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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, S20 Home Healthcare Nurse 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. www.homehealthcarenurseonline.com Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 Home Healthcare Nurse S21 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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. S22 Home Healthcare Nurse 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 www.homehealthcarenurseonline.com Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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- S24 Home Healthcare Nurse 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 www.homehealthcarenurseonline.com Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 S26 Home Healthcare Nurse www.homehealthcarenurseonline.com Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.