Cultural Traditions and Healthcare Beliefs of Some Older Adults The following information is based on generalizations. Always note that there will be individual differences in patients and families. The cultural behaviours will also be affected by the acculturation process.
Information assembled from a variety of sources by Barbara Dixon, Manager, Diversity and Immigrant Student Support, Red River College, 2009 1
Older Patients of Arab and/or Muslim Origin
Dietary issues are important for Muslim elders, because traditionally they do not drink alcohol, eat pork, or eat blood products. Lard is another avoided ingredient; baked goods and crackers are therefore examined for their content before consumption. Hospitalized Muslims may prefer to eat food prepared by their families in order to maintain dietary standards. Muslims may also resist eating or taking medications during the daytime hours of Ramadan, a holy month whose timing varies from year to year. Sick and elderly believers may be exempt from fasting during Ramadan, as some exceptions are made for frail individuals. Elderly persons of Arab origin may subscribe to folk remedies and beliefs. Beliefs may include concern about the evil eye – those who are envious may have the power to inflict injury on the family. Folk prevention measures, which include religious measures, are taken to divert the evil spirit to prevent harm.
Tip for Nurses: Explore these issues gently with elderly patients and incorporate an understanding of traditional remedies into an overall care plan.
Mental illness is one of the most feared medical conditions among Arab Muslims. Psychiatric issues are thought to arise from a loss of faith in God or possession by evil. Those suffering from “madness” are likely to seek the help of a religious intermediary or a fold healer and may neglect formal medical care. Among elderly persons of Arab origin and their families, mental illness may be considered a secret to be minimized, covered up, or denied. Traditionally, the young adult offspring’s chances of marriage are believed to be affected if family medical secrets are disclosed. Preventive medical treatment may be seen less important than treatment of acute symptoms of illness and injury. 2
Older patients may expect prescription drugs to address their symptoms, but once the symptoms subside, they may discontinue their prescribed regimen. There is a belief in individual responsibility to obtain medical care but ultimately most believe that recovery from illness is in the hands of God.
Tip for Nurses: Provide an explanation to patients about why extended medication use is necessary. Negotiate with the patient may be necessary to promote adherence to long-term drug regimens.
In Arab tradition, family members are obligated to visit and bring gifts to hospitalized elderly persons, and therefore may not wish to adhere to visitation restrictions in the hospital. Muslims practice and expect high standards of modesty and may also be embarrassed by personal questions. Cleanliness is another important aspect of Islamic tradition. After death, family members may have specific wishes regarding what is to be done with the patient’s body such as the ceremonial washing of the body by the family, wrapping the loved one’s body in sheets and immediate burial. “Good families” traditionally are considered capable of handling any health crisis – older family members may be hesitant to accept help from “outsiders”. Males in the family may be considered to have more authority with regard to medical decisions than females.
Tip for Nurses: Ask older patients of Arab ancestry if they prefer to make their own health decisions or if they would prefer to involve or defer to others in the decision-making process.
In Arab countries, patients are typically told only the good news about their diagnosis.
Tip for Nurses: When there is a terminal or serious diagnosis, explore each patient’s preferences regarding disclosure of clinical findings early in the clinical association and to reconfirm these wishes at intervals.
Older Patients of Chinese Origin
Older patients tend to be polite and may smile and nod. Nodding does not necessarily indicate agreement or even understanding of medical facts. If the older patient is nodding their head, it may only be a sign of respect to the speaker and not comprehension of the message.
Tip for Nurses: Agreement and disagreement is expressed differently across cultures both verbally and non-verbally. Always check for understanding by having the patient re-state or demonstrate their understanding of your directions, information, etc. back to you.
The older patient may avoid prolonged eye contact with healthcare practitioners as a sign of respect for authority. Home and folk remedies is very common, and are generally used first before seeking Western medical approaches. Traditional Chinese people believe that most illnesses are caused by an imbalance of qi (vital force or energy) and yin and yang in the body. Mental illness is thought to be due to a lack of harmony of emotions or caused by evil spirits. Mental wellness occurs when psychological and physiologic functions are integrated. Health is maintained by balancing yin-yang not only in the body but in the environment.
The “sick” role is a common behaviour among Chinese patients where family members are expected to care for the patient. The patient may take a passive role in his or her illness. Some fear having blood drawn, believing that it will weaken the body and many are adverse to donating blood. Many will avoid surgery believing that the body needs to stay intact so that the soul will have a place to live during future visits to the earth (stems from belief in reincarnation). Foods are thought to have medicinal purposes and food parts correspond to healing of body parts, e.g., eating fish eyes will improve vision. Tends to be a patriarchal society where oldest male may take on decision making role for older patients.
Culture emphasized the implicit rather than the explicit so it would be considered unnecessary, rude and inappropriate to burden a patient who is already suffering by discussing the nature of the illness in detail. Tip for Nurses: The patient may not want to clarify certain statements. Seek help from a family member.
There may be a certain degree of superstition when it comes to death and dying – note that the word “four” sounds similar to the word “death” and is therefore considered to be an unlucky number. Tips for Nurses: Avoid putting a patient in Room or Bed 4.
Some older patients may use proverbs or symbolic language to discuss death rather than the actual word.
Older Patients of East Indian Origin
Older patients expect respectful and deferential treatment as their due. Tip for Nurses: Always address the older patient formally by calling them Mr., Mrs…. until they invite you to call them by their first name.
Healthcare professionals in biomedicine command enormous respect, prestige, and admiration among people from this culture, and as a result may defer to their physicians even for simple decisions. As a way of showing respect to the healthcare practitioner, an older patient is expected to ask many questions about their medication and diet. Many patients may wear religious paraphernalia which should never be removed or cut without the consent of the patient or family member including: special clothing (tupi, a religious cap worn by Muslims), sacred ornaments (mangalsutra, a necklace worn by married Hindu women) sacred threads around the body (worn by Hindu males)
amulets (kara, a steel bracelet worn by Sikh men who have been baptized)
Practicing Hindus or Sikhs believe in reincarnation – every living being has multiple lives and goes through the cycle of birth and death multiple times. One’s actions during previous lives are thought to influence the events of future lives to come. Older patients may believe that illnesses are the result of bad karma from past lives and so may be less inclined to adhere to biomedical regimens.
Ayurveda The ancient Indian science of healing has been practiced for almost 5,000 years. Ayurveda describes three fundamental universal energies that regulate all natural process on both the macrocosmic and microcosmic levels. The three energy systems are known as the tridosha and consist of pitha (bile), vatha (wind, air), and kapha (phlegm). In a healthy person, these three forces are perfectly balanced. Any disequilibrium between the three energies manifests as a sign or symptom of disease. Common beliefs include the conviction that milk and bananas should not be eaten together, and that drinking warm water promotes health and drinking cold water makes the body vulnerable to illness.
Fasting or upwas is a common practice among the elderly particularly women as it is thought to spiritually strengthen the person and bring good luck to the family. Western concepts of autonomy are alien to the East Indian culture which emphasizes interconnectedness and downplays individualism. Important decisions are made are made after consulting with family members which could be nuclear or could be extended which may include close family friends.
Tip for Nurses: Ask the older patient about his or her preferences regarding healthcare decisions to avoid later difficulties during a health crisis.
Modesty is highly valued and may be seen where elderly women may be soft-spoken and not advocate for themselves.
Tip for Nurses: Establish a bond with older patients. Gaining their trust is clinically valuable, as older East Indian patients are more likely to seek help from those with whom they have rapport.
There is a preference to die at home surrounded by loved ones. If person dies in hospital, there is preference for same-sex staff to deal with the body.
Tip for Nurses: East Indians have extensive death rituals, which vary among religions and sects. Gently inquire about these matters from the patient’s relatives in order to avoid a cultural faux pas.
Older Patients of Filipino Origin
Filipino elders who have spent the majority of their lives in Canada may be more accepting of Western biomedical views. More traditional Filipino approaches integrate concepts of illness as being: A humoral imbalance between hot and cold in the body system Divine retribution for sins of omission or commission The role of evil spirits or witches exacting punishment for wrongful deeds The consequences of such natural events as cold drafts, thunder, lightning or typhoons Filipino concept of health is based on the principle of balance – timbang. Specific disorders are perceived to be caused by an excess intake of one type of food. Hot foods such as meat are thought to cause arthritis and hypertension. Cold foods such as many fruits and vegetables may bring about cancer and anemia.
Many elders use a dual system of health care, blending modern medicine with traditional practices and principles.
Tip for Nurses: Ask the older patient about the need for spiritual guidance and prayer while health decisions are being made.
Filial piety and respect for elders is very strong in Filipino families.
The older patient may avoid prolonged eye contact with healthcare practitioners as a sign of respect for authority. If the older patient is nodding their head, it may only be a sign of respect to the speaker and not comprehension of the message.
Tip for Nurses: To show respect to the older person address as Mr., Mrs., or Miss… including the word po in the social greetings, as in, “How are you, po?”
Older patients may more readily express emotions and concerns with a middle-aged healthcare practitioner than with a younger one.
Tip for Nurses: To emphasize respect for elders, avoid asking the question, “Do you understand?” and instead ask the patient to repeat the information, emphasizing that it is for your benefit, to ensure that you did a thorough job.
Families may be expect to be involved and may expect to be provided with substantial information regarding treatment plans. Family may be extended and include uncles, aunts, godparents who have long-standing and close relationship to the patient.
Tip for Nurses: Ask the older patient early in the relationship about his or her preferences regarding healthcare decisions to avoid later difficulties during a health crisis.
Major decisions are commonly delegated to the oldest son or daughter (they may reside outside Canada) or someone in the extended family that is a health care professional. Traditional Filipino families tend to be matriarchal, spousal approval and support will most likely be critical in health care decisions and success of treatment plans.
Older Patients of Korean Origin
Due to influences of Confucianism, it is important to show respect for the older patient’s sense of space during conversation or examination. Etiquette is complicated – avoid putting hand’s in pockets when standing. Older patient may not be accustomed to shaking hands, but if you do shake hands, bow slightly and avoid direct eye contact. During a medical interview with an older patient, always convey a message of formality and respectfulness. Many elderly Koreans may prefer Han bang, also known as Han yak, a traditional form of Asian medicine which is based on balance between un (the same as Chinese yin) and yang, as well as the balance of fire, earth, metal, water, and wood. Diagnosis methods of Han bang include observing the patient, obtaining a history of the illness, listening to a patient’s voice, and talking the patient’s pulse. Four most common treatment methods are acupuncture, herbs, moxibustion (direct or indirect burning with a stick made of the mugwort plant), and cupping (applying heated glass cups directly to the skin, forming a vacuum).
Older patients may attribute the illnesses to a failure to fulfill spiritual obligations whether these are based in Christianity, Confucianism, animism, or shamanism. Some patients may believe that their illnesses are due to failure to pray or that they have displeased an ancestor with their burial place or have offended folk spirits. Hwabyung (fire illness) is a concept that many older Korean women believe in where the illness is believed to be caused by failing to keep their emotions from being expressed openly as tradition requires. Older patients may alternate between western and traditional Korean medicine but may not share this with Western based healthcare practitioners.
Tip for Nurses: Inquire in a respectful and supportive manner about beliefs concerning concepts of wellness and illness and uses of traditional remedies.
Traditional Koreans may not be in favour of direct disclosure or consent at times of serious illness as there is the belief that voicing thoughts about sickness or death will contribute to a poor outcome when someone has a life-threatening illness. Older Koreans may believe that only the family, and not the patient, should be told about a terminal diagnosis.
Tip for Nurses: Ask the older patient early in the relationship about his or her preferences regarding who should make healthcare decisions particularly if there is ever a life-threatening situation. To avoid family conflict or differences of opinion, ask patient or family to assign a principal decision-maker.
In end-of-life care, the eldest son will usually be expected to make decisions. Like those from other cultures, there is a common belief that directly discussing death when a person is terminally ill brings about sadness or depression and hastens death.
Older Patients of Vietnamese Origin
Many South-east Asian patients may believe that their illnesses are caused by shifts in the environment. High winds and rainy weather are believed to result in rheumatism or respiratory diseases. Dampness, from getting caught in the rain, having wet hair, keeping on wet clothes, or drinking too many cold liquids is associated with symptoms of lethargy, indigestion, nausea and vomiting, and arthritis. Respect of older patients is expected and is traditionally shown by: Avoid direct eye contact especially with elders and other persons of higher status which may include healthcare practitioners. A slight bow when greeting someone. Using both hands when giving something to someone else. Keeping one’s arms crossed or hands folded in front. Interpersonal space is slightly more distant than arms length but depending on the relationship between two people can be much closer than arms length. Raising one’s voice, pointing or openly expressing emotion may be considered disrespectful or in bad taste.
Illness is sometimes attributed to “catching bad wind” and is often treated by cupping, coining or pinching.
Cupping: A cup is heated and then placed on the skin, usually on the forehead or abdomen. As it cools, the cup contracts, drawing the skin and what is believed to be the evil energy or “air” into the cup. This causes a skin alteration or scarring. Coining: 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 causing striations. Pinching (used to treat headache and malaise): is done by pinching the skin between the thumb and index finger to the point of producing a contusion at the base of the nose, between the eyes, or on the chest, neck, or back.
Older patients may expect shots to be given for treatment. Younger family members are usually responsible for health care decisions of the elderly and most often do not want the older patient to be told that he or she has a serious or terminal illness.
Tips for Nurses: Keep family members informed of the older patient’s health status and needs.
For older patients, nodding the head may show courtesy rather than understanding or consent. Spiritually based Vietnamese beliefs affect end-of-life decision making which may include: an aversion to dying in a hospital because of the belief that souls of those who die outside the home wander with no place to rest. the belief that consenting to end-of-life support for a terminally ill parent contributes to the parent’s death and is an insult to one’s ancestors. resistance to organ donation. difficult deaths are punishment for bad deeds in former lives by the dying person or another family member.
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