Culture-Sensitive Health Care: Asian

There are five major Asian population groups in the United States: Chinese (including people from Taiwan, Hong Kong, and mainland China), Korean, Japanese, Filipino, and Southeast Asian (including people from Laos, Cambodia, Vietnam, and Thailand). Although also inhabitants of the continent of Asia, people from India, Pakistan, Malaysia, and Indonesia are not included in this classification (or this section), since these groups are racially different from the five groups noted above.

Although Asian groups are very diverse in terms of culture, language, etiquette, and rules for interaction, a common thread of Confucian, Buddhist, and Taoist thought links their health care beliefs and practices.

In terms of immigration, the Asian population is the fastest growing group in the United States. The oldest and largest portion of this population is Chinese. With a population of 1,645,000, Chinese Americans make up about 0.7 percent of the total U.S. population. The second largest group of Asians in the United States is Filipino Americans, with a population of 1,470,000, or about 0.67 percent of the U.S. population. Next in order are the Japanese, Southeast Asians, and Korean Americans.

1. Follow the rules of etiquette. Asian societies are highly stratified by age and social structure; caregivers should understand and observe rules of social interaction, such as these:
• Younger people, regardless of their rank, greet elders first and address them in a formal manner. Since physicians hold a very high position in society, the patient may show respect by looking away when talking to avoid meeting the physician's eye.
• Sitting with the legs crossed, or leaning on a table or desk, or pointing at anything with the foot when talking are considered signs of contempt toward the person whom one is addressing.

2. Be aware of forms of greeting and address. Chinese, Japanese, and Koreans address one another by surname (which may be given first when the patient is asked for his or her name). They tend to address family members in terms of position in the family (e.g., Older Brother, Mother, Eldest Son, Middle Son, Husband). Long-term close friends may address one another by the family name followed by an honorific, such as san in Japanese. Southeast Asians are more at ease if they are addressed by their first names and greeted warmly, and if the caregiver shows a personal interest in their lives and families. One Laotian interviewee suggests that trinkets be kept on hand as token gifts to patients with children.
3. Understand the importance of the head . . . Most Asians consider the head the most sacred part of a human being, so the caregiver should never touch or reach over it without first obtaining the person's-or parent's-permission to do so. If a caregiver pats a child on the head or rumples the child's hair, and then the child becomes ill, the physician may be blamed for taking the child's soul and causing the illness.
4. . . . and the blood. Asians view blood as a vital element, and in Asian traditional medicine blood is not drawn for medical purposes. In fact, some Asians believe that venipuncture not only upsets the body's natural balance but weakens the person, because the body does not replenish lost blood. Caregivers should exercise restraint in the number of tests they order that involve drawing blood. When blood must be drawn, the patient should be assured that the blood will not be given to anyone else. Blood is believed to represent a person's essence, and the thought that one's essence may be given to someone else can cause great fear.
5. Understand Asians' views of dosages . . . Although most Asians expect doctors to prescribe medication (or, at the very least, recommend changes in diet), some patients may adjust the dosage downward-to as little as a half-dose-because they consider most Western or biomedical medicines "hot" and overly potent-especially to Asians, who tend to be smaller in stature than Westerners. The patient may even discontinue the medication completely without consulting the physician if the symptoms are no longer present or if there has been no relief of the symptoms within a few days.
6. . . . and oral medications. Many Asians are unused to taking pills. Medication is more often steeped in water and drunk as a form of a tea or as a slush. Southeast Asian patients also tend to believe that medication in the form of an injection is more effective than oral medication.
7. Understand how harmony and "face" may mask noncompliance. Asian patients, even though they appear to understand a diagnosis and accept a treatment plan, may fail to comply. This may be attributable to the concepts of harmony and "face" in many Asian cultures. Because of a cultural respect for harmony, Asian patients who don't understand a treatment or even disagree with it may avoid conflict and suppress negative thoughts and emotions. This is because nonacceptance of a request, especially if it is made by a physician (who automatically commands respect), would disrupt harmony. Further, to maintain both their own "face" and the physician's, Asian patients may avoid admitting that they don't understand the diagnosis or treatment plan, or will pretend to accept it when they disagree with it. Caregivers should learn to observe the indirect (often nonverbal) communication signs that indicate confusion or displeasure about the diagnosis or treatment plan, and should "test" their patients' comprehension. Rather than ask an Asian patient "Do you understand?" it is better to ask the patient to describe what he or she has been told to do or to describe the condition in his or her own words.
8. Adjust schedules to accommodate holidays. At the time of Asian holidays, it may not be effective to schedule medical appointments or procedures. Regular dietary, sleeping, and eating patterns are interrupted. Women especially are preoccupied with cleaning and food preparation, and no one wants to think about illness or medical problems.

Yin and yang. All Asian groups define health as the harmonious balance between the forces of yin and yang and the corresponding conditions of hot and cold. Illness is attributed to an upset of this balance. Illness can be cured only if the balance is restored by lowering the excessive trait or increasing the deficient one. Most traditional medical investigation involves a search for imbalances within the patient's physical and mental self. Treatment focuses on the restoration of balance.

Hot and cold theory of disease. Everything in the universe is classified as either yin, which is "cold," or yang, which is "hot." The terms refer not to temperatures but to attributes and/or conditions based upon yin and yang. The hot/cold classification, which is applied as much to recently discovered diseases and biomedical treatments as to traditional ones, includes parts of the body and their functions (e.g., childbirth), diseases, foods, and medicines. A "hot" disease is treated by a "cold" medicine in order to rebalance the patient's condition. Linden tea, for example, which may be served hot, is considered a "cold" herb and is used to treat "hot" ailments. Penicillin, on the other hand, is considered a "hot" treatment because it can produce diarrhea and rashes, which are viewed as "hot" symptoms.

While not all Asian patients subscribe to these beliefs, no caregiver can afford to ignore the possibility that a particular patient may consciously or unconsciously be influenced by them to some degree. Their effect on both trust and adherence to prescribed treatments can be enormous. For example, water and fruit juice are "cold" substances that are to be avoided during illness and after childbirth, times that produce a "cold" condition. Consequently, Asian patients may greatly curtail their fluid intake and may be reluctant to bathe or shower for as long as 30 days, since water conducts "cold" into the body. If a Western-trained physician prescribes cold liquids to a person with a cold who is running a high fever, not only might the patient ignore the physician's advice, but he or she might also question the medical knowledge of the physician.

Qi or Ch'i. Other important Asian concepts about health care concern blood and an energy force known in Chinese as Qi or Ch'i. The generation and flow of blood through the vessels, and the flow of the energy force (Qi) through the meridians or acupuncture points, are the fundamental factors most involved in the harmonious/disharmonious states of the body. Blood is believed to be "ruled by the heart, governed by the spleen, and stored in the liver." Qi involves all organs but has a special relationship with the liver, lungs, and spleen. When the flow of Qi is blocked by a broken bone or disease, acupuncture at the meridians permits the force to flow freely again.

Harmony. Diet plays a major role in Asian health and illness beliefs, and many preventives and cures depend on regulating or changing the diet. Because foods and beverages are classified as either yin or yang, "hot" or "cold," what one eats has a major impact upon the balance and harmony essential to health. Many Asian groups, such as the Chinese, Japanese, and Koreans, believe that their cuisine naturally balances these forces. To some extent, this may be true. For example, a study of the symptoms of menopause among women in rural Japan and women in the West found fewer menopausal symptoms among the Japanese women, a finding attributed to a Japanese diet high in soybean, a substance that contains natural estrogen.

Hospital food. Many aspects of the Western diet, which are reflected in dietary suggestions made by physicians and by the food served in hospitals, conflict with beliefs about the balance of "hot" and "cold." In addition, most Asians are lactose intolerant. Salads and raw vegetables are also strange to people who derive most of their vegetable nutrients from stir-frying. Because an Asian patient may find hospital food strange and unappealing, it is customary for relatives to bring food from home. In most cases, the food will provide the patient with a healthful, balanced meal with which he or she is familiar, and hospital staff should be counseled to accept this custom.

Asian "chicken soup." Rice soup with chicken is a common "illness food" among Southeast Asians. It is also believed to diminish the severity of scars from surgery.

Beef and eggs. Many Southeast Asians believe that neither beef nor eggs should be served to those who are ill.

Childbirth. After childbirth Asian women prefer to eat mostly fish and avoid deep-fried foods, meats in any form of sauce, and spicy foods.

The role of the wife or mother. Since the wife or mother is firmly in charge of the Asian family kitchen, any recommended change of diet for her family members should be discussed with her.

In general, most Asians do not seem to perceive any great dichotomy between the Eastern and Western medical belief systems. There is a widespread belief that some illnesses are best treated by traditional Chinese medicine and others by Western physicians. For example, Western physicians are often consulted for problems involving dentistry, fever, allergy, eye problems, heart attack, stroke, surgery, diabetes, and cancer, while traditional physicians and herbalists are sought for asthma, arthritis, bruises, sprains, lumbago, stomach problems, and hypertension.

Often a Western physician is visited for diagnosis and treatment, but, once the complaint has been diagnosed, the person will self-medicate by using herbs and patent medicines purchased over the counter. If the Western treatment doesn't bring immediate relief of the symptoms, the patient may seek the care of a traditional physician or healer. The same thing may happen if a Western diagnosis is rejected because it bears a negative prognosis (including diagnosis of a long-term illness or of an illness that cannot be fully cured) or because surgery is advised. The traditional treatment may either replace the Western treatment or be used along with it. Many Asian patients do not disclose the use of traditional care and medications to their Western physicians because the two medical domains-Western and traditional medicine-are seen as entirely separate. Some patients may also fear that the Western physician (an authority figure) will disapprove, or they believe that disclosure of the traditional care would violate the relationship of trust.

Most traditional medical interventions that may be sought by Asian patients living in America are versions of healing practices that originated in China and then spread throughout Asia.

Acupuncture. This treatment, which is also becoming more popular with Westerners, was developed by Chinese physicians between 106 b.c.e. and 220 a.c.e. Its purpose is to treat an excess of yang and restore the balance between yin and yang. It involves the application of nine needles to specific meridian points. These meridians are said to extend to a fixed network of 360 points where the lines emerge.

Treatments wrongly interpreted as abuse. Three Asian medical treatments that leave welts difficult to distinguish from the bruises left by beatings have been the source of much misunderstanding between Asian parents who have recently immigrated to the West and Western educators and social workers who come into contact with their children. Many parents whose children have been administered these treatments by family members or healers have been charged with child abuse and have had their children taken from them. The marks of these treatments have also led to investigations of spousal abuse when unknowing caregivers have observed them on female patients.

Herbs. Herbs, in the form of a slush, tea, or other drink, are an important part of traditional medicine in all Asian cultures. Herbal remedies require prescriptions from traditional healers. These remedies can be very expensive.

Home remedies. Many Asians routinely engage in home preventive treatment. Sometimes the treatment consists of nothing more than the use of cooling drinks and foods in hot weather and heating foods and drinks in cold weather. Asians often find other curative treatments, such as tonics and herbs and changes in diet, by consulting family and friends or by reading home medical manuals that list home remedies. These herbs and patent medicines, which can be purchased over the counter in herbal dispensaries or groceries, are often a person's first recourse at the initial sign of illness, before any form of medical help is sought. With home remedies, as with medical care, "mixing and matching" and "trial and error" are very common. Patients may buy two or three patent medicines with the same ingredients, or patent medicines that duplicate herbal prescriptions, to test their effectiveness. They may also take herbal medications in combination with prescriptions from Western physicians, or even experiment with the dosages prescribed by physicians.

The similarities in social structure, communication style, and health care beliefs and practices that link very diverse groups of Asian Americans can be traced to the interrelated and overlapping philosophical and religious teachings of Confucianism, Buddhism, and Taoism. These beliefs, including the concepts of yin and yang, the five elements, harmony, tao (the way), the "golden mean," and nature and fate, originated in China and then radiated outward to Japan, Korea, Southeast Asia, and the Philippines.

Confucianism. Confucianism (and neo-Confucianism) concentrates on interpersonal rules and the proper way to conduct social interactions. It reminds people to practice moderation and avoid excess, and to understand that they are destined to fulfill their mission on earth and need to allow ming, or fate, to guide their lives.

The key teachings on social interaction are reciprocity, or pao (one should treat others as one wants to be treated), and loyalty, or chung. These two teachings have led to a respect for authority and a demand for filial piety that manifests itself in most Asian groups by two expectations: that young people will respect and obey the wishes of their parents and other elders, and that one owes unquestioning allegiance and subordination to one's elders and authority figures. Other teachings include benevolence, which involves helping others, and righteousness, which dictates doing what is appropriate and expected.

Western physicians and other caregivers are often taken aback when Asian patients present them with a gift. This custom, too, can be traced to the teachings of Confucius. One expresses good wishes by giving gifts on social occasions and holidays, and an expensive gift enhances one's face or shows off one's wealth. Further, it is expected that a gift or favor will be returned; in the physician-patient relationship, the return usually hoped for is good care.

Another Confucian belief-one that can have a profound effect on an Asian patient's attitude toward surgery-is that "only those shall be truly revered who, at the end of their lives, will return their physical bodies whole and sound." In other words, the body is regarded as being lent to a person during life on earth. Only those who return the body whole at death can expect to go to heaven. Therefore, Asians are not likely to agree easily to removal of any body part or to organ donation.

Buddhism. Buddhism, brought to China from India between 563 and 483 b.c.e., has also shaped the world view and values of most Asians. Out of Buddhist teachings come many attitudes toward life and behavioral traits that may manifest themselves during physician-patient interactions. These include acceptance of fate and suffering, stoicism, behavioral reserve, and suppression of negative thoughts and complaints. Zen Buddhism, which came to Japan from China in the thirteenth century, stresses meditation and enlightenment, which result from intuitive thought, self-discipline, and a direct style of life.

Taoism. Taoism is based upon the philosophy and teachings of Lao Tzu (sometimes translated as "Laotse"), who was born in China about 604 b.c.e. Much of the Asian perspective on health comes from Taoist thought. The central belief of Taoism involves finding the "way," or tao. This is achieved by "flowing in accordance with nature" and remaining in harmony with both the cosmological (yin/yang) and natural spheres. Following the natural ebb and flow of the universe means that one adopts the chung-yung, or golden mean, by maintaining a middle position that avoids extremes.

In many ways, this philosophy advocates noninterference and inaction: learning to detach oneself from the world and allowing things to become what they will. Further, the Taoist cyclical view of nature implies that one should remain in harmony with the changing of the seasons, the waxing and waning of the moon, and the rhythm of night and day. Taoism teaches that life, too, is a cycle consisting of birth, death, and reincarnation; that all things in nature ebb and flow, reaching one extreme (e.g., fortune) and then reverting to the other (e.g., misfortune). The reserve that Asians instinctively show in times of prosperity and the stoicism they display in the face of illness and danger can be misunderstood by Westerners; caregivers should make every effort to understand and respect these beliefs and attitudes.

Ancestor worship. Ancestor worship is an important link in the Asian religious and belief system, as well as in attitudes about health, illness, and forms of cure. The brightly colored altars with offerings of fruit and flowers (and sometimes even articles of clothing) that Westerners are apt to notice when entering an Asian home or place of business honor the family's ancestors, who are often asked to watch over members of the family and prevent or cure illness.

Yin and yang. Even older than the religious philosophies described above is the cosmological principle of complementary duality, better known as the theory of yin and yang. Yin, which represents the negative, dark, cold, feminine side of all things, and yang, which represents the positive, bright, warm, masculine side of all things, must remain in balance and harmony. When they are out of harmony, disease and catastrophe occur.

This theory of yin and yang (am/duong in Vietnamese, um/yang in Korean, and so on) permeates almost every aspect of the Asian world view, including lifestyle, values, health, and illness. According to this theory, every facet of life and nature is made up of opposite but complementary forces that do not exist apart from one another. Since everything that is yin has a small amount of yang in it, and vice versa, Asians tend to view things in shades of gray rather than as absolutes. Sometimes this makes it difficult for Asians to accept a Western diagnosis of a single "cause" of a complaint or to rely on a single form of medical treatment or cure.

Spector, Rachel E. "Health and Illness in the Hispanic-American Community." Cultural Diversity in Health and Illness. 4th ed. Stamford, CT: Appleton & Lange, 1996.

Chen-Louie, T. "Nursing Care of Chinese American Patients." Ethnic Nursing Care: A Multicultural Approach. Ed. M. S. Orque, B. Bloch, and L. S. A. Monrrowy. St. Louis: C. V. Mosby, 1983.

Kaptchuk, Ted. The Web That Has No Weaver:Understanding Chinese Medicine. New York: Congdon & Weed, 1983.

Kleinman, A. Patients and Healers in the Context of Culture. Berkeley: University of California Press, 1980.

Lai, Magdalene C. and Ka-Ming Kevin Yue. "The Chinese." Cross-Cultural Caring: A Handbook for Health Professionals in Western Canada. Ed. N. Waxler-Morison, J. M. Andersen, and E. Richardson. Vancouver: University of British Columbia Press, 1990.

Anderson, J. N. "Health and Illness in Filipino Immigrants." Western Journal of Medicine, 139, 1983, 811-819.

Orque, M.S. "Nursing Care of Filipino American Patients." Ethnic Nursing Care: A Multicultural Approach. Ed. M. S. Orque, B. Bloch, and L. S. A. Monrrowy. St. Louis: C. V. Mosby, 1983.

Lee, P., and Jeanette Takamura. "The Japanese Americans in Hawaii." Crisis in Cultural Caring. Ed. N. Palafox and A. Warren. Transcultural Health Care Forum, John A. Burns School of Medicine, University of Hawaii, 1980.

Lock, M. "Japanese Responses to Social Change-Making the Strange Familiar," Western Journal of Medicine, 139, December 1983.

Pang, Keum Young. "The Practice of Traditional Korean Medicine in Washington, D.C." Social Science Medicine, 28(8), 1989, 875-884.

Muecke, M.A. "In Search of Healers-Southeast Asian Refugees in the American Health Care System," Western Journal of Medicine, 139, December 1983, 835-840.

Calhoun, M.A. "The Vietnamese Woman: Health/Illness Attitudes and Behaviors." Women, Health, and Culture. Ed. P. N. Stern. Washington, D.C.: Hemisphere Publishing, 1985.