young man is at 18 years. A young man asks the young woman’s father for her hand in marriage. Engagements may last several years. In the indigenous population, a young man’s father may seek out a matchmaker to find a suitable bride under age 16. Once an arrangement is reached, the young man offers a dowry. A wedding feast celebrates the marriage.

More Guatemalan women are entering the workforce outside of the home, resulting in more egalitarian male/female roles. Husbands and wives share more of the child rearing and household responsibilities.

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PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES FOR CHILDREN AND ADOLESCENTS

Guatemalans place a high value on the institution of fam- ily, which includes nuclear and extended family members who most often live together or very close. They are involved in each other’s lives on a daily basis. Family is structured as a patrilineal system. Males are the only fam- ily members who receive an inheritance (Glittenberg, 1994).

Children are a gift from God and are highly valued in Guatemalan society. Sons are more valued than daughters (Glittenberg, 1994). Children are taught to be obedient and demonstrate respect for older people. In Mayan com- munities, family members and other adults take an active part in raising a child. They believe it takes a village to raise a child to become a productive member of the com- munity and to continue their culture (Menchu, 1984). Values include being humble, content, and respectful of others; working hard; avoiding arguments; and placing the needs of the family before one’s own individual needs. In Ladino families, individualism and competition are more highly valued (Glittenberg, 1994).

Disobedience among children in Guatemala may be handled with physical punishment (Menchu, 1984). Health-care providers in the United States need to use care in assessing evidence of this to avoid misdiagnosing it as child abuse.

FAMILY GOALS AND PRIORITIES

The Guatemalan family demonstrates a desire to provide for the needs of each member. Parents provide for their children in hopes that they will grow up, marry, work, and have children. When family members are unable to take care of themselves, the expectation is that their fam- ily will take care of them. Life is hard in Guatemala. Families work much of their lives without luxuries such as days off or vacations. Most know poverty will likely pre- vail in their lives regardless of how hard they work. Parents feel they must prepare their children for the same hard life they have lived because very little changes from generation to generation (Menchu, 1984).

Guatemalans expect to work hard and believe that their hard work will result in an increased quality of life. Guatemalan families who migrate to the United States do so with the hope of a better life for themselves and their children. More opportunities are available in the United States, which is why Guatemalans often risk everything to migrate.

ALTERNATIVE LIFESTYLES

When “family” falls outside of defined norms, there is a lack of understanding and acceptance toward those involved. Religious beliefs and tradition often dictate the attitude one holds about what does and does not consti- tute family in Guatemala.

Catholic, Protestant, and Evangelical Guatemalans do not believe in homosexuality, sexual activity among the unmarried, or infidelity. Persons involved in these activi- ties must do so in secrecy. Even today, indigenous women

dress conservatively with a woven long skirt (corte), blouse (huipil), a scarf (tzute), and shawl (rebozo) that pro- mote modesty. A single woman is believed to be a prosti- tute if she is out in public alone.

Despite a prevailing “macho” attitude with a deep- rooted homophobia, some inroads have been made for gays, lesbian, and transgendered populations in Guatemala with Lesbiradas, an organization for lesbians and bisexual women, and an annual Gay Pride March in Guatemala City since 2000 (Gay Guatemala, 2007). Larger cities in the United States offer organizations such as Ellas, a support group for Latina lesbians; El Hotline of Hola Gay, an organization with information and referrals in Spanish; and Dignity, a gay Catholic support organiza- tion. Health-care providers need to be sensitive toward and knowledgeable regarding the resources in their com- munity for Guatemalans who present with an alternative lifestyle.

Workforce Issues CULTURE IN THE WORKPLACE

During the civil war in Guatemala, residents were permit- ted to migrate to the United States and apply for political asylum. If granted, this allowed Guatemalans to stay per- manently in the United States, but they were not permit- ted to ever return to Guatemala. Many who chose this route had no family left in their home country; their lives were at risk should they return. In 1986, the Immigration Reform and Control Act allowed many Guatemalan agri- cultural workers to bypass the process involved in politi- cal asylum and simply obtain residency as farm laborers. This promoted an increase in emigration (Wellmeier, 1998). Guatemalans who migrate to the United States today often find employment in the agricultural industry, including hand-harvesting crops and working on egg or chicken farms, citrus processing plants, and plant and flower nurseries.

Wellmeier (1998) found that Guatemalans in Indiantown, Florida, acquired a reputation for hard work, complained little, and paid close attention to detailed work in agriculture. However, Mayans were not often hired for picking oranges or cutting sugar cane because of their small stature. Agricultural employers preferred Mexican or Haitian workers for these jobs.

When possible, Mayan farm workers in the United States secure nonagricultural employment that offers less migra- tion and more economic stability. Some find positions in housekeeping or maintenance in businesses or schools. Those with skills in English and Spanish may qualify for interpreter positions. If they speak a Mayan dialect as well, their services are even more highly sought by agencies that serve that particular population (Wellmeier, 1998).

Guatemalan women may work in agriculture or house- keeping in the United States or cook instead for Guatemalan men who are single or working in the United States without their families. This provides men with a connection to home, convenience, and the enjoyment of consuming foods prepared according to cultural tradi- tions. Prices for the meals are generally affordable.

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Undocumented Guatemalans have difficulty securing a bank account or driver’s license. Many carry the cash they earn with them. This habit and their small stature have resulted in Guatemalans being victims of robbery. Some Mayan agencies in the United States have developed co- ops that offer simple banking services to reduce the inci- dence of robbery among Guatemalans (Wellmeier, 1998).

Guatemalans may purchase a vehicle in order to secure employment far from home while in the United States. Most have never had formal driver’s training or a driver’s license or driven a vehicle prior to arrival in the United States. Moreover, they may be unaware of driving rules and regulations in the United States owing to unfamiliar- ity with the English language. Driving under these cir- cumstances places the Guatemalan and other drivers at risk for serious accidents. In addition, Guatemalans may be ticketed or arrested for driving violations owing to their lack of understanding regarding laws in the United States, such as seatbelt laws.

Because family is highly valued among Guatemalans, needs of the family take priority over obligations in the employment setting. Guatemalans may miss work owing to an illness of a loved one, a need for transportation to an appointment, or a lack of child care. When Guatemalans living in the United States learn that a loved one in Guatemala is ill or has passed away, they feel compelled to return to Guatemala for an extended period of time, risk- ing loss of their job if a leave of absence is not possible.

Because punctuality is not valued in Guatemala, the Guatemalan employee in the United States may arrive for work late. They may not wear a timepiece, be able to tell time, or understand the importance of punctuality in the United States. This misunderstanding also occurs in health-care settings. The Guatemalan patient may be late for an appointment owing to circumstances related to family, work, or transportation and find the appointment has been cancelled or rescheduled when she or he arrives. To achieve a positive relationship, health-care providers need to demonstrate respect for the Guatemalan patient’s need for flexibility and help her or him to understand the expectations within the health-care setting.

ISSUES RELATED TO AUTONOMY

Guatemalans tend to respect persons in positions of authority. Those of lower socioeconomic status and/or with formal education and English language skills usually acquire positions with responsibility but little authority. They prefer to get along well with others and not criticize or voice complaints when treated poorly. Moreover, the Guatemalan is likely to remain in a position equal to his or her peers rather than seek a promotion.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Most Guatemalans are a mixture of Spanish and Mayan Indian heritage. There is a small population of black Guatemalans with ancestry from the Caribbean and

Africa. This accounts for variations in skin color, facial fea- tures, hair, body structure, and other biological variations. Intermarriage among the racial groups in Guatemala has produced variations in their appearance. No one appear- ance is “typical” for a Guatemalan individual.

Guatemalans who are predominantly Spanish have the appearance of Caucasians. They may have blonde or brown hair, fair (white) complexion, and blue eyes and be of average or taller height with a medium to large build. Guatemalans with predominantly Mayan Indian ancestry tend to have black hair, brown skin, and dark eye color and are of short height with a petite build. Black Guatemalans tend to have black hair, black skin, and dark eyes and be of average or taller height with a medium to large build.

Cyanosis and anemia are assessed differently in dark- skinned people than in white-skinned people. Instead of being bluish in color, the skin color of a cyanotic patient of Indian or black ancestry may appear more ashen. Physical assessment of these individuals should include examination of the sclera, conjunctiva, buccal mucosa, tongue, lips, nailbeds, and palms of hands and soles of feet. In addition, jaundice is more difficult to detect among dark-skinned Guatemalans. Examination of the sclera and buccal mucosa for evidence of bilirubin is important for accurate assessment.

DISEASES AND HEALTH CONDITIONS

Health literature regarding Guatemalans is limited. The primary literature is related to public health statistics compiled by Pan American Health Organization (PAHO) and direct observations by North American health-care professionals who provide primary care through their vol- unteer efforts in Guatemala ( jornadas). Even data com- piled by the NCFH do not differentiate Guatemalan farm workers from other groups within the designation of Hispanic farm workers when discussing health.

The leading causes of mortality in Guatemala are pneu- monia, diarrhea, communicable diseases, diseases of the circulatory system, perinatal conditions, and tumors (PAHO, 2004). These may be directly linked to environ- mental factors, lifestyle, and lack of adequate medical care. Chickering (2006) compiled data of the most frequent complaints of Guatemalans to North American health-care practitioners during jornadas. These are described in order of highest to lowest frequency:

1. Musculoskeletal pain: This is not really surprising, considering the lifestyle of many Guatemalans. They are exposed to difficulties in life, including violence, malnutrition, disease, and high child- bearing rates, all of which take their toll on one’s health and well-being.

Much of the work involved in the daily lives of Guatemalans is difficult. For example, young girls start fetching water, which they carry on their heads, and caring for siblings, whom they carry on their backs, at very young ages.

Boys begin farm work with their fathers as soon as they are physically able. Farming contin- ues much as it traditionally has with primitive tools, requiring lifting, bending, climbing steep

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mountains, and carrying heavy loads without the use of modern machinery.

Adulthood brings requirements for more work, along with an increased need for physical stamina to maintain economic stability, the fam- ily, and the home. Guatemalans often believe that life is hard and pain is expected; instead of complaining about pain, they usually learn to endure the pain and continue their duties until the pain is unbearable or they physically are unable to function as desired.

Other causes for musculoskeletal pain in Guatemalans are diseases such as malaria or dengue fever. “. . . Whole body pain with a history of fever should be considered malaria until proven otherwise” (Chickering, 2006). Guatemalans with dengue are not as likely to be seen by a health-care provider because they are usually too ill to even leave their home (Chickering, 2006).

2. Abdominal pain: These complaints are divided into epigastric and non-epigastric pain. Most commonly, epigastric pain is due to gastritis (gas- tritis), intestinal worms, or chronic giardia. Guatemalans may hold traditional beliefs about the symptoms caused by intestinal worms. These include thunder (trueño) noise in the stomach, swelling (hinchazón) in the stomach (especially in the afternoon following the largest meal of the day), chronic abdominal swelling (panzudo) in children, a ball-like mass (bola) in the stom- ach, gas moving back and forth in the upper abdomen, itchy nose, pica (especially for eating dirt, ashes, and paper), loss of appetite, and sleeping prone (embrocado) (Chickering, 2006).

3. Cough and upper respiratory symptoms: A complaint of chronic coughing or a cough that persists can be a symptom of pulmonary tuberculosis (TB). This may be accompanied by fever, night sweats, or weight loss. Typhoid can also have symptoms of a mild, dry cough, although typhoid is not a very common disease in Guatemala (Chickering, 2006).

A factor increasing the Guatemalan’s risk for acute upper respiratory infections is related to poverty and living conditions. Many Guatemalans of low socioeconomic status are malnourished, so their immune function is compromised. They often live in one- or two-room homes, placing them in close quarters with other family members and enabling germs to spread easily from one per- son to another.

In addition to acute upper respiratory infec- tions, chronic lung disease is seen among Guatemalans. Some areas of Guatemala have very poor air quality, exposing people to high levels of toxic inhalants. Regulations for air qual- ity are few and poorly monitored. Another source of exposure for many Guatemalans is from cooking on wood-burning stoves. Cooking remains primitive for many, and dependence on wood for fuel is high. Exposure to carbon

monoxide presents a risk in itself, but the danger becomes even higher because the cooking area is often enclosed in the home or a building adja- cent to the home, with little, if any, ventilation to the outside. Chronic lung disease may result from years of one or both of these exposures.

Health-care providers may misinterpret signs and symptoms of chronic lung disease in Guatemalans as related to cigarette smoking when, in reality, far more people are exposed to environmental factors than smoke cigarettes. In cases in which the Guatemalan patient does smoke, the risk is obviously higher than that of nonsmokers.

4. Headaches: Headaches can be due to a number of factors. Malnutrition and anemia are common and some headaches are attributed to these. In addition, cooking on the wood-burning stove causes women, especially, to be exposed to high levels of carbon monoxide, which can produce headaches.

Although men usually carry heavy loads on their backs, women carry them on their heads, which leads some women to experience headaches. Finally, worms can cause headaches. Guatemalans themselves often relate the cause of headaches to be from anger or exposure to sun. Relationships that do not involve conflict are highly valued among Guatemalans. Unresolved issues in relationships may increase one’s stress, thereby creating headaches. There is no literature to suggest sun exposure may cause headaches among Guatemalans, but perhaps the belief is related to the hot/cold paradigm. Health-care providers should also assess blood pressure and neurological function in Guatemalans complain- ing of headaches (Chickering, 2006).

5. Weakness: Weakness (debilidad), fatigue (cansan- cio), and dizziness (mareos, baidos, or taran- tamiento) are common complaints. Anemia is the most common cause for these symptoms. Health-care providers must note that weakness can also be used to describe a health problem involving one body organ. For example, weak- ness of the stomach (debilidad del estomago) can refer to a Guatemalan patient’s self-report of poor nutrition, and weakness of the heart (debil- idad del corazon) can imply being upset emotion- ally (Chickering, 2006).

When Guatemalan patients complain of dizzi- ness with or without the weakness and fatigue, dehydration should be considered. Guatemalans consume very little water on a daily basis because of the scarcity and poor quality of the accessible drinking water. Adults are more likely to drink coffee than water, which can lead to dehydration.

6. Skin lesions and/or itching: The most common skin lesions are skin spots (manchas) known scientifi- cally as the yeast Malassezia furfur. Pruritus may result from dry skin, fungi, scabies, worms, or AIDS, known in Spanish as SIDA. In Guatemala,

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HIV, known in Spanish as VIH, is most often transmitted by heterosexual intercourse. Men may contract it through sexual activity with women they meet at bars; wives then contract it from their infected husbands (Chickering, 2006).

Health-care providers should suspect HIV/ AIDS when the Guatemalan patient offers the next most common presenting complaints of anorexia and weight loss and their history includes diarrhea, cough, pruritus, painful swal- lowing, persistent unexplained fever, weakness, or night sweats. The health-care provider should not hesitate to ask about risky sexual behaviors with which the patient may have been involved to further determine if HIV/AIDS may be the most likely diagnosis; testing/counseling should follow (Chickering, 2006).

7. Diarrhea (asientos, chorrio): Causes for diarrhea primarily include shigella, amoebas, and giardia, although it may accompany HIV/AIDS as well (Chickering, 2006). Exposure to these pathogens is high in Guatemala, especially in the rural areas. The infrastructure of the communities simply cannot provide water and sewage services neces- sary for promoting healthy lifestyles because these are nonexistent for most Guatemalans.

Drinking water is obtained from polluted waterways, so it is nonpotable. Either bottled water must be purchased, which is cost prohibi- tive for most Guatemalans, or contaminated water must be boiled for at least 20 minutes to ensure pathogenic organisms are eradicated. Factors such as depending on wood for cooking to boil drinking water and the time required for this option lead to low levels of compliance.

Dehydration, obviously, is the most serious side effect of diarrhea. This is especially true for children and is the second leading cause of death for children under 5 years of age in Guatemala (PAHO, 2004). Severe dehydration needs to be treated promptly with IV fluids when possible. When IV fluids are not available to administer, oral rehydration solutions should be used. They are available in prepared packets or can be made with ingredients readily available at low cost. Whereas the pathogens mentioned are the most common causes of diarrhea in Guatemala, health-care providers who treat immigrant pop- ulations in North America should consider these causes when patients have a history of traveling to and from Guatemala.

8. Eye disorders: Wind, dust, sunlight, and cooking smoke contribute to eye pain in Guatemala through conjunctiva irritation or by the stimula- tion of ptergia (carnosidades). Relief from discom- fort and pain can be accomplished through the use of cool, moist compresses over the eyes. Moistening the compresses with chamomile tea (té de manzanilla) is ideal (Chickering, 2006).

Other painful eye disorders among Guatemalan patients include dacrocytosis and tracoma.

Cataracts (even in children), congenital toxoplas- mosis, toxic optic neuropathy (usually related to TB treatment), vitamin A deficiency, and actinic allergy are examples of nonpainful eye conditions common to Guatemalans. Vitamin A deficiency, however, is decreasing because sugar has been for- tified with vitamin A (Chickering, 2006).

Chickering (2006) identified additional presenting complaints of Guatemalan patients as falling into cate- gories related to menstrual/vaginal, psychiatric, urinary tract infection, pregnancy, pure fever and chills, ear and hearing, chest pain, and male genitourinary issues.

VARIATIONS IN DRUG METABOLISM

Although some studies have identified differences in drug metabolism related to racial/ethnic groups, it is difficult to use these for Guatemalans owing to the mixed heritage of many. These variations, however, can influence the deter- mination of a therapeutic dose and affect absorption, dis- tribution, metabolism, and excretion of drugs. A few stud- ies using one subgroup of Hispanics noted that they required lower doses of antidepressants and experienced more side effects than non-Hispanic whites.

High-Risk Behaviors Although Guatemala as a country struggles to maintain traditional and faith-based values, the reality is that increasing numbers of residents seek relief from the hard- ships of life through abuse of substances. The prevalence of substance abuse is highest among men. Alcohol is the most readily available substance and the most widely abused. In Guatemala, it is not uncommon to see men staggering in public owing to drunkenness and uncon- scious on sidewalks and roads from excessive intoxica- tion. Accidents are more prone to occur in these settings. Injuries and even death occur from falls, confrontations, and collisions with vehicles.

Men who immigrate to the United States from Guatemala for work may find themselves drinking alco- hol excessively, even if they did not prior to migration. This may be due to such factors as (1) the stress of living in another country illegally, (2) being away from the fam- ily, friends, and support systems, (3) fears of inadequate work and deportation, and (4) illness and being victims of violence and injury. They may work and live closely with other men they hardly know and yet develop a cama- raderie based on their shared lifestyle. Their role changes from being actively involved in family to that of a long- distance economic provider, which leads to loneliness, emptiness, and unstructured time when the work day is done. Alcohol can become the antidote (NCFH, 2005).

HEALTH-CARE PRACTICES

Guatemalans of low socioeconomic status receive little health education, have limited access to health care, and often believe illness is punishment from God. These fac- tors result in their poor participation in illness prevention

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practices. In addition, health care in rural areas is mostly provided by government health promoters who focus on episodic illness care rather than preventive measures such as sanitary housing, potable water, balanced diets, and family planning (Icu, 2000).

Guatemalan families readily participate in immuniza- tion programs for their children yet do not participate themselves. Adult immunizations such as tetanus, flu, and pneumonia are underutilized by Guatemalans. Moreover, women do not participate in routine screening for breast and cervical cancer. Guatemalan men do not participate in routine screening for testicular or colon cancer.

Lack of routine health-care screenings place Guatemalans at high risk for communicable diseases and cancers at advanced stages of disease, severely compro- mising positive outcomes. Health-care professionals should educate Guatemalans in a family context for dis- ease, illness, and injury prevention; assist with low-cost referrals; and respect their cultural beliefs.

Nutrition

V I G N E T T E 8 . 2

Pablo Salvador, a Ladino Guatemalan political refugee, has been in the United States for 15 years. Señor Salvador has worked in the same poultry processing plant since his arrival. Over the last 10 years, he has sent almost half of his salary to his parents in Guatemala. His parents were able to afford the trip to the United States and moved in with him 4 months ago. He told his supervisor that he is happy that his mother is cook- ing his childhood Guatemalan foods, especially tortillas treated with limestone, which he has missed since his arrival in the United States.

1. What are the implications of being a political refugee and a political asylee? What is the difference?

2. What foods might be included in a Ladino Guatemalan diet? How might they be prepared?

3. What health problem can occur with eating tortillas cooked with limestone?

4. What evidence of the value of familism is in this vignette?

MEANING OF FOOD

Food to Guatemalans signifies physical, spiritual, and cul- tural wellness. Foods vary among Guatemalans based on cultural traditions and accessibility.

COMMON FOODS AND FOOD RITUALS

Gari’funa cuisine reflects the Caribbean coast and includes recipes from African ancestors. Common foods include sea bass, flounder, red snapper, tarpon, shrimp, seviche, coconut milk, tomato, onion, garlic, lime, and lemon (Shea, 2001).

Their ancestors taught that the Maya come from the corn. As a result, corn is highly valued in the Mayan cul- ture. Corn is the chief crop and the basis for many food products and meals. Foods bring strength, good health,

and a spiritual connection to the past. The Mayan diet primarily consists of maize, black beans, rice, chicken, squash, tomatoes, carrots, chilies, beets, cauliflower, let- tuce, cabbage, chard, leek, onion, and garlic. These foods are used to make tortillas, atole (liquid corn drink), pinol (chicken-flavored corn gruel), pepi’an (chicken stew with squash seeds, hot chilies, tomatoes, and tomatillos [small green tomato]), and caldos (soups made of chicken stock and vegetables) (Shea, 2001). Preferred beverages are Hibiscus tea and coffee. Coffee is brewed weaker than that in North America.

Ladino foods reflect their Spanish ancestry and include maize, rice, beans, beef, chicken, pork, milk, cheese, plan- tains, carrots, peppers, tomatoes, squash, avocado, cilantro, chilies, onion, garlic, lemon, lime, and chocolate. Common dishes include arroz con pollo (chicken with rice), chile rellenos (peppers stuffed with pork or beef with carrot, onion, and tomato and fried in egg batter), and tamales (chicken or pork in a corn paste steamed in banana leaves or corn husks) (Shea, 2001). Foods are seasoned with toasted squash seeds ground to a powder. Guatemalan food is not served spicy. A spicy hot sauce may be served alongside a meal for individuals who prefer to add it.

DIETARY PRACTICES FOR HEALTH PROMOTION

Guatemalans value corn because it brings good health. Corn is eaten at every meal, most often in the form of tor- tillas. Tortillas are made by soaking corn kernels in lime, creating dough by adding animal fat, flattening the dough, and cooking it over an open fire or wood-burning stove. The lime used is limestone rather than the fruit lime and is believed to strengthen bones. Consuming foods with limestone, however, has also been associated with dental problems and gallstones (Glittenberg, 1994).

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

The diet of many Guatemalans is low in protein (Steltzer, 1983), iron, and vitamin C (Chickering, 2006). Lactose intolerance is especially prevalent among indigenous populations (National Digestive Diseases Information Clearinghouse, 2007). Some families encourage their chil- dren to drink coffee with sugar when they refuse the poor- tasting drinking water. This practice leads to gastritis, dehy- dration, and dental caries.

Pregnancy and Childbearing Practices

V I G N E T T E 8 . 3

A 15-year-old “typical” Mayan, Angelica speaks Mam, which is not a written language. She is 8 months’ pregnant and was sent by her family with a group of migrant Guatemalan and Mexican workers to prepare their meals. Her family sent her because they did not want to face the stigma of her unwed pregnancy, even though she was a victim of rape. The public

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health worker has witnessed her walking through the fields in the late afternoon looking at her abdomen and talking to her fetus. Initially, the public health nurse thought Angelica was 11 or 12 years old.

1. Identify Mayan beliefs regarding pregnancy and virginity. 2. Why is Angelica talking to her fetus? 3. Describe the physical attributes of “typical Mayans.”

Why did the public health worker initially think Angelica was only 11 or 12 years of age?

4. Identify Mayan foods that Angelica might eat to ensure a healthy baby.

FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

Guatemalans value life beginning from conception; a baby is a gift from God. For religious reasons, most do not believe in contraception or abortion. A Guatemalan woman may bear 10 or more children in her lifetime. Of these, many die before the age of 5 years (PAHO, 2004). Women who desire contraception will not actually seek it because of lack of support from their spouse, family, and church. Access to modern birth control methods is diffi- cult, if not impossible, for many Guatemalan women who may consider alternatives to pregnancy.

In Guatemala, Mayan midwives (comadronas) deliver 80 percent of all children in the home. The other 20 per- cent are delivered by medical professionals in the hospital setting. Comadronas are “wise” women who are trusted in their community. They feel midwifery is a sacred “call- ing” by God or a saint who requires special knowledge and rituals. The Ministry of Health has permitted mid- wives to practice since 1935 (Lang & Elkin, 1997). Many midwives do not have formal training. They may have learned the practice from their mother (mama) or grand- mother (abuela) or through “dreams or visions.” Prior to delivery, the midwife prays at her own home and then again at the home of the pregnant mother. Some use can- dles, incense, or religious icons during prayer. The deliv- ery is followed by additional prayers. If the baby dies dur- ing delivery, the midwife and family accept it as God’s will (Walsh, 2006).

Health-care providers must ask the Guatemalan woman whether she is interested in family planning instead of directing the question as “which form of birth control do you prefer?” The latter clearly arises from the health-care provider’s own values, which may be in direct conflict with those of the patient. Moreover, when the patient does express a desire to learn more about family planning, she may request the session include her hus- band. Arrangements should be made to accommodate the patient’s request.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

On the day a Guatemalan woman becomes pregnant, she and her husband share the news with respected elders of the village. The community becomes the grandparents (abuelos) of the unborn child. Godparents are also selected at this time (Menchu, 1984).

In the seventh month of pregnancy, the woman intro- duces her fetus to the environment. She walks the fields and hills and goes through her daily activities, showing and telling her fetus about the life she leads. The mother tells the fetus to be honest and never abuse nature. If someone eats in front of the pregnant woman without offering her food, she believes she will have a miscarriage. Children are permitted at the delivery. The woman’s husband, village leaders, and parents of the couple may be present. A single woman must not observe the birth of the baby (Menchu, 1984). A midwife and a witch (brujo) may both attend the birth. The midwife helps with delivery, while the brujo prays for long life, good health, and protection from the evil eye (mal ojo). A breech delivery or one in which the baby’s cord is around the neck is considered good luck.

Mayan women do not believe in lying down to give birth or delivering in a hospital. Following delivery, the placenta has to be burned, not buried, because it is disre- spectful to the earth to do so. The placenta can be burned on a log and then the ashes used for a steam bath, temas- cal (Menchu, 1984).

To celebrate the birth of a baby, the villagers slaughter a sheep. The mother and baby are kept separated from others for 8 days. When the baby is born, its hands and feet are bound for 8 days. This signifies that they are meant for hard work, not for stealing, and they are not meant to have things the rest of the community does not have (Menchu, 1984). Guatemalan women may continue breastfeeding until the child reaches the age of 5 years. Moreover, they may be breastfeeding a new baby while continuing to breastfeed a toddler.

During the first 8 postpartum days, friends and extended family bring food, clothing, small animals, or wood as gifts for the newborn’s family. They also offer their services, like carrying water or chopping wood. The family of the newborn does nothing for these 8 days. All their needs are taken care of by others (Menchu, 1984).

After 8 days, the newborn’s hands and feet are untied. While the newborn is in bed with mom, all community members visit to officially welcome him or her. The baby is told he or she is made of corn. A bag with garlic, lime, salt, and tobacco is hung around the baby’s neck and a red thread is used to tie the umbilical cord to protect the baby, provide strength, and denote respect for the ances- tors. If the baby is a female, the midwife pierces her ears at birth (Menchu, 1984).

Death Rituals DEATH RITUALS AND EXPECTATIONS

Death rituals among Guatemalans vary depending on tra- ditional and/or religious beliefs. Guatemalans grow up experiencing far more death than most North Americans. They see babies and children die of malnutrition and dis- ease, parents and grandparents die from violence, and loved ones die because the health care they needed was too far away or was too expensive. The family may decide the cost for treatment of one family member is too much and decide against it because of the financial strain on the entire family.

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When a person is seriously ill, she or he is usually cared for at home. Family members and the community pro- vide assistance and support. When family must take a seriously ill family member to a hospital, extended family and the community help care for members left at home. Often, hospitals are such a great distance that the ill per- son dies before she or he arrives or during the hospitaliza- tion. Prayers are offered for the sick. Rituals and cere- monies are offered to prepare the body and spirit of the dying for death.

RESPONSES TO DEATH AND GRIEF

When death occurs in Guatemala, it is customary to place the deceased in a simple wooden coffin/casket and con- duct a funeral. In small villages, the entire community is present. The casket may be carried by key family members through town from the church to the cemetery while onlookers show their respect, mourn, and offer flowers. Graves are decorated with flowers on All Saint’s Day in memory of the deceased. Some Guatemalans relate their illness to “punishment” or impending death to “God’s will” and refuse an intervention or heroic measures to reverse the outcome.

When a Guatemalan dies in the United States, the fam- ily may request repatriation, because it is important for the final resting place to be the home country. Often, immediate and extended family and social service agen- cies pool their resources to send the body home.

Guatemalans believe in burial; they do not practice cremation. At Indian funerals, the Mayan priest may spin the coffin at the grave to fool the devil and point the spirit of the deceased toward heaven. Yellow is the color of mourning. Yellow flowers are placed at the grave. Food is placed at the head for the spirit of the departed. Church bells are rung to gain favor with the gods. Ladinos mourn the dead by wearing black. Maya do not believe in this practice.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

Approximately 65 to 80 percent of Guatemalans are Roman Catholic. Regular church attendance is not possi- ble for many, as there is a shortage of priests. Most priests in Guatemala are foreigners (Gall, 1998).

Prior to the Spanish conquest, the Maya practiced a reli- gion based on gods associated with the sun, moon, and other natural phenomena. The causes of natural disasters were related to punishments from heavenly beings. They believed animal spirits (nahuales) inhabited the human spirit (Shea, 2001). Maximon is a Mayan saint popular among Maya and Ladinos. He is believed to represent ordi- nary Guatemalans, has supernatural powers, and produces witches (brujos) and shaman (zajorines) (Sexton, 1999).

When the Spanish brought Roman Catholicism to Guatemala, some Maya converted to Christianity. Others continued to practice their Mayan religion. Still other Guatemalans combined beliefs and practices of the two. In some cases, Guatemalans integrated aspects of Catholicism

into their lives while continuing to believe in the spiritual- ity of their ancestors in private (Shea, 2001).

Two practices influenced by the Spanish are guachibal and cofradia. Guachibal involves the practice of keeping an image of a Christian saint in the home and celebrating on the particular saint’s day. Cofradia refers to a “religious brotherhood” that serves to maintain the “cult” of a par- ticular saint. Cofradias consist of dues-paying members and elected leaders. In addition to religious activities, they often serve needy persons in the community by vis- iting the sick and paying for funerals (Shea, 2001).

Protestantism arrived in Guatemala in the 19th cen- tury. Today, there are an increasing number of evangelical Christian religions in Guatemala. The Christian holidays of Holy Week, All Saint’s Day, and Christmas are cele- brated by Catholic and Protestant Guatemalans (Shea, 2001). Health-care providers must determine whether the Guatemalan patient has a religious preference and demonstrate respect and sensitivity for his or her beliefs.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

Family provides Guatemalans with meaning in their lives. Life revolves around the nuclear and extended family. Spirituality helps to explain life and the circumstances faced by Guatemalans. For example, whether Catholic, Protestant, or traditional Maya, many believe that life’s events happen for a reason. The reason may be attributed to favor from God or gods when positive experiences occur and to punishment or disfavor from God or gods when negative events occur. Some feel nothing can be done to change the outcome of these experiences. This belief is referred to as fatalism.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

When illness occurs, many Guatemalans turn to their faith for strength, wisdom, and hope. Health-care providers may be uncomfortable with patients who have a statue of a patron saint, picture of a saint, or candles burning while prayers are being said. The family may pray together; they need time and space to do so. They may even ask the health-care professional to join prayer, which is acceptable if the provider wishes. Praying with the family promotes confidence in the relationship. The patient and family feel the compassion and respect such actions demonstrate. The health-care provider may also help arrange for spiritual care services for the patient and family through their church or hospital resources.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

Transculturation is continually occurring in Guatemala. Characteristics between Ladinos and Indians used to vary greatly. Ladinos were Spanish speakers, wore Western style clothing, practiced Catholicism, were better educated, worked in nonagricultural occupations, were economically

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better off, lived in superior housing with sanitation, had a better diet, and were healthier. Indians more often than not spoke a Mayan dialect; wore traditional woven cloth- ing (traje); worked in agriculture; used primitive technol- ogy; and maintained social, political, and religious life through cofradias (Woods & Graves, 1973).

Today, the distinction between the Ladino and the Indian in Guatemala is less clear. For example, more Indian men speak Spanish, wear Western clothing, and receive an education.

The preferred mode of treatment among Ladinos is medication administered by hypodermic injection. For example, if an infant has a cold, Ladinos believe an injec- tion is necessary to treat it effectively. If someone has the flu, an IV infusion is preferred. Intramuscular medica- tions are preferred to those taken orally (Kunkel, 1985).

Health-care seeking among Guatemalans generally occurs by first seeking advice from a mother, grand- mother, or other respected elder. If this approach is unsuccessful, then the family usually seeks health care from folk healers. Modern medical care may be the last resort. Many are fearful of hospitals. In Guatemala, when hospital care is necessary, patients are often seriously ill, resulting in death, which perpetuates the belief that “hos- pitals are places where patients go to die.”

RESPONSIBILITY FOR HEALTH CARE

Guatemalans often delay seeking health care until they are incapacitated by illness, disease, or injury. Many times, they are unaware of the dangers associated with working in agriculture in the United States. They may be exposed to pesticides and dangerous equipment without proper training. Although the government has specific laws in place to protect farm workers, enforcement is lim- ited. Companies may not tell the workers the dangers or the workers may not understand owing to language dif- ferences. Health-care providers caring for Guatemalan patients who are farm workers must be aware of the chemical exposures, laws, and resources available in order to adequately advocate for the patient.

BARRIERS TO HEALTH CARE

Only 33 percent of Guatemalans have regular access to health services (Gall, 1998). Guatemalans experience bar- riers to health care, whether in Guatemala or in the United States, that include

1. Availability: The hours many health services are offered are inconvenient for Guatemalan patients who cannot afford to take time off work.

2. Accessibility/reliability: Transportation is not available to access health-care services.

3. Affordability: Most Guatemalans do not have health insurance and are limited to health-ser- vice agencies offering low-cost care.

4. Appropriateness: Low-cost health care offers lim- ited services; dental, women’s, or pediatric care may not be available.

5. Accountability: Health-care providers lack educa- tion regarding Guatemalan cultures, languages, and lifestyles required to offer culturally com- petent care.

6. Adaptability: Many health-care settings do not offer one-stop shopping in which the patient may be seen for dental care and a mammogram the same day in the same location.

7. Acceptability: Many health-care settings do not offer patient education materials in the lan- guages or literacy levels common to Guatemalan patients.

8. Awareness: Many times, Guatemalan patients are unaware of the services available in the area in which they live.

9. Attitudes: Sometimes health-care providers con- vey negative attitudes toward the Guatemalan patient, making it unlikely she or he will return for care.

10. Approachability: Guatemalan patients may not feel welcome in the health-care setting because they interpret verbal and nonverbal communi- cation from providers as lacking in care and compassion.

11. Alternative practices and practitioners: Guatemalan patients may prefer to integrate modern medi- cine with traditional therapies; yet, the health- care provider may be resistant to this.

12. Additional services: The health-care setting may lack child care; the Guatemalan family that does not have extended family members in the United States to assist is required to bring chil- dren and older family members with them to the visit, which is disruptive.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

Guatemalans tend to view health and illness in relation to their ability to perform duties associated with their roles. As long as women are functioning in their role of caring for the home and family, and men are function- ing in their job, then they feel “healthy.” Aches, pains, and minor illnesses that do not prevent functioning are tolerated. When an illness prevents normal function- ing required for their roles, then Guatemalans view it seriously.

The cause of debilitating illness or disease may be viewed as punishment from God rather than lack of pre- vention or early detection. Sometimes, early warning signs of illness or disease are ignored in hopes they will go away on their own. When symptoms persist, fear may keep the Guatemalan patient from seeking medical attention.

When a member of a Guatemalan family needs to be cared for, others gladly comply. This occurs for reasons of advanced age, illness, and mental or physical disability, among others. Residential homes for persons with these conditions are not readily available in Guatemala and are usually cost prohibitive for families living in the United States. Family members would rather care for their loved one at home if at all possible.

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Health-care providers may demonstrate respect for the cultural values of Guatemalan patients by providing com- munity resources that enable them to adequately care for a family member at home if they so desire.

BLOOD TRANSFUSIONS AND ORGAN DONATION

Blood transfusions and organ donation are not common in Guatemala, and with many living outside of the realm of modern medicine, residents may be uneducated regarding the medical situations in which they are indicated, bene- fits, and risks. Questions related to organ donation will be puzzling and elicit fear and anxiety. The Guatemalan patient may think the health-care provider is asking his or her to consent to organ donation because he or she is going to die rather than understanding the context to which the question applies.

Some Guatemalans fear venipuncture because taking blood leaves the body without enough blood to keep them strong and healthy. Health-care providers need to carefully assess the level of education and understanding of the Guatemalan patient regarding these issues and use an inter- preter who is competent in the language and culture of the patient in order to promote successful communication.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

Three distinct health care systems exist in Guatemala: modern medicine, Ladino folk medicine, and Indian folk medicine. Modern medicine refers to health care provided by educated physicians and nurses. Ladino folk medicine is provided by Ladino pharmacists, spiritualists, and lay healers (curanderos). Mayan Indians seek medical care from Mayan shaman, herbalists, and comadronas. When Ladinos and Mayan Indians have access to modern medicine, the utilization increases.

STATUS OF HEALTH-CARE PROVIDERS

Guatemalans have great respect and admiration for health-care providers, who are viewed as authority figures with clinical expertise. Guatemalans expect their health- care provider to have the appearance and manners of a professional (Purnell, 2001). When this is not the case, Guatemalans lose confidence in the provider.

Guatemalans are very private and are not accustomed to discussing issues and concerns openly. It may take a while to develop the trust and rapport with the provider neces- sary for them to share. They fear disclosure may result in deportation or rejection. Patients also fear confidentiality will not be maintained in the health-care setting.

Health-care providers who are most successful in caring for Guatemalan patients practice personalismo, respect, and genuine compassion in their approach to care.

Moreover, Purnell (2001) found the following behav- iors and comments by health-care providers best con- veyed respect to their Guatemalan patients:

1. Greets me when I come in. 2. The way the doctor/nurse talks to me (denotes

respect). 3. Asks questions about what bothers me. 4. Says things to make me feel better. 5. Explains things to me. Guatemalan women are usually very modest. They

may refuse to discuss personal issues or receive an examination by a male health-care provider. Likewise, a male Guatemalan patient may refuse a female health- care provider. Because Guatemalans dislike conflict, they may not actually refuse care; yet they withhold personal information owing to discomfort with the health-care provider. Incorporating these preferences into the encounter with Guatemalan patients enhances the development of relationships that result in effec- tive and meaningful care.

REFERENCES Chickering, W. H. (2006). A guide for visiting clinicians to Guatemala:

Common presenting symptoms and treatment. Journal of Transcultural Nursing, 17(2), 190–197.

CIA. (2007). World FactBook: Guatemala. Retrieved March 16, 2007, from https://www.cia.gov/cia/publications/factbook/geos/gt.html#People

Gall, T. L. (Ed.). (1998). Worldmark encyclopedia of cultures and daily life: Vol. 2, Americas. Detroit, MI: Gale Research.

Gay Guatemala. (2007). Retrieved March 17, 2007, from www.zoomvaca- tions.com/guatemala.htm

Glittenberg, J. (1994). To the mountain and back: The mysteries of Guatemalan highland family life. Lake Zurich, IL: Waveland Press, Inc.

Icu, H. (2000). Health care reform in Guatemala. Retrieved March 17, 2007, from http://phmovement.org/pha2000/stories/icu.html

Information Please Almanac. (2007). Guatemala. Retrieved March 16, 2007, from http://www.infoplease.com/encyclopedia/

Kunkel, P. (1985). Paul Kunkel: Guatemala journal part 2. The Washington Nurse, 15(4), 34–35.

Lang, J. B., & Elkin, E. D. (1997). International exchange: A study of the beliefs and birthing practices of traditional midwives in Guatemala. Journal of Nurse Midwifery, 42(1), 25–31.

Menchu, R. (1984). I, Rigoberta Menchu: An Indian woman in Guatemala. London: Verso.

National Center for Farmworker Health (NCFH). (2005). Facts about farm- workers. Retrieved November 22, 2006, at http://www.ncfh.org

National Digestive Diseases Information Clearinghouse. (2007). Lactose intol- erance. Retrieved February 3, 2007, at http://digestive.niddk,nih.gov

Pan American Health Organization (PAHO). (2004). Country profile: Guatemala. Retrieved January 6, 2007, at http://www.paho.org

Purnell, L. (2001). Guatemalan’s practices for health promotion and the meaning of respect afforded them by health care providers. Journal of Transcultural Nursing, 12(1), 40–47.

Sexton, J. D. (1999). Heart of heaven, heart of earth and other Mayan folktales. Washington, DC: Smithsonian Institution Press.

Shea, M. E. (2001). Culture and customs of Guatemala. Westport, CT: Greenwood Press.

Steltzer, V. (1983). Health in the Guatemalan highlands. Anthropological Quarterly, 57(3), 141–142.

U.S. Bureau of the Census. (2005). Census 2000 demographic profiles. Retrieved January 6, 2007, at http://www.census.gov

Walsh, L. V. (2006). Beliefs and rituals in traditional birth attendant prac- tices in Guatemala. Journal of Transcultural Nursing, 17(2), 148–154.

Wellmeier, N. (1998). Ritual, identity, and the Mayan diaspora. New York: Garland Publishing, Inc.

Woods, C. M., & Graves, T. D. (1973). The process of medical change in a highland Guatemalan town. Los Angeles: University of California.

For case studies, review questions, and additional information, go to http://davisplus.fadavis.com

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Guatemalan Culture

Larry Purnell, PhD, RN, FAAN

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage

People of Guatemalan heritage comprise a growing number of Hispanic/Latino populations in the United States.
Guatemalans may share a common Spanish language with other Hispanic ethnic groups.
In Guatemala, 56 percent of the population lives below the poverty level.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage

Guatemala is inhabited by Mestizo (mixed Amerindian-Spanish - in local Spanish called Ladino) and European 59.4 percent, K'iche 9.1 percent, Kaqchikel 8.4 percent, Mam 7.9 percent, Q'eqchi 6.3 percent, other Mayan 8.6 percent, indigenous non-Mayan 0.2 percent, other 0.1 percent.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communication

The major languages in Guatemala include the official language, Spanish, which is spoken by 60 percent of the population, and Amerindian languages, which are spoken by the remaining 40 percent.
There are 23 officially recognized Amerindian languages.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communication

Some Mayan men do not have a formal education but are able to speak Spanish because of frequent interactions with Spanish speakers.
Guatemalan people tend to value the past and live in the present, being more concerned with today than the future because the future is uncertain for many.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communication

Time is related to the natural environment, such as sunrise, sunset, rainy season, etc.
Punctuality is difficult for many because of limited transportation and unexpected family needs.
Guatemalans who have a Hispanic heritage use the Spanish format for names.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communication

At birth, a child is given a first name (Ovidio) followed by the surname of his father (Garcia), and then the surname of his mother (Salvador), resulting in Ovidio Garcia Salvador.
Men’s names remain the same through their lifetime.
However, when a woman named Jovita Garcia Salvador marries Francisco Vasquez Gutierrez, she then becomes Jovita Garcia de Vasquez or simply Jovita Garcia Vasquez.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communication

To convey respect, address the Guatemalan in a formal manner unless otherwise requested by the patient.
Male children and adults are referred to as Mr. (Señor). Females are referred to as Ms. (Señorita) or Mrs. (Señora).
Guatemalans are customarily greeted with a handshake. In rural areas, people shake hands softly.
To give a firm handshake indicates aggressive behavior.
In the cities, the handshake tends to be more firm.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communication

Guatemalans avoid direct eye contact with others, including health-care providers, which is a way of demonstrating respect and should not be misinterpreted as avoidance, low self-esteem, or disinterest.
Guatemalans speak softly in public.
Speaking loud is considered rude.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

Many Guatemala families follow traditional roles for husbands, wives, and children, although this is changing for some.
Traditionally, the man has been the head of household and is the primary “breadwinner” and provider for the family.
Ultimate decision-making power resides with the man of the house.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

Women’s roles have traditionally involved raising the children and caring for the home.
Guatemalans place a high value on the family and extended family.
Most families are nuclear.
Extended family is important and may include grandparents, aunts, uncles, and cousins.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

A young woman’s 15th birthday (quinceñera) is celebrated as her passage to womanhood.
Coming of age for a young man is age 18 years.
Children are a gift from God and are highly valued in Guatemalan society.
Sons are more valued than daughters.
Children are taught to be obedient and demonstrate respect for older people.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

Among Mayan communities, family members and other adults take an active part in raising a child.
They believe it takes a village to raise a child to become a productive member of the community and to continue their culture.
Values include being humble, content, and respectful of others, working hard, avoiding arguments, and placing the needs of the family before one’s own individual needs.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

When family members are unable to take care of themselves, the expectation is that their family will take care of them.
Guatemalan families who migrate to the United States do so with the hope of a better life for themselves and their children.
More opportunities are available in the United States.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

Catholic, protestant, and evangelical Guatemalans do not believe in homosexuality or sexual activity among the unmarried, or infidelity.
Indigenous women dress conservatively with a woven long skirt (corte), blouse (huipil), a scarf (tzute), and shawl (rebozo) that promote modesty.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

A single woman is believed to be a prostitute if she is out in public alone.
Despite a prevailing macho attitude with a deep-rooted homophobia, some inroads have been made for gays, lesbian, and transgendered populations in Guatemala with Lesbiradas, an organization for lesbians and bisexual women.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

Larger cities in the United States offer organizations such as Ellas, a support group for Latina lesbians; El Hotline of Hola Gay, an organization with information and referrals in Spanish; and Dignity, a gay Catholic support organization.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Workforce Issues

During the civil war in Guatemala, residents were permitted to migrate to the United States and apply for political asylum.
If granted, this allowed Guatemalans to stay permanently in the United States, but they were not permitted to ever return to Guatemala.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Workforce Issues

Guatemalans may miss work due to an illness of a loved one, a need for transportation to an appointment, or lack of childcare.
When a Guatemalan learns that a loved one in Guatemala is ill or has passed away, they feel compelled to return to Guatemala for an extended period of time, risking loss of their job if a leave of absence is not possible.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Workforce Issues

Because punctuality is not valued in Guatemala, the Guatemalan employee in the United States may arrive for work late.
They may not wear a timepiece, be able to tell time, or understand the importance of punctuality in the United States.
Guatemalans tend to respect persons in positions of authority.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Workforce Issues

Those of lower socioeconomic status and/or with formal education and English language skills usually acquire positions with responsibility but little authority.
They prefer to get along well with others and not criticize or voice complaints when treated poorly.
The Guatemalan is likely to remain in a position equal to his peers rather than seek a promotion.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

Most Guatemalans are a mixture of Spanish and Mayan Indian heritage.
There is a small population of Black Guatemalans with ancestry from the Caribbean and Africa.
This accounts for variations in skin color, facial features, hair, body structure, and other biological variations.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

Guatemalans who are predominately Spanish may have blonde or brown hair, fair complexion, and blue eyes and be of average or taller height with a medium to large build.
Guatemalans with predominately Mayan Indian ancestry tend to have black hair, brown skin, and dark eye color and are of short height with a petite build.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

The leading causes of mortality in Guatemala are pneumonia, diarrhea, communicable diseases, diseases of the circulatory system, perinatal conditions, and tumors.
Other major health problems for Guatemalans include musculoskeletal pain, abdominal pain, upper respiratory problems, headaches, rashes and itching, and eye disorders.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

High-Risk Health Behaviors

Alcohol is the most misused substance.
Guatemalan families readily participate in immunization programs for their children yet do not participate themselves.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition

Food to Guatemalans signifies physical, spiritual, and cultural wellness.
Foods vary among Guatemalans based on cultural traditions and accessibility.
Corn is highly valued in the Mayan culture. Corn is the chief crop and the basis for many food products and meals. Foods bring strength, good health, and a spiritual connection to the past.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition

The Mayan diet primarily consists of maize, black beans, rice, chicken, squash, tomatoes, carrots, chilies, beets, cauliflower, lettuce, cabbage, chard, leek, onion and garlic.
These foods are used to maketortillas, atole, (liquid corn drink), pinol (chicken flavored corn gruel), pepi'an (chicken stew with squash seeds, hot chilies, tomatoes, and tomatillos [small green tomato]), and caldos (soups made of chicken stock and vegetables.)

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition

Guatemalan food is not served spicy. A spicy hot sauce may be served alongside a meal for individuals who prefer to add it.
The diet of many Guatemalans is low in protein, iron, and vitamin C.
Lactose intolerance is especially prevalent among indigenous populations.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition

Some Guatemalan families encourage their children to drink coffee with sugar when they refuse the poor tasting drinking water.
This practice leads to gastritis, dehydration, and dental caries.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy and Childbearing Practices

Guatemalans value life beginning from conception; a baby is a gift from God.
Most do not believe in contraception or abortion for religious reasons.
A Guatemalan woman may bear 10 or more children in her lifetime. In Guatemala, of these, many die before the age of 5 years.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy and Childbearing Practices

Mayan midwives (comadronas) deliver 80 percent of all children born in Guatemala in the home. It is unknown how widespread this practice is in the United States.
If the baby dies during delivery, the family accept it as God’s will.
On the day a Guatemalan woman becomes pregnant, she and her husband share the news with respected elders of the village. Godparents are also selected at this time.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy and Childbearing Practices

In the 7th month of pregnancy, the woman introduces her fetus to the environment.
She goes through her daily activities showing and telling her fetus about the life she leads. The mother tells the fetus to be honest and never abuse nature.
If someone eats in front of the pregnant woman without offering her food, she will have a miscarriage.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy and Childbearing Practices

Children are permitted at the delivery.
The woman’s husband, village leaders, and parents of the couple may be present.
A single woman must not observe the birth of the baby.
Mayan women do not believe in lying down to give birth or delivering in a hospital.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy and Childbearing Practices

A midwife and witch (brujo) may both attend the birth.
The midwife helps with delivery.
The brujo prays for long life, good health, and protection from the evil eye (mal ojo).
A breech delivery or one in which the baby’s cord is around the neck are considered good luck.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy and Childbearing Practices

Following delivery, the placenta has to be burned, not buried, because it is disrespectful to the earth to do so.
The placenta can be burned on a log and then the ashes used for a steam bath, temascal.
To celebrate the birth of a baby, the villagers slaughter a sheep.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy and Childbearing Practices

The mother and baby are kept separated from others for 8 days.
When the baby is born, the hands and feet are bound for 8 days. This signifies that they are meant for hard work, not for stealing.
Guatemalan women may continue breastfeeding until the child reaches the age of 5 years.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy and Childbearing Practices

During the first 8 postpartum days, friends and extended family bring food, clothing, small animals, or wood as gifts for the newborn’s family.
They also offer their services, like carrying water or chopping wood.
The family of the newborn does nothing for these 8 days; their needs are taken care of by others.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy and Childbearing Practices

A bag with garlic, lime, salt, and tobacco is hung around the baby’s neck and a red thread is used to tie the umbilical cord to protect the baby, provide strength, and denote respect for the ancestors.
If the baby is a female, the midwife pierces her ears at birth.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

ClickerCheck

Juanita Juarez, is pregnant with her second child. The nurse recommended that she increase her milk consumption, which she has not done. He has been compliant with other dietary recommendations. The most likely reason for not increasing her milk consumption is that she

Does not like milk.

Cannot afford milk.

Has lactose intolerance.

Has fructose intolerance.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Correct Answer

Correct answer: C

Many Guatemalans have lactose intolerance and cannot drink milk or milk products because it caused bloating and indigestion.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

Many Guatemalans grow up experiencing far more death than most North Americans.
They see babies and children die of malnutrition and disease, parents and grandparents die from violence, and loved ones die because the health care they needed was too far away or was too expensive.
The family may decide the cost for treatment of one family member is too much and decide against it because of the financial strain on the entire family.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

When death occurs in Guatemala, it is customary to place the deceased in a simple wooden coffin/casket and conduct a funeral.
Graves are decorated with flowers on All Saint’s Day in memory of the deceased.
Some Guatemalans relate their illness to “punishment” or impending death to “God’s will”.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

When a Guatemalan dies in the United States, the family may request repatriation because it is important for the final resting place to be the home country.
Guatemalans believe in burial; they do not practice cremation.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

Yellow is the color of mourning.
Yellow flowers are placed at the grave.
Food is placed at the head for the spirit of the departed.
Church bells are rung to gain favor with the gods.
Ladinos mourn the dead by wearing black.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality

Approximately 65-80 percent of Guatemalans are Roman Catholic.
Others continued to practice their Mayan religion.
Still other Guatemalans combined beliefs and practices of the two.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality

Two practices influenced by the Spanish are guachibal and cofradia.
Guachibal involves the practice of keeping an image of a Christian saint in the home and celebrating on the particular saint’s day.
Cofradia refers to a “religious brotherhood” that serves to maintain the “cult” of a particular saint.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality

Family provides Guatemalans with meaning in their lives.
Spirituality helps to explain life and the circumstances faced by Guatemalans.
When illness occurs, many Guatemalans turn to their faith for strength, wisdom, and hope.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

The preferred mode of treatment among Ladinos is medication administered by hypodermic injection. For example, if an infant has a cold, Ladinos believe an injection is necessary to treat it effectively.
If someone has the flu, they like an intravenous infusion. Intramuscular medications are preferred to those taken orally.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

Health-care seeking among Guatemalans generally occurs by first seeking advice from a mother, grandmother, or other respected elder.
If this approach is unsuccessful, then the family usually seeks health care from folk healers.
Modern medical care may be the last resort.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

Many are fearful of hospitals.
In Guatemala, when hospital care is necessary, patients are often seriously ill, resulting in death, which perpetuates the belief that “hospitals are places where patients go to die.”
Guatemalans often delay seeking health care until they are incapacitated by illness, disease, or injury.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

Many times, they are unaware of the dangers associated with working in agriculture in the United States.
They may be exposed to pesticides and dangerous equipment without proper training.
Some Guatemalans fear venipuncture because taking blood leaves the body without enough blood to keep them strong and healthy.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

Guatemalans tend to view health and illness in relation to their ability to perform duties associated with their roles.
As long as women are functioning in their role of caring for the home and family and men are functioning in their job, then they feel “healthy”.
Aches, pains, and minor illnesses that do not prevent functioning are tolerated.
When an illness prevents normal functioning required for their roles, then Guatemalans view it seriously.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

The cause of debilitating illness or disease may be viewed as punishment from God rather than lack of prevention or early detection.
Sometimes, early warning signs of illness or disease are ignored in hopes they will go away on their own.
Family members would rather care for their loved one at home if at all possible.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

Questions related to organ donation will be puzzling and elicit fear and anxiety.
The Guatemalan patient may think the health-care provider is asking them to consent to organ donation because they are going to die rather than understanding the context to which the question applies.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

ClickerCheck

Maria and Pedro bring their 3 day old male newborn baby to the pediatric clinic because he is not nursing and they are sure he is losing weight. The baby has his hands and feet bound. The nurse recognizes this Mayan custom is so that the baby will

Grow up to work and not steal.

Not get colic.

Be a religious person in adulthood.

Be safe from evil spirits.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Correct Answer

Correct answer: A

Traditional Guatemalans bind the baby’s hands and feet for the first 8 days of life so it will grow up to be a good worker and not steal.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practitioners

Three distinct health care systems exist in Guatemala:

Modern medicine

Ladino folk medicine

Indian folk medicine

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practitioners

Modern medicine refers to health care provided by educated physicians and nurses.
Ladino folk medicine is provided by Ladino pharmacists, spiritualists, and lay healers (curanderos).

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practitioners

Mayan Indians seek medical care from Mayan shaman, herbalists, and comadronas.
When Ladinos and Mayan Indians have access to modern medicine, the utilization increases.
Guatemalans have great respect and admiration for health-care providers. They are viewed as authority figures with clinical expertise.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practitioners

Guatemalans expect their health-care provider to have the appearance and manners of a professional.
When this is not the case, Guatemalans lose confidence in the provider.
Guatemalans are very private and are not accustomed to discussing issues and concerns openly. It may take a while to develop the trust and rapport.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practitioners

They fear disclosure may result in deportation or rejection.
Patients also fear confidentiality will not be maintained in the health-care setting.
Guatemalan women are usually very modest.
They may refuse to discuss personal issues or receive an examination by a male health-care provider.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practitioners

A male Guatemalan patient may refuse a female health-care provider.
Because Guatemalans dislike conflict, they may not actually refuse care instead they may withhold personal information due to discomfort with the health-care provider.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese American Culture

Larry Purnell, PhD, RN, FAAN

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Overview/Heritage

China’s population of over 1.3 billion people is dispersed over 3.7 million square miles, with cultural values differing according to geographic location as well as other variant cultural characteristics.
Chinese in the United States exceed 1.6 million people with the largest communities in California, New York, Hawaii, and Texas.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Overview/Heritage

A university education is highly valued; however, few have the opportunity to achieve this life goal because of limited enrollment opportunities.
Often, young adults come to Western countries to attend universities seeking more advanced prestigious educations.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Overview/Heritage

Many newer immigrants are professionals from Hong Kong.
Chinese Confucian ideals emphasize the importance family and neighbors and reinforce the idea that all relationships embody power and rule.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Overview/Heritage

Other important values are filial piety, industry, patriotism, deference to those in hierarchal positions, tolerance of others, loyalty to superiors, respect for rites and social rituals, knowledge, benevolent authority, thrift, patience, courtesy, and respect for tradition.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Communication

The official language of China is Mandarin (pu tong hua), spoken by about 70% of the population, but other major, distinct dialects such as Cantonese, Fujianese, Shanghainese, Toishanese, and Hunanese exist.
The dialects are so different that often two groups cannot understand one another verbally.
The written language is the same.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Communication

Most Chinese people speak in a moderate to low voice tone and consider Americans to be loud.
When asked whether they understand what was just said, the Chinese invariably answer in the affirmative to avoid loss of face.
The Chinese share information freely once a trusting relationship has developed.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Communication

Most Chinese maintain a formal distance with each other as a form of respect.
Many are uncomfortable with face-to-face communications, especially when there is direct eye contact.
Titles are important to Chinese people.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Communication

The family name is stated first and then the given name.
Calling an individual by any name except his/her family name is impolite. If a person’s family name is Li and the given name is Ruiming, then the proper form of address is Li Ruiming.
Traditional women do not use their husband’s name after they get married.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Communication

Many Chinese take an English name as an additional given name because Chinese names are often difficult for Westerners to pronounce.
Some give permission to use only the English name.
Some switch the order of their names to be the same as those of Westerners with the family name last.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Family Roles and Organization

Traditionally the Chinese family was organized around the male lines.
Most believe that the family is most important and, thus, each family member assumes changes in roles to achieve this harmony.
Children are highly valued because of the Chinese government’s past mandate that each married couple may only have one child.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Family Roles and Organization

Independence is not fostered. The entire family makes decisions for the child even into young adulthood.
Children born in Western countries tend to adopt the Western culture easily.
Adolescents maintain their respect for elders even when they disagree with them.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Family Roles and Organization

Children feel pressure to succeed to help improve the future of the family; thus, most children and adolescents value studying over playing and peer relationships.
Children are taught to curb their expression of feelings because individuals who do not stand out are successful.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Family Roles and Organization

Chinese children in the USA are becoming more outspoken as they read more and watch television and movies from the Western world.
The perception of family is developed through the concept of relationships. Each person is identified in relation to others in the family.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Family Roles and Organization

The individual is not lost, just defined differently from individuals in Western cultures.
Extended families are important.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Family Roles and Organization

Children may live with their grandparents or aunts and uncles so individual family members can obtain a better education or reduce financial burdens.
Teenage pregnancy is not common, but it is increasing among Chinese in America.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Family Roles and Organization

Older people are venerated and viewed as very wise.
Children are expected to care for their parents when self-care becomes a concern; in China, law mandates this.
The Chinese word for privacy has a negative connotation and means something underhanded, secret, and furtive.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Family Roles and Organization

The one subject that is taboo is sex and anything related to sex.
Same-sex relationships are not condoned.
In many provinces, they are illegal and punishable by death.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Workforce Issues

True equality does not exist in the Chinese mind; if more than one person is in power, then consensus is important.
If the person in power is not present at decision-making meetings, barriers are raised, and any decisions made are negated unless the person in power agrees.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Workforce Issues

Chinese adapt to the culture in the workplace quickly.
They frequently call on other Chinese people to teach them and to discuss how to fit into the new culture more quickly.
Autonomy is limited and is based on functioning for the good of the group.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Workforce Issues

When a situation arises that requires independent decision making, many times the Chinese know what should be done but do not take action until the leader or superior gives permission.
Language may be a barrier for some Chinese.
The Chinese language does not have verbs that denote tense, as in Western languages.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Biocultural Ecology

Skin color among Chinese is varied. Many have skin color with pink undertones; some have a yellow tone, and others are very dark.
Hair is generally black and straight, but some have naturally curly hair. Most men do not have much facial or chest hair.
Mongolian spots—dark bluish spots over the lower back and buttocks—are present in about 80 percent of infants.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Biocultural Ecology

Bilirubin levels are usually higher in Chinese newborns with the highest levels occurring on the fifth or sixth day after birth.
The Rh-negative blood group is rare.
Chinese people generally have an increased sensitivity to the effects of alcohol

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Biocultural Ecology

Poor metabolism of mephenytoin occurs in 15 to 20 percent of Chinese.
Sensitivity to beta blockers, such as propranolol, is evidenced by a decrease in overall blood levels accompanied by a more profound response.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Biocultural Ecology

Atropine sensitivity is evidenced by an increased heart rate. Increased responses to antidepressants and neuroleptics occur at lower doses.
Analgesics have been found to cause increased gastrointestinal side effects, despite a decreased sensitivity to them.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Biocultural Ecology

Common health problems include lactose intolerance Thalassemia, hepatitis b, tuberculosis, liver cancer and pancreatic cancer, diabetes, and cardiovascular disease.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese High-Risk Health Behaviors

Smoking is a high-risk behavior for many Chinese men and teenagers.
Most women do not smoke.
The numbers for Chinese women who smoke are increasing, especially after immigration to the United States.

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Chinese Nutrition

Food habits are important, and food is offered to guests at any time of the day or night.
Foods served at meals have a specific order with focus on a balance for a healthy body.
The typical diet is difficult to describe because each region in China has its own traditional diet.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Nutrition

Traditional Chinese medicine frequently uses food and food derivatives to prevent and cure diseases and illnesses and to increase strength in weak and older people.
Peanuts and soybeans are popular.
Common grains include wheat, sorghum, and maize (a type of corn.) Rice is usually steamed but can be fried with eggs, vegetables, and meats.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Nutrition

Fruits and vegetables may be peeled and eaten raw.
Vegetables are lightly stir-fried in oil with salt and spice.
Salt, oil, and oil products are important parts of the Chinese diet.
Foreign-born and older people may not like ice in their drinks.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Nutrition

Foods that are considered yin and yang prevent sudden imbalances.
A balanced diet is considered essential for physical and emotional harmony.
Chopsticks should never be stuck in the food upright because that is considered bad luck.

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Chinese Pregnancy and Childbearing Practices

Pregnancy is seen as women’s business, although men are beginning to demonstrate an active interest in pregnancy and the welfare of the mother and baby.
Women are very modest and may insist on a female midwife or obstetrician.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Pregnancy and Childbearing Practices

Pregnant women usually increase meat in their diets because their blood needs to be stronger for the fetus.
Pregnant women may avoid shellfish during the first trimester because it causes allergies.
Some may be unwilling to take iron: they believe that it makes the delivery more difficult.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Pregnancy and Childbearing Practices

Traditional postpartum care includes 1 month of recovery, with the mother eating foods that decrease the yin (cold) energy.
Many mothers do not expose themselves to the cold air and do not go outside or bathe for the first month postpartum because cold air can enter the body and cause health problems.
Drinking and touching cold water are taboo for women in the postpartum period.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Pregnancy and Childbearing Practices

Raw fruits and vegetables are avoided because they are considered “cold” foods. They must be cooked and be warm.
Mothers eat five to six meals a day with high-nutritional ingredients including rice, soups, and seven to eight eggs.
Brown sugar is commonly used because it helps rebuild blood loss.
Drinking rice wine is encouraged to increase the mother’s breast-milk production.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Death Rituals

Death is viewed as a part of the natural cycle of life; some believe that something good happens to them after they die.
Death and bereavement traditions are centered on ancestor worship, a form of paying respect.
Many believe that their spirits will never rest unless living descendants provide care for the grave and worship the memory of the deceased.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Death Rituals

The dead are honored by placing food, money for the person’s spirit, or articles made of paper around the coffin.
The belief that the Chinese greet death with stoicism and fatalism is a myth.
The number 4 is considered unlucky because it is pronounced like the Chinese word for death.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Death Rituals

The color white is associated with death and is also considered bad luck.
Mourners are recognized by black armbands on their left arm and white strips of cloth tied around their heads.
The purchase of life insurance may be avoided because of a fear that it is inviting death.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Spirituality

The main formal religions among Chinese are Buddhism, Catholicism, Protestantism, Taoism, and Islam.
Prayer is generally a source of comfort.
Many use a combination of meditation, exercise, massage, and prayer.
As immigration increases, many who practice Christian religions have become more visible.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Health-care Practices

While many Chinese people have made the transition to Western medicine, others maintain their roots in traditional Chinese medicine, and still others practice both types of medicine.
Younger people usually do not hesitate to seek healthcare providers when necessary unless they believe that it does not work for them, then they use traditional Chinese medicine.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Health-care Practices

Older people may try traditional Chinese medicine first and only seek Western medicine when traditional medicine does not seem to work.
The Chinese tend to describe their pain in terms of more diverse body symptoms, whereas Westerners tend to describe pain locally.
The Western description includes words like “stabbing” and “localized,” whereas the Chinese describe pain as “dull” and more “diffuse.”

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Health-care Practices

Chinese cope with pain by applying oils and massage, using warmth, sleeping on the area of pain, relaxation, and aspirin.
The balance between yin and yang is used to explain mental as well as physical health. Because a stigma is associated with having a family member who is mentally ill, many families initially seek the help of a folk healer.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Health-Care Practices

Many Chinese still view mental and physical disabilities as a part of life that should be hidden.
Families may be reluctant to allow autopsies because of their fear of being “cut up.”
Most accept blood transfusions, organ donations, and organ transplants.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Health-care Practices

Traditional Chinese medicine includes 5 basic substances:

qi, energy
xue, blood
jing, essence
shen, spirit
jing ye, body fluids

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Health-care Practices

Acupuncture and moxibustion are used in many treatments. Acupuncture is the insertion of needles into precise points along the channel system of flow of the qi called the 14 meridians.
The system has over 400 points. Many of the same points can be used in applying pressure (acupressure) and massage (acumassage) to achieve relief from imbalances in the system.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Health-care Practices

Moxibustion is the application of heat from different sources to various points.
For example, one source, such as garlic, is placed on the distal end of the needle after it is inserted through the skin, and the garlic is set on fire. Sometimes the substance is burned directly over the point without a needle insertion.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Health-care Practices

Cupping: A heated cup or glass jar is put on the skin creating a vacuum, which causes the skin to be drawn into the cup. The heat that is generated is used to treat joint pain.
Herbal therapy falls into four categories of energy (cold, hot, warm, and cool), five categories of taste (sour, bitter, sweet, pungent, and salty), and a neutral category.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Health-care Practitioners

Traditional Chinese medicine practitioners are shown great respect by the Chinese. In many instances, they are shown equal, if not more, respect than Western practitioners.
Some distrust Western practitioners because of the pain and invasiveness of their treatments.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Chinese Health-care Practitioners

Older health-care providers receive more respect than younger providers, and men usually receive more respect than women.
Physicians receive the highest respect, followed closely by nurses with a university education.

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