Escolar Documentos
Profissional Documentos
Cultura Documentos
Course
Content
PREPARED BY
PROF. VALENTINA B.
PATACSIL
1
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;
•
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
COURSE SYLLABUS
3. Pre-requisite : NONE
4. Co-requisite :
6. Course Description
2
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.
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
9. Course Coverage :
3
METHODOLOGY &
WEEK TOPIC STRATEGY EVALUATION TOOLS
MIDTERM EXAMINATION
4
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
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decision-making
E. Transcultural Care Principles, Human
Rights and Ethical Considerations
Bibliography
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
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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;
•
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
COURSE CONTENT
8
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
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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
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.
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.
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
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:
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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.
Subculture – smaller groups within a culture. Each subculture has its own value
system and related expectations of behavior.
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.
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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
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.
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.
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?
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.
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.
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Cultural Imposition – The belief that everyone should conform to the majority
belief system.
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.
Divided into units or continents: Africa, Asia, Europe, North America, South America,
Oceania. Of these, Asia is the largest continent.
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ASIA
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NORTH AMERICA and CANADA
SOUTH AMERICA
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C. POPULATION OVERVIEW
1. World Population
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
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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
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.
California
New York
Florida
Texas
New Jersey
Illinois
Massachusetts
Virginia
Washington
Pennsylvania
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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.
Source: Andrews and Boyle, Transcultural concepts in nursing care (2003) 4rd ed
Lippincott Wiliams & Wilkins, Philadelphia, p. 338
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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.
1. The health traditions model for maintaining, practicing, and restoring health
The Nine Interrelated Facets of Health (Physical, Mental, and Spiritual) and
Personal Methods of Maintaining Health, Protecting Health and
Restoring Health
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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
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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.
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.
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.
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
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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.
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)
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.
Healing System – refers to the accumulated sciences, arts, and techniques of restoring
and preserving health that are used by a cultural group (Smith, 1983).
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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.
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
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
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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.
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1. Surgery – refers to excision or surgical removal of diseased body parts.
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)
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.
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.
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of the body’s systems work together, and disturbance in one system may affect
function elsewhere in the body.
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.
Example: Immunization
Nursing Implications:
Nurses must know and understand the nursing implications of CAM Therapies:
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).
30
DIVERSITY AND UNIVERSALITY
(Leininger, 1991, pp. 48-49, in Andrews and Boyle, 3rd ed. op. cit. p. 521).
31
THE SUNRISE MODEL
32
C. THE GIGER AND DAVIDHIZAR’S TRANSCULTURAL ASSESSMENT
MODEL
33
The Giger and Davidhizar’s Transcultural Assessment Model
Model shows:
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.
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,”
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.
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
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.
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
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.
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.
39
“Language allows us to initially identify, label, attach significance
A. Basic/Related Concepts:
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.
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
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
• Posture
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
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.
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.
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
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
45
West Indian Islands (Dominican Republic, Haiti, Jamaica)Many African countriesWest coast (as slaves)African
SpaceClose Personal
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
Social organizationsCommunity Judeo-Christian religionsExtended familiesNuclear families
medicine traditions
Some remaining folk illness beliefsTraditional health and system health care Primary reliance on modern
47
Eskimos Aleuts Indian tribes 500 American American Indian
language
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
48
organizationssocial Community GodparentsCompadrozzo;Extended familiesNuclear family
Value physical presenceEmbracingTouch, HandshakesTactile relationships
Present
Central and South American Mexico Cuba SpainHispanic countries
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.
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.
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.
Source: Andrews and Boyle, Transcultural concepts in nursing care (2003) 4rd ed
Lippincott Wiliams & Wilkins, Philadelphia, p. 338.
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?
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)?
50
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.
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.
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?
51
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?
52
A. INDIVIDUALLY
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
53
UNIT VI. Contemporary Challenges in Transcultural Nursing
1. Definition
Definitions of pain are diverse because of its complex nature and because of the
many different existing perspectives on pain.
2. Basic/Related Concepts
3. Measurement of Pain
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
CHARACTERISTIC QUESTIONS
55
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
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
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
High incidence of
illness
d. The Homeless
In the U.S. it is estimated that 350,000 to 6 million people are homeless (Walker,
1998, p. 27).
The racial/ethnic diversity among registered nurses in the United States (1993)
57
Sex – the net rate of growth between 1986 and 2000 in the U.S. labor force:
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.
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.
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.
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.
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.
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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.
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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.
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
1. Basic/Related Concepts
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).
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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.
The model for ethical decision-making, was drawn from Mann’s human right’s model
and Leininger’s culturally congruent theory.
SOCIETY
PROFESSION
ORGANIZATION
CA CR
CP
CA CR
CP 64
CA – Cultural Accomodation
CP – Cultural Preservation
CR –Cultural Repatterning
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
2. PLANNING
3. INTERVENTION
4. EVALUATION
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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.
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
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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. 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
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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
72
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
73
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
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
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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.
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.
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
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.
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
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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/HEALING PRACTIONERS
Allopathic doctor
END
BIBLIOGRAPHY
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.
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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
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
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".
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.
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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
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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