People of Korean and Mexican Heritage

Transcultural Health Care: A Culturally Competent Approach, 4th Edition Mexican Americans Larry Purnell, PhD, RN,

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FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Mexican, Mexican American, Latino(a), Chicano(a), la gente de la raza, Hispanic, etc. are commonly used terms. ▪ Second largest Spanish speaking group in the world ▪ 500+ different dialects and ethnic groups in Mexico ▪ Mexico City is one of the largest cities in the world Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ 60% of the population is mestizo—a blend of Spanish white and Indigenous Indian ▪ The majority of the Hispanic population in the United States ▪ Hispanic is the largest “minority” group in the United States surpassing African Americans in 1999 Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Original inhabitants, along with Native American Indians, of southwest United States ▪ Majority of newer immigrants come to the United States for economic opportunities and are poorer than previous immigrants ▪ Low educational rates in the United States ▪ Ninth-grade educational level required in Mexico —mean is 5 years Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications ▪ Dialect varies by region of Mexico, including Mayan ▪ Rapid speech pattern with apocopation (e.g., como esta usted = com-esta-sted) ▪ Idiomatic and slang expressions are common— like English Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Concepts of personalismo is important. ▪ Touch between the men and between women is acceptable. ▪ Men and women greet with a hug and kiss to the cheek. ▪ Eye contact with staring is expected for peers. ▪ Many avoid direct eye contact with superiors as a sign of respect. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Intense eye contact can cause the “evil eye,” a folk illness common in all Hispanic and Mediterranean cultures. ▪ Children are more susceptible to the evil eye than are women who are more susceptible than men. ▪ Healthcare provider should greet men with a firm handshake. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Temporality varies via socioeconomic level ▪ Clock time is not categorically imperative; events begin when they begin and not until then ▪ Name format: First name, middle name, father’s surname followed by mother’s maiden name. ▪ A woman takes her husband’s last name which is place before her maiden name.. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles ▪ Traditional families are patriarchal but vary greatly. ▪ Current research is dispelling the myth of machismo and patriarchal decision-making. ▪ Children are closely protected and are not expected to work or do many chores in middleclass families—children are supposed to be allowed to be children. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Children are taught to respect parents, elders, and teachers, etc. ▪ Multigenerational families in Mexico, less so in the United States. ▪ Children have comadres, compadres (godparents). ▪ Single parenting somewhat stigmatized, severely so in some groups. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Significant number of Unido until at which time the family has the money for a religious wedding ceremony. ▪ Academic and professional degrees are highly respected. ▪ A good education also means having good manners. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ If family and close friends are aware of gay/lesbian relationships, they are not talked about. ▪ Stigma continues to be a significant problem with many. ▪ Dignity, Hola, and Ellas are support groups and they all have 800 numbers and are located in Washington, DC. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Intestinal parasites and diarrhea are major health problem among immigrants; also tuberculosis, STIs, and HIV/AIDS. ▪ Hypertension, cardiovascular disease, diabetes, malaria, cholera, typhoid, dengue fever, and high suicide rates. Incidence varies from point of migration and living conditions. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology Continued ▪ Alcohol metabolism is slowed, especially among those with an Indigenous Indian ancestry. ▪ Require lower doses of antidepressants and are poor metabolizers of debrisoquinine. ▪ Greater toxicity from tuberculosis drugs. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Large percentage of women are overweight— seen as positive and is a sign of health, fertility, wealth, and beauty. ▪ Anytime is a time to celebrate with food. ▪ Food choices vary by area of immigration— mountains, metropolitan areas, seaports, etc. ▪ Staples include tacos and rice and plantains. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Lactose intolerance, especially from adults so calcium obtained from soups with bones and bone marrow, leafy greens, and corn tortillas treated with calcium carbonate. ▪ Many ascribe to the hot/cold theory of foods, although they may not speak to it directly. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Not all foods are spicy! And Nachos are American—not Mexican ▪ Meal times vary, but many continue with the afternoon siesta if job permits ▪ Many foods are deep fried or fried in some manner—high-fat diet mostly ▪ Iron and Vitamin A deficiency—especially among lower socioeconomic groups Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Birth rate in Mexico and United States is higher among Mexican Americans than among other United States groups. ▪ Wide range of contraceptives when used, but not always admitted. ▪ Condom use: used mostly with prostitutes for infection prevention. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Many Hispanic Americans have lactose intolerance. A good source of calcium if the diet is a. Flour tortillas. b. Corn tortillas. c. Chicken d. Pork. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: B Corn tortillas are high in calcium because they are made with calcium carbonate. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Pregnancy is natural so why see a healthcare provider for prenatal care? ▪ Many are not used to prenatal care in their home country because it is not available—thus, advice comes from older females in the family. ▪ Hot and cold theory extends to foods and practices during pregnancy and postpartum. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Do not walk in moonlight while pregnant because it may cause a birth deformity. ▪ Man not to see wife or baby until several hours after birth because harm can come to the baby or mother. ▪ Do not reach over your head while pregnant because it can cause the cord to wrap around the baby’s neck. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Some do not bathe or wash hair for 40 days postpartum – do take a sponge bath. ▪ Cutting the baby’s nails before 3 months of age may cause blindness and/or deafness. ▪ Umbilical belt and/or coin or key placed on abdomen to keep it from protruding when crying. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Death seen as a natural part of life ▪ Sit vigil over the dying and after death with the family ▪ Children are not shielded from death ▪ El dia de muerte celebrated at the gravesite of family members ▪ Velorio—festive watch over the dead before internment and may be a long procession Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals Continued ▪ El ataque de nervios (nervous attack) occurs with death and other strong emotions ▪ A few may still hire llorandos (criers) for the funeral Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Family is foremost among Mexicans and most other Hispanic families ▪ Take great pride in their heritage and family lineage ▪ Religiosity supports fatalism—it is God’s Will Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality Continued ▪ Majority are Catholic with Indigenous variation practices. ▪ Priests are major sources of support for the individual and family and may be sought before seeking advice from a healthcare professional. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices ▪ External focus of control works against prevention measures. ▪ To express negative feelings is not considered polite—therefore do not complain of health ailments until symptoms are severe. ▪ Good health means being free of pain. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Mrs. de la caza, 32 year old pregnant Mexican American, is pregnant. The nurse recommends walking for exercise for weight control. The patient works at a sedentary job during the day and tells the nurse she cannot walk at night the baby will be born a. Too large. b. Too small. c. With a cleft-palate. d. With a birth mark. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C Walking at night, especially in the moonlight, is believed to cause the baby to have a cleft-lip or palate. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Many do not protect themselves from environmental hazards because they are not knowledgeable about the hazards. ▪ Seek over-the-counter drugs and indigenous healers before seeing a Western healthcare provider. ▪ All socioeconomic levels seek traditional healthcare providers. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Hot and Cold Illnesses ▪ See book chapter with hot and cold illnesses and their treatments—varies greatly among families because they are handed down within the family and community—need to specifically ask! ▪ Barriers in the United States include money, access, appropriateness, language, limited knowledge, and gender. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cultural Responses ▪ Accept and expect pain as a necessary part of life. ▪ Obliged to endure pain in the performance of duties. ▪ Ability to endure pain stoically is valued. ▪ Pain and suffering may be due to immoral behavior. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cultural Responses Continued ▪ Physical and mental illnesses are readily accepted but may keep family member at home to protect others, not the patient. ▪ Can enter the sick role readily without stigma. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Organ Donation and Transplantation ▪ Not morally averse to organ donation. ▪ Hesitant to donate while alive because the body should be buried whole. ▪ If abdominal surgery, bad air may enter the body and increase the potential for cancer or other problems. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Traditional Hispanic Healthcare Providers ▪ ▪ ▪ ▪ ▪ ▪ ▪ Curanderos: folk healers Masijistas: massage therapists Brujos: witches Sobadoros: manipulate bones Padres: priests Espiritistas—Espiritualistas—Espiritus (spiritualists) Jerberos—yerberos: herbalists Transcultural Health Care: A Culturally Competent Approach, 4th Edition Korean American Culture Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Korean Overview/Heritage ▪ This presentation focuses on the commonalities among Koreans from the Republic of South Korea, although some information may be congruent with North Koreans.. ▪ The first major immigration from Korea occurred between 1903 and 1905, when more than 7,000 men arrived in Hawaii. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Korean Overview/Heritage ▪ South Koreans immigrate to America to increase socioeconomic opportunities and improve educational opportunities. ▪ They place a high value on education. ▪ Their reputation for hard work, independence, and self-motivation has earned them the label of the “model minority.” Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Communication ▪ The dominant Korean language, han’gul, was the first phonetic alphabet in East Asia. ▪ Most Koreans in America can speak, read, write, and understand English to some extent. ▪ Some Americans may have difficulty understanding their English, especially those who learned English from Koreans who spoke with their native intonations and pronunciations. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Korean Communication ▪ A high value is placed on harmony and the maintenance of a peaceful environment. ▪ Most are comfortable with silence. ▪ Small talk may appear senseless and insincere. ▪ Most stand close when conversing. ▪ Touch in the realm of health care is readily accepted. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Korean Communication ▪ Touching among friends and social equals is common and does not carry a sexual connotation, as it might in Western societies. ▪ Hugging and kissing are uncommon among parents and children as well as among children and older aunts or uncles. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Korean Communication ▪ Age, gender, and social status determine the use of eye contact. ▪ Respect for those in senior positions is shown by not looking them directly in the eye. ▪ Feelings are infrequently communicated in facial expressions. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Korean Communication ▪ More traditional Koreans are past-oriented. Much attention is paid to the ancestry of a family. ▪ Yearly, during the Harvest Moon in Korea, chusok (respect) is paid to ancestors by bringing fresh fruits from the autumn harvest, dry fish, and rice wine to gravesites. ▪ The younger and more educated generation is more futuristic and achievement-oriented. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Korean Communication ▪ Punctuality is the norm for keeping important appointments, making transportation connections, and reporting to work. ▪ The number of surnames in Korea is limited: the most common ones are Kim, Lee, Park, Rhee or Yi, Choi or Choe, and Chung or Jung. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Korean Communication ▪ Korean names contain two Chinese characters, one of which describes the generation and the other the person’s given name. ▪ The surname comes first. ▪ However, because this may be confusing to many Americans, some Koreans in the United States follow the Western tradition of Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Family Roles and Organization ▪ Men are the primary financial providers. ▪ Women are expected to stay home and care for the children and domestic affairs unless they are professionals. ▪ Women have long been degraded in Korean society and seen as appendages of male family members. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Family Roles and Organization ▪ In earlier times, a woman’s identity was determined by her role as someone’s daughter, wife, or mother. While many still practice these gender relationships, more educated women and men no longer adhere to these Confucian values. ▪ Parenting in Korea is authoritative, although class differences play a more influential role in determining parenting styles and family roles. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Family Roles & Organization ▪ Children are expected to be well behaved because the whole family is disgraced if a child behaves in an embarrassing manner. ▪ Discussing domestic violence violates Korean cultural norms. ▪ Dating is uncommon among high school students, although it is gaining in the US. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Family Roles & Organization ▪ Once young adults have entered a university, they receive their freedom and are permitted to make their own decisions about personal and study time. ▪ With rapid acculturation, children often take on the values of the dominant society or culture and challenge parents who support traditional values and ideals. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Family Roles & Organization ▪ Parents expect their children to care for them in old age. ▪ Hyo (filial piety) is the obligation to respect and obey parents, care for them in old age, give them a good funeral, and worship them after death. ▪ The obligation to care for one’s parents is written into civil code in Korea. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Family Roles & Organization ▪ Older people are frequently consulted on important family matters as a sign of respect for their life experiences. ▪ Old age begins when one reaches the age of 60 years. ▪ Women who divorce may suffer social stigma. ▪ Living together before marriage is not customary in Korea. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Family Roles & Organization ▪ If pregnancy occurs outside marriage, it may be taken care of quietly and without family and friends being aware of the situation. ▪ Lesbian and gay relationships are frowned upon. ▪ Personal disclosure to friends and family jeopardizes the family name and may lead to ostracism. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Workforce Issues ▪ The skills and work experiences Koreans bring from their home country are often not accepted in the American workforce, forcing them to take jobs in which they may be over skilled. ▪ A supervisor is treated with much respect in work and in social settings. ▪ Informalities and small talk may be difficult for Korean immigrants. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition ClickerCheck An older adult Korean American man does not maintain eye contact with the nurse who is teaching him insulin injection. The nurse recognizes that lack of eye contact means he a. Does not understand the instructions. b. Does not care about the instructions. c. Is demonstrating respect. d. Is hard of hearing. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Correct Answer Correct answer: C Many traditional Koreans do not maintain eye contact with people in authoritative positions as a means of demonstrating respect. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Workforce Issues ▪ For an employee to refuse a request of an employer is unacceptable, even if the employee does not want or feel qualified to complete the request. ▪ American slang and colloquial language is difficult for Koreans to understand. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Biocultural Ecology ▪ Common physical characteristics include dark hair and dark eyes, with variations in skin color and hair darkness. ▪ Skin color ranges from fair to light brown, with those residing in the southern part of South Korea being darker. ▪ Epicanthal skin folds create the distinctive appearance of Asian eyes. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Biocultural Ecology ▪ Common health conditions occurring with Koreans include the following: schistosomiasis, renal failure, asbestosis, hypertension, tuberculosis, hepatitis, stomach cancer, lactase deficiency, osteoporosis, peptic ulcer disease, and insulin autoimmune deficiency disease. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean High-Risk Health Behaviors ▪ Korea continues to manufacture and use asbestos-containing products ▪ Smoking by women in public is taboo, but some women smoke at home. ▪ Men have a high incidence of alcohol consumption. ▪ Seat belts are worn infrequently in South Korea. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Nutrition ▪ The traditional Korean diet includes steamed rice; hot soup; kimchee; and side dishes of fish, meat, or vegetables served in some variation for breakfast, lunch, and dinner. ▪ Breakfast is traditionally considered the most important meal. ▪ Rice is served with 5 to 20 small side dishes of mostly vegetables and some fish and meats. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Nutrition ▪ Food is flavorful and spicy. Cooking includes a variety of seasonings: red and black pepper, garlic, green onion, ginger, soy sauce, and sesame seed oil. ▪ Most Korean Americans are at high risk for calcium deficiencies due to lactose intolerance. ▪ A cultural treatment for the common cold is soup made from bean sprouts, anchovies, garlic, and other hot spices Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Pregnancy & Childbearing Practices ▪ Pregnancy is a highly protected time for women. ▪ Both pregnancy and the postpartum period are ritualized. ▪ Once a woman is pregnant, she starts practicing Tae-Kyo, which literally means “fetus education.” Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Pregnancy & Childbearing Practices ▪ The objective of Tae-Kyo is to promote the health and well-being of the fetus and mother by having the mother focus on art and beautiful objects. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Death Rituals ▪ Death and dying are fairly well accepted in the Korean culture. ▪ Prolonging life may not be highly regarded in the face of modern technology. ▪ Families are expected to stay with family members and assist in feeding and personal care around the clock. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Death Rituals ▪ Many believe that patients should not be told they have a terminal illness. ▪ Crying and open displays of grief are common and signify the utmost respect for the dead. ▪ Relatives and friends pay respect by viewing photographs of the deceased instead of viewing the body. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Death Rituals ▪ An ancestral burial ceremony follows death, with the body being placed in the ground facing south or north. ▪ Rice wine is sprinkled around the gravesite. ▪ The eldest son or male family member sits by the deceased, sometimes holds a cane, and makes a moaning noise to display his grief. ▪ The cane is a symbol of needing support. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Spirituality ▪ Organized religions include Christianity, Buddhism, and Chondokyo. ▪ The church is a powerful social support group for Korean immigrants. ▪ Christians believe the spirit goes to heaven; Buddhists believe the spirit starts a new life as a person or an animal. ▪ Family and education are central themes that give meaning to life. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Health-care Practices ▪ Herbal medicine may be used in conjunction with Western biomedicine. ▪ Herbal remedies include ginseng, seaweed soup, and haigefen (clamshell powder), which has high levels of lead, causing abdominal colic, muscle pain, and fatigue. ▪ Acupuncture, acumassage, acupressure, and moxibustion therapy are commonly used. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Health-care Practices ▪ Some Korean Americans are stoic and are slow to express emotional distress from pain. ▪ Others are expressive and discuss their smallest discomforts. ▪ Organ donation and organ transplantation are rare, reflecting traditional attitudes toward integrity and purity. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Health-care Practices ▪ Mental illness may be stigmatized. Hwa-Byung, a traditional Korean illness, occurs from the suppression of anger or other emotions. ▪ These emotions are expressed as physical complaints, ranging from headaches and poor appetite to insomnia and lack of energy. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Korean Health-care Practitioners ▪ More traditional individuals frequently prefer health-care providers who speak Korean and are older. ▪ Because of modesty, women prefer women health care providers to perform Pap smears, mammography, and breast examinations. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition ClickerCheck Mrs. Kim brings her 15 year old daughter to the parish nurse because she is having abdominal cramps and fatigue that have worsened since she began giving her haigefen. The nurse should request a blood test for a. Iron levels. b. Lead levels. c. Calcium levels d. Potassium levels. Transcultural Health Care: A Culturally Competent Approach, 3rd Edition Correct Answer Correct answer: B Haigefen is an herbal compound that is made with clamshells which has a high lead content. Chapter 20 People of Korean Heritage Eun-Ok Im Overview, Inhabited Localities, and Topography Overview This chapter focuses on the commonalities among people of Korean heritage, with historical reference to the mother country, South Korea. The word Korea limitedly refers to the Republic of Korea. Because some information may not be pertinent to every Korean, this chapter serves as a guide for health-care providers rather than as a mandate of facts. Differences in beliefs and practices among Koreans in Korea, the United States, and other countries vary according to variant cultural characteristics as presented in Chapter 1. An understanding of Korean culture and history gives health providers the insight needed to perform culturally appropriate assessments, plan effective care and followup, and work effectively with Koreans in the workforce. South Korea is a peninsula separated by North Korea to the north at the 38th parallel and surrounded by the former Soviet Union to the northeast, the Yellow Sea to the west, and the East Sea to the east. South Korea has a landmass of 98,480 square kilometers (38,031 square miles), which is about the size of the state of Indiana, and a population of 48 million (CIA World Factbook, 2010). South Korea has 1 percent of the landmass of the United States, but has one-sixth as many people, making it 16 times more densely populated than the United States (Kohls, 2001). The mega-modern metropolitan area of Seoul, the capital, has a population of 10.3 million people (Asianinfo, 2010a). A new international state-of-the-art airport is located in Incheon, 60 kilometers from the center of Seoul. Other large cities are Busan (Pusan) and Daegu (Taegu). Planes, trains, and buses link all South Korean major cities, making travel easy and efficient. With the recent increase in the number of automobiles and the construction of highways, motorways are becoming more congested. Major industries are electronics, telecommunications, automobile production, chemicals, shipbuilding, and steel (CIA World Factbook, 2010). South Korea is now well known as riding on the “hallyu movement” or the “Korean wave,” which is the globalization of Korean dramas throughout Singapore, Malaysia, Japan, China, and the United States. Since the 1990s, the entertainment industry of South Korea has grown explosively, producing Asia-wide successes in music, television, and film (Asianinfo, 2010b). The continental and monsoon climate of Korea is fairly consistent throughout the peninsula, except during the winter months. North Korea has cold, snowy winters, with an average temperature in January of 17°F. South Korea is milder, with an average January temperature of 23°F. During the summer months, the monsoon winds create an average temperature of 80°F, with high humidity throughout the peninsula. August is the hottest month of the year, when temperatures reach over 100°F in many areas. Precipitation occurs mostly during the summer months and is heavier in the south. The peninsula is mountainous; only 20 percent of the terrain is located in lowlands. Such topography encourages the development of concentrated living areas. Most cities and residential areas are located along the coastal plains and the inland valleys opening to the west coast. Heritage and Residence Korea is one of the two oldest continuous civilizations in the world, second only to China. Koreans trace their heritage to 2333 B.C. In the 1st century A.D., tribes from central and northern Asia banded together to form this “Hermit Kingdom,” littering the countryside with palaces, pagodas, and gardens. Over the ensuing centuries, Mongols, Japanese, and Chinese invaded the Korean peninsula. Japan forcibly annexed Korea in the early 20th century, ruling it harshly and leaving ill will that persists to this day. As a result of the Potsdam Conference after World War II, the United States took over the occupation of South Korea, with the USSR occupying North Korea. By 1948, Korea’s new government was recognized by the United Nations, only to be followed by the North Korean Communist forces invading South Korea in 1950. The result was the Korean War, which lasted 357 358 Aggregate Data for Cultural-Specific Groups until 1953 and caused mass devastation, from which the country has made a remarkable recovery. Open aggression between North and South Korea again occurred in 1998 and 1999. In 2000, the two Koreas signed a vague, yet hopeful, agreement that the two countries would be reunited. However, North Korea’s recent resumption of its nuclear weapons program has set its neighbors and much of the rest of the world on edge (CNN, 2010). In 1988, the year Seoul hosted the Olympic Games, elections were held, and relations were reestablished with China and the Soviet Union. Intermittent corruption among political officials has continued to surface, threatening internal relationships and the economy. In 1997, South Korea’s economy tumbled dramatically, resulting in economic and democratic reforms. With unwavering persistence, Koreans have rebuilt their major world economy, reflecting a 4 to 5 percent annual growth rate with moderate inflation from 2003 to 2007 but decreased to .2 percent in 2009 (CIA World Factbook, 2010). The United States continues to maintain a strong military presence throughout South Korea (Fig. 20-1). Reasons for Migration and Associated Economic Factors Koreans are one of the most rapidly increasing immigrant groups in the United States (Migration Information Source, 2010). The first major immigration from Korea to the United States occurred between 1903 and 1905, when the Korean government prohibited further emigration; about 10,000 Koreans had entered Hawaii, and 1000 reached the U.S. mainland. The U.S. Immigration Act of 1924 practically closed the door to Japanese and Koreans. During the civil rights movements of the 1950s and 1960s, new immigration laws repealed the earlier limitations on Asian immigration. Koreans continue to immigrate to America to pursue the American dream, to increase socioeconomic opportunities, and to attend colleges and universities. In addition, many Koreans and Americans marry, making both Korea and America their homes. In a 2005 U.S. Census Bureau survey, an Figure 20-1 Traditional Korean games that are played in the beginning of a new year. estimated 432,907 Koreans in the United States were native-born Americans, 1 million were foreign-born Korean, and more than 57 percent were women (U.S. Census Bureau, 2006). Most of the population pursues higher education, and South Korea has more citizens with PhDs per capita than any other country in the world. Owing to Confucian cultural influence, education is emphasized as a virtue of human beings (all human beings should be educated) and is highly valued in the Korean culture (Im, 2002). Before the late 19th century, education was primarily for those who could afford it. State schools educated the youth from the yangban (upper class), focusing on Chinese classics in the belief that these contained the tools of Confucian morality and philosophy that also apply in politics. In the late 1800s, the state schools were opened to all citizens. Early Christian missionary work introduced the Western style of modern education to Korea. Initially, many Koreans were skeptical of the radical curriculum and instruction for females, but the popularity of this style grew rapidly. After the takeover of Korea by the Japanese in 1910, two types of schools emerged—one for Japanese and another for Koreans. The Korean schools focused on vocational training, which prepared Koreans for only lower-level positions. Japanese colonial education was designed to keep Koreans subordinate to ethnic Japanese in all ways (Sorensen, 1994). In 1949, South Korea allowed for the implementation of an educational system similar to that of the United States. This 6–3–3–4 ladder (6 years in elementary school, 3 years in junior high, 3 years in high school, and 4 years in college) continues today in contemporary South Korea. Anti-Communism and morality are taught throughout elementary and secondary schools. In the United States, many Koreans own their own small businesses, which vary from mom-and-pop stores and gas stations to grocery stores and real estate agencies to retail shops. Their reputation for hard work, independence, and self-motivation has given them the label “the model minority.” However, this has caused a backlash in some communities, such as Washington, DC, where they have been compared with other minority groups. The message has become “If the Koreans can do it, why not other groups?” The turmoil and riots that took place in Los Angeles in April 1992 between the African American community and the Korean American merchants are examples of conflicts that arise from such labeling. Many Korean small businesses are located in African American neighborhoods because of low capital investment requirements and limited resources of the owners. Korean merchants begin dealing in inexpensive consumer goods as a practical way to start a business in a capitalistic society. Koreans often assist each other in establishing businesses by pooling their People of Korean Heritage 359 money and taking turns with rotating credit associations to provide each family with the opportunity for financial success. Communication Dominant Language and Dialects The dominant language in Korea is Korean, or han’gul, which originated in the 15th century with King Se Jong, and is believed to be the first phonetic alphabet in East Asia. Several dialects exist in the Korean language, called saturi in Korean (Korean Language, 2010). The Korean standard language in South Korea is based on the dialect of the area around Seoul, and the Korean standard language in North Korea is based on the dialect of the area around Pyongyang. All the dialects of Koreans are similar to one another except that of Jeju Island (Korean Language, 2010). The most notable difference among dialects is the accent. For example, the Korean standard language has a very flat intonation, while the Gyeongsang dialect has a very strong accent and intonation (Korean Language, 2010). The Korean language has four levels of speech that are determined based on the degree of intimacy between speakers. These varying levels reflect inequalities in social status based on gender, age, and social positions. Use of an inappropriate sociolinguistic level of speech is unacceptable and is normally interpreted as intended formality to, disrespect for, or contempt to a social superior. Chinese and Japanese have influenced the Korean language. Before the Japanese occupation in Korea, highly educated Koreans used Chinese characters, and Chinese characters were taught in Korean traditional schools. Then, during the Japanese occupation in the early 20th century, the Japanese forbade public use of the Korean language, requiring the use of the Japanese written and spoken language, which introduced some Japanese terms and words into contemporary Korean language. Most Koreans in the United States can speak, read, write, and understand English to some degree. However, some Americans may have difficulty understanding the English spoken by Koreans, especially those who learned English from Koreans who spoke with their native intonations and pronunciations. Cultural Communication Patterns Sharing thoughts, feelings, and ideas is very much based on age, gender, and status in Korean society. Traditionally, the Korean community values the group over the individual, men over women, and age over youth. Those holding the dominant position are the decision makers who share thoughts and ideas on issues. Koreans prefer indirect communication because they perceive direct communication as an indication of intention or opinions as rude. Moreover, Koreans may agree with the health-care provider in order to avoid conflict or hurting someone’s feelings, even if something is impossible (Im, 2002). Thus, it is important to read between the lines when working with these families and remember those growing up in the United States may adopt the dominant American communication style. Koreans tend to avoid eye contact, especially with older people, perceived authorities (e.g., health-care providers), and strangers. Avoiding direct eye contact with older people and perceived authorities indicates respect, and women’s avoiding direct eye contact with men shows modesty. Younger generations of Koreans educated in the United States may adopt the dominant communication style of eye contact. Koreans are usually comfortable with silence owing to the Confucian teaching “Silence is golden.” Silence was traditionally emphasized as a virtue of educated people. Even among Korean Americans, people who are silent, especially men, are viewed as humble and well educated. However, the social fabric and cultural norms of Koreans are changing as they interact with Western societies and culture. Younger generations of Koreans, even in South Korea, are noted as being very sociable and kind to visitors (Asianinfo, 2010a). Close personal space (less than a foot) is shared with family members and close friends, but it is inappropriate for strangers to step into “intimate space” unless needed for health care (Im, 2002). Visitors from America may be uncomfortable with Koreans’ spatial distancing in public spaces. Koreans stand close to one another and do not excuse themselves if they bump into someone on the street. This may be due to the high population density in the metropolitan areas of South Korea and Koreans’ cultural attitudes toward strangers (e.g., they usually do not speak with strangers). Among family members and close friends, touching, friendly pushing, and hugging are accepted. However, among strangers, touching is considered disrespectful unless needed for care. Also, touching among friends and social equals of the same sex is common and does not carry a homosexual connotation as it might in Western societies. However, more social etiquette rules apply when it comes to touching older family members or those of higher social status. Hugging and kissing recently have become common among parents and young children, as well as among young children and aunts or uncles. Feelings are infrequently communicated in facial expressions. Smiling a lot shows a lack of intellect and disrespect. One would not smile at a stranger on the street or joke around during a serious conversation. Joking and amusement have their designated times. In Korea, men frequent bars after work and may express their sense of humor in this setting. Men and women alike appreciate and encourage jokes and laughter in appropriate settings. Koreans generally do not express 360 Aggregate Data for Cultural-Specific Groups their emotions directly or in public; expressing emotions in front of others, including family members, is regarded as shameful, especially among men (Im, 2002). A common Korean belief related to men’s emotions is that men should cry only three times in their lives: when they are born, when their parents die, and when their country perishes (Im, 2002). Given these cultural communication patterns, health-care providers should not interpret these nonverbal behaviors as meaning that Korean patients are not interested in, or do not care about, information presented during health teaching and health promotion interventions. Temporal Relationships Traditional Koreans are past oriented. Much attention is paid to the ancestry of a family. Yearly, during the Harvest Moon in Korea, chusok (respect) is paid to ancestors by bringing fresh fruits from the autumn harvest, dry fish, and rice wine to gravesites. However, the younger and more educated generation is more futuristic and achievement oriented. In Korea, Korean traditional shamans (called modang and/or jumjangi) are visited to determine the best home to purchase, the best date for having a wedding, and the best time to start a new business. The busiest time of the year for the shaman is just before the Chinese New Year. Koreans are eager to know their fortune for the coming year. Many believe that misfortunes occur because ancestors are unhappy. During these times, families show respect to ancestors by more frequent visits to their gravesites in the hope of appeasing the spirits. Shamans, who may be used by Koreans of all socioeconomic levels, are also used in Korea to rid homes and new places of business of spirits. The Korean concept of time depends on the circumstances. Koreans embrace the Western respect REFLECTIVE EXERCISE 20.1 Lisa, a school nurse, is examining Mina Lee, who was referred by her teacher because of her reluctance to speak in class. Mina Lee is a first-grader whose family has recently immigrated from South Korea. She is the second child of her family, and she is living with her mother, father, and brother who do not speak English fluently. 1. What should the nurse to do assess Mina’s reluctance to speak in class? 2. Could language be a possible barrier? 3. What cultural barriers besides language might explain Mina’s silence in class? 4. What are the traditional Korean cultural attitudes and values related to silence and teacher–student relationships? 5. What are some implications for nursing practices for children who recently immigrated from Korean culture? for time for important appointments, transportation connections, and working hours, all of which are recognized as situations in which punctuality is necessary. Yet, socially, Korean Americans arrive at parties and visit family and friends up to 30 minutes later (and sometimes 1 to 2 hours later) than the agreed-upon time. This is socially acceptable when the person or family is waiting at home. If the social meeting is being held in a public setting, a half-hour time span for arrival at the meetingplace can be expected. Format for Names The number of surnames in Korea is limited, with the most common ones being Kim, Lee, Park, Rhee or Yi, Choi or Choe, and Chung or Jung. Korean names contain two Chinese characters, one of which describes the generation and the other the person’s given name. The surname comes first; however, because this may be confusing to many Americans, some Koreans in the United States follow the Western tradition of using the given name first, followed by the surname. Adults are not addressed by their given names unless they are on friendly terms; individuals should be addressed by their surname with the title Mr., Mrs., Ms., Dr., or Minister. Given the diversity and acculturation of Korean Americans, health-care providers need to determine the Korean patient’s language ability, comfort level with silence, and spatial-distancing characteristics. In addition, Koreans should be addressed formally until they indicate otherwise. Family Roles and Organization Head of Household and Gender Roles Fundamental ideas about morality and the proper ordering of human relationships among Koreans are closely associated with kinship values derived mainly from Confucian concepts of filial piety, ancestor worship, funerary rites, position of women, the institution of marriage, kinship groups, social status and rank, and respect for scholars and political officials. Although constitutional law in South Korea declares equality for all citizens, not all aspects of society have accepted this. Korean culture is largely based on patriarchal and Confucian norms that subordinate women (Im, 2002). In Confucian traditional Korean families, the father was always the head of the family; he had power to control the family, and the family had to obey any order from the father. Wives did not share household tasks with their husbands, so they tended to be physically overloaded and psychologically distressed. Wives’ exploitation was hidden under Confucian norms that praised women who sacrifice themselves for their families and nation (Im & Meleis, 2001). Also, the wife was confined to the home and bore the major responsibility for household tasks; the husband was the breadwinner. People of Korean Heritage 361 Nowadays, this typical family structure has been changed, especially among younger generations. Many women and men remain single until their 30s and 40s. Even when they marry, they sometimes do not have a child; they choose to enjoy their lives rather than raise the next generation. Among Korean immigrants in the United States, women hold the family together and play a vital role in building an economic base for the family and community, often sacrificing themselves in the immigration process. The Korean immigrant woman may have started as a cleaning woman or seamstress, then worked at a fast-food restaurant, and then in a small shop owned with her husband. However, the women’s financial contributions to the family usually do not change the gender roles; their husbands still occupy center stage, exercise the authority, and make the major family decisions (Im & Meleis, 2001). Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents In contrast to the Western culture in which mothering is individually fashioned and relies on the expertise of health-care providers, in the highly ritualistic Korean culture mothering is molded by societal rules and information is less frequently sought from health-care providers. In this context, mothers tend to view infants as passive and dependent, and they seek guidance from folklore and the extended family (Choi, 1995). In Korea, children over the age of 5 years are expected to be well behaved because the whole family is disgraced if a child acts in an embarrassing manner. Most children are not encouraged to state their opinions. Parents usually make the decisions. Korean families have high standards and expectations for their children, and “giving a whip to a beloved child” is the basis for discipline of children (Im, 2002). Thus, the pressure of high performance in school and entering a highly ranked university is prevalent among Korean children and adolescents (Im, 2002). Usually, Koreans are not happy with very masculine girls or very feminine boys (Im, 2002). “Teaching to the test” is also common in Korea, but the role of teachers is also to encourage self-study. The future of Korean students is determined by their teachers’ recommendations, and this pressure can be extremely intense for students who are not doing well. The teaching style is one in which students listen and learn what is being taught. Regardless of private doubts, a student rarely questions a teacher’s authority. Korean children in America must be taught the teaching style in American schools, in which questioning is positive and is valued as class participation. Even if Korean American students understand the style of teaching, it can be difficult to know the appropriate timing for asking questions. The pressure of doing well in school and attending a university of high quality leaves Korean adolescents little room for social interactions. Activities that interfere with one’s education are considered taboo for adolescents. In Korea, students frequently attend study groups after school or special tutoring sessions paid for by their families in preparation for examinations to enter a university. Short coffee breaks or snacks at local coffee shops or noodle houses are permissible, but then it is “back to the books.” Dating is now common among high school students in South Korea. Even an elementary student would say that she or he has a boyfriend or a girlfriend. Yet, adolescent girls are usually not allowed to spend the night at their friends’ houses, virginity is emphasized, and sexual activities and pregnancy at puberty stigmatize the family across social classes. Although talking about sexuality, contraception, or pregnancy in public is taboo, close girlfriends or boyfriends exchange information on these topics or get their information from women’s magazines. Neither the school system nor the family assumes responsibility for sex education. Girls in elementary school are given a class regarding their menstrual cycle, but no information is given about sexual relations. Once young adults have entered a university, they receive their freedom and are then permitted to make their own decisions about personal and study time. Group outings are common for meeting the opposite sex. Dating may occur from these group meetings and consists of movies, dinner, and walks in the park. Issues arise between the first-generation Korean immigrant parents and the second-generation children in relation to conflicting values and communication. With rapid acculturation, the second generation often takes on the values of the dominant society or culture. Thus, parents who are of the first generation in most cases are challenged when their second-generation children do not accept traditional values and ideals that they may still hold dear. The different cultures between the firstgeneration parents and the second-generation children are sometimes the cause of domestic violence. Most of the first generation of Korean immigrants were educated in Korea, and they have a strong stereotype of Korean patriarchal culture. However, because the second generation is educated in the United States (some of them never visited Korea), most second-generation individuals feel a spirit of insubordination and often quarrel. For some, physical abuse might be involved if they do not follow orders (Kim, Cain, & McCubbin, 2006; Kim & Chung, 2003; Park, 2001). Family Goals and Priorities In a Korean traditional family, family members have specific rights and duties within their family. For example, the first son inherits all the properties of his parents and has the duty of caring for his elderly parents until they die. A family member replaces the roles 362 Aggregate Data for Cultural-Specific Groups of another family member who dies. Thus, if the first son dies, the second son is in charge of all the duties of the first son. However, this traditional family system is dissolving among both Koreans and Korean Americans. Usually in Korean Americans, both parents work to provide every opportunity possible for their family. As each family member learns to adjust to the changing roles in the new country, conflict can result. Children adapt most easily to the new culture and may even take on the dominant culture’s values. Lee and Lee (1990) studied the adjustment of Korean immigrant families in the United States in relation to roles, values, and living conditions between husbands and wives, and parents and children. The findings showed a transition from an independent family structure, in which the woman had little knowledge of the man’s activities outside the home, to a joint family structure. Many activities were carried out together with an interchange of roles at home. Conflict centered on undefined role expectations. In Korea, the roles of men and women were very clear. However, upon immigrating to the United States, men and women were faced with conflicting roles in the new culture and had to struggle to redefine them. Other conflict areas were the couple’s ability to speak English, the woman’s inability to drive, the degree of acculturation, the limited social contact, and the stressors of living in a new culture. In Korea, education is a family priority. The outcome of having a highly educated child was a secure old age for the parents. Because of the dependent relationship between parents and their children, parents were more willing to make drastic sacrifices for the advancement of their children’s education. Today, status is achieved rather than inherited in Korea. Education in Korea is a determinant of status, independent of its contribution to economic success. Traditionally in Korea, parents expected their children to care for them in old age. Hyo (filial piety), which is the obligation to respect and obey parents, care for them in old age, give them a good funeral, and worship them after death, was a core value of Korean ethics. The obligation to care for one’s parents is written into civil code in Korea. The burden was on the eldest son, who was obliged to reside with his parents and carry on the family line. Such an arrangement made the generations dependent on each other. The son felt obligated to care for his parents because of the sacrifices they made for him. Similarly, he made the same sacrifices for his children and expected them to provide for him and his wife in their old age. Many of these traditions in Korea have changed. Some of the eldest children emigrated, leaving the responsibility for their parents to the siblings who remained in Korea. Some older Koreans were brought to the United States without their friends and with minimal or no English skills. They often felt obligated to assist the family in any way possible by preparing meals or taking care of the children when the parents were not home. Decision making for older people was hampered in their new culture. Korean older people were frequently consulted on important family matters as a sign of respect for their life experiences. Older people’s roles as decision makers in the United States have shifted with the younger generation of Korean Americans wanting the final decision-making authority in their young families. Traditionally, Koreans give great respect to their elders. Old age begins when one reaches the age of 60 years, with an impressive celebration prepared for the occasion. The historical significance of this celebration is related to the Chinese lunar calendar. The lunar calendar has 60 cycles, each with a different name. At the age of 60, the person is starting the calendar cycle over again. This is called hwangap. This celebration was more significant in the past when life expectancy in Korea was much lower than it is today. Despite a change in the direct role of older people in their families, older Koreans are socially well respected in Korea. In public, an older woman is called Halmoni (grandmother), and those who are not blood relatives call an older man Harabuji (grandfather). Older people are offered seats on buses out of respect and honor. However, recent changes in Korean culture have made this tradition change as well. Sometimes quarrels between older people and young people, usually about respect, are reported in the daily news in South Korea. Traditionally, the extended Korean family played an important role in supporting its members throughout the life span. With the breakup of the extended family, Korean Americans support one another through secondary organizations such as the church. The church assists new immigrants with the transition to life in the United States. The church is a resource for information about child care, language classes, and social activities (Im & Yang, 2006). Korean Americans without family support may seek other Korean Americans who live in the area. With Korean Americans dispersed throughout the United States, this task can be difficult. Whereas some Koreans inherit social status, many have the ability to change their status through their education and professions. Traditional Korean culture espouses respect not only for older people but also for those of valued professions. In modern Korea, professors, bureaucrats, business executives, physicians, and attorneys receive a high level of respect. Historically, those with the highest education were handsomely paid. Even though the salary differences between university professors and other professions have narrowed significantly in recent years in Korea, the status of the intellectual remains high. Similarly, the bureaucratic officer has a high social status, wielding much respect and influence. People of Korean Heritage 363 Alternative Lifestyles Alternative lifestyles are usually frowned upon in Korean culture. Women who divorce suffer social stigma, the degree of which depends on the situation. However, recent changes in the Family Law in South Korea now permit women to head a household, recognize a wife’s right to a portion of the couple’s property, and allow a woman to maintain greater contact with her children after a divorce. South Korea now has one of the highest divorce rates in the world; Korea has the highest divorce rate among 33 Organization for Economic Cooperation and Development (OECD) countries (OECD, 2010). Yet, the stigma of divorce remains strong among Koreans in both South Korea and the United States, and there is little government or private assistance for divorced women in South Korea. Mixed marriages, between a Korean and a non-Korean, are highly disregarded by some, and the Korean government makes it very difficult for these marriages to occur. Korean women who have married American servicemen are often the objects of Korean jokes and are ridiculed by some. Living together before marriage is not customary in Korea. If pregnancy occurs outside marriage, it may be taken care of quietly and without family and friends being aware of the situation. However, with recent changes in Korean culture, some celebrities began to announce their pregnancies before marriage, and a pregnancy right before marriage is not looked upon as harshly as in the past. In the United States, pregnancy outside of marriage may not carry such a great stigma among the more acculturated. As in other Asian cultures, homosexuality has not been accepted in Korean culture (Kimmel & Yi, 2004). Also, Korean’s understanding and knowledge of homosexuality are ambiguous and limited (Kim & Hahn, 2006). Koreans believe that homosexuality is an abnormal and impure modern phenomenon. Despite the recent coming out of several Korean homosexual entertainers in South Korea, those who have relations with a person of the same sex still remain “in the closet.” Personal disclosure to friends and family usually jeopardizes the family name and may lead to ostracism. The community may stigmatize both the family and the individual, making it difficult to conduct their personal lives. Workforce Issues Culture in the Workplace Korean Americans come from a culture that places a high value on education. Many Korean immigrants are college educated and held white-collar jobs in Korea. Moreover, it is difficult for Korean immigrants to obtain work in the United States commensurate with their experience because of language difficulties, restricted access to corporate America, and unfamiliarity with American culture (Im & Meleis, 2001). The skills and work experiences they had in Korea are often not accepted by American businesses, forcing them to take jobs in which they may be over skilled while they save money to start their own businesses. Korean American women frequently need to find jobs to assist the family financially, which may cause role conflicts between more traditional husbands and wives. Korean Americans have a strong work ethic. They work long hours each week for the advancement of family opportunities. Family is the priority for Korean Americans, but on the surface this may not always be apparent when long hours are devoted to work. The goal is to save money for education and other opportunities so the family can provide for their children in the future. The number of Korean medical personnel working in the American health-care system is unknown. Significant numbers of Korean nurses and physicians are practicing in the United States and Canada; many have received part or all of their education in the United States. Yi and Jezewski’s study (2000) of 12 Korean nurses’ adjustment to hospitals in the United States identified five phases of adjustment. The first three phases—relieving psychological stress, overcoming language barriers, and accepting American nursing practices—take 2 to 3 years. The remaining two phases—adopting the styles of American problem-solving strategies and adopting the styles of American interpersonal relationships—take an additional 5 to 10 years. Accordingly, orientation programs need to address language skills, practice differences, and communication and interpersonal relationships to help Koreans adjust to the American workforce. These same phases may occur with other Korean health-care providers. Issues Related to Autonomy Those in supervisory positions need to recognize the roles and relationships that exist between Koreans and their employers. A supervisor is treated with much respect in work and in social settings. Informalities and small talk may be difficult for Korean immigrants. For an employee to refuse an employer’s request is unacceptable, even if the employee does not want or feel qualified to complete the request. Supervisors should make an effort to promote open conversation and the expression of ideas among Korean Americans. Asking Korean employees to demonstrate procedures is better than asking them whether they know how to perform them. Those who have adjusted to the American business style may be more assertive in their positions, but an understanding of this work role gives supervisors the tools to more readily use Korean Americans’ skills and knowledge. 364 Aggregate Data for Cultural-Specific Groups As with any new language, it is often difficult to understand American slang and colloquial language. Employers and other employees should be clear in their communication style and be understanding of miscommunications. Ethnic biases are often directed at Korean Americans who speak English with an accent. Employers’ and coworkers’ preconceived notions of immigrants can also be a deterrent to Korean Americans in the workforce. Biocultural Ecology Skin Color and Other Biological Variations Koreans are an ethnically homogeneous Mongoloid people who have shared a common history, language, and culture since the 7th century A.D. when the peninsula was first united. Common physical characteristics include dark hair and dark eyes, with variations in skin color and degree of hair darkness. Skin color ranges from fair to light brown. Epicanthal skin folds create the distinctive appearance of Asian eyes. With the popularity of drastic plastic surgeries in recent years, Koreans’ typical facial characteristics might not be easily found in some cases. Diseases and Health Conditions Schistosomiasis and other parasitic diseases are endemic to certain regions of Korea, and Koreans love sushi and sashimi (raw fish). Therefore, health-care providers should consider parasite screening with Korean immigrants, when appropriate. South Korea continues to manufacture and use asbestos-containing products and has not taken the precautions necessary to adequately protect employees and meet international standards. Thus, Korean immigrants to the United States need to be assessed for asbestos-related health problems (Johanning, Goldberg, & Kim, 1994). The high prevalence of stomach and liver cancer, tuberculosis, hepatitis, and hypertension in South Korea predispose recent immigrants to these conditions. High rates of hypertension lead to an increase in cardiovascular accidents and renal failure. The high incidence of stomach cancer is associated with environmental risks, such as diet and infection (Helicobacter pylori), and in some cases, genetic predisposition (Kim, 2003). As with other Asians, a high occurrence of lactose intolerance exists among people of Korean ancestry. Dental hygiene and preventive dentistry have recently been emphasized in health promotion in South Korea. Because of the high incidence of gum disease and oral problems, however, these conditions deserve attention. Variations in Drug Metabolism Growing research in the field of pharmacogenetics has found variations in drug metabolism among ethnic groups. Studies suggest that Asian populations require lower dosages of psychotropic drugs (Levy, 1993). Other REFLECTIVE EXERCISE 20.2 Laurie, a nurse working at a local clinic, is assessing Young Kim, who is a high school senior entering college in the coming fall. Born in South Korea, he was 4 years old when his family emigrated from South Korea. His mother accompanied him to the clinic to get his immunization records cleared for his entrance to college. All immunization records were adequately documented in his medical records, but there was an issue related to his tuberculosis (TB) immunization because his TB skin test was positive. His mother claimed that he received the Bacille Calmette Guerin (BCG) vaccination. 1. What might explain Young’s positive TB skin test? 2. Most Korean immigrants have BCG immunization records and subsequent positive TB skin tests. What are the pros and cons of BCG vaccination, subsequent positive TB skin tests, x-rays for verifying TB status, and taking preventive medications? 3. Besides tuberculosis, what are some other prevalent infectious diseases among Koreans? studies have shown variations in drug metabolism and interaction with propranolol, isoniazid, and diazepam among Asians in comparison with those of European Americans and other ethnic groups (Meyer, 1992). Although these studies primarily focus on people of Chinese and Japanese heritage, health-care providers should be aware and attentive to the possibility of drug metabolism variations among Korean Americans (Munoz & Hilgenberg, 2005). High-Risk Behaviors Because Koreans place great emphasis on education, many subject their children to intense pressure to do well in school. A national survey conducted among 80,000 middle and high school students in South Korea demonstrated such pressures: 1 out of 20 Korean youths attempted suicide, and a major reason was their lack of success in school (The Hankyoreh, 2007). Similar pressures have been seen in the United States, where suicide has occurred in Korean high school and college students because of intense pressure to do well in school. Korea has a high incidence of alcohol consumption, up from 7.0 liters in 1980 to 8.1 liters per adult per capita, which is similar to that of the United States and Ireland at 7.8 liters per adult per capita (World Health Organization, 2004). Korean business transactions commonly occur after the decision makers have had several drinks. Koreans believe that people let their masks down when they drink and that they truly get to know someone after they have had a few drinks. Socioeconomic changes in Korea have resulted in differences in alcohol-related social and health problems, with a change from drinking mild fermented beverages with meals to drinking distilled liquors without meals. People of Korean Heritage 365 In Korea, women drink far less than men. Sons’ drinking patterns are similar to their fathers’ patterns. A substantial generational difference exists among females, with daughters abstaining from alcohol less frequently than their mothers and drinking more, and more often, than their mothers (Weatherspoon, Park, & Johnson, 2001). In the United States and South Korea, drinking and vehicular accidents among Koreans and Korean Americans are a cause for concern. In a study by Lew and colleagues (2001), about 39 percent of Korean American men and 6 percent of Korean American women were current smokers. Lee, Sobal, and Frongillo (2000) also found that bicultural Korean men were least likely to smoke, whereas acculturated and bicultural women were more likely than traditional women to smoke. In Korea, a few women do smoke, and for those who do, smoking in public, such as on the street, is considered taboo. Cho and Faulkner (1993) studied the cultural conceptions of alcoholism among Korean and American university students. Students had to decide whether the person described in a vignette was an “alcoholic” or not and why. The results showed that American-born students tended to define alcoholism in terms of social and interpersonal problems related to drinking, whereas Korean-born students defined alcoholism in terms of physical degeneration and physiological addiction. The authors caution against the misuse of American concepts and diagnostic scales in the cross-cultural arena. Cultural factors should be examined closely in relation to the study, diagnosis, and treatment of alcohol problems. Nakashima and Wong (2000) also reported alcohol misuse among Korean American adolescents and concluded that alcohol misuse among Korean American adolescents is influenced by the social variables found to affect the use among other ethnic groups, such as psychological variables (depression, self-esteem), perceived prejudice, and feeling safe where one lives. 60 who lived during the Korean War experienced a time when their next meal was not guaranteed. Because of a devastated economy and agricultural base, barley and kimchee, a spicy pickled cabbage, were dietary staples during the war. Koreans are taught to respect and not waste food. Common Foods and Food Rituals Korean food is flavorful and spicy. Rice is served with 3 to 5 (and sometimes up to 20) small side dishes of mostly vegetables and some fish and meats. Seasonings in Korean cooking include red and black pepper, garlic, green onion, ginger, soy sauce, and sesame seed oil. The traditional Korean diet includes steamed rice; hot soup; kimchee; and side dishes of fish, meat, or vegetables served in some variation for breakfast, lunch, and dinner. Breakfast is traditionally considered the most important meal. Kimchee is made from a variety of vegetables but is primarily made from a Chinese, or Napa, cabbage (Fig. 20-2). Spices and herbs are added to the previously salted cabbage, which is allowed to ferment over time and is served with every meal in a variety of forms. Some common Korean American dishes include the following: • Beebimbap is a combination of rice, finely chopped mixed vegetables, and a fried egg served in a hot pottery bowl. Hot pepper paste is usually added. • Bulgolgi is thinly sliced pieces of beef marinated in soy sauce, sesame oil, green onions, garlic, and sugar, which is then barbecued. • Chopchae are clear noodles mixed with lightly stir-fried vegetables and meats. Rice is usually served in individual bowls, set to the left of the diner. Soup is served in another bowl, placed to the right of the rice. Chopsticks and large soupspoons are used at all meals. Korean Americans Health-Care Practices Seat belts are infrequently worn in South Korea, although seat belts are now mandatory (U.S. Department of State, 2010). Korean Americans understand the legal mandates in the United States and comply with seat belt and child-restraint laws. Hobbies such as hiking and golf are enjoyed in South Korea. Korean Americans do not identify hiking as a frequent pastime, either because of environmental constraints or because of living situations. Golf remains a significant activity among those Korean Americans who are financially able to play the sport. Nutrition Meaning of Food Food takes on a significant meaning when one has been without food. Many Koreans over the age of Figure 20-2 Kimchee, a spicy pickled cabbage that is a staple of the Korean diet. 366 Aggregate Data for Cultural-Specific Groups may use forks and knives, depending on their degree of assimilation into American culture. Meals are frequently eaten in silence, using this opportunity to enjoy the food. When Koreans migrate to the United States, they increase their consumption of beef, dairy products, coffee, soda, and bread, as well as decrease their intake of fish, rice, and other grains. However, incorporating a larger quantity of Western foods does not make a less healthy diet. They consume diets consistent with their traditional Korean food patterns, with 60 percent of calories coming from carbohydrates and 16 percent of calories from fat (Kim, Yu, Chen, Cross, & Kim, 2000). To increase compliance with dietary prescriptions, health teaching should be geared to the unique Korean American food choices and practices. Understanding the ritual offering of food and drink to guests is important. Koreans offer a guest a drink on first arriving at their home. The guest declines courteously. The host offers the drink again and the guest again declines. This ritual can occur three to five times before the guest accepts the offer. This interaction is done out of respect for the hosts and their generosity to share with their guest and to express an unwillingness to impose on the hosts. Accepting an offer when first asked is considered rude and selfish. Dietary Practices for Health Promotion Most dietary practices for health promotion apply to pregnancy, discussed later in this chapter. Someone suffering from the common cold is served soup made from bean sprouts. Dried anchovies, garlic, and other hot spices are added to the hot soup, which assists in clearing a congested nose. Nutritional Deficiencies and Food Limitations Lee, Lee, Kim, and Han (2009) conducted an in-depth assessment of the nutritional status of 202 Korean American elderly in a metropolitan city on the East Coast and reported that the Korean American elderly consumed more than two regular meals in a day that were considered part of a Korean food pattern. The average consumption of nutrients was generally lower than in Americans reported in the National Health and Nutrition Examination Survey III, except carbohydrates, vegetable protein, and sodium intake. The researchers noted inadequate intake of calcium, dietary fiber, and folate, and suggested that health-care providers consider ways to lower sodium intake and increase fruit and vegetable consumption. A study by Park, Murphy, Sharma, and Kolonel (2005) indicated that the proportion of overweight or obesity was 31.4 percent in U.S.-born Korean women and 9.4 percent in Korean-born Korean women. They also reported that U.S.-born Korean women had higher intakes of total fat and fat as a percentage of energy and lower intakes of sodium, vitamin C, beta-carotene, and carbohydrate as a percentage of energy than Korean-born women. In addition, Cho and Juon (2006) reported that of 492 Korean American respondents, 38 percent were overweight and 8 percent were obese according to the World Health Organization for Asian populations. These findings suggest that acculturation of Korean immigrants affects dietary intakes in ways that may alter their risks of several chronic diseases. Korean Americans, as with most other Asians, are at a high risk for lactose intolerance. Thus, milk and other dairy products are not part of the traditional Korean diet, emphasizing the need to assess them for calcium deficiencies. Korean Americans living in or near large metropolitan cities have access to Korean markets and restaurants. When no Korean stores are available, Chinese or Japanese markets may contain some of the foods Koreans enjoy. When no Asian markets are available, the American grocery store suffices. Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy To curtail population growth in Korea, the government promotes the concept of two children per household. The government supported the use of contraception when a 10-year family planning program was adopted in the early 1960s, resulting in a mass public education program on contraception. When contraceptive devices became easily available in Korea, fertility control spread widely among married women. Contraceptive devices are covered by the present national health insurance of Korea. Recently, South Korea’s fertility rate fell to a new record low in 2007 as more women engaged in economic activities and got married at older ages (The Korean Times, 2007). The average number of babies per woman of childbearing age was 1.19 as of the end of 2006, which is much lower than the average 2.56 for the UN member countries (The Korean Times, 2007). Induced abortion only with legally acceptable rationales is allowed in South Korea, yet there is an unspoken acceptance of the practice. The legally acceptable reasons for induced abortion include genetic defects, communicable diseases, pregnancy due to rape, pregnancy by family members or close relatives, and pregnancy that threatens the mother’s health. Pritham and Sammons (1993) investigated Korean women’s attitudes toward pregnancy and prenatal care with regard to their beliefs and interactions with health-care providers from the United States. The survey was conducted with 40 unemployed Korean women between the ages of 18 and 35 at an American military medical-care facility in a major metropolitan area of Korea. Attitudes toward childbearing practices and relationships with health-care providers were elicited. The results indicated that these women were People of Korean Heritage 367 happy about their pregnancies. Only one-third of the respondents agreed with the traditional preference for a male child. About 40 percent of the women reinforced strong food taboos and restrictions and acknowledged the need to avoid certain foods during pregnancy. Twenty percent disagreed with the use of prenatal vitamins, and 25 percent indicated needing only a 10- to 15-pound weight gain in pregnancy. The women generally had sound health habits in relation to physical activity and recognized the harm of smoking while pregnant. The study sample was homogeneous and small, limiting the ability to generalize about the findings. Pregnancy in the Korean culture is traditionally a highly protected time for women. Both the pregnancy and the postpartum period have been ritualized by the culture. A pregnancy begins with the tae-mong, a dream of the conception of pregnancy. Once a woman is pregnant, she starts practicing tae-kyo, which literally means “fetus education.” The objective of tae-kyo is to promote the health and well-being of the fetus and the mother by having the mother focus on art and beautiful objects. Some beliefs include the following: • If the pregnant woman handles unclean objects or kills a living creature, a difficult birth can ensue (Howard & Barbiglia, 1997). • Some women wear tight abdominal binders beginning at 20 weeks gestation or work physically hard toward the end of the pregnancy to increase the chances of having a small baby (Howard & Barbiglia, 1997). • In addition, expectant mothers should avoid duck, chicken, fish with scales, squid, or crab because eating these foods may affect the child’s appearance. For example, eating duck may cause the baby to be born with webbed feet (Howard & Barbiglia, 1997). REFLECTIVE EXERCISE 20.3 Alex, a nurse working at a prenatal clinic in a hospital, is assessing Sook Park, who is 12 weeks pregnant. Sook was raised and educated in South Korea; recently married Robert Kim, a Korean American; and moved to the United States early in her pregnancy. Alex found that Sook lost 5 pounds since her last visit. 1. From a cultural standpoint, what might explain Sook’s recent loss of weight? 2. Identify Koreans’ cultural beliefs, attitudes, and practices related to foods during pregnancy. 3. What Korean cultural beliefs, attitudes, and practices related to foods during pregnancy might explain Sook’s weight loss? 4. What are some immigration and acculturation issues that might influence Sook’s nutrition? Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Ludman, Kang, and Lynn’s study (1992) explored the food beliefs and diets of 200 pregnant Korean American women. The food items most frequently consumed were kimchee (82.5 percent), rice or noodles (81.5 percent), and fresh fruit (79 percent). Foods avoided during pregnancy included coffee (19.8 percent), spicy foods (9.9 percent), chicken (6.9 percent), and crab (6.9 percent). A list of 20 food items was then given to the women, who were asked to respond whether they consumed the food or not and, if not, to indicate their reasons. A number of respondents indicated that they did not eat rabbit (91.5 percent), sparrow (91.5 percent), duck (89.5 percent), goat (84 percent), or blemished fruit (63 percent) because of dislike or lack of availability. The reason most frequently given for not eating blemished fruit was that it might produce a skin disease on the infant or cause an unpleasant face. The study showed that although many Korean American women were aware of traditionally taboo foods, they did not avoid consuming them. An awareness of these beliefs can give health providers a basis for nutritional education for Korean American women. Birthing practices among both Koreans and Korean Americans are highly influenced by Western methods. Women commonly labor and deliver in the supine position. After the delivery, women are traditionally served seaweed soup, a rich source of iron, which is believed to facilitate lactation and to promote healing of the mother. Bed rest is encouraged after pregnancy for 7 to 90 days. Women are also encouraged to keep warm by avoiding showers, baths, and cold fluids or foods. The postpartum period is seen as the time when women undergo profound physiological, psychological, and sociological changes; this period is known as the Sanhujori belief system. In this dynamic process, postpartum women should care for their bodies by augmenting heat and avoiding cold, resting without working, eating well, protecting the body from harmful strains, and keeping clean (Howard & Barbiglia, 1997). In Western society in which they may lack extended family members from whom to seek assistance, Korean women may be faced with a cultural dilemma. Park and Peterson (1991) studied Korean American women’s health beliefs, practices, and experiences in relation to childbirth. Using structured questions, they interviewed in Korean a nonrandom sample of 20 female volunteers. Those interviewed subscribed to a holistic view, which emphasized both emotional and physical health. Only one-half of the women interviewed rated themselves healthy. The authors related this to the stresses of immigration and pregnancy. Preventive practices were not found among members of this group. Only one woman regularly received Pap smears and did breast self-examinations. A common 368 Aggregate Data for Cultural-Specific Groups finding was that most women participated in a significant rest period during puerperium. Those who did not rest lacked help for the home. All the women ate brown seaweed soup and steamed rice for about 20 days after childbirth to cleanse the blood and to assist in milk production. Because pregnancy is a hot condition and heat is lost during labor and delivery, some women avoided cold foods and water after childbirth to prevent chronic illnesses such as arthritis. The baby should be wrapped in warm blankets to prevent harm from cold winds. Herbal medicines are also used during puerperium to promote healing and health (Howard & Barbiglia, 1997). Health-care providers can improve the health of Korean American women by providing factual information about Pap smears and teaching breast self-examination. Pregnant Korean American women should be asked about their use of herbal medicine during pregnancy so that harmless practices can be incorporated into biomedical care. Recommendations for improving postpartum care among Korean American women include (1) developing an assessment tool that health-care providers can use to identify traditional beliefs early in a pregnancy, (2) developing a bilingual dictionary of common foods, (3) developing pamphlets with medical terms used in the U.S. health-care system, and (4) providing time for practicing English skills (Park & Peterson, 1991). Death Rituals Death Rituals and Expectations Traditionally in Korea, it was important for Koreans to die at home. Bringing a dead body home if the person died in the hospital was considered bad luck. Consequently, viewing of the deceased occurred at home if the individual died at home and at the hospital if the person died at the hospital. Several days or more were set aside for the viewing, depending on the status of the deceased. The eldest son was expected to sit by the body of the parent during the viewing (Martinson, 1998). Friends and relatives paid their respects by bowing to a photograph of the deceased placed in the same room in which the body rested. The guests were then offered the favorite foods of the deceased. Today, most Korean Americans are not accustomed to viewing the body of the deceased. More commonly, relatives and friends come to pay their respects by viewing photographs of the deceased. Although Korean Americans view life support more positively than European Americans, the majority in one study did not want such technology (Blackhall et al., 1999). In addition, they were less likely to have made a prior decision about life support. Older and more educated Koreans were less likely to favor telling patients the truth, believing that patients should not be told that they have a terminal illness. An ancestral burial ceremony follows, with the body being placed in the ground facing south or north. Both the place and the position of the deceased are important for the future fortune of the living relatives. Koreans believe that if the spirit is content, good fortune will be awarded to the family. Unlike Western graves, a mound of dirt covers the gravesite of the deceased in Korea. Cremation is an individual and family choice and is practiced more commonly in Korea for those who have no family or die at a young age. For example, when unmarried people die without any children to perform ancestral ceremonies, they are often cremated and their ashes scattered over a body of water. Rice wine is traditionally sprinkled around the grave. Korean families bow two to four times in respect at the gravesite, and then the men, in descending order from the eldest to the youngest, drink rice wine. Some Korean Americans dedicate a corner of their home to honor their ancestors because they cannot go to the gravesite. Circumstances in which “do not resuscitate” orders are an issue need to be addressed cautiously. Families trust physicians and may not question other options. Because death and dying are fairly well accepted in the Korean culture, prolonging life may not be highly regarded in the face of modern technology. Korean hospitals focus on acute care. Families are expected to stay with family members to assist in feeding and personal care around the clock. Thus, many Korean Americans may expect to care for their hospitalized family members in health-care facilities. Responses to Death and Grief Mourning rituals, with crying and open displays of grief, are commonly practiced and socially accepted at funerals, and they signify the utmost respect for the dead. The eldest son or male family member who sits by the deceased sometimes holds a cane and makes a moaning noise to display his grief. The cane is a symbol of needing support. Health-care providers may need to provide a private setting for Korean Americans to be able to grieve in culturally congruent ways. Spirituality Dominant Religion and Use of Prayer Confucianism was the official religion of Korea from the 14th to the 20th centuries. Buddhism, Confucianism, Christianity, shamanism, and Chondo-Kyo are practiced in Korea today. Chondo-Kyo (religion of the Heavenly Way) is a nationalistic religion founded in the 19th century that combines Confucianism, Buddhism, and Daoism. Among Koreans in South Korea, the most recent estimates of organized religions include no affiliation, 49 percent; Christianity, 26 percent; Buddhism, 23 percent; and other and People of Korean Heritage 369 unknown, 2 percent (CIA World Factbook, 2010). In the United States, the church acts as a powerful social support group for Korean immigrants (Im & Yang, 2006). Jo, Maxwell, Yang, and Bastani (2010) even suggest that Korean churches have a high potential to serve an important role in the health of Korean Americans. Koreans in America might not pray in the same fashion as Westerners, but for many people, the spirits demand homage. Korean churches often have prayer meetings several times a week, some with earlymorning prayers. Buddhist temples have spirit rooms attached to them. Although Buddhists believe the spirit enters a new life, the beliefs of the shamans are so strong that the Buddhist church incorporated an area of their church for those who believe that ancestral spirits need honoring and homage. With such a variety of spiritual beliefs, caregivers must assess each Korean patient individually for religious beliefs and prayer practices. Meaning of Life and Individual Sources of Strength Family and education are central themes that give meaning to life for Korean Americans. The nuclear and extended families are primary sources of strength for Korean Americans in their daily lives. These concepts were covered earlier under Family Roles and Organization and Educational Status and Occupations. Spiritual Beliefs and Health-Care Practices Shamanism is a powerful belief in natural spirits. All parts of nature contain spirits: rivers, animals, and even inanimate objects. The many religions of Koreans create numerous ideologies about what happens with the spirits of the deceased. Christians believe the spirit goes to heaven; Buddhists believe the spirit starts a new life as a person or an animal; and shamanists believe the spirit stays with the family to watch over them and guide their actions and fortunes. Such a variety of faith systems provide a great diversity in beliefs of the Korean people. Given this diversity of spiritual beliefs among Koreans, each patient needs an individual assessment with regard to spiritual and health-care practices. Health-Care Practices Health-Seeking Beliefs and Behaviors Beliefs that influence health-care practices include religious beliefs (see Dominant Religion and Use of Prayer) and dietary practices (see Nutrition). Healthcare providers need to be aware that the theme dominating these beliefs is a holistic approach, which emphasizes both emotional and physical health. Health-care practices among Koreans in America are primarily focused on curative rather than preventive measures. Health promotion in Korea is a relatively new public-health focus. In Korea, education on dental hygiene, sanitation, environmental issues, and other preventive health measures is being encouraged. Visits to the physician for an annual physical examination, Pap smears, and mammograms are uncommon. Among Koreans, traditional patterns of health promotion include harmony with nature and the universe, activity and rest, diet, sexual life, covetousness, temperament, and apprehension (Lee, 1993). Responsibility for Health Care One American study reported that only 13.5 percent of Korean American men and 11.3 percent of Korean American women had a digital rectal examination (DRE) for occult blood. Regression analysis indicated that gender, education, knowledge of the warning signs of cancer, and length of residence in the United States were significantly related to having undergone DRE. The researchers determined that this group of Korean Americans did not see health-care providers or health brochures as valuable sources of information, and to target this group, efforts should be coordinated with church and community leaders (Jo et al., 2010). Because of women’s modesty during physical examinations and their preferences that women perform intimate examinations, many Korean women defer having Pap tests or breast cancer screening tests (Lee, Fogg, & Sadler, 2006). A recent study among Korean immigrant women reported that 78 percent of the participants had gotten a mammogram at some point in their lives and that 38.6 percent had gotten one in the previous year (Lee et al., 2006). The reluctance for undergoing Pap tests directly relates to cervical cancer’s rating as the number one female cancer diagnosed among women in Korea (Lee, 2000). Modesty has also been associated with low rates of mammography among Korean Americans (Lee, Kim, & Han, 2009), as well as limited knowledge about breast self-examination and causes of breast cancer (Han, Williams, & Harrison, 2000). Recent Korean immigrants come from a country in which universal health insurance was implemented in the late 1980s. A government mandate established employer-based health insurance for medium and large firms. Regional health insurance systems, subsidized by the government, were later established for small firms, farmers, and the self-employed. Ryu, Young, and Park (2001) reported that health insurance coverage was the strongest predictor of Korean Americans’ utilization of health-care services and that uninsured Korean Americans have less access regardless of their health-care needs. The use and availability of over-the-counter medications vary tremendously between the United States and Korea. Many prescription drugs in the United States such as antibiotics, anti-inflammatory and cardiac medications, and certain pain control medications can be 370 Aggregate Data for Cultural-Specific Groups purchased over-the-counter in Korea at any yak bang (pharmacy). For example, when feeling “tired” or “fatigued,” older people in Korea may perform home infusions of dextrose and water or albumin. Self-medication with herbal remedies is also practiced. Ginseng is a root used for anything from a remedy for the common cold to an aphrodisiac. Seaweed soup is used as a medicine. Chinese traditional herbs are used to control the degree of “wind” that may be in the body. Other herbal medications are taken for preventive or restorative purposes. Accordingly, healthcare providers should query their patients about their use of traditional Korean medicine and must be aware that herbal medicine may be used in conjunction with Western biomedicine. has special abilities for communicating with spirits. The shaman is used to treat illnesses after other means of treatment are exhausted. The shaman performs a kut, a shamanistic ceremony to eliminate the evil spirits causing the illness. Such a ceremony may take place when a young person dies to prevent his or her spirit from staying tied to the earth. Others believe a shaman can eliminate evil spirits that may be causing difficulty with financial transactions. Although shamans have been around for many years, Koreans consider them part of the lowest class. Health-care providers need to determine whether Koreans in America are using folk therapies and should include nonharmful practices with biomedical therapies and prescriptions. Folk and Traditional Practices Because many Korean Americans use various options for healing, Western medical practices may be used in conjunction with acupressure, acupuncture, and herbal medicine. Barriers for Koreans in America may result from the expense of non-Western therapies, because many insurance companies do not cover alternative therapies. As for many other American residents, the lack of insurance creates barriers to health care. Paying for health care out-of-pocket is expensive and not feasible for many Korean American families. Language, modesty, cultural attitudes toward certain illnesses, and communication problems also serve as impediments for access to health care. Hanyak, traditional herbal medicine used for creating harmony between oneself and the larger cosmology, is a healing method for the body and soul. Hanbang, the traditional Korean medical-care system, works on the principle of a disturbed state of ki, cosmological vital energy. Symptoms are often interpreted in terms of a psychological base. Treatments include acupuncture, acumassage, acupressure, herbal medicines, and moxibustion therapy. The therapeutic relationship between hanui (oriental medicine) doctors and their patients is genuine, spontaneous, and harmonious. Patients who use both Western and traditional Korean practitioners may experience conflicts because of the lack of cooperation between hanui and biomedical health-care providers. Even Korean Americans are known to use both hanui and biomedical health-care providers. Shamans are used in healing rituals to ward off restless spirits. Shamans originated with the religious belief of shamanism, the belief that all things possess spirits. A shaman, mundang, is usually a woman who REFLECTIVE EXERCISE 20.4 Maria, a nurse working in an in-patient oncology unit, is assessing Jong Kim, age 72 years, who was recently diagnosed with lung cancer. Jong Kim emigrated from South Korea about 40 years ago and has smoked since he was in his early 20s. Although Jong does not request pain medication, his facial expressions show that he is obviously in significant pain. 1. What should the nurse do to adequately assess Jong’s pain level? 2. What are some Korean cultural beliefs, attitudes, and practices related to cancer? 3. What Korean cultural belief…
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