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The majority of Chinese Americans are immigrants from Taiwan, Hong Kong, and mainland China. Chinese Americans have the largest population among Asian immigrants. According to the U.S. Census Bureau (1993c), 1,645,472 Chinese Americans reside in the United States, representing 0.7% of the total United States population. Of the number of Chinese Americans residing in this country, a total of 66% of Chinese Americans live in five states; California, New York, Hawaii, Illinois, and Texas. While the Asian American population stands at only 10 million (3 percent), it is the fastest growing visible racial-ethnic minority in the United States and is expected to double by the year 2010, reaching 10 percent by the year 2050.
Statistics support Chinese American's interest in higher education. For example, in 1990, 77.2% of Chinese American males and 70.2% of Chinese American females 25 years of age or older held a high school diploma and 46.7% of males and 35.0% of females held a bachelor's degree. On the other hand, the poverty rate for Chinese Americans is 14.0% compared with 13.0% for the general United States population. Educational achievement and professional success are highly valued because pride and honor are brought to the family and the community as a result. Therefore, Chinese parents willingly provide support for children to pursue higher education.
During the 1840's, the first Asian immigrants came to the United States encouraged by social and economic unrest in China and overpopulation in certain provinces. During this period there was a demand for Chinese to help build the transcontinental railroad because of need for cheap labor and were welcomed into the labor forces. However, a series of business recessions, coupled with the completion of the Union-Central Pacific Railroad in 1869, made competition for jobs fierce. Because the Chinese constituted a large fraction of the California population and labor force, White workingmen saw them as an economic threat. Pronounced racial and cultural differences from the white majority made them conspicuous and they served as scapegoats for resentments of white workers viewing
Chinese laborers were seen as infringing upon economic opportunities. This economic aspect soon developed into an ideology of white supremacy compatible with mainstream of American racism. Chinese were seen as "subhuman" or "heathens" and their mode of living was viewed as undesirable and detrimental to the well-being of the United States. Laws were passed to harass the Chinese. At the height of the anti-Chinese movement, the Chinese were denied rights of citizenship, ownership of land, right of marriage and many were assaulted and killed by mobs of Whites.
In 1882, the Federal Chinese Exclusion Act was passed which was the first exclusion act against any group in America. This law was justified by the alleged need to exclude masses of cheap Chinese labor from the United States. Because of the Chinese Exclusion Act, there was a disproportionately large number of Chinese men who had immigrated to America to work, compared with a lower percentage of Chinese women. Many of these unmarried Chinese men had virtually no opportunity to marry. Thus, in 1890 only 26.1% of the total number of Chinese American men were married. The Federal Chinese Exclusion Act was not repealed until 1943 as a gesture of friendship towards China, an ally of the United States during World War II.
Chinese culture is dominated by Confucius' teachings which encourage individuals to pursue love, righteousness, decorum, and wisdom. A harmonious relationship with nature and other people is stressed, and a person is expected to accommodate rather than confront. If private interest conflicts with community interest, a person is expected to submit to the interest of the group rather than advocate personal concerns. Public debating of conflicting views is unacceptable. A person is expected to be sensitive to what people think and to be gracious toward others so as not to make them "lose face." Self-expression and individualism are discouraged, whereas filial piety to parents and loyalty to family, friends, and government is highly praised. Chinese culture values modesty, self-control, self-reliance, self-resistance, and face-saving. Shame or guilt is the result of failure to follow these cultural practices.
Treating others as one would wish to be treated is often used in interpersonal relationships. Interpersonal interactions have a hierarchical structure, so that older or higher-status people have authority over younger or lower-status people. A person's status is always referred to during interactions. For example, brothers address each other as "older brother" and "younger brother" in addition to the first name.
The sharp contrast between the Chinese and American cultures cause a high level of stress among Chinese Americans during the acculturation process. Some may hold on to traditional Chinese culture, observe holidays according to the lunar calendar, and maintain Chinese customs; some may reject all their traditional heritage; and some may assimilate both the Chinese culture and American culture.
Kinship ties and the family are basic to the Chinese American. Traditionally, the family is patriarchal. Chinese Americans traced their descent through the paternal descent lines with patrilinial ownership of property. Confucian and Buddhist teachings give support to the extended family, husband, wife, and unmarried children, and often the son's wives and children, as well as the ancestors. The extended family shows close interdependence of roles and activities within the patriarchal family structure.
The family structure derives support from the Confucian doctrine of filial piety that recognizes the "three obendiences" of women to obey her father as a daughter, her husband as a wife, and her eldest son as a widow. Each family member has a designated form of address with honorific kinship terms. The form of address indicates one's relative position and role within the family structure with respect to gender, age, generation, authority, and reverence, i.e., the highest level with paternal grandparents.
A deep sense of duty, responsibility, and obligation to each other is evident in Chinese American families. Family members are expected but to honor and respect extended family members and the family name. Children are expected to obey their parents and not bring dishonor to the family. Accordingly, childrearing practices in Chinese American families focus on developing children who are obedient, respect parents, and serve their extended family.
Mothers and female kin are the primary caretakers in the family and are responsible for disciplining the children. Mothers develop close physical and sociocultural bonds with their children. Infants are seldom allowed to cry for long periods of time, are fed on demand and weaned about two years of age. On the other hand, the father and male kin assume an indirect protective caring role.
In general, the extended family is viewed as the single strongest unit and it is from the family that one gains honor, self-esteem, and support. The success or disgrace of one member is felt by all family members. Parents often sacrifice to provide for their children, especially to give them the best possible education available. Children are highly valued as security for old age, since they are expected to return the sacrifice and care to their elder parents in advancing years. Caring for the elderly and all family members is an expected norm, and to not care for parents would be viewed as ungrateful and disgraceful.
However, the values of the Chinese American family are eroding in the acculturation process. For example, the younger generation may not show the same respect to the elderly that is expected from the previous generation. As a result of this change, many elderly persons cannot count on their children or relatives for help and may suffer from depression. In extreme cases, this may lead to suicide.
Chinese Americans tend to value silence more than mainstream society and will avoid disagreeing or criticizing. Disagreements are not verbalized so harmonious relationships will be maintained, at least outwardly. To raise one’s voice to make a point is viewed by some Chinese as being associated with anger and a sign of loss of control. To avoid confrontation, the word no is rarely used because it may cause the individual to lose face. Furthermore, the word yes can mean "no" or "perhaps."
Chinese Americans have less eye contact than White Americans because it is considered rude to have prolonged eye contact. They do not easily express emotions although they may narrow their eyes to express anger and disgust. Also, Chinese Americans do not ordinarily touch each other during conversation. Touching someone's head indicates a serious breach of etiquette. Touching during an argument indicates shameful loss of self-control. In the same respect, putting one's feet on a desk, table, or chair is regarded as impolite and disrespectful. Public displays of affection toward a person of the same sex are quite permissible. On the other hand, public displays between the opposite sex are not considered acceptable, and as a result, the Chinese are often viewed as uninterested, shy, polite, passive, or cold.
Chinese people greet others by bowing. Nodding the head may indicate "yes," whereas shaking the head may indicate "no." The nurse needs to avoid using negative questions to elicit responses, because negative questions are comprehended differently in the Chinese language. To answer a question such as "Haven't you taken your medication?" may be problematic and may lead to confusion about responding affirmatively or negatively. For instance, the response could be "No, I haven't taken my medication yet." or "Yes, I haven't taken my medication yet." Chinese Americans experience feelings of shame and embarrassment when they cannot communicate well. Some will apologize frequently for linguistic inabilities because they think they are inconveniencing others.
Because Chinese Americans often believe that they do not have control over nature and maintain a fatalistic outlook on life, they may be hesitant about seeking health care treatment. In addition, some Chinese Americans subscribe to the theory of yin and yang, which attempts to restore balance to the body. These individuals are more likely to engage in self-treatment. The nurse must be able to distinguish between practices that could be harmful, neutral, or beneficial to the client's particular medical problem. For example, some Chinese American who subscribe to the theory of yin and yang believe that food has yin and yang qualities, therefore, the nurse can help the client select the appropriate foods according to these beliefs.
Since the Chinese language is quite different from English, the nurse must remember that when Chinese Americans communicate in English, they often experience a great deal of stress. The nurse may observe symptoms of stress and can help the client relax to lower the stress level. Because Chinese Americans tend to be quiet, polite, and unassertive and tend to suppress feelings such as anxiety, fear, depression, or pain, it is important for the nurse to recognize nonverbal cues and their cultural meanings in order to develop culturally appropriate nursing care plans. Showing respect, demonstrating empathy, and being nonjudgmental can help establish rapport with Chinese American clients.
Some Chinese Americans hesitate to ask questions when they do not understand. The nurse can observe body cues that may indicate that the client seems confused. At this point, the nurse can then encourage the client to ask questions and express feelings. In addition, since some Chinese Americans do not ordinarily touch another individual during conversation it is important for the nurse to explain the necessity of touching, particularly when therapeutic assistance is needed.
Because of the complex cultural values and beliefs, diversified acculturation, and various educational levels among Chinese Americans, the nurse needs to work with individuals to assess their unique values, communication styles, social organization, and illness behaviors, in order to provide effective, culturally appropriate nursing care. The nurse should convey respect to the client, encourage pride in the Chinese culture, reduce feelings of shame, and facilitate adaptation to Western health care procedures. Whenever possible, native healing practices can be combined with Western practices, as long as there is no harm to the client.
According to the 1990 Census data (1993c) there were 847,562 Japanese Americans residing in the United States. Overall, Japanese Americans represent 12.3% of the total Asian American population. Of the number of Japanese Americans residing in the United States, 75.9% live in the West. By states, the largest populations of Japanese Americans are found in California, Hawaii, New York, and Washington.
Japanese Americans are the only immigrant group to identify themselves by the generation in which they were born, and these generational groups are distinguishable by the individual's age, experience, language, and values. The Issei are first generation to live in the United States, their children (second generation) are referred to as the Nisei, the grandchildren (third generation) are known as the Sansei and the fourth generation are known as the Sonsei.
For Issei, the family provided the anchor for the values and traditions of Japan. Today the family remains one of the most important factors in the lives of the Japanese people. The Issei generations withstood extreme hardships and made personal sacrifices for the benefit of their children. Second-generation Japanese Americans were highly influenced by the values and norms of their parents, whereas third and fourth generation Japanese Americans may be unfamiliar with Japanese language and customs. In addition, 50% of the Japanese in the United States have married outside the Japanese ethnic group, promoting further assimilation into mainstream American culture.
The Japanese were the second major Asian group to immigrate in large numbers to the United States. They came in large numbers beginning in the 1890s. Most of the early Japanese immigrants found employment in railroads, canneries, mining, and industrial occupations. Many of the Japanese immigrants were farmers in Japan and eventually gravitated towards farming and gardening. Japanese immigrants' knowledge of agriculture and their perseverance made them highly successful in these fields, where they subsequently became economic competitors. The now familiar pattern of violence and harassment previously directed at the Chinese was now channeled toward the Japanese. This pervasive anti-Oriental feeling became labeled as the "Yellow Peril."
During this period of history, Japan was a rising international power and the anti-Japanese feeling did not manifest itself in direct governmental legislation to restrict immigration. Instead, a "Gentlemen's Agreement" was made with Japan to seal the flow of Asians to United States. To further harass the Japanese, California passed the Alien Land Act in 1913 that forbade aliens to own land. The discrimination and prejudice toward the Japanese was most blatantly evident in the World War II incarceration of 110,000 Japanese Americans into concentration camps. This caused many serious problems with the tragic disruption of family interdependency and the loss of Japanese businesses, farms, and homes. To prove their loyalty as Americans and combat the racism that confronted them, an overwhelming number of Nisei volunteered for the all-Nisei 100th Infantry Battalion and its larger unit of Japanese Americans, the 442nd Regimental Combat Team. These volunteers, who came from Hawaii and mainland internment camps, emerged as the most decorated unit for its size and duration of services.
The relocation camps were declared unconstitutional in 1945. But it wasn't until 1991, that recognition of Japanese American rights and political power occurred when the United States Congress passed the Civil Liberties Act of 1988 to make redress payments of $20,000 to each survivor who had been incarcerated during World War II. It took nearly fifty years to partially heal the distrust between the two nations although the effects of the atrocity perpetrated against the Japanese are still very much evident today in the suspiciousness that many Asians have for mainstream Americans. Racism and discrimination remains evident today as demonstrated by billboards situated in the South which proclaim the warning "Remember Pearl Harbor, don't buy Japanese cars." This message contributes to the level of economic wariness displayed by some Americans for Japanese success in the automobile industry and continues to set up barriers between cultures.
Japanese Americans view the world with harmony and relative congruence between one's internal and external environments, which essentially means being attentive to harmony factors within and outside oneself. The Japanese worldview includes collective group harmony by being attentive to kin and work group lifeways rather than being preoccupied with individual concerns. Many Japanese Americans value their traditional lifeways and retain these values in their thinking, business, and daily living activities. The following are dominant cultural core values although one must be aware that there are cultural variations among individuals. These differences are especially evident between the Issei, the Nisei, (first generation and second generations living in the United States), and the subsequent generations that follow.
The most prevalent cultural values attributed to Japanese Americans are as follows: duty and obligation to family, honor and respect towards elders, politeness, self-restraint and control, group compliance, forbearance, non-assertiveness in interactions, fatalism (calm acceptance of one's situation), patience, high educational standards and ambitiousness with achievements.
The model minority thesis surfaced in the mid-1960s because of publicity regarding high educational attainment levels, high median family incomes, low crime rates, lack of mental health problems, and absence of juvenile delinquency among Asian Americans. More recently, according to the U.S. Bureau of Census, (1993c), Japanese Americans (and Asian Americans as a total population) arc portrayed as extraordinary achievers, exceeding the national average for high school and college graduates with high rates of graduation from colleges and universities. For many Japanese Americans, educational attainment is viewed as providing opportunities for upward mobility and family members will sacrifice their own socioeconomic standing in exchange for giving the next generation a better chance to succeed in the world.
For some Japanese Americans, the self is viewed as part of a set of interpersonal relationships of which the family system is the central core. In this context, the self is subordinate to the family unit, and consequently most Japanese Americans find it difficult to stand out publicly as individuals. This difficulty is evidenced by the reluctance of some Japanese Americans to give speeches, talk about themselves in casual conversation, of engage in self-serving behaviors.
The family is one of the most important factors in the lives of most Japanese Americans and there is frequent contact with other family members. A sense of obligation within the Japanese hierarchy forms the basis of reciprocal relationships among peers and social networks although casual help from strangers is usually avoided. The phrase kodomo no tame ni (for the sake of the children) reflects the sacrifices and hardships families will endure to ensure the success of the next generation. Intergenerational relations are close as evidenced by the flow of food, money, help, and goods between generations. A common example of sacrifice is when an adult child will care for a parent or other elderly relative to the point of sacrificing financial security, career, and/or social stability.
Japanese families traditionally value authoritarian styles of leadership where the father makes unilateral family decisions. Japanese American families can be described as patriarchal with authority and communication exercised from the top town. Roles are interdependent, there is strict adherence to traditional norms, and minimization of conflict by suppression of overt emotion.
Shame is used as a method of controlling undesirable behavior. Seen from a Japanese American point of view, individualism, with its emphasis on aggressive competition, conflicts totally with traditional Asian respect for authority and filial piety towards parents and ancestors. Violation of these traditions almost inevitably leads to family tension and possible disruption. When the Japanese American individual is unable to acquiesce to the teachings and commands of family elders, he or she will suffer a sense of guilt and shame which colors behavior, not only at home but in the total society as well.
The official language in Japan, which is by some 90 million inhabitants, is Japanese. Of the number of Japanese Americans residing in the United States, 42.8% speak Asian or a Pacific Islander language at home, 57.7% do no speak English well, and 33.0% are linguistically isolated (Bureau of Census, 1993c). Japanese characteristics in language and behaviors reflect characteristics of some of the cultural values inherent in this population. The Japanese culture places importance of sympathizing with the speaker. The expectation is that the listener will also empathize with the speaker and constant verbal communication is seen as unnecessary. Behavior and communication are defined by role expectancy and statues and by an attempt to pre-assess the listener’s feelings or wished.
Self-abasement, modesty, and apology used by Japanese Americans could be misinterpreted as self-effacing behaviors. The complex meanings behind these attitudes and behaviors can be understood by the concept of enryo, which directs Japanese Americans to be modest, to defer to others, to play down personal accomplishments and achievements, and to direct attention away from oneself.
The concept of hierarchy and status also dictates communication patterns. For some Japanese Americans, it is considered impolite to disagree publicly with a person of higher status for fear of making this individual to "lose face." Verbal expression is focused on increasing harmony and avoiding conflict. Therefore, answering "yes" to questions may be a way of avoiding embarrassment or shame and does not necessarily imply that communication is agreed with, clear, or understood.
The Japanese culture is a relatively non-eye-contact culture, which is seen both in public speaking and in the communication process. Facial expression plays a crucial role in communicating emotions and attitudes and what may be perceived by some Westerners as an inscrutable facial expression, relates to the traditional behavior of some Japanese Americans to control emotions, especially in formal and public situations. Japanese culture is also a non-touch culture and the Japanese American client may feel uncomfortable with the over use of physical contact, or invasion of personal space when interacting.
Information and explanations regarding treatments and schedules should be given by the nurse or physician to the Japanese American client and family members as well. Because family participation is expected during the illness, accommodations need to be made by letting family members participate in nursing care practices. Family members may want to give direct care to their kin and make decisions about their care except where professional nursing actions or decisions are critical. For example, family members may want to be responsible for feeding and exercising their kin. They may want to use home remedies such as herbal tea and massage. The nurse must remain open to discussing folk remedies and other care practices with the client to observe their limitations or benefits. If a folk practice is a detriment to the healing process, the nurse has an ethical responsibility to share this information with the client and family.
For the nurse who is unfamiliar with the cultural behaviors of Japanese Americans, behaviors in ambiguous, embarrassing, or anxiety-producing situations may be difficult to understand and the client may be labeled as passive or nonresponsive. Some Japanese Americans value self-control, particularly in areas they believe may reflect weakness or inadequacy and are likely to control any expression of anger or pain. The loss of "face" and dignity needs to be maintained in procedures and treatment.
The nurse must be aware of the fact that some Japanese Americans consider it insulting to be addressed by their first names, especially the first generation, who follow strict hierarchical rules of deference and respect. Nurses should not misinterpret the reserved and formal behavior manifested by some Japanese Americans as a dysfunctional sign. The nurse needs to remember that these clients need to establish a caring, trusting relationship before they engage in self-disclosure. Since it is impolite to think of personal needs, some Japanese American clients, when asked if they want something to eat or drink, are likely to respond negatively. In such instances, if the nurse does not try to persuade the client to eat or drink, the nurse may be perceived as insensitive.
It is important to remember that Japanese Americans vary in their degree of acculturation. Because of this diversification, the nurse must assess the unique needs of each individual and the extent to which this information applies to Japanese American clients and their families.
According to the U.S. Census Bureau 798,847 Korean Americans reside in the United States, representing 0.3% of the total U.S. population. Korean immigration is about 30,000 per year, and they are becoming one of the fastest growing cultural minorities in the United States. A large number of recent Korean immigrants have settled in Los Angeles, California, Chicago, Illinois, and New York.
Korea is a peninsula located in eastern Asia, extending southward from the Asian mainland for six hundred miles. Because of Korea's location, it has been a land bridge between Japan and China. Its location has also led to attacks from outsiders and foreign domination and exploitation by Japan, Manchuria, and China. Japan, in an imperialistic expansion, annexed and colonized Korea in 1910 for thirty-five years. The Koreans fiercely retained their cultural values and practices and were finally liberated in 1945. However, at the end of World War II, United Nations troops (mainly composed of United States nationals) occupied South Korea and Soviet troops occupied North Korea. Unfortunately, the Korean War (1949-1953) left the country divided by the 38th parallel demilitarized zone. Today, North Korea remains under Communist rule, isolated from the outside world. In contrast, South Korea has made remarkable economic transformation in the last three decades through the sweat and skills of its people and has made great strides in developing its potential as one of the strongest and most influential countries in the region.
Because of the strict immigration laws in the 1960s and 1970s earlier Korean immigrants where a chosen few in key professions. The massive immigration of highly talented and educated individuals left South Korea with what has become known as the "brain-drain". With relaxation of the immigration laws, later immigrants have not been as well educated as the previous generations, although a major issue that prompted Korean to immigrate to the United States was consideration for their children's future. However, many elderly Koreans found difficulty leaving behind old cultural and social norms and adjusting to new ones. Many of these individuals faced many problems including; financial struggles, poor health and poor care practices, difficulty with social interactions, and mental health problems due to a Korean culture-bound syndrome of suppressed anger, and depression.
Confucian philosophy forms the basis for behavior and position within the social hierarchy. While certain philosophical conflicts are recognized for example, Confucianism versus Christianity, some Korean Americans are able to harmonize the best of both worlds. Korean Americans are generally more oriented to the future than the ancient past and will adapt consistent, provable change, whether religious or political.
Korean Americans are an impressive example of how people can both assimilate and remain true to national heritage and family values. Korean American communities have become a part of American society and still maintain Korean values. Almost every Korean community in the United States (i.e.; Los Angeles, San Francisco, New York, Baltimore, Atlanta), and almost every city with a major university, have Korean schools to ensure that the culture, history, language, and traditions are not lost.
Compared with other Asian immigrants, Korean Americans newly arrived in America are most likely to be self-employed. This means long hours and hard work with limited financial return. Because of their noteworthy achievements and a proliferation of small businesses in Latino and African-American communities in the United States, they have recently become targets of conflict and hostility.
Historically, the Korean American family has been the cornerstone of the culture. In most cases, father and sons enjoy preeminence as leaders and undisputed decision makers. The traditional Korean family is fixated on the need for a male heir. A male heir is needed to guarantee the family line and lead the family in rituals that pay homage to ancestors, both in the home and at burial sites. The firstborn son inherits the mantle of family leadership and a greater portion of property inheritance than his siblings. Daughters receive very little, if any, inheritance. Traditionally, a sense of obligation to parents is strong, especially among male offspring although modem mobility has strengthened relationships between couples and immediate family and has weakened traditional extended family obligations.
When newly arrived Koreans are introduced to other Koreans, whether socially or professionally, they will listen quite attentively before deciding to interact. This reserved behavior is related to the Korean equation of "reserved familiarity" until the individual has mastered the language and has begun to know the individual. Similar to other Asian populations, Koreans tend to be a "non-contact" group. Some Koreans have difficulty making eye contact or engaging in physical contact in public situations. However, in one-on-one and "acquaintance" situations, Koreans are very similar to Americans in interactions and will engage in eye contact when conversing with familiar individuals.
The Korean language itself reinforces attention to rank or position. Different vocabulary and verb endings are used according to whether the person being addressed is of higher, equal, or lower rank or socioeconomic status than the speaker. Etiquette is very important to Koreans, and it is a mistake to appear too familiar of informal. First names are used only within a family or circle of close friends. Among Koreans, it is also social etiquette to belittle oneself as well as family members. Any demonstration of one's importance in social interactions or any associated symbols or connotations of "I" or of self-assertion are thought to be signs of immaturity and lack of social skills.
Silent patience is thought to be a virtue in life and any formal or informal complaint is likely to be delayed as long as possible. The very nature of silent patience hinders open communication and often results in the decision to take action without comment when something is disagreeable to the client. Politeness is expressed through maintaining an agreeable demeanor. The nurse may mistake this for acceptance and rapport when the client actually has little or no understanding of what is expected.
The Korean language (as with Japanese language) has a fundamentally different style in using the responses of "yes" and "no." For example, let us assume that Kim missed her doctor's appointment yesterday. If the nurse asks Kim in English, “You didn't make your appointment to see the doctor yesterday, did you?” Kim would correctly answer, "no." In Korean however, the correct response would be "yes" because Kim would be confirming what the questioner assumes. Therefore, it is best to avoid negative questions when working with Korean clients since this type of question can be confusing for most Asian populations.
Although contemporary changes in traditional family customs have weakened the kinship and family structure, there is no question that Korean Americans are family-oriented. Hospitalization of one client becomes an entire family concern. Some Korean Americans may blame the illness of the father or mother on inadequate attention and care on the part of the child. It is essential to remember that the family is a primary social unit and as such, family members must be included in the plan of care, if culturally appropriate care is to be delivered.
Korean Americans will vary in their response to healthcare providers based on their level of acculturation. When appropriate, health care practices that are based on the client's cultural beliefs must be honored to ensure chances of success through client compliance. Open discussion to enhance rapport and trust is a key ingredient for successful client-oriented care.
Approximately 850,000 Vietnamese, Cambodian, and Laotian refugees have come to the United States since the end of the war in Vietnam. Of this group, there are 614,547 Vietnamese persons residing in the United States and 90,082 Hmongs (Bureau of Census, 1993a).
The first group of refugees began arriving in 1975. A high percentage of these immigrants were educated in Vietnam or abroad, and some spoke English. Some of these immigrants had been exposed to European cultures or to the American culture for years and had economic or vocational assets. They generally did not go through a long stressful period of economic and psychological depravation that affected their health and psyche. Many were young and single, or married with small children.
A second wave of Vietnamese refugees (1979 to 1980) were extended family groups who left Vietnam under duress and pressure from the government. Again, these people were often educated and part of the business community. However, English was their second language and these immigrants also included elderly persons and other extended family members who had varying health needs and problems.
Most of the third-wave Vietnamese refugees that came to the United States during the 1980s were "boat people," who in many cases had lived through not only economic struggles, but also extreme political and social change while in Vietnam. Many had spent months or even years in refugee camps and were in poorer physical condition than those arriving earlier. For the most part, they did not speak English and adjustment to American society was more difficult and more complex than earlier groups.
Laos is a landlocked country consisting of many distinct ethnic groups that are generally divided into three categories: the Lowland (Lao Loum), Midland (Lao Theung), and the Highland (Hmong).
After the 1973 Pans Agreement, a coalition government was formed in Laos which consisted of equal representation of Communist and pro-western cabinet members. After the fall to Communist control of Saigon (Vietnam) and Phnom Penh (Cambodia) in April, 1975, the Coalition government in Laos collapsed. From mid-May to the eve of December 2, 1975, local political sessions were organized throughout the country to ensure that the royal capital and administrative capital were safe zones before the proclamation of the Lao People Democratic Republic. This effort included sending military police and high ranking functionaries to remote areas for "reeducation."
Prisoners in reeducation camps encountered political indoctrination, inadequate amounts of food, and long hours of menial work. Medical care was denied initially to the prisoners and those who became ill, often died. Political sessions were held daily which consisted of self-criticism and criticism of others. This constant review of self and others contributed to a climate of fear and suspicion. Many of those who suffered the degradation and torture of the reeducation camps suffer from symptoms of Post Traumatic Stress (PTSD) and may seek medical treatment for the physical manifestations inherent with this diagnosis.
Hmong’s are of Asian descent and are an indigenous ethnic-cultural group of people who originally lived in the rural highlands of Laos. Many of the Hmong's living in the United States today were displaced from their homeland because of their alignment with the United States during the Vietnam War. During the fall and winter of 1977-1978 the communist Lao government unleashed a search and destroy operation against the Hmong, who had fought as Special Forces during the Vietnam War. Large numbers of Hmong were killed during this period and others undertook treacherous escapes through Lao forests to refugee camps in Thailand.
Although the Hmong refugees essentially came from an agricultural society and had little opportunity for education, they were settled in large cities after coming to America. As a result, the Hmong often face traumatic experiences adjusting to language barriers, racism, extreme environmental differences, and culture shock.
A written Hmong language was not developed until 1952. Even then, few had the opportunity to learn written Hmong or Lao because of the turbulence of war years and subsequent flight from Laos. Many Hmong have suffered the loss of family members while escaping through the jungles of Laos to seek refuge in Thailand. Often, they stayed in refugee camps for years, waiting to immigrate to a host country. Because of these circumstances and the fact that the Hmong are traditionally an agricultural mountain people, the level of formal education for Hmong resettled in the United States is likely to be low and older immigrants (especially females) will probably be illiterate. However, the Hmong are similar to other Asian cultural groups and believe that education can bring a better future.
In 1970, with United States support, Prime Minister Lon Nol overthrew Sihanouk. By May of 1970, Cambodia and USA forces were fighting Vietnamese forces stationed in Cambodia. As the fighting continued, people fled from the countryside to the capital, Phnom Penh. (The population swelled from 500,00 to almost 2 million.) In 1973, the Paris Peace Treaty ended the conflict between North and South Vietnam and marked the end of American involvement. In April of 1975 Lon Nol and the American embassy staff and dependents left Cambodia.
Khmer Rouge occupied Phnom Penh on April 17, 1975. Nothing in Cambodia's history prepared the country for the Pol Pot era which began when he occupied Phnom Penh. Within hours he began the destruction of the city and the forced evacuation of its inhabitants. For the next 3 years there was virtually no contact with the outside world. During that time, a third of the population died.
Pol Pot’s intention was to remove everything foreign and rebuild, using only Cambodian resources and culture. Temples and churches were destroyed, as were municipal phone, water and sewage systems. Cambodians were starved, tortured, executed, or became innocent victims of a ruler who destroyed the country's ability to provide medical care. People who spoke French, had a foreign education, or even wore glasses where executed. Urban, presumably "corrupted" citizens were forced out of cities into rural work brigades to plant and harvest crops. Families were intentionally separated and children were encouraged to spy and inform on their parents.
The next chapter in this grim history began in January 1979 when the North Vietnamese Communists invaded Cambodia. They captured the city of Phnom Penh and drove Pol Pot into the countryside. Roads, rice fields, grain reserves and social infrastructure that had escaped Pol Pot were now consumed in this new war. Vietnam, as part of its war against the guerrilla forces of Pol Pot, instituted and enforced severe restrictions on farming. Seven hundred thousand Cambodians died of starvation. The unbelievable horror and losses suffered by this group of people is pervasive and healthcare systems can expect a multitude of physical and psychological problems with recent Cambodian immigrants. For example, a group of elderly Cambodian women in California were going blind and no physical cause could be determined. It was discovered that many had observed the murder of loved family members and no longer wanted to "see the world" and the pain that is represents.
Southeast Asian culture is closely tied to religious beliefs. Vietnam has a history of religious tolerance except for the period immediately before the French takeover, when Christians were suspected of being spies. Religious beliefs in Vietnam have been strongly influenced by several different religions, including Buddhism, Confucianism, and Taoism. Buddhism is considered less an orthodoxy than a state of mind using the Four Noble Truths, as taught by Buddha: (1) life is suffering, (2) suffering is caused by desire, (3) suffering can be eliminated by eliminating desire, and (4) to eliminate desire, one must follow the eightfold path of right understanding, purpose, speech, conduct, vocation, effort, thinking, and meditation. The Buddhist Truths have played a large part in molding the Vietnamese characteristics of stoicism, strong self-control, and apparent passivity. Confucianism came to Vietnam from China and is a code of ethics rather than a true religion that emphasizes hierarchy of society, worship of ancestors, and respect for age, customs, teacher, and family. Taoism has also been very influential in the Vietnamese culture. Tao is a creative principle that orders the physical universe. Taoism emphasizes that when things are allowed to take their natural course, they move toward harmony and perfection. Therefore individuals should attempt to blend into the natural world rather than trying to conquer it.
Approximately 90% of persons living in Laos has a very close identification with their faith that is based on a combination of Buddhism, Brahminism, and Animism. In Laos, every village has a pagoda or shrine. The core of these three philosophies is difficult to distinguish from each other. Two values distinguish the Lao from other Southeast Asian ethnic groups; the first is "piap" which includes pride, honor, self-esteem, and disgrace. One's piap is affected by the background of his or her family. The concept of "losing face," or bringing shame to oneself or family is a trait of piap. The second concept is "kengchay" which is the value of respecting others while keeping a low personal profile. A Lao is encouraged to never place the self above others and helps to explain the non-assertive, non-aggressive nature of this population.
Spiritualism is dominant in Cambodia. About 99% of the Cambodian population are Buddhist which includes a belief in the theory of Karma, i.e., a person's present life is pre-determined by his or her previous life's good or bad deeds. The cycle of life and rebirth for individuals cease only when they are finally rid of earthly desires and have achieved the state of spiritual liberation. Man is required to live in harmony with nature, rather than try to dominate nature. Animism is also practiced and includes many rituals to deal with demons, evil spirits, angry gods, and elements of the natural world that are not understood.
From 1956 on, American and French missionaries brought Protestantism to the Hmong. About half of the population are now Christians and the other half practice Animism while many Hmong practice a combination of both Christianity and Animism which is a belief in supernatural beings: gods, malicious spirits, household spirits, spirits of places, and spirits of the dead. Illness is believed to be caused when a person's soul strays or is stolen. The shaman is called upon to heal the individual by restoring the soul to the body. All living things have souls which return to an afterworld when they die where they await reincarnation. Hmong’s venerate the dead and practice ancestor worship.
| EASTERN CULTURE | WESTERN CULTURE |
|---|---|
| Harmony with nature | Mastery of nature |
| Tradition | Change, innovation |
| Hierarchy | Social mobility |
| Age revered | Focus on youth |
| Extended family | Nuclear family |
| Convergent thinking | Divergent thinking |
| Cyclical concept of TIme | Specific time schedules |
| Group orientation | Individual self-concept |
| Rote learning | Discovery learning |
| Conformity | Competition |
| Accept world as is | Change world |
| Marry first, then love | Love first, then marry |
| Self-denial, secret to success | Assertiveness key to success |
| Glorify austerity | Emphasize materialism |
Generally speaking, the groups of Southeast Asians including; Vietnamese, Laotian, Hmong and Cambodians are similar in regards to family social structure, such as;
Vietnamese men (before 1959) and Laotian men (1945) could have more than one wife. Cambodian men can have several wives, but written consent of the first wife is compulsory, whereas Hmong men can have several wives and do not need to have the first wife's consent. When immigrating to the United States, only one spouse may remain married to the husband. Second, third, fourth, and subsequent marriages must be dissolved although all wives are informally still accepted as family.
Communication among Southeast Asians arc similar, although assimilation will account for individual differences. Below are communication patterns most likely seen in recent immigrants or elderly Southeast Asian clients.
In Southeast Asian culture, respect and harmony are highly valued in relationships and there is a desire not to disappoint, upset, embarrass, or cause another person to lose face. The desire to maintain harmony takes precedence over what the actual truth of a situation may be. When the client is confronted with difficult or delicate questions, particularly if the answer is negative, such as "Did you take your medicine?" the client may choose not to give a direct answer in favor of the higher good of keeping peace with the nurse.
The nurse should recognize that negative emotions or expressions of disagreement are usually conveyed by silence or a reluctant smile. For the Southeast Asian client a smile may express joy, but more often is used to convey a number of other messages, such as stoicism in the face of difficulty or apology for a minor social offense. Even if angry, neglected, or in need, the client will rarely express this to the nurse or physician but will speak quietly and smile. Instead of asking "Are you having pain?" the nurse should acknowledge the likelihood of pain and state, "Please let me get you something for pain."
Because of the high priority on respect, harmony, "filial piety," and material sharing built into Southeast Asian families and the extended family system, both the immediate and the extended family serve a significant role in providing emotional, physical, and economic support for the client. The nurse must include family members in planning care and use the family to assist the client in regaining physical and mental health. It is not unusual that a family conference will occur when an important medical decision needs to be made. When a family member's life is in danger, it is best to work with the family, although a court order may have to be used as a last resort.
For many refugees, the greatest source of stress lies in the overwhelming priority placed on basic survival needs and it is about 6 to 12 months before psychiatric problems become obvious. Psychologically, the distress is often experienced as a combination of depression and anxiety. Marital conflict, intergenerational conflicts, substance abuse, sociopathic behavior, and somatic preoccupation may all be manifestations of stress of adjustment to a new culture.
Somatization is viewed as being common among Southeast Asian refugees where overt expression of anxiety, disappointment, or anger is considered failure. A high value is placed on suppressing negative feelings. Therefore, expressing mental distress through various physical ailments may be an acceptable option although some would resist seeking help from the healthcare system and turn to folk medicine to alleviate symptoms.
The emotional and behavioral problems of refugees are often related to (1) loss of immediate and extended family, (2) numerous losses faced as a result of being forced to leave their homeland, (3) economic stress, (4) stresses of adaptation. Because of the marked differences between Eastern and Western cultures and traumatic conditions under which the immigration occurred, the culture shock experienced by many Southeast Asian Refugees is profound.
A general pattern of coping/adaptation is experienced by many persons in their cultural adjustment to immigration (Cook and Timberlake, 1984).
Stage I. For the first few months there is a positive attitude and high expectations; energy is focused toward learning the language, gaining employment, and meeting basic needs. The excitement of a new physical environment helps suppress the pain of multiple losses.
Stage II. The period of psychological awareness occurs 6 to 18 months after immigration, when the person becomes more aware of losses and the past becomes idealized. Survivor's guilt must be faced (Why did I survive and my child did not?) Posttraumatic stress disorder (PTSD) is common, and all the normal tensions of close family life arc magnified. Interpersonal conflict is common. Other symptoms may be feelings of hopelessness, acute distress and grief, fatigue, and mood instability. The period may be transitory or long-lasting, mild or severe, and seems to occur regardless of how must support is given. Somatization is common during this period.
Stage III. After 18 to 24 months the person is able to reformulate the grief and get involved with the tasks at hand. There is less idealizing of the past, and helping those left behind becomes important. Adaptation moves ahead more rapidly as former ways of coping are given up for more effective ones. A new self-identity is formed.