TRANSCULTURAL NURSING

Course
Content
PREPARED BY

PROF. VALENTINA B.
PATACSIL
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 MAPÚA INSTITUTE OF TECHNOLOGY
SCHOOL OF HEALTH SCIENCES

VISION
Mapúa shall be an international center of excellence in technology education by:
• providing instructions that are current in content and state-of-the art in delivery;
•

• engaging in cutting-edge research; and

• responding to the big local and global technological challenges of the times

MISSION
a) The mission of Mapúa Institute of Technology is to disseminate, generate, preserve
and apply scientific, engineering, architectural and IT knowledge.
b) The Institute shall, using the most effective means, provide its students with
professional and advanced scientific foundation in engineering, architectural,
information technology and health sciences education through rigorous and up-to-
date academic programs with ample opportunities for the exercise of creativity and
the experience of discovery.
c) It shall implement curricula that, while being steeped in technologies, shall also be
rich in the humanities, languages and social sciences that will inculcate ethics.
d) The Institute shall advance and preserve knowledge by undertaking research and
reporting on the results of such inquiries.
e) The Institute, singly or in collaboration with others, shall bring to bear the world's
vast store of knowledge in health sciences, engineering and other realms on the
problems of the industry, and the community in order to make the Philippines and
the world a better place

MISSION
PROGRAM EDUCATIONAL OBJECTIVES
a b c d e
1. To equip the students with a broad foundation on the
√
basic concepts, theories, principles and fundamentals of √ √
addressed by DLHS

professional nursing practice √ √

2. To develop the student’s capability to apply these learned
concepts, theories, and principles in the practice of √ √ √ √
professional nursing
3. To inculcate in the students the importance of lifelong
√ √
learning.
√ √
4. To develop in the student an appreciation of human
values in the care of individuals, families, population at √ √

COURSE SYLLABUS

1. Course Code : HUN 023

2. Course Title : ASIAN CIVILIZATION

3. Pre-requisite : NONE

4. Co-requisite :

5. Credit/ Class Schedule: 3 Units Lec. Second Year Quarter 3

6. Course Description

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Focuses on health practices of different countries as a basis for the practice of Transcultural Nursing. It examines
the transcultural bases of health care based on Giger and Davidhizer’s six cultural organizing phenomena:
environmental control, biological variations, social organizayion, communication, space, and time orientation. It
also takes into consideration the contemporary challenges in transcultural nursing such as transcultural aspects of
pain, cultural disparities in health and health care delivery, cultural diversity in the workforce and transcultural
values and ethics.

7. Program Outcomes and Relationship to Program Educational Objectives

Program Educational
Program Outcomes Objectives
1 2 3 4
A. Utilize the health process in a variety of institutional and community
settings to design nursing systems which shall assist clients to attain and
(a) maintain an optimum level of self care through: √ √ √ √
1. application of principles of goal oriented communication to establish and
maintain therapeutic relationship with individuals, families, groups
2. synthesizing knowledge from general education, sciences and nursing
(b) courses as basis for health interventions designed to meet the self-care √ √ √ √
deficits of clients across life span
3. collaboration with health team members to improve the delivery of care to
(c) √ √ √ √
individuals, families, groups and the community
4. utilization of research methods and findings in the provision of nursing
(d) √ √ √ √
care and investigation of client health problems

5.implementation of strategies based on knowledge of teaching-learning

(e) principles, leadership-management methodologies and theories in the √ √ √ √
attainment of goals with clients (individual, family, group, community)

B. Demonstrate beginning skills in the application of information technology

√ √ √
in the development of skills for nursing practice
C.Accept responsibility and accountability for the choice and outcomes of
√ √ √ √
nursing interventions and for their legal and ethical implications

8. Course Objectives and Relationship to Program Outcomes:

Course Objectives Program Outcomes

The students should be able to: A1 A2 A3 A4 A5 2 3

1. Examine the interrelationships of socio-cultural,
public health and medical events that have produced
the crisis in today’s modern health care system
√ √ √

2. Develop cultural sensitivity for appropriate,

individualized clinical approach
√ √ √
3. Appreciate human life and values of different √ √ √

cultures as they affect health-illness

9. Course Coverage :

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 METHODOLOGY &
WEEK TOPIC STRATEGY EVALUATION TOOLS

Week 1 Orientation to the Course & Leveling of Orientation & presentation of

expectations; discussing the course course syllabus; discussion of
requirements objectives, course
requirements & leveling of
expectations

Week 2, 3 UNIT I. Transcultural Framework

Class participation
A. Introduction Pencil-paper evaluation (will
B. Cultural concepts and terminologies not only apply in this UNIT but
C. History of Transcultural Nursing Lecture-discussion (Ppt throughout the course. This
D. Major assumptions to support presentation) activity will either be
Leininger’s Cultural Care Diversity announced or not announced
and Universality Individual and group report and the student is expected to
Experiential group sharing read and prepare for the
UNIT II.Cultural Diversity Case Analysis assigned lesson of the day
Role Play
A. Definition of basic/related concepts Surfing the Internet
B. The World in Review
C. Population Overview
1. Worldwide
2. In the U.S.
3. Others
D. Race
1. Basic/Related concepts
2. Race categories
E. The Immigrants
1. Reasons for migration
2. Metropolitan areas with the
largest no. of immigrants
3. Leading 10 primary destinations
of immigrants (2000)
4. Leading 10 countries of origin of
legal immigrants (1990-2000)
F. Factors to consider in the nursing care
Week 4 of culturally diverse groups

UNIT III. Health and Illness

A. The HEALTH Traditions Paradigm

1. Concepts of health and illness
2. The interrelated aspects of health
B. The HEALTH Traditions model
1. Traditional methods of maintaining,
practicing, and restoring health
2. Symbolic examples
3. Factors influencing traditional
beliefs and practices
Week 4,5 C. Health Belief Systems
1. Magico-religious
2. Scientific or biomedical
3. Holistic
D. Types of Healing Systems
1. Self-care
2. Professional Care
3. Folk Healing System VCD: Ayurveda )
4. Complementary/alternative
therapies

MIDTERM EXAMINATION

UNIT IV. Transcultural Nursing Care

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 Models
A. Leiningers’s Sunrise Cultural Care
Diversity and Universality Model
B. Purnell’s Model for Cultural
Competence
C. Giger and Davidhizar’s Transcultural
Assessment Model and the organizing
phenomena of culture
D Cross-Cultural phenomena impacting
nursing care
F. Selected examples of etiquette related to
selected cultural Phenomena
G. Transcultural assessment
H. Barriers to Health Care

Week 6 Unit V. Application of Organizing

Cultural Phenomena to People from Interactive session:
Different Cultural Heritage: An Group report on Organizing
Interactive Session Cultural Phenomena on people
A. People of Filipino Heritage with different cultural heritage
B. People of Japanese Heritage (mentioned on left)
C. People of Chinese Heritage
D. People of Indian (Hindu) Heritage
E. People of Anglo-American Heritage
Week 7
F. People of African-American Heritage
G. People of Mexican Heritage
H. People of Italian Heritage
I. People of Jewish Heritage
J. People of Middle Eastern Heritage
UNIT VI. Contemporary Challenges in
Transcultural Nursing Lecture/discussion
A. Transcultural aspects of pain
1. Definition of pain
2. Basic/related concepts
3. Measurement of pain
4. Expressions of pain
5. Applying transcultural nursing
concepts to clients in pain Lecture/Discussion
Week 8
B. Cultural Disparities in Health and Group activity
Health Care Delivery
1. Factors that account for cultural
disparities: minority groups,
vulnerable populations, the poor,
the homeless
C. Cultural Diversity in the Workforce
1. The aspects of cultural diversity
2. The effects of multicultural
healthcare workforce
Week 9, 3. Barriers/conflicts in the workforce
10 4. Promoting harmony in multicultural
workplaces
5. Strategies to promote effective
cross-cultural communication in the
multi-cultural workplace
D. Transcultural Values and Ethics
1. Transcultural Values: Basic /related
concepts, transcultural assessment
and clarification of values and
beliefs
2. Transcultural Ethics: Basic/related
concepts, Western and Eastern
ethical theories

D. Culturally competent model of ethical

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 decision-making
E. Transcultural Care Principles, Human
Rights and Ethical Considerations

Bibliography

Week 11 FINAL EXAMINATION Pencil and paper test

10. Course Outcomes and Relationship to Course Objectives/ Program Outcomes

Course Outcomes Course Objectives Program Outcomes

1 2 3 4 5 6 7 A1 A2 A3 A4 A5 2 3
A student completing this course should be able
to:
1. Explain aspects and components of cultural √ √ √ √ √ √ √ √ √
diversity in Asia and in different countries
2. Discuss traditional and transcultural HEALTH √ √ √ √ √ √ √ √
belief models and healing systems, including
assessment of these paradigms
3. Know the different transcultural nursing models √ √ √ √ √ √ √ √ √
and apply culturally competent nursing care.
4. Recognize contemporary challenges in √ √ √ √ √ √ √ √ √
transcultural nursing.

Contribution of Course to Meeting the Professional Component:

HEALTH & NURSING topics – 90%
General education component – 10%
11. Textbook: Books in # 12:
13. Course Evaluation:

The student is evaluated based on his/her performance in the following areas:

LECTURE
Quizzes___________________________________15%
Midterm__________________________________ 25%
Final Examination _______________________ 50%
Academic Requirements and other related
Activities ______________________ 10%
TOTAL 100%

Aside from academic deficiency, other grounds for a failing grade are:
• Cheating during examinations
• More than 20 % of the total number of meetings in a quartermaster as per CHED ruling
• Failure to take the final examination with no valid excuse
Note:

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 The final grade of the student will be given as reflected in the table below.

Average (%) Below 60 60-64 65- 69 70-74 75-79 80-84 85-89 90-94 95-97 98-100
Final Grade 5.00 3.00 2.75 2.50 2.25 2.00 1.75 1.50 1.25 1.00

12. References/Course Materials Made Available:

Andrews, Margaret M. and Joyceen S. Boyle. (1999). Transcultural concepts in nursing care. (3rd ed.).
Lippincott. Philadelphia, New York, Baltimore.
Burkhardt, Margaret A. and Alvita Nathaniel, Ethics and issues in contemporary nursing ( 2nd ed.). Thomson
Asian Edition.
Kozier, B., Erb, G., Berman, A.J., and Snyder, S.. (c2004). Fundamentals of nursing concepts, process, and
practice. (7th ed.).Pearson Education, Inc. Upper Saddle River, New Jersey.
Munoz, Cora and Joan Luckmann (c 2005). Transcultural communication in nursing. (2nd ed.). Delmar
Learning.
Purnell, Larry D. and Betty J. Paulanka (2003). Transcultural health care: a culturally competent approach
(2nd ed.). F.A. Davis Co. Philadelphia.
Spector, R.E. (2000). Cultural diversity in health and illness (5th ed.). Upper Saddle River, N.J: Prentice Hall.
Spector, Rachel E. (2004) Transcultural nursing: beliefs and practices in illness and health care (6th ed.).
Pearson Education South Asia Pte Ltd. Jurong, Singapore.
Taylor, Carol, Lillis and Priscilla LeMone. (2005). Fundamentals of nursing: the art and science of nursing
care (5th ed.) .Lippincott Williams and Wilkins, Philippine edition.

13. Committee Members:

Fortuno , Carolina P.
Capaque, Dawn
Valderrama, Deogracia M.

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 VISION
Mapúa shall be an international center of excellence in technology education by:
• providing instructions that are current in content and state-of-the art in delivery;
•

• engaging in cutting-edge research; and

• responding to the big local and global technological challenges of the times

MISSION
d) The mission of Mapúa Institute of Technology is to disseminate, generate, preserve
and apply scientific, engineering, architectural and IT knowledge.
e) The Institute shall, using the most effective means, provide its students with
professional and advanced scientific foundation in engineering, architectural,
information technology and health sciences education through rigorous and up-to-
date academic programs with ample opportunities for the exercise of creativity and
the experience of discovery.
f) It shall implement curricula that, while being steeped in technologies, shall also be
rich in the humanities, languages and social sciences that will inculcate ethics.
e) The Institute shall advance and preserve knowledge by undertaking research and
reporting on the results of such inquiries.
f) The Institute, singly or in collaboration with others, shall bring to bear the world's
vast store of knowledge in health sciences, engineering and other realms on the
problems of the industry, and the community in order to make the Philippines and
the world a better place

MISSION
PROGRAM EDUCATIONAL OBJECTIVES
a b c d e
5. To equip the students with a broad foundation on the
√
basic concepts, theories, principles and fundamentals of √ √
addressed by DLHS

professional nursing practice √ √

6. To develop the student’s capability to apply these learned
concepts, theories, and principles in the practice of √ √ √ √
professional nursing
7. To inculcate in the students the importance of lifelong
√ √
learning.
√ √
8. To develop in the student an appreciation of human
values in the care of individuals, families, population at √ √

COURSE CONTENT

Unit I. Overview of Transcultural Nursing

A. Introduction
B. Providing a Comprehensive Approach to Health Care
C. Cultural Concepts and Terminologies
D. History of Transcultural Nursing
E. Major Assumptions to Support Leininger’s Culture Care Diversity and Universality

Unit II. Cultural Diversity

V. Definition of Related Concepts

VI. The World in Review

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 C. Population Overview
1. Worldwide
2. Most populous cities of the world
3. US. population
D. Race
1. Basic concepts
2. Race categories
E. The Immigrants
1. Reasons for migration
2. Metropolitan areas with the largest number of immigrants
3. Leading 10 primary destinations of immigrants (2000)
4. Leading 10 countries of origin of legal immigrants (1990-2000)
F. Factors to Consider in the Nursing Care of Culturally Diverse Groups

Unit III. Health and Illness

A. The HEALTH Traditions Paradigm

1. Concepts of health and illness
2. The interrelated aspects of health
B. The HEALTH Traditions Model
1. Traditional methods of maintaining, practicing and restoring health
2. Symbolic examples
3. Factors influencing traditional beliefs and practices
C. Health Belief Systems
1. Magico-religious
2. Scientific or biomedical
3. Holistic
D. Types of Healing Systems
1. Self-care
2. Folk Healing System
3. Professional Care
4. Complementary, alternative and integrative therapies

Unit IV. Transcultural Nursing Care Models

A. Leininger’s Sunrise Cultural Care Diversity and Universality Model

B. Purnell’s Model for Cultural Competence
C. Giger and Davidhizar’sTranscultural Assessment Model and
Cultural Heritage Consistency
D. The Organizing Phenomena of Culture: Environmental control, Biological
variation, Social organization, Space, Time, and Communication
E. Selected Examples of Etiquette Related to Selected Cultural Phenomena
F. Cross-Cultural Phenomena Impacting Nursing Care
G. Transcultural Assessment
H. Barriers to health Care

Unit V. Application of Organizing Cultural Phenomena to People from Different

Cultural Heritage: an Interactive Session

A. People of Filipino Heritage

B. People of Japanese Heritage
C. People of Chinese Heritage
D. People of Indian (Hindu) Heritage
E. People of Anglo-American Heritage
F. People of African-American Heritage
G. People of Mexican Heritage
H. People of Italian Heritage
I. People of Jewish Heritage
J. People of Middle Eastern Heritage

UNIT VI. Contemporary Challenges in Transcultural Nursing

A. Transcultural Aspects of Pain

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 1. Definition of pain
2. Basic/related concepts
3. Measurement of pain
4. Expressions of pain
5. Questions on Cultural Attitude Toward Pain
6. Applying transcultural nursing concepts to clients in pain
B. Cultural Disparities in Health and Health Care Delivery
1. Factors that account for culture disparities: minority groups, the poor,
vulnerable populations, the homeless
C. Cultural Diversity in the Workforce
1. The aspects of cultural diversity in the workforce
2. The effects of multicultural healthcare workforce
3. Barriers/conflicts in the workforce
4. Promoting harmony in multicultural workplaces
5. Strategies to promote effective cross-cultural communication in the
multicultural workplace
D. Transcultural Values and Ethics
1. Transcultural Values
 Basic/related concepts
 Transcultural assessment and clarification of values and beliefs
2. Transcultural Ethics
 Basic/related Concepts
 Overview of Western and Eastern Ethical Theories
 Culturally competent model of ethical decision-making
3. Transcultural Care Principles, Human Rights and Ethical
Considerations

CULTURAL HERITAGE

BIOBLIOGRAPHY

ADDENDUM

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 TRANSCULTURAL NURSING

UNIT I. OVERVIEW OF TRANSCULTURAL NURSING

“…demography is destiny, demographic changes is reality,

and demographic sensitivity is imperative.”
Giger and Davidhizar, Transcultural Nursing

A. INTRODUCTION

The rapidly changing demographic scenario beckons us into viewing the world where
people are no longer bound by physical boundaries. Societies everywhere, particularly in
the United States, are becoming multicultural, multilingual, and pluralistic. Nursing,
therefore, must rapidly adapt itself to a changing heterogeneous society if it is to provide
culturally appropriate and culturally competent nursing care in the twenty-first century.

Madeleine Leininger, a nurse-anthropologist, saw this trend in the 50’s, and

envisioned transcultural nursing as a formal area of study and practice for nurses. Also
called cross-cultural, intercultural, multicultural and culture-care nursing by some
authorities Leininger defined this new field of study as a “humanistic and scientific area of
formal study and practice which is focused upon differences and similarities among cultures
with respect to human care, health or well-being), and illness based upon the people’s
cultural values, beliefs and practices.” The ultimate goal of transcultural nursing, according
to Leininger, is “to use relevant knowledge to provide culturally specific and culturally
congruent nursing care to people.”

An understanding of culture and related concepts is therefore important. Culture

refers to the common lifestyles, knowledge, beliefs, behavior patterns, attitudes, values,
habits, customs, languages, symbols, ritual, ceremonies, and practices that are unique to a
particular group of people.

Some of the characteristics of culture are the following:

 Culture is learned and taught. Cultural knowledge is transmitted from one generation
to another. A person is not born with cultural concepts but instead learns them
through socialization.
 Culture is shared. The sharing of common practices provides a group with part of its
cultural identity.
 Culture is social in nature. Culture develops in and is communicated by groups of
people.
 Culture is dynamic, adaptive, and ever-changing. Adaptation allows cultural groups
to adjust to meet environmental changes. Culture change occurs slowly and in
response to the needs of the group. This dynamic and adaptable nature allows a
culture to survive.

Source: Delaune, Sue C. and Patricia K. Landner. Fundamentals of Nursing. 3rd ed.
Thomson, Asian ed. 2006. p. 389.

B. PROVIDING A COMPREHENSIVE APPROACH TO HEALTH CARE

To provide a comprehensive approach to health care, nurses have to respect common

humanistic aspects of people worldwide, be aware of distinguishing characteristics of
divergent cultural groups, and be able to deliver health care that is culturally sensitive,
culturally appropriate, and culturally competent.

 Culturally sensitive has more to do with personal attitudes and not saying things
that might be offensive to someone from a cultural or ethnic background different

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 from the health-care provider’s. (Ethnic – “You eat like a pig, use spoon and knife as
in our culture,” or saying “You Indians “smell”.

 Culturally appropriate implies that the nurse applies the underlying background
knowledge that must be possessed to provide a given client with the best possible
health care. (End-of-life spiritual care – a nurse will suggest to a Jewish patient and
his family the availability of a rabbi, if they wish)

 Culturally competent implies that within the delivered care the nurse understands
and attends to the total context of the client’s situation and uses a complex
combination of knowledge, attitudes, and skills.

1. Basic/Related Concepts

 Cultural competence is a process in which “the nurse continuously strives to

achieve the ability and availability to effectively work within the cultural context
of an individual, family or community. (Campinha-Bacote, 1998, p.6).
 Culturally competent nursing care treats each person as an individual whether
coming from same or divergent cultural system.
 Nursing care is planned and implemented in a way that is sensitive to the needs
of individuals and families, groups from diverse cultural populations within
society.
 The nurse who recognizes and respects cultural diversity has cultural sensitivity
and provides nursing care that accepts the significance of cultural factors in
health and illness.
 The nurse must be aware that the healthcare system itself is a culture with
customs, rules, values and a language of its own and that cultural imposition and
ethnocentrism must be avoided.
 Interaction between the nurse and patient are affected by the particular set of
cultural values they bring to the interaction.
 The cultural background of each participant
 The expectation and beliefs of each about health care
 The cultural context of the encounter (e.g, hospital, clinic, home)
 The degree of agreement between the two persons’ sets of beliefs and values
(Andrew & Boyle, 2000b).
 Nurses must avoid cultural imposition which is the tendency to impose their
beliefs, practices and values on people of other cultures, and ethnocentrism,
the belief that one’s own ideas, beliefs and practices are the best and superior, or
must be preferred over those of others.

2. The Five Elements of Cultural Competence:

1) Cultural awareness - a cognitive process in which the nurse becomes aware of

and sensitive to the clients cultural vales, beliefs, and practices.

 You play when interacting with individuals who are different from
yourself. (Purnell, op. cit. 3).
 Identify biases in own life and how they affect your feelings about
others, and the nursing care you plan and give to them

2) Cultural knowledge – The nurse seeks a sound educational base about different
cultures.
 Learn as much as possible about the belief system and practices of people
in your community and of the patients in the area in which you work.
 Practice techniques of observation and listening to acquire knowledge of
the beliefs and values of your patients.
3).Cultural skill - The nurse’s ability to perform a culturally specific assessment (i.e.,
physical and psychosocial). Cultural assessment:

 Is an important aspect of comprehensive nursing assessment.

 facilitates better understanding sometimes overlooked factors that influence
health behaviors and decisions.

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  helps nurses to properly identify and understand the meanings of behaviors
that might otherwise be judged negatively or be confusing to the nurse
 recognize that each person is culturally unique and that not all persons in a
particular group believe or respond the same way.
 the nurse can anticipate and assess patient’s values, religion, dietary
practices, family lines of authority, life patterns, and beliefs and practices
related to health and illness.

4. Cultural encounters – The nurse interacts with clients from diverse cultural
backgrounds.
A very essential feature of our humanity is the diversity of cultures and the
many different ways we find meaning in our lives, and in the lives of other people.
The hospital or health care environment is in itself a little world – it typifies the
diversity of culture possessed by patients and health care givers, and other individual
involved in health care. To be culturally competent the nurse must know how to
interact with people from diverse cultural background and learn to adjust and or
adapt her assessment and caring skills accordingly.

5. Cultural desire – The nurse’s motivation (“want to”) to become culturally competent.

The nurse must have the desire and motivation to develop and apply the elements of
cultural competence which are developing awareness, acquiring knowledge, and
practicing skills.

Source: Data from Campinha-Bacote, J. (1999). A model and instrument for

addressing cultural competence in health care. Journal of Nursing Education,
38 (5), 204-205), Quoted in Ethical Issues in Contemporary Nursing, p. 342.

Taylor, Lillis and LeMone, op. cit. pp. 53-54.

B. CULTURAL CONCEPTS AND ESSENTIAL TERMINOLOGY

 Subculture – smaller groups within a culture. Each subculture has its own value
system and related expectations of behavior.

Subcultures may be based on:

1. Professional and occupational affiliations (nurses, engineers)

2. Nationality or race (a shared historical and political past)
3. Age groups (adolescents, senior citizens)
4. Gender ( feminists, men’s groups)
5. Socioeconomic factors ( the working class, the middleclass, the upper class)
6. Political viewpoints (Nationalista, Liberal)
7. Sexual orientation (gay, lesbian group)

 Bicultural – used to describe a person who crosses two cultural, lifestyles, and sets
of values. (Example: a young woman whose mother is Filipino and whose father is
American)

 Acculturation - occur when people adapt to or borrow traits from another culture.
Also defined as the changes of one’s cultural patterns to those of the host society.

 Assimilation – the process by which an individual develops a new cultural identity.

It means becoming like the members of the dominant culture. The person from a
given cultural group loses his or her original cultural identity to acquire the new one.

There are 4 forms of assimilation:

1. Cultural – ability to speak excellent American English

2. Marital – intermarriage with members of another group

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 3. Primary structural – the relationships between people are warm, personal
interactions between group members in the home, the church, and social
groups
4. Secondary structural – there is nondiscriminatory sharing, often of a cold
interpersonal nature between different groups in settings such as school and
workplaces

C. HISTORY OF TRANSCULTURAL NURSING

"That the culture care needs of people in the world will be

met by nurses prepared in transcultural nursing."

M. Leininger, Ph.D.

 In the 1950’s, Dr. Madeleine M. Leininger noted cultural differences between patients
and nurses when working with emotionally disturbed children.
 This clinical experience led her to study cultural differences in the perceptions of care
in 1954, and in 1965 she earned a doctorate in cultural anthropology from the
University of Washington.
 Leininger recognizes that anthropology’s most important contribution to nursing was
the realization that health and illness are strongly influenced by culture.
 In 1991, Leininger already a well-known nurse anthropologist, published her book
Cultural Care Diversity and Universality: A Theory of Nursing.
 Leininger produced the Sunrise model (described in Unit IV) to depict her theory of
culture care diversity and universality.

D. MAJOR ASSUMPTIONS TO SUPPORT LEININGER’S CULTURE CARE

DIVERSITY AND UNIVERSALITY THEORY

1. Care is the essence of nursing and is a distinct dominant, central, and unifying
focus.
2. Care (caring) is essential for well-being, health, healing, growth, survival, and face
handicaps or death.
3. Culture care is the broadest holistic means to know, explain, interpret, and predict
nursing care phenomena to guide nursing care practices.
4. Nursing is a transcultural humanistic and scientific care discipline and profession with
the central purpose to serve human beings worldwide.
5. Care (caring) is essential to curing and healing, or there can be no curing without
caring.
6. Culture care concepts, meanings, expressions, patterns, processes, and structural
forms of care are different (diversity) and similar (towards commonalities or
universalities) among all cultures of the world.
7. Every human culture has generic (lay, folk or indigenous) care knowledge and
practices and usually professional care knowledge and practices, which vary
transculturally.
8. Cultural care values, beliefs and practices are influenced by and tend to be
embedded in the world view, language, religious (or spiritual), kinship (social),
political (or legal) educational, economic, technological, ethnohistorical, and
environmental context of a particular culture.
9. Beneficial, healthy, and satisfying culturally based nursing care contributes to the
well-being of individuals, families, groups, and communities within their
environmental context.

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 10. Culturally congruent (in agreement) or beneficial nursing care an occur only when
the individual, group, family, community, or culture care values, expressions, or
patterns are known and used appropriately and in meaningful ways by the nurse with
the people.
11. Culture care differences and similarities between professional caregiver(s) and client
(generic) care-receiver(s) exist in any human culture worldwide.
12. Clients who experience nursing care that fails to be reasonably congruent with the
client’s beliefs, values, and caring lifeways will show signs of cultural conflicts,
noncompliance, stresses, and ethical or moral concerns.
13. The qualitative paradigm provides new ways of knowing and different ways to
discover epistemic and ontological dimensions of human care transculturally.”

Source: Leininger, Madeleine. (1991). Culture care diversity and universality: A theory
of nursing. New York: National League for Nursing Press. 16:44-45.

UNIT II. CULTURAL DIVERSITY

The world is a conglomeration of people coming from different cultures. More than
ever, because of the great strides made in science and technology, people from all over are
now able to travel, live and work in different parts of the world, bringing with them their
world view, ethnohistory, racial and social structure features (i.e. family, religion, language,
cultural and ethical values, etc), as well as their health behavior and practices. Thus,
everyone in a way is different; this fact or state of being different is known as cultural
diversity.

The nurse has to confront the issue of cultural diversity in the practice of the
profession. She/he has to know and understand cultural diversity as it is manifested in the
world today. What brings about cultural diversity? What are the reasons for population
movement or migration? What racial or ethnic groups comprise the different parts of the
world? What life and health ideologies, beliefs and practices are brought by them?

A. DEFINITION OF RELATED CONCEPTS

 Race – Racial categories are based on specific physical characteristics

 Ethnicity – The sense of identification with a collective cultural group, largely based
on the group’s common heritage. Includes language and dialect. Religious practices,
literature, music, folklore, political interests, food preferences, and employment
patterns.

 Biracial/multiracial – when an individual crosses two or more racial and cultural

groups. Multiracial (Tiger Woods – White, Black, Indian, and Asian)

 Dominant Group – The group within a country or society that has the most
authority to control values and sanctions.

 Minority Group – Most often has some physical or cultural characteristics that
identifies the people within it as different.

 Discrimination - The differential treatment of individuals or groups based on

categories such as race, ethnicity, gender, social class, or exceptionality, occurs when
a person acts on prejudice and denies another person one or more of the
fundamental rights.

 Stereotyping – Assuming that all members of a culture, subculture, or ethnic group

act alike.

15
  Cultural Imposition – The belief that everyone should conform to the majority
belief system.

 Cultural Blindness – The result of ignoring differences and proceeding as though

they do not exist.

 Culture Conflict – The state that occurs when people become aware of cultural
differences, feel threatened, and respond by ridiculing the beliefs and traditions of
others to make themselves feel more secure.

Source: Taylor.p.40; Kozier,208-209.

B. THE WORLD IN REVIEW

Divided into units or continents: Africa, Asia, Europe, North America, South America,
Oceania. Of these, Asia is the largest continent.

16
ASIA

17
NORTH AMERICA and CANADA

SOUTH AMERICA

18
19
C. POPULATION OVERVIEW

1. World Population

 Year 2000 – 6.1 billion

 Projected: Year 2020 – 7.6 billion
Year 2050 – 9.3 billion

2. Most Populous Cities of the World (Source: TIME Almanac 2006).

1. China 1,306,313,812
2. India 1,080,264,388
3. United States 295,734,134
4. Indonesia 241,973,879
5. Brazil 186,112794
6. Pakistan 162,419,946
7. Bangladesh 144,319,628
8. Russia 143,420,309
9. Nigeria 128,771,988
10. Japan 127,417,244
11. Mexico 106,202,903
12. Philippines 87,857,473

3. In the U. S.

 Between 1990 and 2002 – population increased from 248.7 million to 293.02
million
 Composition of population:
• 75.1% - White
• 12.5% - Spanish/Hispanic/Latino (of any race)
• 12.3% - Black or African American
• 0.9% - American Indian or Alaskan Native
• 3.6% - Asian
• 0.1% - Native Hawaiian or other Pacific Islander
• 5.5% - some other race
• 2.4% - are of two or more races

D. RACE

1. Basic Concepts

 Race is an emotionally-charged word that often divides or separates people even

though the Human Genome Project provides evidence that all human beings
share a genetic code that is over 99% identical.
 Race is genetic in origin and includes all physical characteristics that are similar
among members of the group, such as skin color, bone structure, blood type, hair
type, and eye color. However, it is this less than 1% difference that is usually
significant in determining and providing variants in health care as certain
diseases may be racially determined.
 Ethnicity (group identity) and race may sometimes overlap because the cultural
and biological commonalities support one another. The similarities of people in
racial and ethnic groups reinforce a sense of commonality and cohesiveness.

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 2. Race Categories

 White – refers to people having origins in any of the peoples of Europe, the Near
East, and the Middle East, or North Africa. This category includes Irish, German,
Italian, Lebanese, Turkish, Arab and Polish
 Black or African American – refers to people having origins in any of the black
racial groups of Africa, and includes Nigerians and Haitians or any person who
self-designated this category regardless of origin.
 American Indian and Alaskan Native refers to people having origins in any of
the original peoples of North, South or Central America, and who maintains tribal
affiliation or community attachment.
 Asian – refers to people having origins in any of the original peoples of the Far
East, Southeast Asia, or the Indian subcontinent. This category includes the term
Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, Burmese, Hmong,
Pakistani and Thai.
 Native Hawaiian and other Pacific Islander refers to people having origins in
any of the original peoples of Hawaii, Guam, Samoa, Tahiti, the Mariana Islands,
and Chuuk.
 “Some other race” was included for people who are unable to identify with the
other categories. Additionally the respondent could identify, as a write-in, with
two races (http://www.census.gov, 2001.)

E. THE IMMIGRANTS

1. Reasons for migration:

 Economic – seek better economic opportunities
 Religious – escape religious oppression
 Political freedom – escape political persecution

2. Metropolitan Areas with the Largest Numbers of Immigrants

 New York, N.Y.

 Los Angeles-Long Beach, CA
 Miami, FL
 Chicago, IL
 Washington, DC-MD-VA
 Orange County, CA
 Houston, TX
 San Jose, CA
 Boston-Lawrence-Lowell-Brockton MA
 Oakland, CA

In 1996 there were 4.6 to 5.4 million of undocumented immigrants. California is the
leading state of residence for undocumented people, followed by Texas, New York
and Florida.

3. Leading 10 Primary Destination States for Immigrants 2000

 California
 New York
 Florida
 Texas
 New Jersey
 Illinois
 Massachusetts
 Virginia
 Washington
 Pennsylvania

4. Leading 10 Countries of Origin for Legal Immigrants Between 1990-2000.

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  Mexico
 Peoples Republic of China
 Philippines
 India
 Vietnam
 Nicaragua
 El Salvador
 Haiti
 Cuba
 Dominican Republic

It is predicted that by the year 2020 immigration will be a major source of new
people for the United States and will be responsible for whatever growth occurs in
the United States after 2030. The United States will continue to attract about 2/3s of
the world’s immigrants, and 85 % will be from Central and South America.

Source: www.ins.gov.

F. FACTORS TO CONSIDER IN THE NURSING CARE OF CULTURALLY

DIVERSE GROUPS

1. Lack of employment opportunities and finances for health care services.

2. Different traditional belief systems as well as different norm and values.
3. The lack of cultural sensitivity on the part of social service and health care
workers.
4. Lack of bilingual personnel or staff members or the lack of interpreters to
assist clients and providers.
5. Rapid changes in the U.S. health care systems where clients are “lost” in the
gaps between agencies and services.
6. Inconvenient locations or hours that preclude clients from accessing care.
7. A lack of understanding, trust, and commitment on the part of health care
providers.

Source: Andrews and Boyle, Transcultural concepts in nursing care (2003) 4rd ed
Lippincott Wiliams & Wilkins, Philadelphia, p. 338

UNIT IV. CULTURAL HEALTH TRADITIONS, BELIEFS AND

PRACTICES
Cultural and health belief systems are embraced by people from different cultures. This unit
explores the concepts of HEALTH/ILLNESS, health traditions model, belief systems and
practices, healing systems as well as the barriers to health care.

A. THE HEALTH TRADITIONS PARADIGM

1. Concept of Health and Wellness

Health (according to WHO, 1948) – a state of complete physical, mental, emotional,

social well-being and not merely the absence of disease or infirmity.

Health and illness defined from a transcultural standpoint

 Health – is a complex, interrelated phenomena characterized by a balance of

the person, both within one’s being---physical, mental and spiritual---and in the
outside world- the environment, the community, and the natural forces
surrounding him/her.

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  Illness – is the imbalance of one’s being---physical, mental, and spiritual---and
in the outside world- the environment, the community and the natural forces
surrounding him/her.

The health traditions model is predicated on the concept of holistic HEALTH and
describes what people do from a traditional perspective to maintain, protect, and
restore HEALTH.

2. Interrelated Aspects:

 The body includes all physical aspects such as genetic inheritance, body
chemistry, gender, age, nutrition, and physical condition.
 The mind includes cognitive processes, such as thoughts, memories, and
knowledge of such emotional processes feelings, defenses, and self-esteem.
 The spiritual facet includes both positive and negative learned spiritual practices
and teachings, dreams, symbols, stories; protecting forces; and metaphysical or
native forces.

These aspects are in constant flux and change over time, yet each is completely
related to the others an also related to the context of the person. The context
includes the person’s family culture, work, community, history, and environment.

Source: Kozier, op. cit. p. 210.

B. THE HEALTH TRADITIONS MODEL

1. The health traditions model for maintaining, practicing, and restoring health

 Traditional methods of maintaining health - physical, mental, and spiritual –

include following a proper diet and wearing proper clothing, concentrating and
using the mind, and practicing one’s religion.
 Traditional methods of practicing health – physical, mental, and spiritual –
include wearing protective object such as amulets, avoiding people who may
cause trouble, and placing religious objects in the home.-
 Traditional methods of restoring health – physical, mental, and spiritual –
include the use of herbal remedies exorcism, and healing rituals.

The Nine Interrelated Facets of Health (Physical, Mental, and Spiritual) and
Personal Methods of Maintaining Health, Protecting Health and
Restoring Health

PHYSICAL MENTAL SPIRITUAL

Maintain Health  Proper  Concentration  Religious
clothing  Social and worship
 Proper diet family support  Prayer
 Exercise/Rest systems  Meditation
 Hobbies
Protect Health  Special foods  Avoid certain  Religious
and food people who can customs
combination cause illness  Superstitions
 Symbolic  Family activities  Wearing amulets
clothing and other
symbolic objects
to prevent the
“Evil
Eye” or defray
other
sources of harm
Restore Health  Homeopathic  Relaxation  Religious rituals
remedies  Exorcism  Special prayers

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  Lineaments  Curanderos and  Meditation
 Herbal tests other traditional  Traditional
 Special foods healers healings
 Massage  Nerve teas  Exorcism
 Acupuncture

Source: Spector, R.E. Cultural Diversity in Health and Illness (2000), 5th ed. Upper
Saddle River, N.J: Prentice Hall, p. 100.

2. Symbolic examples

Following are related health-related images and symbols that may be used to
maintain, protect, or restore physical, mental, or spiritual health by people of
different heritages.

 Thousand-year old eggs, from China, represent traditional foods that may be
eaten daily to maintain physical health.
 The enjoyment of nature, the nature environment, may be a universal way of
maintaining mental health.
 The Islamic prayer from East Jerusalem, represents a prayer, a way of
maintaining spiritual health.
 Red string, from the Tomb of Rachel in Bethlehem, Israel, may be worn to protect
physical health.
 The eye, from Cuba, represents the plethora of eye-related objects that may be
worn or hung in the home to protect the mental health of people by shielding
them from the envy and bad wishes of others.
 The thunderbird, from the hopi nation, may be worn for spiritual protection and
good luck.
 The herbal remedy from Africa represents aromatic plants that may be used by
people from all ethnocultural traditional backgrounds as one method of restoring
mental health.
 Tiger balm, from Singapore, represents substances that are used in massage
therapy as a way of restoring mental health.
 Rosary beads, from Italy, symbolize prayer and meditation methods used in the
spiritual restoration of health.

Source: Spector, R.E. Cultural Diversity in Health and Illness (2000),, 5th ed. Upper
Saddle River, N.J: Prentice Hall, p. 100).

Maintain

Protect

Restore

Symbolic Examples

3. Factors Influencing Traditional Beliefs and Practices

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  The length of time in the United States.
 The size of the ethnic or cultural group with which an individual identifies and
interacts.
 Age of the individual. As a general rule, children acculturated more rapidly than
adults or seniors.
 The ability to speak English and communicate with members of the majority
culture.
 Economic and education status. If a Salvadorean woman works outside the
home, she may readily learn to speak English than if she remains inside the
home.
 Health status of family members. If individuals and their families seek health
care in the country, they begin to “learn the system”, so to speak.
 Individuals and groups who have distinguishing ethnic characteristics, such as
skin color, may be more isolated because of discrimination and thus may retain
traditional values related to health beliefs and behavior.

Source: Andrews and Boyle, 3rd ed. p. 318.

C. HEALTH BELIEF SYSTEMS

Generally, theories of health and disease/illness causation are based on the prevailing
world view held by a group.

 The worldview developed reflects the group’s total configuration of beliefs and
practices and permeates every aspect of life within the culture of that group.
 These worldviews include a group’s health-related attitudes, beliefs and practices
and frequently are referred to as health belief systems.

Three Major Health Belief Systems

1. Magico-religious

 In this belief system, disease is viewed as the action and result of supernatural
forces. Supernatural forces dominate.
 Characterized by cause-and-effect relationship. Health is seen as a reward or gift
for being good; illness the result of “being bad” or opposing God’s will. Getting
well is also viewed as dependent on God’s will. Illness is viewed as punishment
for sins or committing transgressions.
 Common in countries like: Latino, African American, Middle Eastern and Asian
cultures.
 Five categories of events that are believed to be responsible for illness as derived
from the work of Clements (1932):
• Sorcery – believed in by some African and American Blacks
• Breach of taboo (breaking of social norm, such as committing adultery)
• Intrusion of a disease object
• Intrusion of disease-causing spirit – Example: Mal ojo or the evil eye common
in Latino culture.
• Loss of soul
 Magic can cause illness. Ex. A sorcerer or witch may put a spell or hex on the
client. Such illnesses may require magical treatments in addition to scientific
treatments
 Some view illness as possession by an evil spirit.

2. Scientific or biomedical health belief model

 Disavows the metaphysical. This belief system dominates Western thought and
the practice of health care.
 Based on the belief that life and life processes are controlled by a series of
physical and biochemical processes that can be manipulated by humans. The

25
 client will believe that illness is caused by germs, viruses, bacteria or a
breakdown of the body.
 Disease is viewed metaphorically as the breakdown of the human machine as a
result of:
• Wear and tear (stress)
• External trauma (injury, accident)
• External invasion (pathogens)
• Internal damages (fluid and chemical imbalances or structural damages)
 Using the metaphor of the machine, Western medicine uses specialists to take
care of the “parts “fixing” the part, etc. The client will expect a pill, or treatment,
or surgery to cure health problems.
 Biomedical model defines health as the absence of disease or of the signs and
symptoms of disease. To be healthy, one must be free of disease.

3. The holistic health belief model

 The term holistic was coined in 1926 by Jan Christian Smuts who defined holistic
as “an attitude or mode of perception in which the whole person is viewed in the
context of the total environment.
 In a way it is similar to the magico-religious worldview where the forces of nature
must be maintained in balance or harmony; when the balance of nature is
disturbed illness results.
 The different aspects of the individual’s nature: the physical, the mental, the
emotional, and the spiritual must also be in balance.
 Holistic paradigm seeks to maintain a sense of balance between humans and the
larger universe. Unlike the scientific model which states that disease is caused by
external agents, this paradigm states that disease is caused by imbalance or
disharmony between humans and the larger universe.
 For example:
Biomedical model – TB is caused by mycobacterium tuberculosis
Holistic model - disease is the result of multiple environmental-host
interactions: poverty, malnutrition, overcrowding, and the mycobacterium.
Examples of holistic belief: The medicine wheel of the Native Americans (see
below) and the yin and yang of the Chinese (see Addendum)

THE MEDICINE WHEEL

From our ancestors, we are taught that

everything in life is circular. We are one
within the circle of life. The Medicine Wheel
teaches us that the physical, mental,
emotional and spiritual aspects must be in
balance in order to maintain a healthy mind,
spirit and body.

Medicine wheel used by Native

Americans of North and South America

D. TYPES OF HEALING SYSTEMS

Healing – comes from the Anglo-Saxon word hael, which means to make whole, to
move forward, or to become whole.

It is not the same thing as curing (ridding one of disease) but is a process
that activates the individual’s healing forces from within.

Important Concept: “that healing potential exists in all of us.”

Healing System – refers to the accumulated sciences, arts, and techniques of restoring
and preserving health that are used by a cultural group (Smith, 1983).

26
 1. Self-Care

 For common minor illnesses, an estimated 70-90% of all people resort to self-
care with over-the-counter medicines, megavitamins, herbs, exercise, any or
foods that they believe have healing power.
 Many self-care practices have been handed down from generation to generation,
frequently by oral tradition.
 When self-care is ineffective, people are likely to turn to professional and/or folk
(indigenous, generic, traditional) healing systems.
 Self-care is the largest component of the North American healing care system.

2. Folk Healing System

 Folk healing system (FHS) is a set of beliefs that has a shared social dimension
and reflects what people actually do when they are ill vs. what society says they
ought to do according to a set of social standards.
 All cultures of the world have had a lay health care system, which is referred to
as indigenous or generic.
 Used interchangeably with complementary, alternative, or naturalistic; the key
consideration that defines folk systems is their history of tradition. Many have
endured over time and often transmitted from one generation to the next.
 FHS is a mixture of nonprofessional systems and uses healing practices that are
learned informally. The FHS is often divided into secular and sacred components.
 Most cultures have folk healers:
Examples:
Hispanic – curandero, espiritualista, yerbero, sabador
(manipulates bones and massages)
Black – “Old Lady”, Spiritualist, voodoo priest or priestess
Chinese – herbalist, acupuncturist
Greek – Magissa (magician), bonesetters, priest (Orthodox)
Native Americans – shaman (a folk-healer priest who uses natural and
Supernatural forces to help others), crystal gazer, hand trembler
(Navajo)
Philippines – manghihilot

3. Professional Care Systems

 Are formally taught, learned, and transmitted professional care, health, illness,
wellness and related knowledge and practice skills.
 Characterized by specialized education and knowledge, responsibility for care,
and expectation of remuneration for services rendered.
 Examples of professional care practitioners: Physicians, nurses, physical
therapists, pharmacists etc.
 Conventional medicine is medicine practiced by holders of M.D. (medical doctor)
or D.O. (doctor of osteopathy) degrees and by their allied health professionals
such as physical therapists, psychologists, and registered nurses.
 Professional medicine/medical care is also known as biomedicine, conventional
allopathic, Western medicine

4. Complementary, Alternative and Integrative Therapies

Western biomedicine or allopathic medicine must be differentiated from alternative

medicine.

Comparison of Allopathic and Alternative Medicine

ALLOPATHIC PERSPECTIVE
Health is absence of disease.
Focus is on cure of disease
Mind and body are treated as separate
ALTERNATIVE PERSPECTIVE
Health is a state of well-being characterized
by min/body balance.
Emphasis is on health maintenance and
disease prevention through lifestyle choices.
Mind and body are one; what affects one

27
entities affects the other.

Disease results from causative agents, Disease originates from within and is the
usually external. result of imbalances that occur in response
to unhealthy lifestyle and/or inner
disharmonies.
Healing depends on outside agents to cure The body has a natural ability to heal itself.
disease.
Treatment consists of drugs, surgery, and Treatment consists of det, exercise, herbal
radiation. medicines, social support, and stress
management.
Healing is aggressive, quick and seeks to Healing is a slow, natural process.
destroy the invading organisms.
The doctor plays the central role in healing. The client has the most important role in
healing (i.e., lifestyle choices).
(Data from: Fontaine, K.L. (2000). Healing practices: Alternative therapies for nursing.
Upper Saddle River:Prentice Hall, in DeLaune Fundamentals of Nursing. p. 232.

 Alternative medicine – is used instead of or in place of conventional medicine

Example: Using a special diet to treat cancer instead of undergoing surgery,
radiation, or chemotherapy that has been recommended by a conventional
doctor.

 Complementary medicine – is used together with conventional medicine.

Example: In addition to Valium which an extremely agitated or nervous patient
may receive, one can give tea (chamomile, valerian) that calms down the patient,
provide a quiet environment, play soothing music, give therapeutic massage, etc.
; gargling with salt or saline solution in addition to antibiotic for strep throat

 Integrative medicine – term introduced by Dr. Andrew Weil to define a hybrid of

complementary, alternative and conventional medical therapies for which there is
some high-quality scientific evidence of safety and effectiveness.

Components of integrative healing therapies:

28
1. Surgery – refers to excision or surgical removal of diseased body parts.

2. Pharmaceutical Drugs – use of medicines

3. Herbal medicine - use of herbs or plants that are valued for their medicinal
properties, flavors and scents. Examples: Eucalyptus (antibacterial,
decongestant), Saint John’s worth (antidepressant), garlic (lowers cholesterol)

4. Nutritional medicine – includes special diet therapies (e.g., macrobiotic,

vegetarian, Atkins, South Beach diet, etc.)

Orthomolecular medicine, the use of products used as nutritional and food

supplements like vitamins and mineral (and not covered in any other category

5. Lifestyle and behavior – modifying or changing unhealthy lifestyle behavior/s or

habits to healthy ones; also emphasizes healthy maintenance and disease
prevention. Example: eating healthy instead of junk foods, changing or stopping
addictive behaviors like drinking or smoking

6. Mind/body or behavioral medicine – uses a variety of techniques designed to

enhance the mind’s capacity to affect bodily function and symptoms. These include
biofeedback; relaxation; meditation; guided imagery; hypnosis; prayer; art; music;
dance therapy, and yoga.

7. Energy medicine- involves the use of energy fields. The following are commonly
accepted beliefs about energy and healing:
• All things are manifestations of energy.
• Energy comes from one universal source
• Life depends on the movement of energy.
• People consists of several energy fields that interact with the environment.
• Interpersonal relationships are influenced by energy exchanges.

Types of energy therapies:

 Biofield involves systems that use subtle energy fields that purportedly
surround and penetrate the human in and around the body. Some forms of
energy therapy manipulate biofields by applying pressure and/or manipulating
the body by placing the hands in, or through, these fields.
Example: qi gong, Reiki, and Therapeutic Touch,

 Bioelectromagnetic-based therapies – involve the unconventional use of

electromagnetic fields such as pulsed fields, magnetic fields, or alternating-
current or direct current fields or bone repair, wound healing and stimulation
of the immune system.

Traditional Chinese Medicine (TCM) is based on the premise that the body’s
vital energy qi (pronounced chee) circulates through pathways or meridians and
can be accessed and manipulated through specific anatomical points along the
surface of the body. Disease is described as an imbalance or interruptions in the
flow of qi.

Components of TCM include: herbal and nutritional therapy, restorative physical

exercises, meditation, acupuncture, and remedial massage.

8. Manipulative therapies - are diagnostic and therapeutic mechanisms based on

manipulation and /or movement of the body, such as osteopathic manipulation,
massage therapy, hydrotherapy, chiropractic

Osteopathic medicine is a form of conventional medicine that, in part, emphasizes

diseases arising in the musculoskeletal system. There is an underlying belief that all

29
 of the body’s systems work together, and disturbance in one system may affect
function elsewhere in the body.

9. Others – Humor, laughter therapy, pet therapy, music, aromatherapy

Source: Andrews and Boyle, op. cit, 4th ed. pp. 73-86.

Related Therapies:

Ayurveda – is a CAM alternative medical system that has been practiced in the Indian
subcontinent for 5,000 years. Ayurveda includes diet and herbal remedies and emphasizes
the use of body, mind, and spirit in disease prevention and treatment.

Video showing: Ayurveda

Chiropractic – is a CAM alternative medical system. It focuses on the relationship between

bodily structure (primarily that of the spine) and function, and how that relationship affects
the preservation and restoration of health. Chiropractor use manipulative therapy as an
integral treatment tool.

Homeopathic medicine is a CAM alternative medical system. In homeopathic medicine,

there is a belief tat :like cures like,” meaning that small, highly diluted quantities of
medicinal substances are given to cure symptoms, when the same substance given at
higher or more concentrated dose would actually cause those symptoms.

Example: Immunization

Naturopathic medicine, or naturopathy, is a CAM alternative; it proposes that there is a

healing power in the body that establishes maintains, and restores health. It includes
supporting treatments as nutrition and lifestyle counseling, dietary supplements, medicinal
plants, exercise, homeopathy, and treatments from traditional Chinese medicine.

Nursing Implications:

Nurses must know and understand the nursing implications of CAM Therapies:

 When a nurse enters into a relationship with a client/patient she acts as a

healing facilitator by offering to be a guide, counselor, agent of change , or
instrument of healing, which is help the clients call forth their inner
resources for healing.
 Nurses are encouraged to think critically and assess CAM Therapies before
recommending any one particular method or therapy.
 As such she must develop the following attributes:
 Has knowledge base
 Intentionality – conscious direction of goals that is essential in helping
the healer to focus
 Respect for differences: Demonstrated by honoring clients’ culturally
based health beliefs
 Ability to model wellness: Tending to own needs and attempting to
stay as healthy and balanced as possible

UNIT V. TRANSCULTURAL CARE NURSING MODELS

Following are transcultural care nursing models that depict theory of cultural care and
universality (Leininger’s Sunrise Model), provide a model for cultural competence (Purnell’s),
and a framework for assessing transcultural phenomena (Giger and Davidhizar’s).

A. LEININGER’S SUNRISE MODEL TO DEPICT THEORY OF CULTURAL

CARE

30
DIVERSITY AND UNIVERSALITY

 Focuses on describing, explaining, and predicting nursing similarities and differences

primarily on human care and caring in human cultures.
 Leininger uses word view, social structure, ethnohistory, environmental context, and
the generic (folk) and professional systems to provide a comprehensive and holistic
view of influences in culture care and well-being.
 This model emphasizes that health and care are influenced by elements of the social
structure, such as technology, religious and philosophic factors, kinship and social
systems, cultural values, political and legal factors, economic factors, and
educational factors.
 In order for nurses to assist people of diverse cultures, Leininger presents three
intervention modes to demonstrate ways to provide culturally congruent nursing
care. These modes are assistive, supportive, facilitative, or enabling professional
actions and decisions that help people of a designated culture in:

a. Culture care preservation and maintenance –refers to the assistive,

supportive, facilitative, or enabling professional actions to retain and/or reserve
relevant care values so that they can maintain their well-being, recover from
illness, or face handicaps and/or death.”
b. Culture care accommodation or negotiation – refers to the assistive,
supportive, facilitative, or enabling professional actions to negotiate to /with
others for beneficial or satisfying health outcomes with professional care
providers.”
c. Culture care restructuring and repatterning – refers to the assistive,
supportive, facilitative, or enabling professional actions to help a client reorder,
change, or greatly modify his or her lifeways for a new, different, and beneficial
health care pattern, and maintenance of respect for the client’s cultural values
and beliefs while still providing a beneficial or healthier lifeway than before the
changes were co-established with the client.

(Leininger, 1991, pp. 48-49, in Andrews and Boyle, 3rd ed. op. cit. p. 521).

31
 THE SUNRISE MODEL

C.THE PURNELL MODEL FOR CULTURAL COMPETENCE

1. Macro Aspects of the Model

 Global society – phenomena related to global society include world
communication and politics; conflicts and warfare; natural disasters and famines;
international exchanges in education, advances in health sciences, etc.
 Community – physical, social, and symbolic characteristics that cause people to
connect
 Family – is two or more people who are emotionally connected. Family structure
and roles change according to age, generation, marital status, relocation, etc.
 Person – is a biopsychocultural being who is constantly adapting to his or her
environment.

2. Micro Aspects of the Model

The 12 domains essential for assessing the ethnocultural attributes of an individual,
family, or group are as follows:
 Overview, inhabited localities,  Nutrition
and topography  Pregnancy and child-bearing
 Communication practices
 Family roles and organization  Death rituals
 Workforce Issues  Spirituality
 Biocultural ecology  Health-care practices
 High-risk behaviors  Health-care practitioners

32
C. THE GIGER AND DAVIDHIZAR’S TRANSCULTURAL ASSESSMENT
MODEL

The metaparadigm for this model includes:

1. Transcultural nursing and culturally diverse nursing;

2. culturally competent care;
3. culturally unique individuals;
4. culturally sensitive environments; and,
5. health and health status based on culturally specific illness and wellness behavior.

33
 The Giger and Davidhizar’s Transcultural Assessment Model

Model shows:

 The client, a unique cultural being, in the center. It is important to

remember that the client is culturally unique and as such is a product of past
experiences, cultural beliefs and cultural norms. Cultural expressions vary but it
is that which give an individual a unique identity.

 Cultural heritage consistency: This theory analyzes the degree to which

people identify with the dominant and traditional cultures . Its essential elements
are: culture, ethnicity, and religion

1. Culture – represents non-physical traits, such as values, attitudes, beliefs,

customs shared by a group of people and passed from generation to the next.
Culture is also the sum f beliefs, practices, habits, likes dislikes, norms,
customs and rituals learned from the family during the ears of socialization.
2. Ethnicity – is a sense of identification associated with a cultural group’s
common social and cultural heritage.
Ethnicity is indicative of the following characteristics a group may share in
some combination:
i. Common geographic origin
ii. Migratory status
iii. Race
iv. Language and dialect
v. Religious faith or faiths
vi. Ties that transcend kinship, neighborhood, and community boundaries
vii. Shared traditions, values, and symbols
viii. Literature, folklore, and music
ix. Food preferences
x. Settlement and employment patterns
xi. Special interest with regard to politics in the homeland and in the
United States
xii. Institutions that specifically serve and maintain the group

Filipino ethnicity: The “Filipino blend,” is a considerable mix of cultural and linguistic
groups, the result of varied historical and local relationships:
• Earliest known settlers were the Negritos, small Negroes, related to the
Andaman Islands and Malaya, who entered via land bridges at the height of the
last glacier age. They are found in the Bataan peninsula and other marginal
areas.
• Next wave of settlers came from Southeast Asia by way of the China sea and
remained in Luzon and Visayas.
• Arab and Indian traders added their blood to the Muslim populations and settled
in the southern islands.
• Invasion of the Philippines by Spain in 1521, and the U.S. in 1898.

Language is one of the most identifying ethnic feature of Filipino groups. There are
76 linguistic groups, the 3 most important are Tagalog, Visayas and Ilokano.

Cultural Minorities – 4 million or 12% of total population. ¾ Muslims found in

Mindanao, Sulu Archipelago and Palawan. (See addendum)

There are at least 106 ethnic groups in North America and more than 170 Native
American Indian tribes. (Thernstrom, 1980).

34
 Filipino Ethnicity: The “Filipino Blend,”

3. Religion – “the belief in a divine or superhuman power or powers to be

obeyed and worshipped as the creator(s) and ruler (s) of the universe; and a
system of beliefs, practices and ethical values.

It is not possible to isolate the aspects of culture religion, and ethnicity that
shape a person’s worldview. Each is a part of the other, and all three are
united within the person. Therefore, when religion is discussed, culture
and ethnicity must also be included.

a. Relationship between religion, culture and ethnicity: Examples

 Ethnicity and religion are clearly related, and one’s religion is quite
often the determinant of one’s ethnic group. Example: Israeli- Jewish;
Japanese – Shintoism; Thai - Buddhism
 Religion in many cultures plays a vital role in one’s perception of health
and illness as well as the way people interpret and respond to the signs
and symptoms of illness.
 Religion, religious beliefs, and rituals are closely interwoven with the
cycles and stages of life as birth, marriage, dying and death. Examples:
Baptism is a sacrament in the Catholic religion. In Islam, circumcision
must be performed on the 7th day after birth, and on the 8 th day in the
Jewish faith. In the Hindu religion, the eldest son must perform the
rituals for the dead.
 Personal and cultural values and ethical principles and practices are
greatly determined and influenced by religion. Examples: According to
Christian Science abortion is incompatible with faith. Family life is
valued and birth control is contrary to Mormon belief. Euthanasia is not
acceptable in Islam.
 Healing through prayer, relics or religious objects or through the
intercession of saints is a belief common to many religions. Examples:
Prayer for the sick. Intercession of saints: St. Joseph – dying, St. Vitus
– epilepsy, Our Lady of Lourdes – bodily ills, Use of religious medal,
holy water, etc.

35
 GEOGRAPHICAL DISTRIBUTION

b. Top Ten Organized Religions of the World

RELIGION PERCENTAGE POPULATION

Christianity 3.0% 2.1 billion
Islam 20.1 1.3 billion
Hinduism 13.3 851 million
Buddhism 5.9 375 million
Sikhism 0.4 25 million
Judaism 0.2 15 million
Baha’ism 0.1 7.5 million
Confucianism 0.1 6.4 million
Jainism 0.1 4.5 million
Shintoism 0.0 2.8 million
c.

c. Largest Denominational Families in the United States 2001

DENOMINATION ESTIMATED % OF ESTIMATED ADULT

U.S. POPULATION POPULATION
Catholic 24.5% 50,873,000
Baptist 16.3% 33,830,000
Methodist/ Wesleyan 6.8% 14,150,000
Lutheran 4.6% 9,580,000
Presbyterian 2.7% 5,580,000
Pentecostal, Charismatic 2.1% 4,407,000
Episcopalian/ Anglican 1.7% 3,451,000
Latter-Day Saints/ Mormon 1.3% 2,697,000
Church of Christ 1.2% 2,593,000
Congregational United Church 0.7% 1,373,000
of Christ
Jehovah’s Witness 0.6% 1,331,000
Assemblies of God 0.5% 1,106,000

D. Giger and Davidhizar’s Transcultural Assessment Model: The Six Cultural

Organzing Phenomena

36
Culturally diverse nursing must take into account six cultural phenomena that vary but
are evident in all cultural groups and affect health care. These have been identified by
Giger & Davidhizar, 1999, and Engebertson & Headley(2000), as: (1) environmental
control, (2) biological variations, (3) social organization (4) communication,
(5) space, and (6) time orientation.

1. ENVIRONMENTAL CONTROL – refers to the ability of members of a particular group to

plan activities that control nature or direct environmental factors.
• Plays an extremely important role in the way patients respond to health-related
experiences, including the ways in which they define health and illness and seek
and use health care resources and social supports.

• Examples of environmental control systems: complex traditional health and

illness beliefs, the practice of folk medicine, the use of traditional healers, etc.

2. BIOLOGICAL VARIATIONS – The several ways in which people from one cultural
group differ biologically (i.e., physically and genetically) from other cultural groups
constitute their biological variations. These are:
 Body built and structure – specific bone structure and structural differences
between groups. Example: smaller stature of Asians
 Skin color, including variations in tone, texture, healing abilities, and hair follicles.
Example: African Americans – dark skinned; Europeans – light skinned
 Enzymatic and genetic variations, including differences in response to drug and
dietary therapies
 Susceptibility to disease which can manifest as a higher morbidity rate of certain
diseases within certain groups
 Nutritional variations. Examples: “hot and cold” preferences among Hispanic
Americans, yin and yang among Asian Americans, rules of the kosher diet among
Jewish and Islamic Americans, etc. Common nutritional disorder, lactose
intolerance, is found among Mexicans. Africa, Asian, and Eastern European
Jewish Americans.

37
3. SOCIAL ORGANIZATION – refers to the ways in which groups determine rules of
acceptable behavior and role of individual members.
 Family unit (nuclear, single parent, extended, blended)
Children learn their cultural responses to life events from the family and its
ethnoreligious group through socialization.
 Gender – gender roles vary according to cultural context:
*patriarchal structure – husband/father is the dominant person (Latino,
Hispanic and traditional Muslim families
*matriarchal structure – the wife is responsible for child care and household
maintenance whereas the father’s role is to support and protect the
family members.
 Lifestyle – alternative lifestyles. Example: homosexual couples and communal
groups

Social organization also prescribes behavior for such significant events as birth, death,
child rearing, and illness.

Nurses must demonstrate respect for client’s lifestyles even when they differ from
theirs by:
 Being aware of own tendency to be ethnocentric
 Being sensitive to client’s needs especially those expressed non-verbally
 Use self-awareness to determine the impact of own beliefs and values

4. SPACE (PROXEMICS) – The area around a person’s body, surrounding environment,

and objects within that environment; affects people’s behaviors and attitudes toward the
space around themselves.

Territoriality refers to the behavior and attitude people exhibit about an area they
have claimed and defend or react emotionally when others encroach on it.

Both personal space and territoriality are influenced by culture, thus different
ethnocultural groups have varying norms related to the use of space.

Space and related behaviors have different meanings in the following zones:
 Intimate zone – extends up to 1 ½ feet. Acceptable only in private places
because this distance allows adults to have the most bodily contact for
perception of breath and odor,
 Personal distance – extends from 1 ½ to 4 feet. This is an extension of the
self that is like a “bubble” of space surrounding the body. At this distance the
voice may be moderate, body odor may not be apparent, and visual distortion
may have disappeared.
 Social distance – extends from 4 to 12 feet. This is reserved for impersonal
business transactions. Perceptual information is much less detailed.
 Public distance – extends 12 feet or more. Individuals interact only
impersonally. Communicator’s voices must be projected, and subtle facial
expressions may be lost.

Use of personal space varies among individuals and ethnic groups. The extreme
modesty practiced by members of some cultural groups may prevent members
from seeking preventive health care.

5. Time Orientation (Temporal Relationships) – refers to viewing of time in the present,

past or future; varies among different cultural groups. Most cultures include all three
time orientation, but one orientation is more likely to dominate the cultural perspective.

Examples:
 American culture – future oriented; time is a highly valuable resource: do not
waste time, “time is money”
 German culture – past-oriented society, where laying a proper foundation by
providing historical background information can enhance communication
 Central American culture – present oriented
 Asian, Latin countries – punctuality is not taken seriously.

38
 Selected Consequences of Time Orientation
Time Possible Consequences
Orientation
To Past  When traditions conflict with a prescribed treatment regimen, The
person may have trouble accepting or maintaining the plan of care.
 In contrast, a strong connection with the past may ground the person
with others in the same culture and provide a sense of self that
encourages positive health practices.
To the present  A present-oriented person may have little concern for long-term
preventive health practices and may respond better to sort-term goals.
 In contrast, a present-oriented person may be most able to enjoy the
here-and-now and may engage fully in exercise, enjoy nutritious food,
and appreciate the company of others – all attributes associated with
good health.
To the future  This person has little difficulties and inconvenience of the present,
focusing instead on the future.
 The present is important only if what is happening now will help the
person realize long-term goals.
 This person may have little trouble following a treatment plan as long as
its benefits are clear.
 However, the person may have difficulty with chronic illnesses for which
no complete cure is known.
 A future-oriented person naturally tends to become more of a present-
oriented person with age because, as the future life becomes shorter,
the present becomes more important.
Source: Harreader, Helen and Mar Ann Hogan. Fubdamentals of Nursing. Saunders, An
imprint of lsevier, Inc. reprinted 2005, p. 47.

4. Communication – Language differences possibly play the most important

obstacle to providing multicultural health care because clients come from all over
the world and they affect all stages of the patient caregiver relationship. to, and
evaluate our experience.

39
 “Language allows us to initially identify, label, attach significance

A. Basic/Related Concepts:

 Communication occurs when a person (the sender (S) or encoder) sends a

message to another person (the receiver (R) or decoder).
 Communication is most effective when the message received is exactly the
same as the message that was sent and both sender and receiver agree on
the meaning of the message.
 Communication fails when (1) the sender’s message is blocked for some
reason and the receiver never gets the message; or (2) the message is
distorted.
 Distortion of message occurs when the message has as different meaning for
the receiver than the sender intended. Distortion is amplified when both
receiver and sender fail to clarify message. Factors that can distort
message: anger, fatigue, fear, pain, and anxiety.
 Communication may be blocked. Factors that foster blockage: different
cultural, ethnic, racial, socioeconomic, or educational backgrounds.

Example: Asians (Filipinos, Japanese, Chinese, etc) may silently accept a

physician’s recommendation even when they do not understand the
reasons for the medications or procedures that are ordered.

B. Types of Communication:

1. Verbal – includes spoken or written word. Language is the code senders use to
carry their message. Language barriers can cause severe communication problems
between S and R.

Causes:
1. May arise from use of the language (e.g. S is speaking English and the R is
speaking Spanish.
2. Can arise when the S uses technical terms, abbreviation, idioms or
regionalisms that are unfamiliar to the receiver (e.g., when a nurse uses
medical terms when explaining a procedure to a layperson).

Every culture has standards for verbal communication – especially for word
choice, the degree of emotion considered appropriate, volume and speed of
speech, inflection, directness, and the use of silence.

• Word Choice:
 American speech is filled with abbreviated words, slang, and jargon.
Americans tend to communicate in an informal way with superiors and
subordinates alike.
 Japanese use of language is distinguished by many levels of formality
and directness depending upon the status of the people who are
conversing.

Distinctions are also made between men’s and women’s speech. Choice of
word depends largely on the relationship between the people who are
communicating.

• Emotional Expressiveness, Tone, Pitch, Volume of Voice, and Speed of

Speech
 White American middle-class culture values a controlled tone and
some emotional restraint
 Many black Americans are more verbal and value emotional
expressiveness in conversation

40
  Appalachians – speak very slowly and seem to dwell on each word,
giving their speech a hesitant, disjointed quality.
 Many Asians and Native Americans display great emotional restraint in
their speech patterns, speaking slowly and quietly. These cultures
value the ability to endure pain and grief with silent stoicism.
 Southern Europeans are typically warm, expressive; will loudly express
their discomfort
 Hispanics use a lot of endearing words, are warm and expressive.

• Voice Inflection
 When emphasis is placed on certain words more than the words
themselves.
Example: “What do you need now?”
“What do you need now?”

• Directness in Speech
 Americans – quite direct, they go straight to the point rather than
wasting time on lengthy preliminaries or long silences.
 Japanese – strive to be polite, diplomatic, and tactful.
 Mexicans –may take time for small talk and then lead into a
discussion.

• Use of Silence
 Some cultures value silence, whereas others feel that silence is a
vacuum that must immediately be filled with word.
 Among Native Americans – silence is an essential element of showing
respect and understanding.
 In some Arab cultures, silence may indicate concern for personal
privacy.
 In French, Spanish, and Eastern European cultures silence
may be a sign of agreement.
 Silence during a conversation gives each person an
opportunity to speak without having to interrupt.

B. Nonverbal Communication

It has been estimated that as much as 2/3 of all communication is non-verbal

consisting of messages that are conveyed via body language and facial
expressions.

• Gestures and Facial Expressions

 Common types of nonverbal communication may differ from culture to
culture. A smile may imply acceptance and compliance, or may mean
respect and social grace, or flirting.
 In nearly all cultures, people used their mouths and eyebrows to convey
anger, surprise, pleasure, fear and hand gestures to convey openness or
intimidation.

• Eye Movement and Eye Contact

“The eyes are the windows of the soul.”

 When a person avoids eye contact, many Americans assume that it is a

negative sign. It is not unusual for an American to say, “Look at me when
I talk to you.” or “She must be lying. Did you notice that she avoided
looking at us?”
 American physician and nurses usually note if a patient avoids eye contact
when they perform a psychosocial assessment.
 Some Asians and Native Americans believe that prolonged eye contact is
rude and an invasion of privacy.

41
  Native Americans may direct their eyes to the floor when they are paying
attention or thinking.
 Muslim women may avoid eye contact as a show of modesty.

• Touch

 Touch patients only when you know touching is acceptable.

 Conveys many meanings: gentle, sensual, harsh or brutal
 We use touch to connect with others and to establish a feeling of
warmth, approval, emotional support, and intimacy.
 Touch can also indicate anger, aggression, frustration, and a desire to
control others by invading their personal space.
 Cultures have specific guidelines for times and situations when it is
acceptable to touch others.

 Handshake – a form of greeting, esp. when introduced;
consummate a business deal
 Native Americans – view a firm handshake as aggressive and even
offensive.
 Many Westerners think nothing of kissing or hugging a friend as a
form of greeting when meeting in public places; in traditional Asian
cultures, such behavior is reserved for intimate relationship in
private settings.
 In many Asian cultures (Indians, Vietnamese, Japanese, Thai)
avoid touching the head because the head has been traditionally
considered to be the “the abode of the spirit.”

• Posture

 Helps to communicate how one person feels towards another

 Middle-class Americans may lean in the direction of individuals they like or
respect
 Posture can also communicate a tense or relaxed state
 Rigid muscles and a flexed body may indicate physical pain.

C. Barriers to Transcultural Communication

 Lack of knowledge – remember that each culture dictates what is “normal” when
sick.
Examples:
• Japanese patients might react with silent obedience to your request
• White middle-class patients might wish to discuss their nursing care with you
• Italian patients might dramatically express their discomfort
• Inner city youth might loudly demand your attention

 Fear and Distrust – some people from diverse culture pass through different
stages of adjustment during their initial encounter:
• Fear
• Dislike
• Distrust
• Acceptance
• Respect
• Trust
• Like

 Racism
 Bias and Ethnocentrism
 Stereotyping
 Ritualistic behavior
 Language barrier – 3 types of language barriers:

42
 • Foreign languages
• Different dialects and regionalisms
*There are 3 major Chinese dialects: Mandarin, Cantonese,
and Shanghainese
*Aside from the 3 main Filipino languages there are numerous
regional dialects: Ilongo. Cebuano, Ibanag, Itawis
• Idioms, slang, and “street talk”
 Differences in perceptions and expectations

Source: Munoz, C. and Kuckmann, op. cit. 177.

D. The Use of an Interpreter: A way to resolve language barrier.

When obtaining the precise meaning of words in a language that is difficult, it is best
for health care providers to obtain someone who can interpret the meaning and
message, not just translate the individual words.

Some guidelines for communicating with non-English speaking clients:

 Use interpreters rather than translators. Translators just restate the words from
one language to another. An interpreter decodes the words and provides the
meaning behind the message.
 Use dialect-specific interpreters in the health-care field.
 Use interpreters trained in the health-care field.
 Give the interpreter time alone with the client.
 Provide time for translation and interpretation.
 Use same-gender interpreters whenever possible.
 Maintain eye contact with both the client and interpreter to elicit feedback: read
nonverbal cues.
 Speak slowly without exaggerated mouthing, allow time for translation, use the
active rather than the passive tense, wait for feedback, and restate the message.
Do not rush; do not speak loudly. Use a reference book, a dictionary, etc.
 Use as many words as possible in the client’s language and nonverbal
communication when unable to understand the language.
 Use phrase charts and picture cards if available.
 During the assessment, direct your questions to the patient, not to the
interpreter.
 Ask one question at a time and allow interpretation and a response before
asking another question.
 Be aware that interpreters may affect the reporting of symptoms, insert
their own ideas, or omit information.
 Remember that clients can usually understand more than they can express;
thus, they need time to think in their own language. They are alert to the
health care provider’s body language, and they may forget some or all of
their English in time of stress.
 Avoid the use of relatives who may distort information or not be objective.
 Avoid using children as interpreters, especially with sensitive topics.
 Avoid idiomatic expressions and medical jargon.
 If an interpreter is unavailable, the use of translator may be acceptable.
The difficulty with translation is omission of parts of the message, distortion
of the message, including transmission of information not given to the
speaker, and messages not being fully understood.
 If available, use an interpreter who is older than the patient.
 Review responses with the patient and interpreter at the end of a session.
 Be aware that social class differences between the interpreter and the client
may result in the interpreter’s not reporting information that he or she
perceives as superstitious or unimportant.
Source: Purnell, Lary D. and Betty J. Paulanka, Transculural Health Care, 2nd
ed. 2003. F.A. Davis Co. , p.15.

E. SELECTED EXAMPLES OF ETIQUETTE AS RELATED TO SELECTED CULTURAL

PHENOMENA

43
TIME Visiting Inform person when you are coming
Avoid surprises
Being on time Inform person when you are coming
Explain your expectations about time
Taboo times Ask people from other regions and cultures
what they expect
Be familiar with the times and meanings of
person’s ethnic and religious holidays

SPACE Body language and Know cultural and/or religious customs

distances regarding contact, such as eye and touch,
from many perspectives

COMMUNICATION Greetings Know the proper forms of address for

people from a given culture and the ways
by which people welcome another.
Know when touch, such as embrace or
handshake, is expected and when physical
contact is prohibited.
Gestures Gestures do not have universal meaning;
what is acceptable to one cultural group is
taboo with another.
Smiling Smiles may be indicative of friendliness to
some, taboo to others.
Eye contact Avoiding eye contact may be a sign of
respect

SOCIAL Holidays Know what days are important and why,

ORGANIZATION whether or not to give gifts, what to wear
Special events to special events, what the customs and
beliefs are.
Births Know how the event is celebrated, meaning
Weddings of colors used for gifts, expected rituals at
Funerals home or religious services.

BIOLOGICAL Food customs Know what can be eaten for certain events,
VARIATIONS what foods may be eaten together or are
forbidden, what and how utensils are used.
ENVIRONMENTAL HEALTH practices Know what the general HEALTH traditions
CONTROL and remedies are for a given person and question
observations for validity

44
 Southeast Asia (Cambodia, Laos, Vietnam)JapanKoreanPhilippinesHawaiiChinaAsian

CARE
Sons, Inc.
 
 
Nonverbal and Contextual cuingUse of silenceDialects, written characteristicsNational language preference

Non-contact

Present

  

Many religions, incl. Taoism, Buddhism, Islam, and ChristianityDevotion to tradition loyaltyFamily: Hierarchical structure,

 

Traditional practitioners: Chinese doctors, herbalistsUse of traditional medicinesTraditional health and illness beliefs

    

Lactose intoleranceHypertensionCoccidioidomycosisStomach cancerLiver cancer

Source: Adapted from Dresser, N. (1996). Multicultural manners. New York:Wiley. Copyright c 1960 John Wiley &

F. CROSS-CULTURAL EXAMPLES OF CULTURAL PHENOMENA IMPACTING NURSING

45
 West Indian Islands (Dominican Republic, Haiti, Jamaica)Many African countriesWest coast (as slaves)African

  

Spanish, and FrenchDialect pidgin, Creole,National languages

SpaceClose Personal

Present over Future

within community networks single parent 

   
OrganizationsCommunity social Strong church affiliation Large, extended family Family: many female,

    
workerTraditional healer: Root Folk medicine tradition illness beliefsTraditional health and

    

Lactose intoleranceCoccidiomycosisStomach cancerCancer of the esophagusHypertensionSickle cell anemia

46
 Countries Other European Ireland Italy England GermanyEurope

immediately  

Many learn English National languages

Distant Southern countries: closer contact and touchAloofNon-contact people

Future over present

 
  
Social organizationsCommunity Judeo-Christian religionsExtended familiesNuclear families

medicine traditions   
  
Some remaining folk illness beliefsTraditional health and system health care Primary reliance on modern

   

ThalassemiaDiabetes mellitusHeart diseaseBreast cancer

47
 Eskimos Aleuts Indian tribes 500 American American Indian

language  

Use of silence and body Tribal languages

Space very important and has no boundaries

Present

traditions families  
  
OrganizationsCommunity social grps. Children taught to respect Biological and extended Extremely family oriented

 
  
medicine manTraditional healer: Folk medicine tradition illness beliefsTraditional health and I

   

Diabetes mellitusCirrhosis of the liverHeart diseaseAccidents

48
 organizationssocial Community GodparentsCompadrozzo;Extended familiesNuclear family
Value physical presenceEmbracingTouch, HandshakesTactile relationships

Lactose intoleranceCoccidioidomycosisParasitesDiabetes mellitus

Spanish or Portuguese primary language

Present
Central and South American Mexico Cuba SpainHispanic countries

illness beliefsTraditional health and













Traditional healers:Folk medicine tradition











Curandero,
esperitista,
partera, senora
TIME ORIENTATION

SOCIAL ORGANIZATION
NATIONS OF ORIGIN

COMMUNICATION

VARIATIONSBIOLOGICAL
SPACE

CONTROLENVIRONMENTAL

Compiled by Rachel Spector, R.N., Ph.D. In Potter, P.A. and Perry, A.G. (1997). Fundamentals
of nursing: concepts, process, and practice (ed. 4). St. Louis: Mosby.

G. TRANSCULTURAL ASSESSMENT: BASIC PRINCIPLES OF

CULTURAL
ASSESSMENT

1. All cultures must be viewed in the context in which they have developed. Cultural
practices develop as a “logical” or understandable response to a particular human
problem, and the setting as well as the problem must be considered.

2. Understanding the premises of the behavior must be examined. Example: The

Hispanic clients refusal to take a “hot” medication with a “cold” liquid is
understandable if the client is aware that many Hispanic patients adhere to hot/cold
theories of illness causation.

49
3. The meaning and purpose of the behavior must be interpreted within the context of
the specific culture. Example: Close relationship often seen in Asian and Hispanic
cultures may be viewed as abnormal in European American families.

4.There is such a phenomenon as intracultural variation. Not every member of a

cultural group displays all the behaviors that we might associate with that group.
Example: Not every Filipino will adhere to the same methods of folk healing.

Source: Andrews and Boyle, Transcultural concepts in nursing care (2003) 4rd ed
Lippincott Wiliams & Wilkins, Philadelphia, p. 338.

Sample Assessment Questions

1. To what cause(s) do you attribute your illness or disease (e.g., divine wrath,
imbalance in hot/cold or yin/yang, punishment for moral transgression, hex, soul
loss, pathogenic organisms)?

Ano ang dahilan ng inyong sakit (halimbawa: galt ng diyos, hindi pantay na lamig o
init, yin/yang, kaparushan sa maling Gawain, sumpa kawalan ng kaluluwa,
mickrobyo)?

2. What are your cultural beliefs about the ideal body size and shape? What is the
patient’s self-image compared to the ideal?

Anu-ano ang inyong paniwalang cultural tungkol sa kanaisnais a katawan o hugis?

3. What name do you give to your health related condition?

Ano ang taway ninyo sa iyong kalagayan?

4. What do believe promotes health (eating certain foods; wearing amulets to bring
good luck; sleep; rest; good nutrition; exercise; prayer; rituals to ancestors saints,
or intermediate deities)?

Sa palagay ninyo ano po ang pamamaran upang makabuti and inyong kalusugan?
Kahgaya ng pagpili ng tamang pagkain, pagsuot ng anting-anting, pagbigayang
swerte, pagtulog, pagehersisyo, pagdadasal, agsamba sa mga santo?

5. What is your religious affiliation?)? How actively involved are you in the practice of
your religion?

Ano po and relihyon ninyo? Gaano kayo kaaktibo sa inat-ibang Gawain ng inyong
relihyon?

6. Do you rely on cultural healers? Who determines when you are sick and when you
are healthy? Who influences the choice/type of healer and treatment that should
be sought?

Naniniwala ba kayo sa mga hilot o albularyo? Sino and nagsasabi kung may sakit
kayo o wala. Sino ang namimili ng uri ng panggagamot/mangagamot?

7. What types of cultural practices do you patient engage or use (use of herbal
remedies, potions, massage, wearing of talisman, copper bracelets, or charms to
discourage evil spirits; healing rituals, incantations, prayers)?

Nong klase ng gawain or paniniwala and inyomg ginagamit o ginagawa (paggamit ng

mga gamut, gayuma, masahe, anting-anting, porselas, o mga alahas na nagtataboy
ng masamang espiritu, dasal)?

8. How do you perceive biomedical/scientific healthcare providers? How do you and

your family perceive nurses? What are your expectations of nurses and nursing
care?

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 Ano ang tingin ninyo sa mga nagbibigay ng syentipikong panggagamot? Ano ang
tingin ninyo at inyong pamilya sa mga narses? Ano ang inaasahan ninyo sa mga
nars at pamamaran ng pagalaga?

9. What comprises appropriate “sick role” behavior? Who determines what symptoms
constitute disease/illness? Who decides when you are no longer sick? Who cares for
for you at home?

Ano ang bumubuo ng tamang pag-aasal ng may sakit? Sino ang nagsasabi kung
ano ang sintomas ng inyong sakit? Sino ang nagdedesisyon kung may sakit ka o
wala na? Sino ang nag-aalaga sa iyo sa bahay?
10. How does your cultural group view mental disorders? Are there differences in
acceptable behaviors for physical versus psychological illnesses?

Ano ang tingin ng nyong grupo cultural sa mga taong may sakit sa pag-iisip? Ano
ang pagkakaiba ng phisikal ng paguugali sa pag-iisip ba karamdaman?

Source: Andrews, M. & Boyle, J. (2002b). Transcultural concepts in nursing care (4th
ed.). Philadelphia: Lippincott Williams & Wilkins.

Assessment questions revised and translated in Pilipino.

H. BARRIERS TO HEALTH CARE

In order for people to receive adequate health care, a number of considerations need to
be addressed.

Availability: Is the service available and at a time when needed? For ex.: No services
after 6:00 p.m.

Accessibility: Transportation services may not be available, or rivers and mountains

may make it difficult for people to obtain needed health-care services when no health
provider is available in their immediate region?

Affordability: The service is available, but the client does not have financial resources.

Appropriateness: Maternal and child services are available, but what might be needed
are geriatric and psychiatric services.

Accountability: Are health-care providers accountable for their own education and do
they learn about the cultures of the people they serve?

Adaptability: A mother brings her child to the clinic for an immunization. Can she get
a mammogram at the same time or must she make an appointment?

Acceptability: Are services and client education offered in a language preferred by the
client?

Awareness: Is the client aware that needed services exist in the community? The
service may be available, but if clients are not aware of it, the service will not be used.

Attitudes: Adverse subjective beliefs and attitudes from caregivers means that the
client will not return for needed services until the condition is more compromised. Do
health-care providers have negative attitudes about patients’ home-based traditional
practices?

Approachability: Do clients feel welcomed? Do health-care providers and

receptionists greet patients in the manner in which they prefer? This includes greeting
patients with their preferred names.

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 Alternative practices and practitioners: Do biomedical providers incorporate clients’
alternative or complementary practices into treatment plans?

Additional services: Are child and adult services available if a parent must bring
children or an aging parent to the appointment with them?

Source: Purnell, Larry D. & Betty J. Paulanka, op. cit. p. 35.

UNIT V. APPLICATION OF ORGANIZING CULTURAL

PHENOMENA TO PEOPLE
FROM DIFFERENT CULTURAL HERITAGE: AN
INTERACTIVE SESSION

INTERACTIVE SESSION IS AN OPPORTUNITY FOR THE STUDENT TO PRESENT:

52
 A. INDIVIDUALLY

Present and submit a “Search Paper” on a transcultural subject/phenomenon/issue/topic, or

about culturally based health-related beliefs and practices of people from diverse
backgrounds. You may search the internet or use any book or magazine as source material.
Credit Source.

 Search Paper must not be less than 3 pages long on 8 1/2 x 11 bond, double-spaced,
Font 12.
 Must be submitted on day of Midterm. No late papers will be accepted.
 You may be requested to provide a diskette of your paper.
 If time permits, you may be asked to read your “Search Paper” in class.

B. AS A GROUP MEMBER

Group report on application of Organizing Cultural Phenomena to Nursing Care in diverse

groups from Different Cultural Heritage.

A. People of Filipino Heritage

B. People of Japanese Heritage
C. People of Chinese Heritage
VII.People of Indian (Hindu) Heritage
VIII.People of Mexican Heritage
IX. People of Arabian Heritage
X. People of African-American Heritage
XI. People of Anglo-American Heritage
XII.People of Italian Heritage
XIII.People of Jewish Heritage

Group report must contain information given below.

I. SocialOrganization  Eye Contact

 Family:  Other
 Gender Roles V. Space
 Religion  Social Distance
 Others  Touch
II. Biological Variation VI. Time Orientation
 Dietary  Present oriented
Practices/Preferences  Past oriented
 Increased  Future oriented
Susceptibility to:  Flexible
III. Environmental Control VII. Cultural beliefs and
 Definition of Health practices across
 Causative Factors of lifespan
Illness VIII. Nursing Implication/s of the
IV. Communication different
 Language(s) cultural phenomena
 Silence described.

 You are encouraged to be as creative as possible. Make report concise.

 You are NOT TO READ YOUR REPORT in its entirety.
 Submit hard copy of report before or on the day of reporting.

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UNIT VI. Contemporary Challenges in Transcultural Nursing

A. TRANSCULTURAL ASPECTS OF PAIN

“Pain is whatever the experiencing person says it is, existing

whenever he says it does.”
McCafery (1979)

WHY IS THE SUBJECT OF PAIN A CHALLENGE IN CONTEMPORARY TRANSCULTURAL

NURSING?

1. Definition

Pain – an unpleasant sensory and emotional experience arising from actual or

potential tissue damage or described in terms of such damage.

U.S. Department of Health and

Human Services, 1992

Definitions of pain are diverse because of its complex nature and because of the
many different existing perspectives on pain.

2. Basic/Related Concepts

 Pain is a universally recognized phenomenon and the most frequent and

compelling reason for seeking health care.
 Pain is a very private experience and is influenced by cultural heritage.
 Thus, expectations, manifestations and management of pain are embedded in a
cultural context. Therefore, understanding culture is critical when dealing with
clients in pain.
 The experience of pain is determined by the:
 meaning of painful stimuli for individuals;
 way individuals define their situation; and,
 impact of previous personal experiences help determine the experience of
pain.

3. Measurement of Pain

In terms of pain measurement, it is generally believed that humans normally

experience similar pain thresholds. Research suggests that there are no differences
in the amount of stimulation needed to produce a detectable sensation.

Measurement of pain would differ in pain threshold, pain tolerance and

encouraged pain tolerance.

Pain Threshold – refers to the point at which the individual reports that a stimulus
is painful. For example, some people required higher intensities before describing the
stimuli as painful.

Pain Tolerance – is the point at which the individual withdraws or asks to have the
stimulus stopped. Cultural background appears to have a strong influence on pain
tolerance levels.

Examples from studies using radiant heat techniques in South African Americans,
Northern European Americans, Russian Jewish Americans, and Italian Americans.

 Northern European Americans – had the highest pain and pain reaction threshold
 Italian Americans – vocalized their pain
 African Americans – did not verbally express their pain

54
 Encouraged Pain Tolerance – is the amount of painful stimuli an individual accepts
when encouraged to tolerate increasingly higher levels of stimulation. Example:
North American Plains Indians – tolerate large amounts of
pain as described in Sun Dance “self-torture” ceremonies.

Nursing Implication:

Because many factors, aside from culture, play a role in pain perception, the nurse
should not expect all clients to react in the same way to painful stimuli.

4. Expressions of Pain

 Expressions of pain vary from culture to culture. What are appropriate verbal
behavior and body language in response to pain are dictated by culture.
Example: the Japanese culture does not approve of loud verbal expressions of
pain.
 Within each culture, expressions of pain may vary from person to person. How
people express their pain is strongly influenced by their level of assimilation and
acculturation.
 In relation to gender – men demonstrate greater stoicism than women. However,
stoicism decreases with increasing age. (Zatzick & Dimsdale, 1990)

Categories of responses:

a. Stoic – responses to pain are less expressive verbally and nonverbally. Some
reasons are:
 Denial of pain
 A desire to be the perfect patient
 Avoiding loss of control
 Avoiding worrying the family
 Fear of addiction
 Fear of overdose and side effects from pain medications
 Paying a price for past sins and future joys
 Acceptance of the pain

b. Emotive – responses are quite vocal and will express their pain loudly. Some
reasons are:
 Fear of the pain
 A desire for help and fear of not receiving it
 Anger
 Grief over loss of dignity
 Exorcism of the pain through the act of crying out
 Experiencing great pain

4. Questions on Cultural Attitude Toward Pain

CHARACTERISTIC QUESTIONS

Experience of pain How do we express pain?

Is it ok to show pain?
Is there a difference in how people in my culture
show pain (gender, age, married, poor/rich)?

Causes of pain What causes physical pain?

Does the evil eye cause pain?
Is pain a form of punishment? An opportunity
For reward in the afterlife? Or atonement?

Treatment of pain Does every pain justify relief?

What traditional and other healing methods are
used?

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 What is the impact of religion on treatment of pain?
Do you seek medical attention self-medicate?
What are the beliefs about using narcotics to treat
pain?

Values about pain What types of pain have stigma? Are people
avoided/marginalized?
Do people use pain to seek attention?
Source: http://tcn.sagepub.com

5. Applying Transcultural Nursing Concepts to People in Pain

 Respect clients as individuals

 Respect the client’s response to pain and their autonomy regarding choices
they make about pain control.
 Never stereotype a person based on culture
 Communicate openness, acceptance, and a willingness to listen to views of
client
 Seek the support of colleagues and health team members to assist you in
exploring culture-specific pain management strategies.

B. CULTURAL DISPARITIES IN HEALTH AND HEALTH CARE DELIVERY

1. Some factors that account for cultural disparities in the delivery of health care.
a. Minority groups. According to ANA (1998), minorities experience some
diseases at a much higher rate than white Americans.

 Cancer is the leading cause of death for Chinese and Vietnamese individuals.
 Vietnamese women suffer from cervical cancer at nearly 5x the rate of white
American women.
 Compared with the general population, Hispanics have a higher incidence of
cancer of the stomach, esophagus, pancreas, and cervix.
 African-Americans have a life expectancy that is six times shorter than the life
expectancy for white Americans.
 The Native American population has significant rates of diabetes, sudden
infant death syndrome, and congenital malformation.
 Overall Native Americans and Alaskan Native rates of diabetes, tuberculosis
fetal alcohol syndrome, alcohol-related morbidity and mortality, and suicide
exceed those of other racial and ethnic groups in the United States.
(Kavanagh et al., 1999, p. 10).

b. Vulnerable Populations

 As a result of societal changes more people are at risk for health problems.
As a result, many vulnerable populations are underserved because of the high
demand for services, lack of services, and limited availability and access to
services.
 Groups that are especially susceptible for health-related problems include the
poor, the homeless, migrant workers, abused individuals, the elderly,
pregnant adolescents, and people with std’s such as HIV/AIDS.

c. The Poor

 In every race and ethnic group there is a relationship between socioeconomic

status and health.
 Poverty affects health status and accessibility to health care services. Living in
poverty means being unable to meet the financial demands of basic living
expenses, such as food, shelter, and clothing.
 “Childhood poverty has long-lasting negative effect on one’s health. Children
in low-income families fare less well than children in more affluent families.”
(U.S. Bureau of the Census, 2000).

56
  The poor population has more complex health problems including a higher
incidence of chronic illness. (U.S. Bureau of the Census, 2000).
 The following high risk factors are related to lower income: (CDC, 1998)
• Higher prevalence with cigarette smoking
• Greater incidence of obesity
• Elevated blood pressure
• Sedentary lifestyle
• Less likely to be covered by health insurance
• Less likely to receive preventive health care services

Poor Production

Insufficient Salaries
Poor intellectual and Increased Sickness
physical development
Subsistence Economy

Poor economic Lack of Preventive

production Care
Lack of Potable Water

Important role of high Poor Nutrition

human reproduction High Cost of Health-
Care needs Poor and Densely
Populated Housing

High incidence of
illness

The Cycle of Poverty

d. The Homeless

In the U.S. it is estimated that 350,000 to 6 million people are homeless (Walker,
1998, p. 27).

Societal factors that contribute to homelessness are:

 Lack of affordable housing
 Increasingly stringent criteria for public assistance
 Decreased availability of social services
 Inadequate or lack of employment
 A history of psychological trauma
 Deinstitutionalization of clients from mental health facilities without
community support (such as half-way houses and group homes).

C. CULTURAL DIVERSITY IN THE WORKFORCE

1. The aspects of cultural diversity in the workforce:

 Race and ethnicity

The racial/ethnic diversity among registered nurses in the United States (1993)

RACE NO. OF REGISTERED

NURSES IN THE U.S.
BLACK (NON-HISPANIC) 90,600
HISPANIC 30,400
ASIAN/PACIFIC ISLANDER 76,000
AMERICAN INDIAN 10,000
ALASKAN NATIVE
GRADUATES OF FOREIGN PROGRAM 73,000

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  Sex – the net rate of growth between 1986 and 2000 in the U.S. labor force:

RACE % GROWTH IN U.S.

HISPANIC FEMALES 85%
ASIAN FEMALES 83%
HISPANIC MALES 68%
ASIAN MALES 61%
AFRICAN AMERICAN FEMALES 83%
AFRICAN AMERICAN MALES 24%
WHITE FEMALES 22%
WHITE MALES -9%

Source: Schwartz & Sullivan, 1993

2. The effects of multicultural healthcare workforce

a. Positive:
 Healthcare workers from diverse background bring a variety of experiences
and a wide range of knowledge to the health care setting
 They offer fresh ideas and different solutions to long- term problems.
 Foreign nurses can help American nurses understand and relate better to
patients who are also from diverse cultural backgrounds.

b. Negative:
 Cultural diversity in the workforce may produce serious barriers and conflicts.

3. Barriers/conflicts in the workforce

 Different cultural patterns and biases that affect the relationship between
physicians, nurses and ancillary personnel. Example: many male physicians from
the Middle East think of women as subservient and feel that they have the right
to shout at female nurses.

 Racism and prejudice that can undermine professional relationships. Three

types of racism:

a. Individual racism – Discrimination based on visible biological characteristics.

Example: black skin or the epicanthic fold of the eyelid in Asians.
b. Cultural racism – Occurs when an individual or institution claims that its
cultural heritage is superior to that of other individual institutions. Example:
During World War II, the Nazis claimed that their Aryan genetic and cultural
heritage was superior to the Jewish heritage. They justified persecution of the
Jews by convincing themselves that the Jews were an inferior people.
c. Institutional racism – Institutions (universities, businesses, hospitals, schools
of nursing) manipulate or tolerate policies that unfairly restrict the
opportunities of certain races, cultures, or groups. Example: At one time,
“black” people were not allowed to use the comfort room used by “white”
people, sit in the front row of transportation facilities, enroll their children in
universities, etc.
d. Bias and ethnocentrism – Whatever their cultural background, people have a
tendency to be biased toward their own cultural values and to feel that their
values are right and the values of others are wrong or not as good. Example:
“White” nurses are biased not only toward their own health care system but
also toward their learned values, such as cleanliness. Cleanliness is essential
to good health care. A nurse who finds that a child is dirty might translate her
observation into a value judgment that the mother is not practicing good
health practices.

 Clashes in values that arise between foreign nurses and nurses trained in the
United States. In a study of Philippine American nurses, the most important
finding was the theme of obligation to care that prevailed in all aspects o their
work (Spangler, 1992). This theme was expressed in 3 important ways:

58
 (1) Expressed seriousness and dedication to work;
(2) Attentiveness to the patients’ physical comfort; and,
(3) Respect and patience. Example of conflict: The theme of an obligation
to care reflected the Philippine American nurses’ strong belief that
bedside nursing is truly the core of nursing practice. This value
conflicts with the attitude of some American nurses that the physical
care of patient is devalued work with low prestige and should therefore
be delegated to ancillary personnel.

 Different perceptions of nursing responsibilities and patient care that are

based on different cultural values. Example: Unlike Western nurses, Asian
nurses tend to accept difficult assignments without complaint. They may also be
more willing to do what American nurses might consider demeaning (e.g.,
cleaning cabinets).

 Differences in time orientation. Cultural groups are either past, present, or

future oriented. American value future over the present, Southern blacks and
Puerto Ricans value the present over the future, and Mexican Americans value
the present. Example: People who work in the operating room must be both
future and present oriented. Surgical cases are scheduled ahead of time (future)
and health workers must abide by the calendar and clock, but once surgical
procedure begins, nurses must now switch to a present orientation)

 Language differences that result in serious miscommunications. Example: A

Filipino nurse who was temporarily assigned to an unfamiliar medical unit
transcribed a telephone order from a physician. The physician said: “Give
Johnson 50 mg. Demerol for pain. If she is still complaining of pain after an hour,
call me and I’ll increase the dosage.” When transcribing the order the nurse
missed the physician’s reference to the patient as a she, a common error among
Filipinos and other Asians. Mr. Johnson, who happened to be on the same ward
might have received the medication had another nurse not intervened and
questioned the order.

Source: Muniz & Luckmann, op. cit.

4. Promoting harmony in multicultural workplaces

 Identification of cultural values of the organization, institution, or agency

 Mission statement and policies about diversity
 Zero tolerance for discrimination
 Effective cross-cultural communication
 Skill with conflict resolution involving diversity
 Commitment to multiculturism at all levels of management

5. Strategies to promote effective cross-cultural communication in the multi-

cultural workplace.

STRATEGIES
1. Pronounce names correctly. When in doubt, ask the person for the correct
pronunciation.
2. Use proper titles of respect: “Doctor,” “Reverend,” “mister.” Be sure to ask for the
person’s permission to use his or her first name, or wait until you are given the
permission to do so.
3. Be aware of gender sensitivities. If uncertain about the marital stats of a woman or
her preferred title, it is best to refer to her as Ms. (pronounced mizz).
4. Be aware of subtle linguistic messages that may convey bias or inequality, for
example, referring to a white man as Mister while addressing a Black female by
her first name.
5. Refrain from Anglicizing or shortening a person’s given name without his or her
permission. For example, calling a Russian American “Mike” instead of Mikhael,
or shortening the Italian American Maria Rosa to Maria. The same principle
applies to the last name, or surname.
6. Call people by their proper names. Avoid slang such as “girl”, “boy”, “honey”,

59
 “dear”, “guy”, “fella”, “babe”, “chief”, “mama”, “sweetheart”, or similar terms.
7. Refrain from using slang, pejorative, or derogatory terms when referring to persons
ethnic, racial, or religious groups, and convey to all staff that this is a work
environment in which there is zero tolerance for the use of such language.
Violators should be counseled immediately.
8. Identify people by race, color, gender, and ethnic origin only when necessary and
appropriate.
9. Avoid using words and phrases that may be offensive to others. For example,
“culturally deprived” or culturally disadvantaged” imply inferiority, and “non-
White” implies that White is the normative standard.
10. Avoid clichés and platitudes such as “Some of my best friends are Mexicans” or “I
went to school with Blacks”.
11. Use language in communication that includes all staff rather than excludes some of
them.
12. Do not expect a staff member to know all other employees of his or her background
or to speak for them. They share ethnicity, not necessarily the same experience,
friendship, or beliefs.
13. Communications describing staff should pertain to their job skills, not their color,
age, sex, race, or national origin.
14. Refrain from telling stories or jokes demeaning to certain ethnic, racial, age, or
religious groups. Also avoid those pertaining to gender-related issues or persons
with physical or mental disabilities. Convey to all staff that there will be zero
tolerance for this inappropriate behavior. Violators should be counseled
immediately.
15. Avoid remarks that suggest to staff from diverse backgrounds that they should
consider themselves fortunate to be in the organization. Do not compare their
employment opportunities and conditions with those people in their country of
origin.
16. Remember that communication problems multiply in telephone communications
because important nonverbal cues are lost and accents may be difficult to interpret.
17. Provide staff with opportunities to explore diversity issues in their workplace, and
constructively resolve differences.
Source: Boyle and Andrews, 4th ed. op. cit., pp. 380, 398.

D. TRANSCULTURAL VALUES AND ETHICS

“The nurse…promotes an environment in which the values,

customs, and spiritual beliefs of the individuals are respected.”

International Council of Nurses, 1973.

Cultural values – are principles or standards that members of a cultural group share in
common.

1. Basic/Related Concepts

a. Accepting and respecting the values of patients from other cultures is the first
step toward successful transcultural communication.

b. Values have important functions:

 They provide people with a set of rules by which to govern their lives.
 They serve as a basis for attitudes, beliefs, and behavior.
 They help to guide actions and decisions
 They give direction to people’s lives and help them solve common problems.
 They influence how individuals perceive and react to other individuals.
 They help determine basic attitudes regarding personal, social and
philosophical issues.
 They reflect a person’s identity and provide a basis for self-evaluation.

c. Values differ from culture to culture. For example:

Examples of traditional Asian, Mainstream American, and Hispanic

values.

ASIAN VALUES AMERICAN VALUES HISPANIC VALUES

Group Individuality, independence Group

60
 Submission to authority Resistance to authority Submission to authority
Extended family Nuclear/blended family Extended family
Tradition Innovation Tradition
Respect for elders Emphasis on youth Respect for elders
Respect for the past Future orientation Present orientation
Conformity Competition Conformity
Fatalism Self-determination Fatalism
Acceptance /resignation Aggression/assertion Acceptance/resignation

d. Culture care values carry cultural care meanings. To provide congruent care the
nurse must understand that cultural values carry care meanings which influence
nurse-client interaction, provide useful information about the client’s expectations
of care, and influence the client’s sense of appropriate sick role behaviors, choice
of healers, views toward technology, and health-related beliefs and practices.

Examples of cultural values and culture care meanings and action modes
for selected groups.

CULTURAL VALUES CULTURAL CARE MEANINGS

AND ACTION MODES
ANGLO AMERICAN CULTURE
(MAINLY U.S. MIDDLE AND UPPER CLASSES) 1. Stress alleviation by
 Physical means
1. Individualism- focus on self-reliance  Emotional means
2. Independence and freedom 2. Personalized acts
3. Competition and achievement  doing special things
4. Materialism (things and money)  giving individual attention
5. Technology dependent 3. Self-reliance (individualism) by
6. Instant time and actions  reliance on self
7. Youth and beauty  reliance on self (self-care)
8. Equal sex rights  becoming as independent as
9. Leisure time highly valued possible
10. Reliance on scientific facts and numbers  reliance on technology
11. Less respect for authority 4. Health instruction
12. Generosity in time of crisis  teach us how “to do” this care for
self
 Give us the “medical” facts
MEXICAN AMERICAN CULTURE
1. Extended family valued 1. Succorance (direct family aid)
2. Interdependence with kin and social activities 2. Involvement with extended family
3. Patriarchal (machismo) 3. (“other care”)
4. Filial love/loving
4. Exact time less valued
5. Respect for authority
5. High respect for authority and the elderly
6. Mother as care decision maker
6. Religion valued (many Roman Catholics
7. Protective (external) male care
7. Native food for well-being
8. Acceptance of God’s will
8. Traditional folk-care healers for folk illnesses
9. Use of folk-care practices
9. Belief in hot/cold therapy
10. Healing with foods
11. Touching
HAITIAN AMERICAN CULTURE
1. Extended family as support system 1. Involve family for support (other care)
2. Religion – God’s will must prevail 2. Respect
3. Reliance on folk foods and treatments 3. Trust
4. Belief in hot/cold theory 4. Touching (body closeness)
5. Male decision makes and direct caregiver 5. Reassurance
6. Reliance on native language 6. Succorance
7. Spiritual Healing
8. Use of folk food, care rituals
9. Avoid evil eye and witches
10. Speak the language
AFRICAN AMERICAN CULTURE
1. Extended family networks 1. Concern for “my brother and sisters”
2. Religion valued (many are Baptists 2. Being involved
3. Interdependence with “Blacks” 3. Giving presence (physical)
4. Daily survival 4. Family support and get togethers”
5. Technology valued, e.g., radio, care 5. Touching appropriately
6. Folk (soul) foods 6. Reliance on folk home remedies
7. Folk healing modes 7. Rely on “Jesus to save us” with
prayers and songs
8. Music and physical activities
NORTH-AMERICAN INDIAN CULTURE
1. Harmony between land, people, and 1. Establishing harmony between
environment people and environment with
2. Reciprocity with Mother Earth reciprocity
3. Spiritual inspiration (spirit guidance) 2. Actively listening
4. Folk healers (shamans; the circle and four 3. Using periods of silence (“Great Spirit”
directions) guidance)

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 5. Practice culture rituals and taboos 4. Rhythmic timing (nature, land, and
6. Rhythmicity of life and nature people) in harmony
7. Authority of elder 5. Respect for native folk healers,
8. Pride in cultural heritage and “nations” careers, and curers (use of circle)
9. Respect and value for children 6. Maintaining reciprocity (replenish what
is taken from Mother Earth)

These findings were from the author’s (Leininger) transcultural nurse studies
(1970, 1984) and other transcultural nurse studies in the United States during
recent two decades. From M. M. Leininger (1991). Culture care diversity and
universality: A theory of nursing (pp. 355-357). New York:National League for
Nursing Press.

Sources: Andrews and Boyle, op. cit. 86-88.

Kozier, op. cit. 209.
Munoz, Cora and Joan Luckmann, Transcultural Communication in Nursing. 2nd
ed. C 2005, Delmar Learning. p. 24, 29.
Purnell, Lary D. and Betty J. Paulanka, Transculural Health Care, 2nd ed. 2003.
F.A. Davis Co.

2. Transcultural Assessment and Clarification of Values and Beliefs

Assessment of values and beliefs is a starting point in continuing dialogue to foster

mutual understanding among health care providers and recipients of care. This
assessment, though not exhaustive, encompasses cultural values and ethical issues
regarding health care delivery from the patient’s perspective.

TO THE CLIENT
The health care professionals assigned to care for you want to understand your values and
beliefs so they can deliver culturally relevant health care. Please assist them in better
understanding you by completing this form.
BACKGROUND INFORMATION
1. Where were you born?
2. How long have you lived in the ____________?
3. Did you receive any formal education in the __________? How much?
4. Where were your family members born? _____________

RELATIONSHIPS
5. Who are the decision makers in your family?
6. Who do you consider “family?”
7. Who do you want to make health care decisions for you?
8. In the event you cannot make health care decisions fo yourself, who would
you appoint to make these decisions for you?

COMMUNICATION
9. What language do you consider you “mother” tongue?
10. Do you read and write in your “mother” tongue?
11. In which language do you prefer you receive health information?

CULTURAL BONDS
12. What cultural traditions do you observe in your home?

RELIGIOUS AFFILIATION
13. Do you have a religious affiliation? If so, what is the affiliation?
14. Do your cultural or religious beliefs influence your attitude toward
prevention of illness? If so, how?
15. How would describe your health status?
16. Do you have any symptoms that require “healing?”
17. How long have you had these symptoms?
18. What “healing” strategies do you use to relieve these symptoms?
19. Do these symptoms affect your ability to work or fulfill other obligations?
20. During your course of treatment what cultural/religious beliefs would you
like us to consider?
OTHER
21. Is there anything else you would like to share with us that would help us
care for you in a more sensitive way?

62
 If clinically related to the diagnosis or chief complaint, it may be useful to collect data about
transplantation, organ donation, autopsy, blood transfusions, drugs containing alcohol of
caffeine, or foods that are taboo or prohibited.
Developed using data from Spector, R.E. (1996). Cultural Diversity in Health and
Illness (4th ed.). Stamford, CT: Appleton and Lange. In Andrews and Boyle, op. cit.
3rd ed. P. 448.
2. TRANSCULTURAL ETHICS

Ethics is a systematic philosophical method of inquiry that assists people in

understanding the morality (rightness or wrongness) of human behavior and social
policies.

1. Basic/Related Concepts

 Ethics also refers to the standards of behavior expected of professional groups as

described in their code of professional conduct.
 It is important for nurses to have a knowledge of ethics in order to develop an
ethical framework to guide their professional practice and to cope with unethical
uncertainties stemming from work with clients, their families, and colleagues.
 Ethical knowledge also prepares nurses to fully understand and participate in
multidisciplinary committees on bioethical issues.
 Ethical theories and principles are not universal in theory and application. Thus,
ethical conflicts may occur when applied transculturally. Example: Issue
surrounding informed consent, disclosure of diagnosis and prognosis, and
discussion of termination of treatments are reflections of Western cultural values.
In some cultures, particularly in Oriental or Eastern cultures, the approach is
different:
 In Oriental cultures like Japanese, Chinese, Pakistani, etc – the family
expects to be informed of bad news first, and then decides whether to
inform patient or not.
 Autonomy does not exist in numerous cultures. Decision/s regarding
health care are made in consultation with other family members.
 Ethical relativism views morality as relative to the community within which an
individual lives and the manner in which the individual was raised. When applied
transculturally ethical conflicts may arise. Example: Freedom of speech would
only be a moral value for cultures that believe in it. Therefore, moral values
are only right in sociocutural contexts that think they are right.
 The nurse and other health care professionals should be aware of existing ethical
theories and principles and their implications for care in a client’s lifeway, belief
system and health care practices. Two contrasting ethical theories come from the
East and West.

2. Overview of Western and Eastern Ethical Theories

 Western Ethical Theories – are based on European or American philosophies

and are influenced by Judeo-Christian belief systems.
 Review Western ethical theories – Utilitarianism, consequentialism,
character ethics, ethic of care, situation ethics, ethical relativism, natural
law ethics, etc.
 Review ethical principles: autonomy, beneficence, nonmaleficence justice,
veracity, fidelity, etc.

 Eastern Ethical Theories

During the 6th B.C. two philosophical systems developed in China – Confucianism
and Taoism. The theories developed in these systems are based on Asian/Indian
philosophies and may also be influenced by religious beliefs. The theories serve
as ethical guidelines for living.

Confucianism
 All teachings of this theory emphasize human relations.
 Emphasizes the virtues of: Righteousness (yi) and Benevolence (yen).

63
  This virtue combines all virtues and is considered “perfect virtue”.
 Another aspect of benevolence is Shu, which stresses treating others as
we would want to be treated.
 This theory views humans as essentially social creatures.
 Humans are bound together by jen, that is, sympathy, human-
heartedness, or loving others.
 Jen is expressed through five relations:
 Sovereign and subject
 Parent and Child
 Elder/Younger/Brother
 Husband and Wife
 Friend and Friend
 Rituals and etiquette help these relations function smoothly.
 Correct conduct proceeds through a sense of virtue developed by
observing appropriate models of ethical conduct.
 The standards of conduct come from within a person.
 If after thoughtful consideration a person finds an action morally
acceptable, that person should act without any hesitation.

Taoism - This philosophical system developed in china during the 6th B.C.
 Taoism is concerned with the origin and meaning of life.
 This system believes that human happiness is achieved in following the
natural order.
 It emphasizes trusting in one’s intuitive knowledge.
 Taoism focuses on the observation of nature in order to discover the
“characteristic of the Tao”, or the way of life knowledge.
 Taoism focuses on the observation of nature to discover the way of life,
whereas Confucianism focuses on man and values, social conventions and
rituals.
Source: Andrews and Boyle, 3rd ed. pp. 444-456.

3. Culturally Competent Model of Ethical-Decision Making

The model for ethical decision-making, was drawn from Mann’s human right’s model
and Leininger’s culturally congruent theory.

 It affirms the fundamental rights of individuals, families, groups, and populations

to health care that is meaningful, supportive, and beneficial.
 It is predicated on the basic human right of respect for diversity of values and
assumptions about life transitions and events.
 It is based on the principle that caring preserves human rights and dignity.

SOCIETY

PROFESSION

ORGANIZATION

HUMAN RIGHTS HUMAN RIGHTS

PATIENTS FAMILIES

CA CR
CP
CA CR

CP 64
 CA – Cultural Accomodation
CP – Cultural Preservation
CR –Cultural Repatterning

Culturally Competent Model of Ethical Decision Making

GUIDE FOR USING THE CULTURALLY COMPETENT MODEL

1. ASSESSMENT

Client/families Ethnohistory
Concepts of the human body and soul
Meaning of life, pain, suffering, and death
Caring values, patterns, and expressions
Social organization
Established social hierarchy
Roles and obligations of family members and kin
Differential acculturation of family/group members
Family and community resources
Cultural gatekeepers and brokers in the community
Communication norms and linguistic patterns
Experience with professional health care

Organizational cultural Staff cultural knowledge and skills

Variables Conflicting values between staff and patient/ family/
group
Conflicting values among care providers
Cultural expertise available
Policies and procedures
Flexibility in accommodating cultural differences
Material resources available

Determination of Legal mandates

professional and Regulatory requirements
societal services Impact of decisions on other patients and self
Professional code of ethics

2. PLANNING

Establish relationship with client/s/families/communities

Define problems and priorities that reflect the emic perspectives of client/s
Determine material and personnel resources needed
Determine aspects of action plans that need to be negotiated with participants

3. INTERVENTION

Cultural care preservation or maintenance

Cultural care accommodation or negotiation
Cultural care repatterning or restructuring

4. EVALUATION

Allow clients/families to identify outcomes and indices for achievement

Differentiate culturally meaningful from biomedical outcomes
Validate outcomes achievement with clients/families

Source: Andrews and Boyle, op. cit. p. 525.

65
3. TRANSCULTURAL CARE PRINCIPLES, HUMAN RIGHTS AND ETHICAL
CONSIDERATIONS

1. Human beings of any culture in the world have a right to have their cultural care
values known, respected and appropriately used in nursing and other health care
services.
2. Human cultures have diverse and universal modes of caring and healing practices
that need to be recognized and used by professional nurses to function effectively
and therapeutically with people of different cultures.
3. Care is the essence of nursing and a basic human need for growth, well-being,
recovery, and survival.
4. Cultural care is a critical component influencing health, well-being, and recovery from
illness or disabilities.
5. Every culture has at least two major types of health care systems namely, the folk
(generic, lay or indigenous) care system and the professional care system which
influences their health outcomes, and the transcultural nurse is challenged to use
this knowledge to guide nursing care decisions and actions.
6. All professional nurses are challenged to respect common humanistic aspects of
people worldwide, and also the divergent care expressions, meaning, and practices.
7. Transcultural nurses are expected to respect Western and non-Western cultures who
often have different values, beliefs, and norms to assess and understand human
beings.
8. Transcultural nursing principles and practices are the arching framework for all
nursing care practices which differ from nursing practices that rely on traditional
medical symptoms diseases and treatment regimes.
9. Since transcultural nursing focuses upon comparative cultural care values, beliefs
and practices of cultures, the nurse is expected to work with individuals, families,
groups, cultures, subcultures and institutions that reflect cultural care variables.
10. Nurses with transcultural knowledge are expected to respond appropriately to culture
care differences and similarities in order to ease or ameliorate a human condition or
lifeway, and to help clients face death.
11. Ethical and moral differences and similarities exist among human cultures which
necessitates that nurses recognize, respect, and respond appropriately to such
variables.
12. It is essential that transcultural nurses be open-minded and willing to learn from
cultural informants about their human values, beliefs, needs and practices in order to
make appropriate nursing care plans, judgments and actions.
13. The ability of the nurse to listen, use silence and envision the client’s or family’s
human condition or cultural circumstance with its positive or less positive
features is important in transcultural nursing.
14. Transcultural nursing often requires that nurses communicate with clients in their
native language to know, learn, and understand individuals, families and groups
of different cultures.
15. Transcultural nurses are challenged to identify what constitutes ethical or moral
principles and norms of cultures and not assume that all cultures are alike.
16. Transcultural nurses are expected to guide other nurses who have not been
prepared in transcultural nursing in order to prevent marked ethnocentricism,
cultural imposition practices and inappropriate ethical and moral judgments about
clients.
17. Transcultural nursing reflects that an individual or group of a designated culture are
active participants and decision-makers in culture care practices in order to develop
and maintain creative and effective professional care practices.
18. Clients of diverse or similar culture have a right to have their caring life styles and
expressions known and used in transcultural nursing in order to promote client health
or well-being,
19. Transcultural nursing takes into account the world view, environmental context
ethnohistory, social structure features (including the religious, kinship philosophic
economic, political, technological and cultural values) language, expressions, gender
and age difference of people.
20. Transcultural nursing is concerned with the assessment of caregiver and care-
receiver expressions, beliefs and lifeways that often go beyond nurse-client dyadic

66
 relationship to that of care relationships with families, groups, institutions and
communities in order to facilitate congruent care practices and to avoid unfavorable
care conflicts stress and negligent care practices.
21. Since ethical, moral and legal systems of human values and rights exist in all
cultures, it is the task and responsibility of transcultural nurses to discover these
dimensions with key and general informants and in diverse cultural contexts.
22. Human care rights tend to be covert and embedded in social structure, cultural
values and world view of clients, and so the transcultural nurse is challenged to
discover these dimensions mainly through qualitative research methods.
23. Transcultural nurses recognize that culture is complex, dynamic and change over
time and in varying ways.
24. Transcultural nurses recognize that many cultures and subcultures in the world have
not been studied and yet nurses are expected to care or all peoples including
minorities.
25. Transcultural nursing is a major breakthrough for new nursing knowledge and
practices that do not follow the traditional nursing or medical disease, symptom and
illness models.

Source: Leininger, M. (1991) Journal of Transcultural Nursing, 3, 21-23, as printed in

Ethics and Issues in Contemporary Nursing by Margaret A. Burkhardt and Alvita K.
Nathaniel. 2nd ed. Thomson Asian Edition. pp. 341-342.

67
 CULTURAL HERITAGE – A SUMMARY

I. FILIPINO HERITAGE

A. OVERVIEW
 Location – in Southeast Asia, surrounded by the South China Sea, Celebes Sea, Philippine Sea, and the
Sulu Sea.
 Composed of 7,107 islands; 3 major islands: Luzon, Visayas, Mindanao
 Negritos – earliest known settlers. Successive foreign invasions by the Chinese, Arabian, Indian Spanish,
American, and Japanese.
 Filipino culture - “Filipino blend” from mixture of different languages, traditions and religions has resulted
in “identity crisis.”
 Weather – tropical; hot and dry during summer months,
Wet and humid during monsoon season July to December
 Population – 87,857473 (2006)

B. BIOLOGICAL VARIATION
 Body built and structure – short to medium built; small thoracic capacity, eyes set in almond shaped
eyelids, mildly flared nostrils, slightly low to flat nose bridges.
 Skin color – of Malay stock (brown complexion) light to fair complexion – resulting from intermarriage
with foreigners
 Hair – black, very curly or kinky (Negritos); straight
 Enzymatic and genetic variations
o Blood type “B” – 40%; low incidence of Rh-negative factor
o As with other Asians, Filipinos have lower tolerance for alcohol but are more sensitive to its
adverse effects.
o lactose intolerance
 Nutritional variations
o Food more than nourishment for the body; it is a fundamental form of socialization
o Rice – staple food; although known to be carnivores, fish and seafood forms bulk of Filipino diet.
o Regional cooking variations; in Manila – a variety of food preparations – Pilipino, Chinese,
Spanish, Japanese. fast-food catching on
o Traditional 3 meals a day with merienda
o Milk almost absent in Filipino diet
o Malnutrition especially among the poor and less educated; one of the 10 leading cause of infant
mortality

C. SOCIAL ORGANIZATION
 Strong family attachment =nuclear +extended family
 Traditionally patriarchal, but now egalitarian - tendency is for husband and wife to share in decision
making, disciplining and finances
 Filipino women enjoy better status in society than their Asian counterpart, e.g. women working outside the
home, decision-making and social and political movers, more women now occupy managerial or
administrative positions as CEO’s, COO’s
 Values orientation is characterized by a deep sense of personal indebtedness (utang na loob) and loyalty to
kin which carries an obligation to repay or perform service to another; hospitality, community togetherness
(bayanihan).

D. RELIGION
 Predominantly Christians – majority of which are Catholics (83%), 9% Protestant, 5% Muslim, and 3%
Buddhist and other religions.
 Novenas and prayers are often said on behalf of sick persons
 Rosaries, medals, scapulars and talismans are often worn by the sick

68
  Source of strength found in religion - intimate relationship with God, The expression Bahala na (it is up to
God) points to a higher power to take care of the rest when almost everything fails.

E. COMMUNICATION
 Tagalog – national language;
 87 languages and 111 dialects
 Third largest English speaking country following US and UK.
 Silence – may imply “yes,” “no” or don’t know May also convey emotional expressions of disgust, anger,
resentment.
 Eye contact – eyes may convey many messages as shown by eye rolling up and down, squinting, eyes
popping to show surprise
 Telecommunication literate especially in Manila. Availability of newspapers, local and foreign publications,
TV, landline and mobile phones. Philippines has been dubbed the “Texting capital of the world.”
 Touch – Filipinos are a warm people, affection usually expressed by touching and embracing. Rural folks
are more conservative
 Though known to be shy and non-aggressive, as nurses they are known to be dedicated, patient, respectful,
and attentive to the needs of their patient
 Use of words to show respect like Manong, Manang, “oho”, “opo”
F. SPACE
 In poor families, space is limited and family members all live and sleep together.
 As they are family-oriented, they do not perceive the family as invasive in personal space parameters.
G. TIME ORIENTATION
 Past oriented – respect for elderly wisdom, familial closeness and honoring dead ancestors
 Future oriented – parents conscious of sacrificing and saving for the future of their children
 Poor observers of punctuality

H. ENVIRONMENTAL CONTROL
 Health care beliefs and practices
o Many still believe in the magico-religious (witchcraft, soul loss, soul intrusion, evil eye) predominantly
in areas far from hospitals, clinics and professionally trained health care givers.
o Many health beliefs
o Intimate circle of family largely influence decisions about when, where, and from whom to seek help.
o The ethical principles of beneficence and nonmaleficence take precedence over patient autonomy.
Before a decision is made to inform the patient about his or her terminal condition, a discussion among
family members occurs, and they may request the doctor not to divulge the truth to protect the patient.
o Major decision maker – doctor more than patient or family members

 Health/healing practitioners
o Use of folk practitioners like
• Hilot – in rural areas hilot ambiguously refers to both the midwife (magpapaanak) and the
chiropractic practitioner (manghihilot, masahe).
• mangihihilot-manipulation and massage for the diagnosis and treatment of
musculoligamentous and musculoskeletal ailments
• albularyo-are general practictioners, usually with a history of healer in the family-line and
their healing considered a “calling”, a power bestowed by a supernatural being. Their
treatment modalities: tapal, lunas, kudlit, pang-kontra, bulon, otasyon
• manglulop
• manghihila
• mantatawas
• spiritista; faith healers
o Western medicine familiar and acceptable to most Filipinos
o Increase in use of integrative or alternative health practitioners noted
 Health Census
a. Ten leading causes of mortality (2007)
1. Heart diseases
2. Vascular system diseases
3. Accidents
4. Pneumonia
5. Tuberculosis
6. Diabetes
7. CVA/stroke

69
 8. Chronic lower respiratory diseases
9. Liver cirrhosis
10. Prenatal conditions
Source: -http://emeritus.blogspot.com/2007/07/Philippines-top-ten-causes-of-mortalitty.html.

b. Ten leading cases of morbidity (2007)

1. Malaria
2. Diarrhea
3. Pneumonia
4. Hypertension
5. Influenza
6. Sepsis
7. Bronchitis
8. Tuberculosis
9. Chickenpox
10. Measles
Source: -http://www.nationmaster.com/discussion/country/rp/Health

II. JAPANESE HERITAGE

A. OVERVIEW
 Location – lies off the east coast of Asia and entirely within the temperate zone.
 Land area – 142,727 sq. miles
 Population – 127,417244 (Time Almanac 2006)
 Environmental risks –Japan is subject to intense crustal movements and violent earthquakes and volcanic
activity.

B. BIOLOGICAL VARIATION
 Body built and structure – short to medium height, rarely tall; medium built. Japanese are rarely obese
 Skin color – white to fair in complexion
 Enzymatic and genetic variations
o Lactose intolerance - inability to digest lactose from milk attributed to inadequate production of/or defect in
the enzyme lactase. Calcium is supplied in tofu small, unboned fish
o Rise in obesity, diabetes, heart disease, and premature death associated with increasingly Westernized food
tastes that are higher in fat and carbohydrate content than traditional Japanese food.
o High rate of CVA attributed to sodium content of traditional soups and sauces.

 Nutritional variations
o All food groups are well-represented
o Staple food - rice or gohan. Other foods include miso, nori, fish, pickles, ramen (noodles) vegetables,
soybean cake/curd, pork seasoned with mirin (sweet sake)
o Holidays and family celebrations are times for ritual use of food
o Japanese use chopsticks to eat, meals often eaten on a tatami mat around a low table.
o Widely used for their medicinal properties: green tea, Vitamin C, garlic and various herbs
o Dietary therapy recommends eating seasonal foods and balancing foods from land, sea and mountain
o Proper food combination takes into account the yin/yang properties of food.

C. SOCIAL ORGANIZATION
 Family roles – nuclear family structure
 Marriage – Love not highly valued as a prerequisite for a successful marriage.
 Motivation – to fulfill societal expectations than desire for spousal companionship
 Children’s organization – is family’s paramount concern. Primary relationship is between mother-
child, particularly between mother and son.
 Socialization process – children socialized to study hard, make their best effort, and be good group
members. Self-expression is not valued.
 Girls are taught to take care of boys.
 Traditional Japanese arts as tea ceremony, ikebana, bonsai, kimono wearing, calligraphy, doll making,
etc. diligently studied by women.
 Small size of women of “the floating world” or entertainment industry (Geisha) live outside constraints
of home and gender and enjoy a fair amount to autonomy.

D. RELIGION
 Dominant religions: Shintoism - 110 million
Buddhism – 90 million

70
  Other religions – Confucianism, Christianity
 No strong religious feelings but rather a strong commitment to ancestral traditions like ancestral
worship and ceremonies as births, weddings and funerals.

E. COMMUNICATION
 Illiteracy is nearly zero
 High school graduates complete 6 years of English
 Use of language is distinguished by many levels of formality and directness depending upon the status
of the people who are conversing
 Bowing is an expression of respect and courtesy for elders. Different levels of bowing dependent upon
socio-political status of person
 Handshake – an appropriate form of meeting and greeting.
 Laughter may mean embarrassment or discomfort.
 Eye contact – Direct eye contact may be avoided.
o Prolonged eye contact (staring) is not polite even within families.
 Touch – The Japanese don’t like touching.
o Social touching occurs among group members but not among people who are less closely
acquainted.
o Men do not engage in backslapping or other forms of touching.
 Gestures – avoid expansive arm and hand movements, dramatic or unusual facial expressions.
o Pointing with less than the whole hand is impolite.
o Moving the open hand with palm facing left in a fanning motion in front of one’s face indicates a
negative response
 Silence - a natural and expected form of non-verbal communication.
o Pain is borne in silence.
o Considered inappropriate to yell out during labor as this brings shame to family. Grunting is
encouraged rather than screaming and yelling.
F. SPACE
 Body space is respected.
 Public kissing is criticized. Showing affection such as hugging or shoulder slapping should be avoided
in public.
 Intimate behavior in the presence of others is taboo.

G. TIME ORIENTATION
 Past - future- present oriented: They cherish their history as they will direct future generations as to
how their society evolved so that they will appreciate where they are now.

H. ENVIRONMENTAL CONTROL
 Health care beliefs and practices
o Japanese medicine borrowed from Chinese medicine the concepts of yin and yang, and the
concept of ki(energy)
o Cleanliness and purity are seen as the keys to health alongside correct eating, behavior, respiration,
exercise and spiritual devotion. The Japanese also attribute their generally high level of well-being
to their traditional daily bath in neck-deep water, at temperature of 105F.
o Exposure to the beauty of nature considered important for attaining calmness and serenity.
o Energetic healing through massage or shiatsu (reflexology)
o Reiki – a Japanese form of therapy based on the belief that when spiritual energy is channeled
through a practitioner, the patient’s spirit is healed and this in turn heals the body.
o Shiatsu – a form of massage that uses thumb pressure along the energy meridians in the body
o Herbal medicine (kanpo)
o Macrobiotic diet – a form of vegetarian diet that consists of balancing yin and yang energies of
food.
 Health care practitioners
o Traditional health practitioners – diet, herbs, energetics
o Allopathic physician
 Mortality and morbidity
o Leading causes of death: cancer, heart disease, stroke, pneumonia, accidents, liver disease,
diabetes, hypertension (related to high sodium diet) tuberculosis.
o Asthma – related to dust mites in tatami straw mats and air pollution in urban areas

III. CHINESE HERITAGE

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A. OVERVIEW
 Location - East Asia. One of the world’s oldest civilization dating back more than six millennia.
 The last Chinese Civil War produced two political entities using the name China:
• the People’s Republic of China (PRC)- comprising mainland China, Hong Kong and
Macau, and
• the Republic of China (ROC) administering Taiwan and its surrounding islands.
 Population – 1,306,313,812 (TIME Almanac 2006)
B. BIOLOGICAL VARIATION
 Body built and structure
o Generally small in stature but some can get over 6 ft. tall, small slanted eyes, thick and straight hair,
and a flat face.
 Skin color
o May vary; many skin colors similar to Westerners with pink undertone, yellow tones, and others very
dark
o Chinese men do not have facial hair. Hair color is black
 Enzymatic and genetic variations
o Thalassemia –– an inherited disease of the RBC classified as hemoglobinopathy. The genetic defect
results in synthesis of an abnormal hemoglobin molecule. The blood cells are vulnerable to
mechanical injury and die easily. People with thalassemia need blood transfusion at regular intervals
to survive.
o Lactose intolerance (90%). Condition gives rise to higher risk of osteoporosis.
o Higher prevalence of insulin autoimmune syndrome characterized by spontaneous hypoglycemia
o Hantavirus (HVD) characterized by flu-like symptoms, fever, headache, hemorrhagic manifestations,
shock and renal failure. Spread via rodent excreta.
o Diverticulosis or inflammatory bowel disease (IDS) are uncommon due to high intake of vegetables
and high fiber food.
o Hypertension leading CV risk factor due too frequent consumption of salty and spicy food
o Deficiencies associated with food - rickets, goiter, and anemia
o Tobacco consumption – major problem in rural China giving rise to increased incidence of lung
disease.
o Tuberculosis and Hepatitis B among Chinese immigrants due to overcrowding, malnutrition, and
unsanitary conditions
 Nutritional variations
o Food meals have specific orders with focus on the balance for a healthy body.
o Traditional Chinese medicine (TCM) uses food and food derivatives to prevent and cure disease.
o Foods are also classified as yin (cold) or yang (hot) and a proper balance is required to maintain health.
o Chinese daily meal consists of four food groups: grains, vegetables, fruit and meat.
o Regional cuisine - food depends upon weather conditions: Szechuan (cold weather), food is hot and
spicy; Fujian, a seaport, sea foods are plentiful
o Usual desserts – sliced fruit and bean curd

C. SOCIAL ORGANIZATION
 Confucianism – plays a very important role in forming Chinese character and behavior. Its purpose is to
achieve harmony, considered the most important social value. Confucianism prescribes well-defined roles
and acting in a proper way to achieve harmony. There are 5 cardinal relations: sovereign-subject, father-
son, elder- younger brother, husband-wife, and friend-friend. Family unit is the center and comes before
the individual. There is no Chinese equivalent for the word “self.”
o Extended family – relatives expected to help each other; filial loyalty very strong. Elderly are viewed
as very wise
o Father –the undisputed head of the family.
o Male dominance fathers, sons and uncles assume very important roles in family and business. With
regards to filial piety, sons, especially the eldest son, have specific obligations towards the family and
are expected to respect and care for parents.
o Son preferred to daughter
o Female gender – perpetuated to ensure male dominance in a society, female feticide common
Traditional role of women – to maintain a happy and efficient home
 “Me” generation – new and changing orientation of young, educated Chinese men and women.
Quotation by Wang Ning, 27, Advertising Company owner, “We are more self-centered. We live for
ourselves, and that’s good. We contribute to the economy. That’s our power.”(TIME magazine, August 6,
2007, pp. 24-27).

D. RELIGION

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  Primary religions:
o Buddhism – a religious movement which originated in India. Religious precepts of the Buddha make
up the tenets of this religion.
o Taoism (Lao Tsu) – 20 million followers mostly in Taiwan. “Tao” or “The Way” – refers to the
ultimate being or ultimate truth, the power which envelopes, surrounds and flows through all things,
living and non-living. It regulates the natural processes and nourishes balance in the Universe and
embodies the harmony of opposites, no love without hate, no light without dark, no male without
female.
o Confucianism – named after the great Chinese emperor. Emphasis is on governance and family
relations.

E. COMMUNICATION
 Language – Mandarin official language of China spoken by 70% of the population
o Other dialects: 10: Cantonese, Fujianese, Shanghainese,Taoishanese, and Hunanese
o They speak in a moderate to low voice although many times they sound loud.
 Silence – is held in high regard in China. They want to contemplate without interruption.
o They avoid disagreeing or criticizing, especially in public.
 Smile – they appreciate smiles when talking with others
 Touching – Chinese generally not a touching society especially with visitors. Hence, health care workers
must know the meaning of touch.
o Non-family members should not touch the head of a child, especially an adult, as head is traditionally
considered sacred.
o By family members, patting gently on the shoulder or cheek shows affection for children
o Friendship by the same sex – handholding or walking arm in arm.
o Using feet t move objects, such as chairs or doors, are considered disrespectful to others.
 Distance – they maintain a formal distance from each other, which is a form of respect
 Eye contact – uncomfortable with face-to-face communication especially when there is direct eye contact
o Excessive eye contact may indicate impoliteness and rudeness, even threatening
 Gestures – More reserved, gestures expressing emotions are comparatively less expressive.
o To show special respect, a slight bow may be given to the elderly or to government officials.
o The whole open palm should be used in pointing rather than the index finger.
o Beckoning to people should be done with the palm facing done instead of up.
o Handshake – common greeting when meeting for the first time.
 Emotional display – no public display of affection but open and demonstrative among family and friends
 Addressed by their whole name or by their family name and title. To health care providers ask the person
how they wish to be called.

F. SPACE
 Group interaction – facing each other directly, being closer, touching more, eye contact, and speaking more
loudly
 Non-contact – Body position while sitting/standing can be side by side or right angle arrangement because
they feel uncomfortable facing each other.

G.TIME ORIENTATION
 Chinese perception of time is different, neither past, present or future oriented.
 Time is perceived as a dynamic wheel with circular movements and the present as a reflection of the
eternal. The wheel continually turns in an unforeseeable direction and individuals are expected to adjust to
the present, which surrounds the rotating wheel, and seek harmonious relationship with their surroundings.
 Time concept is described as polychromic and Westerners as monochromic.
 Polychronic time orientation adheres less rigidly to time as a distinct and linear entity, focuses on
completion of the present, and often implements one activity at a time.
 Monochronic orientation to time emphasizes schedules, promptness, standardization of activities and
synchronization with clocks.

I. ENVIRONMENTAL CONTROL

 Philosophical belief - Many Chinese subscribe to fatalism, accepting things as they come.
o The body as an energy system – ancient belief that the body is an energy system of opposing
forces of yin (negative energy, female, inactive cold) and yang ( positive energy, male, active,
hot) .
o Every aspect of the universe is a constant interplay of yin and yang.

 HEALTH BELIEFS

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 o Illness results from an imbalance of yin and yang. Proper balance is required to maintain health
and treatments are geared to this end.
o Chinese believe in feng shui (meaning wind and water) which refers to art of location, orientation
and design of physical structures in an effort to achieve harmony and balance.
o Positive feng shui wards of evil spirits and promotes good health and prosperity.
o Belief in colors and numbers. White is considered bad luck, red good luck. 8 is considered a
lucky number and 4 extremely unlucky as 4(si) when pronounced the same as the word death in
Chinese.
 HEALING PRACTICES
o Belief in Traditional Chinese Medicine (TCM) and its practices remain strong.
o Acupuncture – insertion of an ultra-fine needing into meridian points or pathways of energy (chi)
to balance energy
o Cupping – heated cups to rduce stress, congestion and colds
o Herbology – use of herbs and medicinal plants to stimulate chi.
o Qi jong – combines body movements, meditation, regulation of breathing to enhance the flow of
chi and improve the circulation and enhance the immune system.
o Meditation to relieve stress

 HEALTH CARE PRACTIONERS

o Acupuncturist
o Herbologist

IV. INDIAN HERITAGE

A. OVERVIEW
 Location – in S Asia, south of the Himalayas, including a large peninsula between te Arabian Sea and the
Bay of Bengal
 1,177,000 sq.mil.
 Population - 1,080,264,388 (TIME Almanac 2006)
B. BIOLOGICAL VARIATION
 Body built and structure – varies according to racial strain (6): Mediterranean strain, Broad-headed strain,
Nordic strain, Mongoloid strain, Negritos, and Proto-Australoids
 Skin color – varies according to racial strain; light to dark brown
 Enzymatic and genetic variations
o Thallasemia, G-6-PD, lactose intolerance (2)
o Susceptibility to diseases: heat stress, food or waterborne diseases: bacterial diarrhea, hepatitis A
and E, typhoid fever, vector borne diseases: dengue fever, malaria, encephalitis, rabies, mental
illness
 Nutritional variations
o Indian cuisine has been designed by the medicine men of old, in contrast to Western cuisine,
which is designed by creative chefs.
o Most Hindus are vegetarians – diet consisting primarily of grains and legumes, vegetables
o Non-vegetarian diet includes different kinds of meat except beef as the cow is considered a
sacred animal
o Rice (in the North), different kinds of bread (in the South) like chapatti, puri,naan, paratha
o A healthy and balanced diet which involves a combination of the six main tastes:
sweet - ex: sugarcane, breads, pasta
sour - acidic: yoghurt, lemon
salty - salt and alkalis – rock salt, sea salt
pungent -acrid, often aromatic – ginger, chili, hot peppers,
bitter - neem, bitter melon, fenugreek
astringent - constricting quality – beans, lentils, pomegranate
o Eating utensil: use of right hand for eating, never left hand as it is used for hygiene and
toileting

C. SOCIAL ORGANIZATION
 Extended - family structure living together as a single family unit, usually composed of grandparents,
parents, children, may include families of parental uncles.
 Respect is highly valued; touching the feet of the elderly
 Gender roles
o Men –dominant and authoritative role because they are the point of contact with society
o Women – passive role; manage the home, keeping all finances, family and social issues in
order.

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  Caste system – is the world’s longest surviving social hierarchy. A person is considered a member of
the case into which he or she is born and remains within that caste until death, although the particular
ranking of that cate may vary from region to region. The caste categories are: the Brahmins (priests
and teachers), the Ksyatriyas (rulers and soldiers), the Vaisyas (merchants and traders), and the Sudras
(laborers and artisans). A fifth category consists of the “untouchables” or Dulits, who are often
assigned tasks too ritually polluting to merit inclusion within the traditional caste system.

D. COMMUNICATION
 National language – Hindi (40% of population)
 Second language – English
 Use of head movements and hand gestures during conversation
 Silence – to show respect
 Eye contact – men maintain eye contact with each other while conversing, while women look
downward when talking to their husband, grandfather and father to show respect.
 Touching – Public display of affection and touching among relatives, friends and acquaintances
are socially not acceptable in Hindu culture.
o Show of affection is private but not in the view of children or elders.

E. SPACE
 In poor families, space is limited and family members all live and sleep together.
 As they are family-oriented, they do not perceive the family as invasive in personal space
parameters.

F. TIME ORIENTATION
 Past oriented – importance paid to traditions and rituals that are inherent to their culture
 Present oriented – because they view that individuals are continuously in the process of
“becoming.”
 Future oriented – because life in the present is lived with an emphasis on the hereafter.

G. RELIGION
 Hinduism – dominant religion; about 83% of total population
Religious tenets of Hinduism:
o aims for freedom from endless reincarnation and suffering from bad karma
o belief in Dharma – a code of conduct that secures human happiness, contentment and saves
from suffering and degradation
 Other religions: Buddhism, Sikhism, Jainism
 Islam – practiced by approx. 13.4% of all Indians
 Christianity, Zoroasterianism, Judaism, Baha’I Faith – small number
H. ENVIRONMENTAL CONTROL
 HEALTH BELIEFS
o Health reflects living in total harmony with nature
o Illness is an external event or misfortune; karmic
o Good health and illness – may be karmic in origin
o Body consists of 5 elements (earth, water, fire, wind, space). Health is achieved when there is
a balance of the elements; illness results from an excess or deficiency of one of the elements.
Environmental factors affecting illness:
o air pollution
o water pollution from raw sewage, agricultural pesticides, untreated water
o huge growing population that overstrain natural resources
o lifestyle, climatic factors
 HEALING PRACTICES
o Ayurveda (Science of Life) - 30000 BC, said to be the oldest most complete medical system
in the world. Its sources are the Atharva Veda and the Samhitas with
comprehensive treatises on health-care and medical procedures.
o Ayurveda system of natural healing involves the totality of life and the whole human being
and its relationship with the environment.
o Ayurvedic treatments involves a process of detoxification or cleansing and purification known
as Pancharma Treatments through fasting, massage application of oily herbal preparation,
ingestion of herbal oils and pills.
o Balancing of yin and yang
o Yoga – breathing exercises, asanas or physical exercises, meditation

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 o Allopathy

 HEALTH PRACTIONERS
o Ayurvedic physician
o Allopathic doctor

V. MEXICAN

A. OVERVIEW
 Location – Middle America, bordering the Caribbean Sea and the Guild of Mexico between Belize and
the US and bordering the North Pacific Ocean, between Guatemala and the United States.
 Population – 107,449,525 (20006 est.
 Climate – varies from tropical to desert
B. BIOLOGICAL VARIATION
 Body built and structure – short, medium to tall
 Skin color – dark skinned as among the indigenous inhabitants, fair to light skin
 Enzymatic and genetic variations
o Vitamin A deficiency and anemia prevalent in lower socio-economic group lactose intolerance
High risk behavior
o Alcoholism – associated with their colorful lifestyle; a crucial health problem for many
Mexicans
o Drug addiction: Marijuana – readily available from people who are in farming and ranching
occupations; cocaine, heroin, and inhalants .
 Nutritional variations
o Mexican food is rich in color, flavor, texture and spiciness.
o Food is a primary form of socialization so much so that prescribed diet for illness such as D.M.
and CV diseases may not be adhered to.
o *Diet depends upon the individual’s region of origin .
o Staple food – rice (arroz),
o Popular Mexican foods – taco, beans and tortillas from corn (maiz). eggs, pork, chicken, sausage,
chili, peppers, squash, potatoes, leche flan

C. SOCIAL ORGANIZATION
 Family– traditional family is still the foundation of society
o Patriarchal slowing moving towards egalitarian pattern in more educated and higher
socioeconomic families
o Extended family
o Blended communal families – the norm in lower socioeconomic groups and migrant worker
camps. Single, divorced, and never-married male and female children usually live with their
parents and extended families regardless of economics
 Social status highly valued. A person with an academic degree or position commands great respect
and admiration from family, friends and the community.
 Gender roles – Machismo complex sees men as having strength, valor, self-confidence which is
considered a valued trait. Men are seen as wiser, braver, stronger, and more knowledgeable regarding
sexual matters.
o Women – expected to be devoted wife and mother, responsible for maintaining the home and
family’s health.
o The mother is the “queen” of the home and kitchen and socialization, family affairs and
communication revolve around food

D. COMMUNICATION
 Language – Spanish; 54 indigenous languages and more than 500 different dialects
 Meaningful conversations important, often loud and seemingly disorganized
 “Small talk” often indulged in before addressing real issues, also apply to actual health concerns
 Touch – touching and embracing acceptable. Handshake – initial form of greeting, then smiling,
backslapping or nodding of head.
 Eye-contact – as a rule, sustained eye contact when speaking directly to an older person
is considered rude.
o Avoiding direct eye-contact with a superior is a sign of respect.
 Addressing non-family members more formal; Titles often used as Dona, Don, Senor, Senora

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 o Approaching the Mex-Am client with respect and personalismo (being friend-like) and directing
questions to the dominant member of the group (usually a man) may help to facilitate more open
communication.

E. SPACE
 Intimate zone – with family members and friends as touching and embracing between the sexes
acceptable.

F.TIME ORIENTATION
 Present-oriented – especially those from lower socio-economic group. Trend is to live in the “more
important” here and now because tomorrow (manana) cannot be predicted.
 Unclear meaning of Manana – may or may not really mean tomorrow; it often means “not today” or
“later.”
 More relaxed concept of time – hence punctuality is not generally practiced. Time is perceived as relative
than categorically imperative. they may arrive late for appointments. This presents a problem in scheduling
appointment.

G. RELIGION – predominantly Roman Catholic (89%). Catholic religious practices are influenced by
indigenous Indian practices.

H. ENVIRONMENTAL CONTROL
 Current Issues
o scarcity of hazardous waste disposal facilities,
o scarce and polluted fresh water resources
o raw sewage and industrial effluents polluting rivers and urban areas
o deforestation – widespread erosion
o deteriorating agricultural lands
o serious air and water pollution
 HEALTH and ILLNESS BELIEFS
o Definition of health – to be free of pain, to be able to work, and spend time with family. Good
health is a gift from God and from living a good life.
o Traditional Illness Theory
• The body’s imbalance – “Hot and Cold”

Hot and Cold theory – a theory which originated in ancient Greece during the time of
Hippocrates, who considered illness to be the result of humoral imbalance causing the body to
become too hot or too cold. A state of balance among the body humours (blood, phlegm, lack
bile, and yellow bile) manifest itself in a wet, warm body. Illness results from imbalance.

Hot-cold theory describes intrinsic properties of food, beverage, or medication and its effect on
the body. If imbalance occurs, symptoms are treated by eating food from the opposite group
to restore body equilibrium.
• Dislocation of parts of the body – empacho (caused by a ball of food
clinging to the wall of the stomach) and caida de mollera (depressed
anterior fontanel in infants and child) due to diarrhea, dehydration.
• Magic or supernatural causes outside the body
• Strong emotional stress
• Envidia (envy)
o Common health problems: malnutrition, malaria, cancer, alcoholism, drug abuse, obesity,
hypertension, diabetes, heart disease, adolescent pregnancy, dental disease, HIV and AIDS.
o Among Mex-American migrant workers: infectious, communicable and parasitic diseases;
tuberculosis
o Leading cause of death
• cardiovascular disease – influenced by behavioral, cultural and social factors
• diabetes mellitus – five times higher in Mexican-Americans than European-American
groups

I. HEALING MODALITIES and PRACTIONERS

 Folk practitioners
o brujas (witches) – to remove evil spirits from the body
o curandero –who may claim to have received talent from God or has
served as apprentice to another curandero; treats many traditional illnesses; usually a member of
extended family, does not accept payment

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 o yerbero –uses herbs, teas, and roots for prevention and cure of illness
o sobador – similar to a Western chiropractor; treats illnesses affecting joints and musculoskeletal
system, with massage and manipulation.
o partera - midwives
 Professional health care professionals – doctors, nurses, therapist
 It is suggested that health care providers must always consider clients’ use of FHS practitioners to
prevent conflicting treatment regimens.

VI. MIDDLE EASTERN HERITAGE (Arabian)

A. OVERVIEW
 Arab – this term often connotes the Middle East, but the larger (and more populous) part of the Arab
World is North Africa.
 The Arab League defines Arab as “A person whose language is Arabic, who lives in an Arabic
speaking country, who is in sympathy with the aspirations of the Arabic speaking peoples.”
 Saudi Arabia – largest country in the Arab Middle East
 The Arab World straddles two continents, Africa and Asia.
 Population – 287 million, 5% of global population
B. BIOLOGICAL VARIATION
 Body built and structure – medium built to tall, medium to heavy in weight
 Skin color – dark brown or olive skin; some may have blonde or auburn hair, blue eyes and fair
complexion
 Enzymatic and genetic variations
o G-6-PD deficiency, sickle cell anemia, thalassemia
o Hypertension, diabetes, and coronary heart disease (due to high prevalence of
cigarette smoking, high cholesterol diets, obesity, and sedentary lifestyle
 Nutritional variations
o Medicines derived from pork such as insulin are not prescribed or administered
o Muslims are prohibited from eating pork and its by-products such as insulin, lard, gelatin such as
Jell-O, and marshmallows.
o “Kosher” meat – some Muslims will abstain from eating meat if they are uncertain of how it was
slaughtered. Animals must have been slaughtered in a humane fashion with the remembrance of
God and gratefulness for the sacrifice of the animal’s life.
o “Thahiba” – proper way of slaughtering an animal.
o “Halal” – animal must be properly slaughtered by a Mudlim or a Person of the Book (Christian or
Jew), while remembering the name of Allah. Animal may not be killed by being boiled or
electrocuted, and the carcass should be hung upside down long enough to be blood-free.
o Consuming alcohol or any intoxicants likes drugs of abuse eating or drinking blood and its by-
products, and eating the meat of a carnivore or omnivore (pig, monkey, dog, cat) and fish without
scales are prohibited.
*Fasting – during Ramadan, 30-day period, strictly observed.

C. SOCIAL ORGANIZATION
 Family – foundation and basis of society
 Extended family with 3 to 4 generations
• Gender roles are clearly defined.
o Men - leadership role, breadwinners, protectors, and decision makers
o Women – responsible for care and education of the children and or maintenance of a successful
marriage by tending to satisfy their husband’s needs.
• Women have to be totally dependent, loyal and obedient to their husband.
• Wives are considered the sexual property of their husband.
• High status accorded to women as mothers in Islam
• 60% - educated Muslim women
o Sons – taught to be protectors of their sisters, help father with duties inside and outside the house
o Daughters – taught to be the source of love and emotional support in the family, help mother with
household chores.
 Equitability in the role of the sexes. Allah has no bias for or against men and women. Both spouses might
need to engage in financial activities
 Rights and responsibilities within the family are intertwined.
 Men are obliged to cover themselves from navel to their knees.

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  Childbearing Muslim women (except old women) wear the hijab including headscarf; should be fully
covered in public, except hands and face. Color of outfit – black except in:
o Africa – women wear cloths of different colours depending on their tribe, area or family.
o Bangladesh, Pakistan, India – bright orange or red garments
o Turkey and Indonesia – majority do not wear veil except when they attend Friday Salat
o Iran – younger ones wear transparent Hijabs to protest but keep within the law of the state.
 Reason for wearing Hijab: men and women are not to be viewed as sexual objects
 Most Arab marriages are monogamous; 2-5% are polygamous.
o Men can marry up to four women if they can support them currently.
o “Talaq” – divorce is practiced. Men can divorce and remarry the same woman many times.
o Islamic law forbids a Muslim woman from marrying a non-Muslim unless he converts to Islam.
o A woman may propose marriage to a man directly or through an intermediary
o When a couple is to be married, the man must pay mahr or dowry to his future bride.

D. RELIGION
 Life centers on worshipping Allah
 Allah – Almighty God
 Mohammed – messenger of God
 Islam – founded between 610 and 632 A.D. by the prophet Muhammad.
 Islam means “submission to Allah.
 Moslem, Muslim – follower of Islam
 Qur’an – Bible, Holy Book
 Seven components of Islamic Foundation:
o Allah, the Only True God
o Prophets and Messengers
o The Guidance from Allah
o The Last Day
o The Life Hereafter
o Al Qadr (Measure, Destiny, Decree
 Mosque or Masjid – temple; women and men are completely segregated
 Women cannot lead (as an imam) men in prayer

E.COMMUNICATION
 Language: Arabic is the universal language of Muslims, as it is the language of the Qu’ran
 Silence
o Arabs behave conservatively
o Display of affection between spouses, arguments are kept private
o Acting in a manner that attracts attention is looked upon as a sign of imbalance in behavior and
character
 Eye Contact
o Maintain steady eye contact when conversing to Arabs
o Do not prolong eye contact with a Arab woman. Arab women are conservative and sensitive.
 Touch
o Greeting with a kiss is taboo.
o Between members of the same sex, touch hand or shoulder to gain trust
o Do not compliment your Arab host/associate on the beauty of wife or sister or daughter.

F. SPACE
 Face-to-face meetings in doing business
 Gender separation - no mixing of Arab men and women who are not directly blood related, or not married
to each other.
 Dewaiahs or Majlis – for male guest gathering only, separate from rest of the house
 Only female doctors and health care personnel are permitted to attend to female patients

G. TIME ORIENTATION
 Predestination – believed by first generation Arabs. This means that God has predetermined the events of
one’s life
 Plans and intentions are qualified with the phrase inshallah, “if God wills.”
 Punctuality – at prayer 5x a day and in business appointments.
 Praying and observance of death rituals include turning one’s head and the patient’s bed in the direction
of their prophet.

H. ENVIRONMENTAL CONTROL

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  HEALTH BELIEFS
o Good health is seen as the ability to fulfill one’s roles.
o Diseases are attributed to a variety of factors: inadequate diet, hot and cold shifts, emotional or
spiritual distress envy or evil eye.
o Preventive care not generally sought; Arabs seek care for actual symptoms
o Cultural emphasis on modesty – women shy about disrobing for examination. Only female health
care providers can attend to an Arab woman.
o Muslim concept of death is the return of the soul to its Creator, God, and the inevitability of death
and the Hereafter is never far from his consciousness.
o Notifying the nearest Islamic Center so that someone could come and pray and read from the
Qu’ran to a seriously ill is appreciated.

 HEALTH CARE PRACTICES

o Birth Rites – Baby is bathed immediately after birth.
o Circumcision to facilitate cleanliness recommended at anytime but especially during the first 5 days.
o Life Interventions – Permissible to use life support to save and lengthen life.
o Euthanasia or Physician Assisted Aid in Dying is prohibited
o Death Rites – cremation is forbidden. Burial recommended as soon as possible especially during
summer.
o As soon as death occurs, the body should be completely covered and placed if possible with feet
towards Mecca.
o Only family member should touch and wash the dead body, usually by the same gender.
o Embalming the body is prohibited. A corpse is not left alone between death and burial.

 HEALTH CARE PRACTIONERS

Allopathic doctor

VII. BLACKS or AFRICAN AMERICANS

A. OVERVIEW
 Refers to people having origins in any of the Black race groups of Africa who were brought as slaves about
the 17th century.
 Today the black population comprise those who migrated voluntarily from African countries, the West
Indian islands, the Dominican Republic, Haiti, and Jamaica.
 The Blacks are the nations largest majority population-12.9% of the US (2000). 54.8% live in the South.
 Blacks are presented in every socioeconomic group; however 21.1% of the group live in poverty. Over half
live in urban areas surrounded by the symptoms of poverty – crowded and inadequate housing, poor
schools, and high crime rates.
 Black population is also young, 54.5% are under 18 (2001).
 Civil Rights Movemen
o 1962- Civil Rights Movement formally organized.
o 1962 – Civil Rights Act passed.
o 1968 – Dr. Martin Luther King Jr. assassinated
o 1995 – Million Man March

B. BIOLOGICAL VARIATION
 Body built and structure
o Differ in bone length
o Tend to have shorter trunks than Whites and have longer legs than Whites, Orientals and
American Indians.
o Have wider shoulders and narrower hips than Orientals, who tend to have narrow shoulders and
wide hips
o Average height and weight between Black and Whites tend to be the same 18-74 years age group,
but White men tend to be taller than black men.
o Black women are consistently heavier than White women, although average in height for both
races.
 Skin color
o Color - “white” to very dark brown or
o Black – lower risk for cancer
o The groin, the genitalia and the nipples tend to be darker than the rest of the body.
o Hypopigmentation and hyperpigmentation in different parts of the body.
 Enzymatic and genetic variations

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 o Sickle-cell anemia - genetically inherited trait hypothesized to fight malaria. Results in hemolysis
and thrombosis of red blood cells because these cells do not flow properly through the blood
vessels.Symptoms: hemolysis, anemia, states of sickle cell crises in which severe pain occurs in
the areas of the body where the thrombosed cells are located, i.e spleen, liver
o Hypertension – attributed to diet; too much red meat and high fatcontent
o Cancer of the esophagus
o Stomach cancer
o Coccidiodomycosis
o Lactose intolerance
o Obesity
o Diabetes
o AIDS and STD’s – high incidence; rapid increase of infectious primary and secondary syphilis
since 1985.
Mortality:
Heart disease
Cancer
Stroke
Diabetes
Pneumonia/influenza
Morbidity:
Hypertension
Coronary artery disease
Stroke
End stage renal disease
Dementia
Diabetes
Certain cancers

 Nutritional variations and Dietary Practices:

o Black Muslims observe Jewish kosher diet and halal- no pork or pork products which they believe
to be filthy.
o Food is used as a way to celebrate special events, holidays, and birthdays. Food is a symbol of
health and wealth.
o African-American diet is high in fat, cholesterol and sodium. They eat more animal fat, less fiber,
and fewer fruits and vegetables than the rest of American society.
o Salt pork (fatback or fat meat) – key ingredient in their diet because it is inexpensive.
o “Soul food” – a combination of dishes created with ingredients from Africa, the Caribbean, and
the Southern United States. comes from the need of African Americans to “express the group
feeling of “soul.” Common “soul food” ingredients: black-eyed peas, kidney beans, ham hocks,
bacon or pork chops.
o Being overweight is considered positive. It is important for them to have meat on their bones to be
able to afford to lose weight in times of sickness.
o Pica – the eating of non-food substances such as laundry starch (amylophagia) clay or dirt
(geophagia), ice, burnt matches, ashes,wall plaster, hair and stones have been frequently reported
among African American women of different cultural groups. One theory suggests the body’s need
to acquire certain missing nutrients, hunger, cultural tradition, prevention of nausea, attention
seeking.

C. SOCIAL ORGANIZATION
 Family
o Large, extended family networks
o Many single parent households headed by females. 50-60% of women in this culture are single
mothers. Adolescent pregnancy is a major concern with the population.
o Strong church affiliations within community
o Community social organizations

D. COMMUNICATION
 Language and dialects
o Black English – not a language but a dialect in which the pronunciation of words may be different.
Ex.: th=d; brother-broda; going=goin; going to=gonna
o Dialect: Pidgin – occurs when two groups do not have a common language and are forced to develop a
third language (pidgin), which is a combination of their respective languages.
• Creole – when a pidgin becomes the first language of a group of speakers.
• Gullah – spoken by descendants of freed slaves from the Georgia and South Carolina sea
islands who developed their own culture.
 Expression of feelings

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 o Express feelings openly to family or trusted friends
o Speech is dynamic, expressive, loud
o Body movement are involved when communicating
o Facial expression can be demonstrative
o Use of humor to release hostility, anger, stress, anxiety
 Eye contact
o Maintaining direct eye contact can be misinterpreted as aggressive behavior.
 Touch
o Used freely between adults and children, or people of the same gender as a way to convey empathy,
acceptance and, when dealing with health issues, to infuse hope.

E. SPACE – Comfortable with close personal space more than other ethnic groups.

F.TIME ORIENTATION
 Past orientation – due to factors such as the traumatizing racial segregation
 Future – arose during the time of Martin Luther King Jr. His famous line “I have a dream” gave hope for a
brighter future for the African Americans
 Punctuality – very punctual and normally arrive 15-30 minutes earlier as a sign of respect.

G.ENVIRONMENTAL CONTROL
 HEALTH BELIEFS
o Health is viewed as harmony with nature
o Illness is a disruption of this harmonic state due to demons, “bad spirits,” or both.
o Natural illness - occurs in response to normal forces from which individuals have not
protected themselves.
o Unnatural illness – harm or sickness can come to individuals via a person or spirit.
o Pain – a sign of illness or disease
o Traditional health and illness beliefs may continue to be observed by “traditional” people

 HEALING MODALITIES
Traditional
o Voodoo – synonyms are “fix”, “hex”, or “spell.” - brought by the slaves about 1724.
Involves a lot of rituals and procedures such as drinking blood, use of oils, powders
candles.

Modern health care

o Receiving health care sometimes seen as a degrading and humiliating experience.
Ongoing use of home remedies due to poverty.
o Some Blacks fear or recent health clinics. Appointments not often kept because they may
lose a day’s work, not being understood by health care worker, discrimination
 HEALTH CARE PRACTIONERS
Folk healing practitioners
Conventional or allopathic practitioners

VIII. ANGLO-AMERICAN
A. OVERVIEW
 Anglo-American – an American of English birth or ancestry.
 America - nation of immigrants.
o 1820-1920 – people from Germany, Italy, United Kingdom, Ireland, Austria-Hungary, Canada
and Russia.
o Now considered a “melting pot” of different cultures

B. BIOLOGICAL VARIATION
 Body built and structure – usually tall, medium to heavy built; structure reflective of European
descent
 Skin color - white
 Enzymatic and genetic variations
o Drug variation: Due to liver differences, caffeine is metabolized and excreted faster by
people of other cultural groups.
Genetic Diseases:
o Favism (Hemolytic anemia caused by deficiency of the X-linked enzyme G6PD triggered by
eating fava beans(broad beans).
o Thalassemia syndrome

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 o Increased susceptibility to: Cardiovascular diseases, breast cancer (the most common form of
cancer in women), diabetes,
Leading causes of death:
1. Heart Disease
2. Cancer
3. Stroke
4. Chronic lower respiratory diseases
5. Accidents (unintentional injuries)
6. Diabetes
7. Influenza, Pneumonia
8. Alzheimer’s Disease
9. Nephritis, nephritic syndrome, and nephrosis
10. Septicemia
 Nutritional variations
o Traditional American cuisine – steak and potatoes, hamburger, vegetables, salad, rich deserts
o 20th century – consumption of packaged foods – breads and cookies, preserved fruits, pickles
soups, frozen vegetables, reserved meats, instant puddings and gelatins, fruit juices
o 21st century – Fully prepared meals outside the home reflected changing economic status
(wife working outside home). Emphasis on convenience and rapid consumption gave birth to
fast foods chain like Burger King, McDonalds, Pizza Hut, etc. – French fries, hamburgers
pizza, etc.

C. SOCIAL ORGANIZATION
 Nuclear family structure: small family size - parents and children only
 Decision-making process: made by individual or self, or by either parent or their child
 Independence: children encouraged to be independent; allows children to disagree with parents which
may be considered disrespectful in other cultures
 Few social services to support family: children encouraged to live outside the home at age 18
o No guarantee that children will support their elderly parents; hence, many elderly live in
nursing homes
 Gender roles: males and females expect to be treated with equal respect, rights and role opportunities
at home and in the work place
 Dominant cultural values:
o Individualism and self-reliance
o Independence and freedom
o Competition, assertiveness and achievement oriented
o Highly materialistic and too technologically oriented
o Equal gender roles and rights
o Instant time and action (doing)
o Youth and beauty
o Reliance on “scientific facts” and numbers
o Generosity and helpfulness in crises

D. COMMUNICATION
 Language – predominantly English (about 97%)
o Other languages – speak German, French, Polish, Spanish. Italian,
o English spoken with accent in different parts of the US
 Manner of communication
o Direct, informal, use of person’s name often
o Will ask a lot of explanations and facts, services available, health instructions regarding health
care.
o ”Small talk” on sports, weather, jobs, or past experiences. Most people don’t talk about religion,
politics or personal feelings with strangers.
o Few “ritualistic” exchanges in English like “How are you,” How’s it going” are greetings, not
questions about your life. ”See you later,” or “See you soon” are ways of saying good-bye, not
appointments.
o Conversations are moderate in volume with few gestures.
 Eye contact
o Direct – an important component of direct and honest communication
o Direct eye contact – specially between sexes may be interpreted as sexually suggestive
o Avoidance of eye contact – suggest withholding information, sometimes a psychiatric symptom to
evidence of dissembling direct eye contact
 Touch – Aggressive, self-seeking, independent, individualistic, competitive, and not touch oriented.

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 o Handshaking – acceptable at initial meeting. Touching for casual acquaintances is considered a bit
too intimate.
o Kissing or hugging as a form of greeting even in public places is common between the sexes.
o Holding hands or touching another of the same sex may indicate homosexuality.

 SPACE
o Value space and territory, especially with middle-class and upper class Americans. They often seek
to increase their space at home and at work.
o Require more personal space than in other cultures. Space is an expression of money and
materiality (storing material goods and possession).
o Often described as “territorial animals.” Because they like to protect and control their space.
o Casual conversation – maintain a distance of 36-48 inches, otherwise he/she will feel that you are
“in their face” and will try to back away.

E. TIME ORIENTATION
 “Time is gold”. Time is equated with money,
 Time – a dominant value in American culture. Observe punctuality in keeping and maintaining
appointments and schedules.
 Time closely related to action, doing, efficiency and productivity.
 Generally goal and future oriented especially when it comes to monetary security. Thus they value personal
goals over group goals.
 Outlook on time may vary with their socio-economic class:
Poor – present oriented
Middle and upper class –future oriented

F. RELIGION
 Predominantly Christian – Catholicism, Protestantism
 Minority – Judaism, Islam, Buddhism

G. ENVIRONMENTAL CONTROL
Believe that Man, and not Fate, can and should be the one who controls the environment. Thus, they are
good at planning and executing short-term projects.
 HEALTH BELIEFS AND PRACTICES
o Generally prefer an aggressive approach to treating illness
o Believe that germs and microorganisms cause disease, treatment aimed at destroying them.
Management of microbes is more important than bolstering resistance to them. Antibiotics
often requested.
o Expect to leave doctor’s office with a prescription.
o Have a high expectation that their disease/s will be cured or at least well managed, through
technology and powerful drugs.
o Drug culture - a mixture of legal, illegal and prescription drugs.
 HEALING MODALITIES
o Strong preference for biomedicine.
o Trend towards complementary and alternative medicine

 HEALTH/HEALING PRACTIONERS
o M.D. trained at different levels of specialization
o Trend towards alternative medicine and therapies.
o Certified Nurse Specialist – specialization in different areas of health care

IX. ITALIAN HERITAGE

A. OVERVIEW
 Location – country in S Europe mostly on a peninsula extending into the Mediterranean and including
the islands of Sicily and Sardinia
 Land area – 116,304 sq. miles
 Capital – Rome
B. BIOLOGICAL VARIATION
 Body built and structure – varied physical characteristics because of Italy’s proximity to Switzerland,
Austria, and Germany in the north, and to North Africa in the South.
 Skin color
o northern background have lighter skin, lighter hair, and blue eyes

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 o from the south of Rome, particularly Sicily – have dark often curly hair, dark eyes, and olive-
colored skin.
 Enzymatic and genetic variations
o First generation Italians – suffered from somatic complaints and physical ailments attributed to il
mal occhio (evil eye)
o Second generation immigrants – tend to develop neurologic and psychotic symptoms attributable
to guilt toward the parents whose culture they have broken.
o People of Italian ancestry have some notable genetic diseases: familial Mediterraneanfever, G6PD,
B-thalassemia
o Italian-Americans - high incidence of hypertension and AD related to smoking and Type A
behavior
 Nutritional variations
o Nutritional deficiencies are rare because the Italian diet is rich in fruits, vegetables, garlic, pasta
and olive oil
o Food – is symbolic of life and the principal medium of family life. An Italian mother may
demonstrate her affection by feeding her family and anyone else she likes. To the average Italian
mom, love is a four letter word: food.
o Staples of the Italian-American diet: spaghetti, lasagna, ravioli, pasta, manicotti, vegetables, fruits,
lentils, sausages, eggplant parmigiana, etc.

C. SOCIAL ORGANIZATION
 Family – central in Italian’s lives, and “Mama” is queen
 Father – breadwinner, authority absolute in traditional Italian families; decision maker
 Women – dominate decision making on childbearing issues and family social events; have more power in
economic decisions because the husband turns over paycheck to her.
 Sons frequently live at home well into their 20’s
 Parents often live in children’s homes and care for grandchildren

D. RELIGION
 Predominantly Roman Catholic (90%); 30% regularly attend service
 Religious beliefs have evolved from diverse cultures in Italy through the centuries.Thus Italian-
Americans’ spiritual and religious beliefs have their roots in:
-pagan customs
-magical beliefs
-Mohammedan practices
-Christian doctrines
-Italian pragmatism
 Most Italians pray to the Virgin Mary, the Madonna, and a number of saints
 Italians view God as an all-understanding, compassionate and forgiving being.

E. COMMUNICATION
 Italian – official language
 Several different dialects spoken in 19 regions of Italy
 Voice – discussions can become quite passionate, with voice volume raised and many people speaking
at the same time
 Willingness to share thoughts and feelings among family members is a major distinguishing characteristic
of the Italian-American family.
 Emotional people, conflict expressed as periodic outbursts
 Value close family ties expressed as warmth feeling, emotional bond reaffirmed by frequent kissing on
each cheek
 Touch – frequently touch and embrace family and friends. Touching between men and women, frequently
seen during verbal communication.

F. SPACE
o Related to close family ties, Italians like contact which makes them feel comforted, secure, and
make them feel that they belong.

G. TIME ORIENTATION
 Past orientation –is evidenced by the pride they take in their home country’s rich Roman heritage
 Present orientation – occupy themselves with concrete problems and situations, and accept things
 Future – they give importance to planning ahead and saving financially for the future.
H. ENVIRONMENTAL CONTROL
 HEALTH BELIEFS AND PRACTICES

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 o In traditional terms, illnesses are attributable to:
-wind currents that carry disease
-contamination
-heredity
-supernatural (God’s will) or human causes
-psychosomatic interactions
o Superstition
Evil spirits manifesting in hysteria, nervousness, mental illness

 HEALING MODALITIES
o The family is viewed as the most credible source of health-care practices.
o Italians take responsibility for their own health care and engage in health promotions.
o Majority also have health insurance coverage
o From the family perspective, the mother assumes responsibility for the health of the children
 HEALTH/HEALING PRACTIONERS
o Traditional vs. Biomedical Care: Some humans are believed to have potent magical powers:
shaman, maghi (male witch); maghe (female witch), lupo mannaro (powerful sorcerer)
o *Health Care Providers
• Some physicians collaborate with shamans and herbalists to accommodate clients cultural
preferences
o Success in persuading children of Italian parentage to take medicine depends on the trust the
mother has on health care provider.

X. JEWISH HERITAGE
A. OVERVIEW
 Jewish refer to both a people and a religion; it is not a race
 Jew is derived from Judah, one of Jacob’s son
 Hebrew – is the official language and is used for religious prayers by all Jews wherever they live.
 The people are called Jewish, their faith Judaism, their language Hebrew, and their land Israel.
 Religious persecution – cause of mass migration of Jews from Europe in the 1800’s.
o Ashkenazi Jews – from Eastern Europe and Russia
o Sephardic – from Spain, Portugal, Mediterranean area, North Africa, South and Central
America
o Sabra – is a Jew born in Israel
 Continued learning – most respected value of the Jewish people. Prominent in all fields of endeavor – 39%
Nobel prize in the life sciences, 11% in Chemistry, 41% in Physics; business, arts and culture

B. BIOLOGICAL VARIATION
 Body built and structure – varies according to region of country of origin
 Skin color
o Ashkenazi Jews – same as white Americans. White to fair; blonde hair to darker skin and
brunette hair
o Sephardic Jews – slightly darer skin tone and hair coloring, similar to those from
Mediterranean area.
 Enzymatic and genetic variations
o Bloom syndrome – a specific abnormality of chromosome 15 in which the individual suffers
from recurrent infection blistering areas of the hand and lips, and poor growth
o Breast and ovarian cancer
o Cystic fibrosis – a hereditary disease affecting cells of exocrine glands including mucus
secreting glands)
o Fanconi anemia – disorder characterized by severe aplastic anemia (failure of the bone
marrow to produce either red or white blood cell)
o Gaucher’s disease a genetically determined disease resulting from deposition of
glucocerebrosis in the brain and other tissues (bone)
o Pempigus vulgaris – a rare but serious disease marked by successive outbreaks of blisters
o Tay-Sachs disease – an inherited disease of lipid metabolism in which abnormal accumulation
of lipid in the brain leads to blindness mental retardation, and death in infancy.
o Torsion dystonia – Abnormal twisting of a testis within the scrotum or a loop of bowel in the
abdomen

 Nutritional variations

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 o Food satisfies hunger but also teaches discipline and reverence for life as also an instrument
of ethnic identity. Chicken soup is frequently referred to as “Jewish Penicillin.”
o Kashrut (keeping Jewish dietary laws or keeping Kosher found in Leviticus and
Deuteronomy)
Strict observance of Kashrut. Some patients will not eat hospital food unless it is
certified Kosher and cooked in a Kosher kitchen. The family should identify their level
of Kashrut and help the hospital staff with their needs.
o Meat and milk are not mixed in cooking, serving, or eating.

When working in a Jewish person’s home, the health care provider should not bring food
into the house without knowing whether or not the client adheres to kosher standards. Kosher
meals are available in most hospitals.

C.SOCIAL ORGANIZATION
 Family – core of Jewish society. Needs of all family members are respected.
 Gender roles:
o Men – breadwinner; father’s legal obligation is to educate children and provides daughter
with the means to make them marriageable.
• Jewish husband are required to provide their wife with food, clothing, medical care
and conjugal return
• Jewish men are prohibited from “beating their wives, restricting or forcing them into
sex.
o Women – raises children, keeps a Jewish home. Are at the forefront of activities to demand
and protect all human rights, gain women’s suffrage, reproductive health care rights
o Children – most valued treasure. Families are encouraged to have at least 2 children
• In Judaism, age of majority is 13 years for boy and 12 for a girl. At this age they are
deemed capable of differentiating right from wrong. Recognition of adulthood occurs
during a ceremony called a bar or bar mitzvah
 Marriage – an ideal human state for adult.
Goal – to propagate the race and companionship. Sexuality is a right of both men and women. Sexual
intercourse is viewed as a pure and holy act when performed within marriage.

Women must physically separate themselves from all men during their menstrual period and for seven
days after. No man may touch a woman nor sit where she sat until she has been to the mikveh for
purification.

D. RELIGION
 Judaism – a monotheistic faith that believes only in one God.
o Jews consider only the Old Testament as their Bible.
o Torah refers to the first five books of the Bible also known as the five books of Moses, directs
Jews on how they should live their lives.
o 3 main branches of Judaism:
1. the Orthodox – the most traditional. They observe the Sabbath by attending the
synagogue on Friday evening and Saturday morning; abstain from work, spending
money and driving on the Sabbath
2. the Conservative and
3. the Reconstructionism.
o Hasidic (or Chadsidic) - ultra orthodox fundamentalist, usually live, work and study within a
segregated area. They have full beards, uncut hair around the ears, wear black hats or fur
streimels, dark clothing and no exposed extremities. Women, especially those who are
married, keep their extremities covered and may have shaved heads covered by a wig and hat
as well.
o Saturday is considered as the 7th day of the week and should be kept very holy.
o Visiting the sick (bikkur cholin) is considered as one of their most religious practice; it is one
the social obligations of Judaism and assures that Jews look after the physical, emotional,
psychological and social well-being of others.

E. COMMUNICATION
 Language: English – primary language; Hebrew – official language
o Yiddish – a Judeo-German dialect, spoken by Ashkenazi Jews
 Use of Humor – frequently used; the Jews like self-criticism thru humor, but any jokes that refer to the
holocaust or concentration camps are considered inappropriate.
 Touch – Jewish men are not permitted to touch a woman other than their wives. They
often keep their hands in their pocket to avoid touch.

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 o They do not shake hands with women, engage in idle talk with them nor look directly at their
faces.
 Non-Hasidic Jews – more informal, may use touch and short spatial distance when communicating.

F. SPACE
 Intimate and personal space between husband and wife
 Maintain distance outside of family home
 “Distance oneself from a bad neighbor, and do no befriend an evil person.” (Avot 1:7)

G. TIME ORIENTATION
 They are past, present, and future oriented.
o Present – Jews live for today and plan and worry about tomorrow.
o Past – they are raised with stories of their past. They are warned to “never forget.”
 They value time. Punctuality is observed.

H. ENVIRONMENTAL CONTROL

 HEALTH BELIEFS AND PRACTICES

o Beliefs are determined by Jewish law. Hasidic husband may not touch his wife during labor,
attend delivery, or view her genitals.
o Circumcision – both a medical and a religious rite, performed on the 8th day by a mohel,
trained in the circumcision procedure, asepsis and the religious ceremony.
o Sabbath begins 18 inutes before sunset on Friday and ends 42 minutes after sunset (or when
3 stars can be seen) on Saturday. Day is devoted to prayer. Jews do no work on this day.
In Health Care: Doctor appointments are not scheduled on the Sabbath or Holy Days.
Surgical procedures, except life-saving procedures, are not done on the Sabbath or holy days,
o Death is an expected part of the life cycle.

 HEALTH/HEALING PRACTIONERS
Allopathic doctor

END

BIBLIOGRAPHY

Andrews, Margaret M. and Joyceen S. Boyle. (1999). Transcultural concepts in nursing

care. (3rd ed.). Lippincott. Philadelphia, New York, Baltimore.

Burkhardt, Margaret A. and Alvita Nathaniel, Ethics and issues in contemporary nursing
( 2nd ed.). Thomson Asian Edition.

Kozier, B., Erb, G., Berman, A.J., and Snyder, S.. (c2004). Fundamentals of nursing
concepts, process, and practice. (7th ed.).Pearson Education, Inc. Upper Saddle River,
New Jersey.

Munoz, Cora and Joan Luckmann (c 2005). Transcultural communication in nursing. (2nd
ed.). Delmar Learning.

Purnell, Larry D. and Betty J. Paulanka (2003). Transcultural health care: a

culturally competent approach ( 2nd ed.). F.A. Davis Co. Philadelphia.

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 Spector, R.E. (2000). Cultural diversity in health and illness (5th ed.). Upper Saddle
River, N.J: Prentice Hall.

Spector, Rachel E. (2004) Transcultural nursing: beliefs and practices in illness and
health care (6th ed.). Pearson Education South Asia Pte Ltd. Jurong, Singapore.

Taylor, Carol, Lillis and Priscilla LeMone. (2005). Fundamentals of nursing: the art and
science of nursing care (5th ed.) .Lippincott Williams and Wilkins, Philippine edition.

ADDENDDUM

Medicine Wheel teachings are among the oldest teachings of First Nations people. The
teachings create a holistic foundation for human behaviour and interaction; the teachings
are about walking the earth in a peaceful and good way; they assist in helping to seek
healthy minds (East), strong inner spirits (South), inner peace (West), strong healthy bodies
(North).

The term “Medicine” as it is used by First Nations people does not refer to drugs or herbal
remedies. It is used within the context of inner spiritual energy and healing or an
enlightened experience, in other words, spiritual energy. The Medicine Wheel and its sacred
teachings assist individuals along the paths towards physical, mental, emotional and
spiritual enlightenment.

There are several teachings, such as the four directions (north, south, east and west), the four
colours of races (red, black, yellow and white), the four directions, or the four stages of life
(spiritual, mental, physical and emotional). Different tribes have different colours to represent the

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four directions. The Medicine Wheel below is represented in the traditional four colours (red,
black, yellow and white).

EAST (yellow): from the East, we begin to seek knowledge, the direction where everything
is fresh and new. The sacred plant of this direction is tobacco.

SOUTH (red): from the South we experience growth, the direction where everything in life
is replenished and in full bloom. The sacred plant of this direction is cedar.

WEST (black): from the West we encounter reflection and spiritual insight, the direction
where dreams and visions allow you to go within and appreciate yourself and your Creator.
The sacred plant of this direction is sage.

NORTH (white): from the North we experience the purity, the direction where the secret to
many cures is found for healing. The sacred plant being the Sweet Grass, to keep you free
from evil and make your travels safe.

The Aboriginal philosophy is based upon universal principles known as the seven
teachings

 Sharing
2. Caring
3. Kindness
4. Humility
5. Trust
6. Honesty
7. Love

The seven natural ways of healing are:

1. Talking
2. Crying
3. Laughing
4. Yelling
5. Dancing
6. Singing
7. Shaking

All exist within the MEDICINE WHEEL and the CIRCLE OF LIFE

Yin and Yang in Chinese Culture

Originates in ancient Chinese philosophy and metaphysics, which describes two primal
opposing but complementary forces found in all things in the universe. Yin, the darker
element, is passive, dark, feminine, downward-seeking, and corresponds to the night; yang,
the brighter element, is active, light, masculine, upward-seeking and corresponds to the
day; yin is often symbolized by water, while yang is symbolized by fire.

The pair probably goes back to ancient agrarian religion; it exists in Confucianism, and it is
prominent in Taoism. Though the words yin and yang only appear once in the Tao Te Ching,
the book is laden with examples and clarifications of the concept of mutual arising.
Yin and yang are descriptions of complementary opposites rather than absolutes. Any
yin/yang dichotomy can be seen as its opposite when viewed from another perspective. The
categorisation is seen as one of convenience. Most forces in nature can be broken down into
their respective yin and yang states, and the two are usually in movement rather than held
in absolute stasis.

Yin and yang are often used in reference to disease, and many Asian cultures treat the
hot/cold or wet/dry diseases with opposite treatments. For example, a yin symptom such as

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coldness would be treated with yang treatments, such as hot foods. A yang symptom such
as nervousness would be treated with yin treatments- cold foods such as fruits.
Yin and yang can also be seen as a process of transformation which describes the changes
between the phases of a cycle. For example, cold water (yin) can be boiled and eventually
turn into steam (yang).

One way to write the symbols for yin and yang are a solid line (yang) and a broken line
(yin) which could be divided into the four stages of yin and yang and further divided into the
eight trigrams (these trigrams are used on the South Korea flag). The symbol shown at the
top righthand corner of this page, called Taijitu (太極圖), is another way to show yin and
yang. The mostly white portion, being brighter, is yang and the mostly dark portion, being
dim, is yin. Each, however, contains the seed of its opposite. Yin and yang are equally
important, unlike the typical dualism of good and evil.

The concept is called yin yang, not yang yin, just because the former has a preferred
pronunciation in Chinese (see Standard Mandarin - Tones for detail), and the word order has
no cultural or philosophical meaning.

Principles
Everything can be described as both yin and yang.
1. Yin and yang are opposites.
Everything has its opposite—although this is never absolute, only relative. No one thing is
completely yin or completely yang. Each contains the seed of its opposite. For example,
winter can turn into summer; "what goes up must come down".

2. Yin and yang are interdependent.

One cannot exist without the other. For example, day cannot exist without night. Peace
cannot exist without chaos.

3. Yin and yang can be further subdivided into yin and yang.
Any yin or yang aspect can be further subdivided into yin and yang. For example,
temperature can be seen as either hot or cold. However, hot can be further divided into
warm or burning; cold into cool or icy. Within each spectrum, there is a smaller spectrum;
every beginning is a moment in time, and has a beginning and end, just as every hour has a
beginning and end.

4. Yin and yang consume and support each other.

Yin and yang are usually held in balance—as one increases, the other decreases. However,
imbalances can occur. There are four possible imbalances: Excess yin, excess yang, yin
deficiency, and yang deficiency. They can again be seen as a pair: by excess of yin there is
yang deficiency and vice versa. The imbalance is also a relative factor: the excess of yang
"forces" yin to be more "concentrated".

5. Yin and yang can transform into one another.

At a particular stage, yin can transform into yang and vice versa. For example, night
changes into day; warmth cools; life changes to death. However this transformation is
relative too. Night and day coexist on Earth at the same time when shown from space.

6. Part of yin is in yang and part of yang is in yin.

The dots in each serve: 1. as a reminder that there are always traces of one in the other.
For example, there is always light within the dark (e.g., the stars at night), these qualities
are never completely one or the other. 2. as a reminder that absolute extreme side
transforms instantly into the opposite, or that the labels yin and yang are conditioned by an
observer's point of view. For example, the hardest stone is easiest to break. This can show
that absolute discrimination between the two is artificial.

HOT and COLD conditions and their corresponding treatment

Hot conditions Hot foods Hot medicines and herbs
Fever Chocolate Penicillin
Infections Cheese Tobacco
Diarrhea Eggs Ginger root
Kidney problems Peas Garlic
Rashes Onions Cinnamon

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Skin ailments Aromatic beverages Anise
Sore throat Hard liquor Vitamins
Liver problems Oils Castor
Ulcers Meat such as beef
Constipation Goat’s milk
Cereal grains
Chili peppers

Cold conditions Cold foods Cold medicines and herbs

Cancer Fresh vegetables Orange flower water
Pneumonia Tropical fruits Linden
Malaria Dairy products Sage
Joint pain Meat such as goat, chicken Milk of Magnesia
Menstrual periods Fish, cod Bicarbonate of soda
Teething Honey
Earache Raisins
Rheumatism Bottled milk
Tuberculosis Barley water
Colds
Headache
Paralysis
Stomach cramps

PHILIPPINE CULTURAL MINORITIES

Cultural Minorities – 4 million or 12% of total population

¾ Muslims found in Mindanao, Sulu Archipelago and Palawan

Mindanao

A. Negrito
1. Bukidnon 6. Manobo 11. Ata
2. Subanon 7. Bukidnon 12. Bagobo
3. Manggungan 8. Subanon 13. Isamal
4. Mandaya 9. Manggungan
5. Ata 10. Mandava

B. Muslim Group

1. Maranao

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 2. Maguindanao
3. Sangul
4. Yaka
5. Tausug
6. Samal
7. Badjaw

Luzon Visayas

(Negrito) (Negrito)

1. Isneg 1. Sulod
2. Kalinga 2. Bukidnon
3. Bontoc
4. Ifugao
5. Kankanai
6. Tinguian (Itneg)
7. Gaddang
8. Ilongot

Mindoro Palawan
(Pagan Groups)
1. Iraya
2. Nauhan 1. Batak
3. Buwid 2. Tagbanua
4. Buhid 3. Palawan
5. Ratagon
6. Hanunon (Muslim Group)

1. Malbog

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