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Resources for Asian Patients
1.6
HOURS
Continuing Education
Online Resources for Culturally
and Linguistically Appropriate
Services in Home Healthcare and
Hospice, Part 2
By Judith S. Young, MLS
Home care and hospice clinicians are increasingly working with patients for whom English is not their primary
language. Provision of culturally respectful and acceptable patient-centered care includes both an awareness of
cultural beliefs that influence the patient’s health and
also the ability to provide the patient with health information in the language with which he or she is most
comfortable. This article identifies resources for understanding the cultural norms of Asian-born patients and
appropriate patient education materials in the many
languages spoken by this population. The resources
have been made available free on the Web by healthcare professionals and government agencies from around
the world.
This article originally appeared in Home Healthcare Nurse 2013;30(4):225–232.
vol. 32 • no. 5S • May 2014
Home Healthcare Nurse S19
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Introduction
According to the U.S. Office of Minority Health
(OMH) (2011), 5% of the U.S. population (15.5 million) are of Asian or Pacific Islander descent. This
group includes individuals of Far Eastern, Southeast Asian, Indian subcontinent, and Filipino origin, in addition to immigrants from a large number of small Pacific Island nations. The U.S.
Census Bureau (2002) provided statistics for 17
individual Asian population groups from the Far
East, Southeast Asia, and the Indian subcontinent.
VITS Language Link (n.d.) reported that these
populations speak a total of more than 500 languages and dialects. The groups and their major
languages are identified in Table 1. OMH (2011)
also stated that language use varies among Asian
groups with 50% of the Chinese, 24% of the Filipinos, 23% of the Asian Indians, and 62% of the
Vietnamese lacking in fluency in English.
Asian patients have a higher incidence of liver,
bowel, and stomach cancers than non-Hispanic
Whites. They also experience higher rates of tuberculosis, Hepatitis B, chronic obstructive pulmonary disease (COPD), smoking, and liver disease. Nevertheless, Asian women have the
highest life expectancy of any U.S. ethnic group
(Office of Minority Health, 2011).
The large number of countries and languages of
origin combined with the differences in Asian customs for interacting with healthcare professionals
present a challenge to home care and hospice clinicians in the provision of culturally and linguistically appropriate care. Many home care clinicians
are associated with independent agencies that do
not have access to the resources of a large healthcare system or university health sciences library.
They must find information on various cultures
and locate multilingual patient education without
the benefit of institutional resources. This article—
the second in a series—reviews a variety of Asian
culture resources and sources of Web-based patient education materials in many of the languages
and dialects spoken by these population groups.
Asian Culture and Religion Resources
Delivery of culturally appropriate healthcare includes an understanding of the role different belief
systems have on concepts of health and illness;
the cultural variations in reaction to illness, death,
disease, and disability; the role of the family in decision making; and the use of alternative or complementary therapies. For example, Confucianism,
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Taoism, Islam, and Buddhism are all influential on
Asian attitudes toward health practices.
http://www.mfghc.com/resources/
resources_16.htm
The Multi-Faith Group for Healthcare Chaplaincy
in England has a comprehensive document, titled
Respecting Religious and Cultural Beliefs, on the
Web. It includes Buddhism, Taoism and Confucianism, Jainism, Shintoism, Sikhism, and the Unification Church. The material for each group includes
information on beliefs, food, and death and dying
practices. The publication also includes key points
for healthcare providers, including discussion of
contraception attitudes, transplants, transfusion,
and birth and postpartum practices.
http://www.health.qld.gov.au/multicultural/
health_workers/support_tools.asp#guides
Queensland Health, in Australia, has developed a
series of quick-reference handbooks to help
health workers understand the beliefs and practices of Muslim, Hindu, and Sikh patients. The
booklets discuss end of life issues, transplants,
mental health, sexual and reproductive health,
and food requirements.
http://www.ethnicityonline.net/ethnic_
groups.htm
The British site Ethnicity Online has a section of
information about several religious groups including Buddhists, Hindus, Muslims, and Sikhs. The
site provides an introduction to the religion and
then sections addressing birth, babies, and motherhood; death and the dead, dietary guidelines,
dying, inpatient care, medications, physical examinations, sexual health, and taking a clinical
history. There is also a section on issues for
healthcare staff who belong to the religious group.
http://www.healthcarechaplaincy.org/
userimages/Cultural%20&%20Spiritual
%20Dictionary%2012-20-10.pdf
The HealthCare Chaplaincy in New York also provides information on Muslim, Hindu, and Sikh
beliefs in A Dictionary of Patients’ Spiritual &
Cultural Values for Health Care Professionals. The
discussion of Islam (Muslims) includes the differences between the Sunni and Shia sects. The document also covers Buddhism. Daily practices, death
and dying, facilitating practices, food, health, and
pregnancy and birth are all briefly reviewed.
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The dictionary has information on cultural
groups as well. Asian cultures covered include
Chinese-American, Filipino-American, JapaneseAmerican, Korean-American, and VietnameseAmerican. Culture and family structure; health,
illness, and death; pregnancy, birth, and postpartum; and religious and spiritual practices are the
major topics for which brief notes are provided.
http://www.bu.edu/bhlp/Resources/Islam/
health/index.html
The Boston Healing Landscape Project Web site
has a section on “Islam and Health.” The General Guidelines have comprehensive coverage
of dietary regulations, end of life issues, gender
issues, language and communication, maternal
and child health, medical decision-making and
family structures, medications, mental health,
modesty and respect, personal devotion and
religious objects, and sexual health. The “Illness
and Health” section discusses attitudes toward
death, health maintenance, illness and suffering, the influence of jinn (invisible spirits) on
health, and mental health.
Discussions of death, living wills, and do-notresuscitate status should not be raised with an
Asian family while the patient is alive. These topics are uncomfortable ones for family to discuss
and must be approached sensitively. Many older
people may refuse to discuss these topics at all.
Table 1. Asian Populations and Their Primary Languages
Population Group
Major Languages Spoken
Other Languages and Dialects Spoken
Asian Indian
Hindi, Gujarati, Kannada, Malayalam,
Konkani, and Manipuri
25 other official languages including Bengali
and Punjabi
Bangladeshi
Bengali
Urdu, Assamese
Bhutanese
Dzongkha
Sharchhopka, Lhotshamkha, and others
Cambodian
Khmer
Mandarin, Teo Chiew, Vietnamese, French
Chinese (includes PRC, Taiwan,
Hong Kong, and Singapore)
Cantonese, Mandarin
Taiwanese, Tibetan, Mongolian, and more than
500 other languages
Filipino
Filipino (Tagalog)
Cebuano, Hilgayano, Bikolano
Hmong
Hmong, Mong
Indonesian
Bahasa Indonesian
Japanese
Japanese
Korean
Korean
Laotian
Laotian
Hmong, Chinese dialects, French
Malaysian
Bahasa Malaysian
Tamil, Sinhalese, Hokkien, Cantonese & other
Chinese dialects
Nepalese
Nepali
Other dialects
Pakistani
Urdu
Punjabi, Sindhi, Pashtu, Buluchi
Sri Lankan
Sinhalese
Tamil
Thai
Thai
Malay, Khmer, and Chinese dialects
Vietnamese
Vietnamese
Cantonese, Khmer, Teo Chiew
Javanese, Sudanese, Madurese
Source: Author.
vol. 32 • no. 5S • May 2014
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Body language and facial
expressions are another
important facet of Asian
culture. Direct eye contact
is often avoided. In
addition, in Hong Kong,
excessive blinking may be
seen as a sign of boredom
or lack of respect.
Winking is considered
rude by many Chinese.
Bangladeshis often
communicate in flowing,
lengthy sentences that
may be difficult to
understand unless one
pays close attention to
their body language.
Autopsy is another subject to avoid since these
cultures believe the dead body must remain
intact.
http://www.asianhealthservices.co.nz/
documents/Culture/Death%20&%20
Dying%20Handout%20Nov%2004.pdf
The Asian Health Support Service in New Zealand
has compiled an excellent booklet “Death &
Dying: Information from Different Asian Cultures
& Religions.”
http://www.bcv.org.au/media_dirs/11/media_
files_data/buddhist_care_for_dying_booklet
.pdf
The multilingual publication “Buddhist Care for
the Dying” addresses the specific practices for
various sects of Buddhism as well as Tibetan,
Vietnamese, Japanese, and Chinese Buddhists. It
was developed by the Buddhist Council of Victoria,
Australia.
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http://depts.washington.edu/pfes/PDFs/
End%20of%20Life-Vietnamese.pdf
The University of Washington’s End-of-Life Culture
CluesTM series includes a tip sheet for care of the
terminally ill Vietnamese patient. It provides information on rituals and offers suggestions for
dealing appropriately with the patient and his or
her family.
As part of their religious beliefs, many Asians
try to avoid physical contact between men and
women. When meeting a new patient of the opposite sex, it is appropriate to wait and see if he or
she initiates a handshake (International Etiquette
Guide, n.d.). If conversing with a man, a woman
may increase her personal space, while a man may
stand closer to another man than most patients of
European origin would.
Body language and facial expressions are another important facet of Asian culture. Direct eye
contact is often avoided. In addition, in Hong
Kong, excessive blinking may be seen as a sign of
boredom or lack of respect. Winking is considered
rude by many Chinese. Bangladeshis often communicate in flowing, lengthy sentences that may
be difficult to understand unless one pays close
attention to their body language (International
Etiquette Guide, n.d.).
Confrontation is undesirable and asking questions is considered threatening, especially if they
are phrased as negatives. As a result, the patient
may nod and smile even if he or she does not understand what is being said. Asking the patient to
paraphrase what was explained or to demonstrate what was taught will assist the home care
clinician in evaluating the extent of the patient’s
understanding.
Older clients are more inclined to use herbal
modalities, home remedies, and traditional
Chinese medicines or to combine them with
Western modalities. It is important for home care
clinicians to address this issue in their initial
assessments. Because Western medications often
have more adverse effects than herbal remedies,
Southeast Asians are reluctant to take them. In
addition to herbs, they prefer touch and energy
therapies or spiritual rituals. Furthermore,
genetic differences can affect the patient's
metabolism when taking a Western medicine
(Narayan, 2010).
Some Asian groups are very concerned about
losing face. As a result, they are uncomfortable
with making decisions since a wrong choice
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could lead to loss of face. They also may prefer
not to answer a question that would normally be
answered with “no,” instead giving a vague,
noncommittal answer (International Etiquette
Guide, n.d.).
Extended family is important in most Asian
cultures. Many are patriarchal with decisions
being made by the oldest male. However, in
families of Pakistani origin, the most senior
member, regardless of sex, is expected to make
the decisions.
http://depts.washington.edu/pfes/
CultureClues.htm
Tip sheets for dealing with Chinese, Korean, and
Vietnamese cultures are available in the University of Washington’s Culture CluesTM series. The
sheets discuss how the individual culture deals
with illness, how members of the culture make
medical decisions, and the culture’s preferences
for eye and body contact.
http://www.nh.gov/oep/programs/refugee/
documents/ethnic_community_profiles.pdf
The New Hampshire Governor’s Office of Energy
and Community Services, in conjunction with the
Manchester Health Department and Baylor University, offers a 116-page document called Ethnic
Community Profiles. The document provides
information on Cambodian (Khmer), Laotian, and
Vietnamese refugees. Each profile begins with a
short description of the group’s resettlement in
New Hampshire, followed by background information on the country and its religion. Healthcare
beliefs and practices are reviewed with particular
attention paid to traditional or indigenous practices and spiritual healing practices. Advice for
interacting with the population on both healthcare and social issues is offered. Finally, the
profiles identify specific health risks in Asian refugees and recommends appropriate laboratory
tests and other assessments that should be given.
http://www.miceastmelb.com.au/
culturalresources.htm
The Migrant Information Centre of Eastern
Melbourne, Australia, offers cultural profiles for
Cambodians, Chinese, Indians, Malaysians, Sri
Lankans, and Vietnamese. Healthcare issues
discussed include attitudes and issues with
aging, attitudes to disability and mental illness,
attitudes to death and palliative care, and health
vol. 32 • no. 5S • May 2014
belief and practices. Cultural norms presented
include customs and values, communication
styles, and naming conventions. A few basic
greetings are also included with the closest
English pronunciation.
Scrolling further down the page leads the end
user to the link to a 40-page document providing
information on palliative care for these communities. Topics covered include pain management,
attittudes toward palliative care, beliefs and
practices related to death and dying, appropriate
food, and suitable music.
http://erc.msh.org/mainpage.cfm?file=5.4.0
.htm&module=provider&language=English
The Provider’s Guide to Quality & Culture, a joint
project of Management Sciences for Health (MSH)
and the U.S. Department of Health and Human
Services, has an extensive menu with links to
information about Asian Americans, Central
Asians, and South Asians. For each group, the
site discusses challenges to health and wellbeing and principles for culturally competent
health services. There are also links to more information on topics such as common beliefs and
cultural practices and common health problems.
Having to jump around the Web site to find the
information is frustrating, but it is detailed and
ultimately useful.
Patient Education Materials in Asian
Languages
There are many sources of patient education
materials available free online in a variety of
the languages spoken by the many Asian
population groups.
http://spiral.tufts.edu/
The Selected Patient Information Resources in
Asian Languages (called S*P*I*R*A*L), which
was developed by Tufts University and is updated
frequently, is one of the most comprehensive
sites available. It provides links to material in
Cambodian/Khmer, Chinese, Hmong, Japanese,
Korean, Laotian, Thai, and Vietnamese. The site
offers the option of searching by subject or by
language.
The topics range from AIDS/HIV through
women’s health and include specific diseases,
mental health issues, age groups, safety, and nutrition. For the most prevalent conditions in this
population, there is tuberculosis information in
Home Healthcare Nurse S23
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Diabetes UK has a good
selection of materials in
Bengali, Chinese,
Gujarati, Hindi, Punjabi,
Tamil, and Urdu. Topics
covered include disease
management,
cardiovascular issues,
kidney disease,
neuropathy, and vision
problems. The Bengali
and Hindi resources are
available in both print
and audio files.
Khmer, Hmong, Laotian, Korean, and Vietnamese.
Hepatitis B resources are available in Chinese,
Vietnamese, Hmong, Korean, and Laotian. There
are links to liver cancer pamphlets in Chinese and
Khmer as well as stomach cancer brochures in
Chinese and bowel cancer information in Khmer,
Chinese, and Vietnamese.
Not every topic has material in each language.
Once you click on a topic, you get a list of each
item related to that topic. The entry lists the title
of the individual resources available, the available
languages, and the source of the information.
Sources include government agencies, university
medical centers, and established groups such as
the Canadian Cancer Society. Some items are
bilingual, others are entirely in the individual
language. Clicking on the desired language primarily leads to a printable pdf file. However,
there are also links to video and audio files.
Clicking on the Information by Language option leads to a list of the topics available in that
specific language. Again, the title of the publication is provided and the source is identified.
http://www.healthtranslations.vic.gov.au/
The provincial government of Victoria, Australia, has links to materials in many Asian lan-
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guages. Topics such as asthma, cancer, diabetes, infections, mental illness, nutrition,
postpartum care, dementia, and kidney and
bladder issues are available in Chinese, Korean,
Khmer, and Vietnamese. Hepatitis B information
is available in Khmer, Korean, Laotian, and Vietnamese. In addition, there are links to tuberculosis resources in Khmer and Vietnamese. They
cover some hard-to-find conditions, including:
varicose veins, cystitis, and thyroid disease in
Chinese, Khmer, Korean, Lao, Thai, and Vietnamese; cerebral palsy in Chinese, Korean, Thai,
and Vietnamese; pressure ulcers, motor neuron
disease, and chronic fatigue syndrome in Chinese and Vietnamese; catheter management in
Korean, traditional Chinese, and Hindi; and
home peritoneal dialysis in both simplified and
traditional Chinese.
https://www.healthinfotranslations.org/
languages.php
An extensive selection of patient education material is also available at Health Information Translations, which was developed by four central
Ohio healthcare providers. Languages covered
include both simplified and traditional Chinese,
Hindi, Japanese, Korean, Tagalog, and Vietnamese. Most of the pamphlets are bilingual and
contain helpful illustrations. Topics particularly
useful to home care clinicians include atrial fibrillation, care of a Foley catheter, COPD, Coumadin,
heart catheterization and angioplasty, home care
after total joint replacement, how to use a glucose monitor, pacemakers, types of dementia,
and using a walker.
http://healthlibrary.stanford.edu/resources/
foreign
Stanford Hospital and Clinics offer links to multilingual health information in 20 of the languages identified in Table 1. However, the site must be used with
caution because many of the links are to Web pages
that are no longer available. The amount of information varies from language to language. The Chinese
resources identified lead to general health information portals as well as multiple links grouped under
the headings Alzheimer’s disease and dementia,
cancer, diabetes, infections, mental health, other
diseases and topics, and other health topics, which
includes surgery, tests, and transplantation. However, under the option for Tamil, there are only four
choices: one to a general portal with a large amount
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of information; one under cancer leading to a portal
with two prevention brochures; and two under mental health, linking directly to fact sheets on coping
with stress and on understanding addiction.
http://www.healthtranslations.com/aspx/
languages/default.aspx
HealthTranslations.com, sponsored by the Missouri Hospital Association, has links to information in 15 Asian languages. The amount available
varies from language to language. For example,
there are 18 links to Hmong material, 13 links to
resources in Laotian, and 15 to items in Thai, all
of which deal with infectious diseases, including
Hepatitis B. However, there are 85 links to Chinese materials that cover infectious diseases as
well has heart issues and diabetes.
http://www.diabetes.org.uk/Other_languages/
Diabetes UK has a good selection of materials in
Bengali, Chinese, Gujarati, Hindi, Punjabi, Tamil,
and Urdu. Topics covered include disease management, cardiovascular issues, kidney disease,
neuropathy, and vision problems. The Bengali
and Hindi resources are available in both print
and audio files.
http://www.asianhealthservices.co.nz/
diabetesresources.html
The Asian Health Support Service in New Zealand
has a page with links to diabetes resources in traditional Chinese and Korean. There are pamphlets
for the various complications associated with the
disease, healthy lifestyle advice, diet information,
stroke prevention, and stress management.
http://www.rhin.org/Default.aspx
Diabetes information in Japanese, Mandarin,
Nepali, and Thai is available from the Refugee
Health Information Network, a national collaborative partnership dedicated to providing multilingual patient education materials and information
on refugee populations and cultures for U.S. healthcare providers. The brochures also include the text
in English. They focus on diet guidelines, but a few
also describe the disease and how to manage it.
http://www.thewomens.org.au/
MultilingualFactSheets
The Royal Women’s Hospital in Australia offers a
collection of multilingual fact sheets on gynecological diseases, contraception, pregnancy and
vol. 32 • no. 5S • May 2014
birth, neonatal care, and breastfeeding in Chinese and Vietnamese. A sheet on miscarriage,
pregnancy loss, and postmortem examination is
available in Burmese, Hindi, Chinese, and Vietnamese. The site also offers several items on endometriosis, contraception, pregnancy, and birth
in Khmer.
http://www.cancervic.org.au/other_languages/
Cancer Council Victoria, Australia, has a selection of pamphlets available in Chinese, Filipino,
Khmer, and Vietnamese. Most of the information
is general to all cancers, such as healthy eating,
treating cancer, and incurable cancer. However,
there are also specific brochures for prostate,
bowel, and breast cancer.
http://www.cancer.ca/Canadawide/
Publications/Cancer%20information%20
in%20other%20 languages.aspx?sc_lang=en
The Canadian Cancer Society has information
available in Punjabi and Chinese. The publications cover 13 kinds of cancer, including ovarian,
testicular, and pancreatic; treatment options, and
risk reduction.
http://www.britishlivertrust.org.uk/data/5/
pages/2.aspx?pid=132
The British Liver Trust has information on liver
cancer in Urdu, Bengali, Hindi, traditional Chinese, and Punjabi. It also has guides to diagnostic
testing and hepatitis in those languages.
http://www.rdns.com.au/media_and_
resources/publications/Pages/Translations
.aspx
Stoma care can be a complex topic to explain to
patients whose English is limited. Australia’s Royal
District Nursing Service has several useful pamphlets available in Chinese and Vietnamese. In addition to individual items for colostomy, ileostomy,
and urostomy care, there is material on skin care
and diet management.
http://www.beyondblue.org.au/index
.aspx?link_id=102
Depression and anxiety are issues of concern for
home care clinicians with elderly patients. The
Australian site Beyond Blue has resources on
these topics available in Cambodian/Khmer, simplified and traditional Chinese, Indonesian, Korean, and Vietnamese. The anxiety information is
Home Healthcare Nurse S25
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also available in Japanese, Laotian, Punjabi, Tamil,
and Thai. Postpartum depression information is
available in all of these languages and a posttraumatic stress disorder sheet is available in Chinese
and Vietnamese.
http://www.strokefoundation.com.au/
component/option,com_docman/Itemid,39/
task,cat_view/gid,84/
Stroke resources in Chinese and Vietnamese are
available on the Australian Stroke Foundation
Website. The material describes what a stroke is,
how to prevent it, treatment, and recovery.
http://www.health.gov.au/internet/main/
publishing.nsf/Content/ageing-publicatsmulti.htm
The Australian Department of Health and Aging
has links to materials in Chinese, Korean, and
Vietnamese on medication management and
home safety. They also have fact sheets on continence in Chinese.
http://www.healthyroadsmedia.org
Healthy Roads Media (2011), from the U.S. National
Library of Medicine, has a good selection of multimedia, multilingual patient resources. Topics vary
from language to language. Material in Hmong includes stroke, heart disease, healthy eating, and
smoking cessation. There are also several resources on colorectal cancer in Khmer and Vietnamese and a pamphlet on heart failure in Laotian.
http://cdc.gov/other/languages/
The U.S. Centers for Disease Control and Prevention (CDC) has resources on some infectious
diseases, Eschericia coli, and various forms of influenza in Vietnamese and Chinese. They also
have information on SARS in Chinese, Korean,
Vietnamese, and Japanese. Diabetes information
is available in Vietnamese and Tagalog. In addition, there is Escherichia coli and influenza material in Tagalog and a pamphlet on stress in Laotian.
http://healthvermont.gov/local/rhealth/
rh_fact.aspx
Fact sheets in Vietnamese are also available from
the Vermont Department of Health. Topics avail-
able include coronary heart disease, healthy blood
pressure, cervical cancer, colorectal cancer, and
infectious diseases.
Conclusion
The patient’s cultural practices impact illness,
reactions to pain, and treatment practices (Ray,
2010). Therefore, it is incumbent upon all home
healthcare and hospice clinicians to provide culturally and linguistically appropriate care to their
patients. Using the resources reviewed here, all
of which are available free on the Web, will help
educate Asian patients in the languages with
which they are most familiar.
Judith S. Young, MLS, is from the Dixon School
of Nursing, Abington Memorial Hospital, Willow
Grove, Pennsylvania.
The author and planners have disclosed that
they have no financial relationships related to this
article.
Address for correspondence: Judith S. Young,
MLS, Dixon School of Nursing, Abington Memorial
Hospital, 2500 Maryland Rd., Willow Grove, PA
19090 ([email protected]).
DOI:10.1097/NHH.0000000000000082
REFERENCES
International Etiquette Guide. (n.d.). Country profiles—
Global guide to culture, customs, and etiquette.
Retrieved from http://www.kwintessential.co.uk/
resources/country-profiles.html
Narayan, M. C. (2010). Culture’s effects on pain assessment and management. American Journal of Nursing,
110(4), 38-47.
Ray, M. A. (2010). Transcultural Caring Dynamics in
Nursing and Health Care. Philadelphia: F.A. Davis.
U.S. Census Bureau. (2002). The Asian population 2000.
Retrieved from http://www.census.gov/prod/2002
pubs/c2kbr01-16.pdf
U.S. Office of Minority Health. (2011). Asian American/
Pacific Islander profile. Retrieved from http://minority
health.hhs.gov/templates/browse.aspx?lvl=2&lvlID=53
VITS Language Link. (n.d.). A world of languages: Countries and languages spoken. Retrieved from http://
www.vits.com.au/documents/countriesandlanguages
spoken_000.pdf
Readers who wish to participate in a CE exercise associated with this article may do so
by clicking on the following link: http://nursing.ceconnection.com/nu/public/modules/2801
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