University of Michigan Health System

Multicultural Health Program

Cultural Competency - Multicultural Health Generalizations

May 2007 Asian American and Pacific Islanders

April 2007 Cambodian Culture and Health Beliefs

March 2007 Baha'i Health Beliefs

February 2007 Caring for Patients from Somalia

January 2007 Geriatric Chinese Patients

December 2006 Jehovah's Witnesses and Bloodless Medicine

November 2006 American Indian Elders

October 2006 Islamic Health Care Beliefs

September 2006 Latino Maternal and Reproductive Health

Maternal and Reproductive Health Beliefs
Reproductive Health of Latinas in the U.S.
Maternal and Child Health (last section - scroll down)
Entre Parejas: An Exploration of Latino Perspectives Regarding Family Planning and Contraception.

August 2006 Korean-Americans

July 2006 Communicating with Russian Patients

June 2006 Judaism and Health

May 2006 Asian Pacific Americans

April 2006 Hinduism and Health

March 2006 Amish Health Care Beliefs and Practices

The Amish believe all life is given and taken by God and their beliefs tell them to accept God's will as it is.
The Amish prefer to give birth at home and to die at home.
The elderly believe in rationing care near the end of life because they do not want to waste the community's/church's money.
Disability is generally feared more than death. If treatment is refused by the Amish patient, be sure to thoroughly educate him/her if disability from his/her illness is a potential possibility.
Amish couples are usually not deterred from having more children when they have a child with a heredity defect. A child with disabilities is referred to as a special child and is accepted as God's will.
The Amish do not forbid the use of modern medical care. If deemed necessary, they can have surgical procedures, dental work, anesthesia and blood transfusions.
Organ transplants are permitted with the exception of heart transplants (the heart is the soul of the body).
They usually do not have health insurance as it is a "worldly product" and may show a lack of faith in God.
Most Amish need to have church (bishop, community) permission to be hospitalized, as it is the community who will come together to help pay the costs.
The Amish generally do not like to be seen by a health care provider who is in the "learning process". The Amish believe if they are going to pay out-of-pocket for their care, they want to be seen by an experienced practicing provider.
Speak to both the husband and wife regarding health care decisions; they consider themselves as partners in family life.

Source:
Lee, D. (2005) Our Amish Neighbors: Providing Culturally Competent Care Multicultural Health Series. Videotape and handout available from the UMHS, PMCH, Cultural Competency Division.

February 2006 African Americans and Death & Dying

Faith or spirituality can play an important role in the life and death of many African Americans.
One reason why some African Americans might be resistant to completing written advanced directives is historical mistreatment, and thus mistrust of the medical system.
Among the younger generations of African Americans, some are giving more consideration to hospice.
Palliative care is an option acceptable among some African Americans.
A dying African American patient or family member might request the presence of a spiritual leader at the bedside.
Many African Americans and their friends may have a desire to mourn together at the death of a loved one.

Sources:
1. Edwards, G. (2006). Program for Multicultural Health, University of Michigan Health System.
2. Andrews, J.D. (2005). African Americans. Cultural, Ethnic, and Religious Reference Manual for Health Care Providers. (3rd edition). JAMARDA Resources, Inc. Winston-Salem, NC.
3. Barrett R.K., Heller K.S. (2001). "Death and dying in the black experience: An interview with Ronald K. Barrett." Innovations in End-of-Life Care. 3(5), http://www.edc.org/lastacts (accessed 2/2006)
4. Crawley, L., Payne, R., Bolden, J., Payne, T., Washington, P., & Willaims, S. (2000). "Palliative and End-of-Life Care in the African American Community" JAMA. 284(19):2518-2521

January 2006 Sikh Perspectives on Health Care

The sanctity of life is an injunction, therefore:
- Assisted suicide and euthanasia are not encouraged.
- Therapeutic genetic engineering is accepted.
Organ transplants and blood transfusions are accepted. Furthermore, the Sikh youth are encouraged to become donors.
When possible, consult the patient and family before procedures requiring the removal of hair.
Advanced directives are individual choices
Maintaining a terminal patient on artificial life support for a prolonged period in a vegetative state is not encouraged. Most Sikhs will probably specify a period of time during which they would prefer to be kept on life support.
When timely, have relatives and granthi (a spiritual leader) nearby to recite Shabad Kirtan (sacred music) at end-of-life.
When possible, avoid interrupting prayer or meditation when patient care can be delayed.
When feasible, allow the family and granthi to follow traditions to prepare the body for cremation.
The body should be cremated expediently, unless the family is waiting for other relatives to arrive
There are no contraindication to autopsies.

Sources:
Bhatia, J.M. (2004). "Sikh Perspectives on Healthcare." Multicultural Health Series, UMHS, PMCH, Cultural Competency Division.
Andrews, J.D. (2005). “Sikhs.” Cultural, Ethnic, and Religious Reference Manual for Health Care Providers. (3rd edition). JAMARDA Resources, Inc. Winston-Salem, NC.
Sikh Patient’s Protocols for Health Care Providers. http://www.sikhwomen.com/health/care/protocol.htm#Practices
(accessed 1/05)

12/19/05 Jewish Dietary Laws

Jewish dietary laws, also known as the laws of kashrut or kosher laws, are very important in Judaism. These laws regulate virtually every aspect of eating, including:

which animals may be eaten. Animals that may be eaten are those that part the hoof, and are cloven-footed, and chew the cud, such as cattle, sheep, and goats. Sea creatures that have fins and scales are also acceptable. While most non-predatory fowl are permitted, only eggs from kosher fowl may be eaten. Animals that do not meet these criteria, such as pigs, are forbidden.
the method of slaughter (the laws of shechitah which are designed to lessen the suffering of animals) by a trained religious person known as a schochet. However, these laws do not apply to fish or invertabrates.
the method of preparing meat and poultry (known as kashering), which primarily involves removing as much of the blood as possible.
a prohibition against cooking or eating dairy products along with meat (fish is excluded from this prohibition). This prohibition has been extended by the rabbis so that religious Jews have separate sets of dishes, pots, and utensils for meat and dairy dishes, and do not wash anything used for meat along with anything used for dairy products. Jews also wait a number of hours (the amount depending on the tradition of the individual) after eating meat (again fish is excluded) before consuming any dairy product.
the prohibition of certain foods during the festival of Pesach (Passover). Any food or food product containing fermented grain products (chametz) may not be used or remain in a Jew's possession on Passover. Jews of Eastern European descent might also not eat many legumes (kitniot) and products containing them as ingredients throughout Passover.
While not strictly part of the kosher laws, there are other laws and traditions associated with eating, including the ritual washing of hands, with an associated blessing, blessings over various foods, and bircat hamazon (blessings of gratitude and praise recited after the meal).

Sources:
Purnell, L. D., and Paulanka, B. J. 1998. Transcultural Health Care: A culturally competent approach. Philadelphia: F. A. Davis Company.

Schwartz, R., Ph.D. Vegetarianism and the Jewish dietary laws. (Online). http://schwartz.enviroweb.org/dietlaws.html (disabled) (2002, Aug. 23).
Redirected to: http://www.jewishveg.com/schwartz/dietlaws.html

12/5/05 Saudi Spiritual Healing

Spiritual healing methods are widely practiced by Saudis for the whole spectrum of disease, with particular emphasis on conditions for which no curative medicinal treatment is known.
These include the healing of conditions such as possession by Jinn, mal-effects of evil eye, and poisonous stings.
The common spiritual healing practices among Saudis are the ones advised according to the teachings in the Noble Qur'an and (or) Sunnah.
The main spiritual modality of treatment is the recitation of verses of the Qur'an and specific sayings of the Prophet Mohammad.
Zamzam water (obtained from the Zamzam well in the Holy Mosque in Makka), honey, and black cumin (Nigella seeds) are considered healing agents.
The use of amulets is extremely rare in Saudi culture, as this practice was discouraged by the Prophet Mohammad.
Expression of respect toward spiritual healing practices by health care providers is likely to foster a good relationship with patients and families.

Source:
Al-Shahri, M. Z. (2002). Culturally Sensitive Caring for Saudi Patients.Journal of Transcultural Nursing 13, 2, 133-138.

11/21/05 Native American Family Relationships

Family is broadly defined to include the immediate family as well as extended family members and fictive kin. "Family" is a matter of blood and spirit. Other members of the family's tribe may also be included as part of the family.
Extended family relationships are important, especially during illness and death. Any illness concerns the entire family.
Decision-making varies with kinship structure.
Generally, individuals speak for themselves, but family members may speak on behalf of the person who is ill. Family spokesperson varies with kinship structure and culture. Spokesperson may not be decision maker.
In many cases, extended family members, rather than the biological parents, may hold primary responsibility for the care of the children.
In interactions with healthcare providers, these extended family members may act as advocates for the child and family in obtaining needed healthcare.

Sources:
Andrews, J.D. (2005). "Native Americans." Cultural, Ethnic, and Religious Reference Manual for Health Care Providers. (3rd edition). Winston-Salem, N.C.: JAMARDA Resources, Inc.

Kramer, J. (1996). "American Indians." Culture and Nursing: A Pocket Guide. San Francisco: University of California.

Lynch, E. W., Hanson, M. J., (1997). A Guide for Working with Children and their Families: Developing Cross-Cultural Competence. (2nd ed.). Maryland: Paul H. Brooks Publishing Co.

11/7/05 Hindu Cultural Responses to Health and Illness

The sick role is assumed without any feeling of guilt or ineptness in doing one's tasks. Because of strong family and kinship ties, the sick role is well accepted. The individual is cared for and relieved of responsibilities for that time.
Also because of strong family ties and joint and extended families, Hindus are not likely to use long-term care facilities.
Because of religious beliefs of karma, Hindus may attempt to be stoic and may not exhibit symptoms of pain. Furthermore, pain is attributed to God's will, the wrath of God, or a punishment from God and is to be endured with courage. As a result, healthcare providers may want to rely more on the nonverbal aspects of pain.
The practice of self-medicating may mask disease symptoms until the health condition is at a more advanced stage, making treatment regimens more complex.
Some Hindus might have a fatalistic attitude about illness causation.
Because of the stigma attached to seeking professional psychiatric help, many Hindus do not access the healthcare system. Instead, family and friends seem to be the best help and a general belief is that time is the best healer.

Source:
Purnell, L. D., & Paulanka, B. J. (1998). Transcultural Health Care: A Culturally Competent Approach. Philadelphia, PA: F. A. Davis Company.

10/24/05 Cambodian Health Beliefs and Practices

In general, Cambodians (or Khmer) are comfortable with western medicine and with traditional healing practices.

Some of the following traditional healings are carried out by family members and some by traditional healers or kruu Khmer. Some kruu Khmer specialize in medicinal practice with a spiritual component, while others specialize in magic with a medicinal component. Regardless of who carries out the below or other procedures, they are often accompanied by prayer and other spiritual activities.

Koo' (rub) kchall (wind) is used to treat a variety of ailments, including fever, upper respiratory infection, nausea, weak heart, and malaise. A coin is dipped in a mentholated medicine and rubbed in one direction (away from the center of the body) in a symmetric pattern on the patient's chest, back, and/or extremities. This is referred to in western literature as "coining" or "dermabrasion."
Jup (pinch) kchall is used to treat headache and malaise. Jup includes pinching and thus bruising the bridge of the nose, neck, or chest or the practice of "cupping" or placing a small candle on the forehead, lighting the candle, and placing a small jar over the candle. The flame consumes the oxygen and creates a vacuum, thus causing a circular contusion.
Oyt pleung (known as "moxibustion" in the literature) is used to treat gastrointestinal and other disorders. Oyt pleung is seldom done in the U.S., but the abdomens of some Cambodian adults might have four to six 1-2 cm round scars resulting from the procedure.
Massage or manipulation is practiced by kruu Khmer and others.

There often are both spiritual and medicinal elements in healing practices. Magico-religious articles such as amulets, strings, and Buddha images are commonly part of treatment or prevention of illness. Other spiritual or magical means of treating illness include blowing on the sick person's body in a prescribed manner and showering or rubbing with lustral water. As noted earlier, many Khmer see no conflict in practicing or using traditional or magic means of treating illness simultaneously with western medicine. Many would further see no conflict in adding Christian prayer to the mix.

Most Khmer are oriented more to illness than prevention of illness. Childhood immunizations are accepted, but adult immunizations (influenza, pneumonia) are of little interest until illness strikes. Most Khmer do not value early detection or disease screening.

As with most other cultures, respect is essential. Communication is often indirect and requests or questions may be couched in seemingly vague terms. It is unusual for older people to make a direct "no" response to a question or request.

Source:
http://www3.baylor.edu/~Charles_Kemp/cambodian_health.html
Accessed October 20, 2005.

10/10/05 Islamic Fasting During Ramadan

About Ramadan
- Ramadan, the holiest of the four holy months, is the ninth month of the Islamic Lunar calendar; beginning approximately October 4, 2005, and concluding around November 2, 2005.
- Ramadan begins with the sighting of the new moon, after which all physically mature and healthy Muslims are obliged to abstain from all food, drink, gum chewing, any kind of tobacco use, and any kind of sexual contact between dawn and sunset.
- However, that is merely the physical component of the fast; the spiritual aspects of the fast include refraining from gossiping, lying, slandering and all traits of bad character. All obscene and irreligious sights and sounds are also to be avoided. Purity of thought and action is paramount.
- The month of Ramadan is a time for spiritual reflection, prayer, doing good deeds and spending time with family and friends. The fasting is intended to help teach Muslims self-discipline, self-restraint and generosity. It also reminds them of the suffering of the poor, who may rarely get to eat well.
- It is common to have one meal (known as the Suhoor), just before sunrise and another (known as the Iftar), directly after sunset. Because Ramadan is a time to spend with friends and family, the fast will often be broken by different Muslim families coming together to share in an evening meal.
- Fasting is not required for children but often by the early teenage years, fasting begins for at least part of the day (Ali, 1996).
Fasting and Health
- Women who are menstruating, pregnant, or lactating, as well as sick individuals and travelers, are exempt from fasting (Ali, 1996). These individuals, however, are required to fast at another time during the year.
- Long periods of fasting from both food and drink, alternating with feasting, can be challenging for those with a chronic illness such as diabetes. If at all possible, health care providers should work with patients to adapt their treatment plans with the fasting schedule.
- If it is not therapeutic for the hospitalized Muslim patient to fast, it is helpful if the healthcare provider can explain such reasons. To the devout Muslim, the fast may be more important than the treatment plan. Hence, it can be beneficial to find a workable compromise.

Sources:
1) Lawrence, P. and Rozmus, C., 2001. Culturally Sensitive Care of the Muslim Patient. Journal of Transcultural Nursing 12, 3, 228-233.
2) http://www.ramadan.co.uk/index1.php?page=others.htm (disabled link - redirected to http://www.ramadan.co.uk/index1.php?page=resource.htm)

9/26/05 Cuban Communications:

Greetings
- Only formal during the first introduction.
- Afterwards, a familiar tone and address are used.
- A handshake is common among men.
- Elderly people are shown more respect.
- Family members and close friends greet by embracing and kissing on the cheek.
Tone of voice
- May seem to speak loudly in normal conversation.
- Requests and commands are direct.
- Conversation may seem aggressive to an outsider.
Nonverbal communication
- Cubans are typically outgoing and confronting.

Close contact and touching are acceptable and a sign of affection among family and friends.
Direct eye contact is expected during conversation. Looking away shows a lack of respect or dishonesty.
Silence usually means awkwardness or uncertainty.
Cubans often use hand gestures to add emphasis when talking.

Do Not Resusciate
- DNR orders are usually not acceptable to Cubans.
- They may feel strongly that everything possible should be done for the patient.
- Agreeing to a DNR shows giving up hope and allowing the patient to die, which is seen by others as uncaring and abandonment.
- A fear of death can be quite strong among Cubans.

Source:
Varela, L. (1996). "Cubans." Culture and Nursing Care: A pocket guide. San Francisco: University of California.

9/12/05 Cultural Barriers to Healthcare among Arab-Americans:

Medical care and providers:
- An Arab-American patient seeing a doctor may expect to receive medication and have relief from pain during the first visit. Such patients may need an explanation for not receiving medication or lab testing.
- When Arab-Americans suffering from mental distress seek medical care, they could be likely to present with a variety of vague complaints. Patients often expect and prefer somatic treatment. Hospitalization is resisted because such placement is viewed as abandonment.
Privacy:
- Some patients may not disclose detailed information about themselves or their families, especially to strangers.
- Women may not want to talk about their private lives. However, they may feel more comfortable talking with female doctors.
- Sexual problems and venereal diseases can be a difficult topic for patients to discuss.
Diet:
- Muslims might eat only Halal meat (meat from animals slaughtered according to Islamic tradition).
- During Ramadan (10/5/05-11/4/05), Islamic patients might not take medications, eat or drink from sunrise to sunset.

Source:
Purnell, L. D., & Paulanka, B. J. (1998). Transcultural Health Care: A Culturally Competent Approach. Philadelphia, PA: F. A. Davis Company.

8/29/05 Symptom and Pain Management among Japanese-Americans:

Many Japanese-American patients hold a cultural belief of self-control and self-discipline which can contribute to symptom and pain management.
While older generations may delay seeking medical assistance until symptoms become severe, younger generations may acknowledge illness sooner and be more open to self-care.
Some Japanese-American patients may seem stoic in expression of pain or discomfort.
While some maintain a high pain threshold, others may simply refrain from asking for pain medication.
Older generations might be especially concerned about becoming addicted to medication and therefore, may refuse to take medication as prescribed.
Patients who do follow healthcare providers' instructions may prefer oral medications to injections.
When pursuing self-care, Japanese-American patients may be more likely to listen to health care professionals than family members.

Source:
Shiba, G. & Oka, R. (1996). "Japanese Americans". Culture and Nursing Care: A Pocket Guide. San Francisco, CA: University of California

which animals may be eaten. Animals that may be eaten are those that part the hoof, and are cloven-footed, and chew the cud, such as cattle, sheep, and goats. Sea creatures that have fins and scales are also acceptable. While most non-predatory fowl are permitted, only eggs from kosher fowl may be eaten. Animals that do not meet these criteria, such as pigs, are forbidden.
the method of slaughter (the laws of shechitah which are designed to lessen the suffering of animals) by a trained religious person known as a schochet. However, these laws do not apply to fish or invertabrates.
the method of preparing meat and poultry (known as kashering), which primarily involves removing as much of the blood as possible.
a prohibition against cooking or eating dairy products along with meat (fish is excluded from this prohibition). This prohibition has been extended by the rabbis so that religious Jews have separate sets of dishes, pots, and utensils for meat and dairy dishes, and do not wash anything used for meat along with anything used for dairy products. Jews also wait a number of hours (the amount depending on the tradition of the individual) after eating meat (again fish is excluded) before consuming any dairy product.
the prohibition of certain foods during the festival of Pesach (Passover). Any food or food product containing fermented grain products (chametz) may not be used or remain in a Jew's possession on Passover. Jews of Eastern European descent might also not eat many legumes (kitniot) and products containing them as ingredients throughout Passover.
While not strictly part of the kosher laws, there are other laws and traditions associated with eating, including the ritual washing of hands, with an associated blessing, blessings over various foods, and bircat hamazon (blessings of gratitude and praise recited after the meal).

Sources:
Purnell, L. D., and Paulanka, B. J. 1998. Transcultural Health Care: A culturally competent approach. Philadelphia: F. A. Davis Company.

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