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Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish American Culture Larry Purnell, PhD,

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RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Overview/Heritage ▪ Over 9 million people in the United States and 800,000 people in Canada identify their ancestry as Polish. ▪ Displaying fierce patriotism, courage, and determination to resist another occupation, Poland was the only country to combat Germany from the first day of the Nazi invasion until the end of the war in Europe. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Overview/Heritage ▪ Between the 1939 Nazi invasion and the end of World War II in 1945, nearly six million Poles, comprising over 15 percent of Poland’s total population, perished. ▪ Many Polish Jews were exterminated by the Nazis in the Holocaust, prisoners killed in concentration or forced labor camps, soldiers, and civilians. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Overview/Heritage ▪ After Stalin’s death, Polish communism vacillated between repression and liberalization until about 1970. ▪ Poland’s resistance to Communist rule began in 1970 with the emergence of Lech Walesa, the leader of a strike in the Gdansk shipyards. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Overview/Heritage ▪ The 1980 emergence of Solidarity and the election of a Polish Pope rekindled a religious rebirth in the Poles, an increased sense of self, social identity, and the realization of their collective strength. ▪ Solidarity became a major social movement and phenomenon unheard of within the Soviet bloc’s political system. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Overview/Heritage ▪ In July, 1989, the newly elected Parliament changed the country’s name and constitution, establishing the Third Republic of Poland and a democratic system of government. ▪ Polish immigrants have maintained their ethnic heritage by promoting their culture, attending Catholic churches, attending parades/festivals, maintaining ethnic food traditions, speaking the Polish language. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Overview/Heritage ▪ Newer immigrants are less concerned with raising consciousness over Polish American issues as they are with financially helping families who remain in Poland and raising concerns over the political/economic climate in their homeland. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Overview/Heritage ▪ Like any other group that perceives themselves as unaccepted, displaced, and different, Polish immigrants established a geographically and socially segregated area which was called a “Polonia”. ▪ Polish immigration to America continues today; many come to earn money then return to Poland. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Overview/Heritage ▪ At the peak of Polish migration, Chicago was considered the most well-developed Polish community in the United States. ▪ Poles are a heterogeneous group. As such, they were slow to assimilate into multicultural America. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Overview/Heritage ▪ Even after displaying a sense of duty, honor, and patriotism during wartime, Polish Americans often experienced discrimination during and after the war. ▪ Poles were passed over for jobs because they had difficulties speaking English and their names were difficult to pronounce or spell. ▪ Name changes became common for Polish Americans seeking upward mobility. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Overview/Heritage ▪ Many Polish Americans still experience discrimination and ridicule through ethnic Polish jokes, which are similar in scope to those about Irish, Italian, and Mexican Americans. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Communication ▪ The dominant language of people living in Poland is Polish, although there are some regional dialects and differences. ▪ Generally, most Polish speaking people can communicate with each other. ▪ Recently, a resurgence of interest in learning to speak the Polish language has occurred among Polish Americans. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Communication ▪ Touch is common among family members and friends, but Poles may be quite formal with strangers and health-care providers. ▪ Handshaking is considered polite. In fact, failing to shake hands with everyone present may be considered rude. ▪ Most Poles feel comfortable with close personal space: distances increase with Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Communication ▪ First-generation Poles and other people from Eastern European countries commonly kiss “Polish style.” That is, once on each cheek and then once again. For Poles, kissing the hand is considered appropriate if the woman extends it. ▪ Two women may walk together arm in arm, or two men may greet each other with an embrace, a hug, and a kiss on both cheeks. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Communication ▪ Many consider the use of spoken second person familiarity rude. Polish people speak in the third person. For example, they might ask, “Would Martin like some coffee?” rather than “Would you like some coffee?” ▪ Many Polish names are difficult to pronounce. Even though a name may be mispronounced, a high value is placed on the attempt to pronounce it correctly. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Communication ▪ Polish Americans use direct eye contact when interacting with others. ▪ Many Americans may feel uncomfortable with this sustained eye contact and feel it is quite close to staring, but to Poles, it is considered ordinary. ▪ Poles tend to share thoughts and ideas freely, particularly as part of their hospitality. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Communication ▪ Americans talk of sports while Poles speak of their personal life, their jobs, families, spouse, aspirations, and misfortunes. ▪ Punctuality is important to Polish Americans. To be late is a sign of bad manners. ▪ Even in social situations, people are expected to arrive on time and stay late. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Communication ▪ Polish Americans are both past and future oriented. ▪ The past is very much a part of Polish culture, with the families passing on their memories of WW II, which still haunt them in some way. ▪ A strong work ethic encourages Poles to plan for the future. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Communication ▪ Traditional Polish names are often a description of a person (e.g., John Wysocki means John the tailor), or a profession (e.g. the surname Recznik means butcher), or a place (e.g., Sokolowski means one from a town named Sokoly, Sokolka, etc.) Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Communication ▪ Changes in surnames may have been made during the country’s record keeping process or during the immigration processing on Ellis Island. ▪ The transfer of information from emigrant to official records was highly dependent on the pronunciation, spelling, and writing skills of both the recorder and the applicant. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Family Roles and Organization ▪ Life in the Polish culture centers on family. ▪ Each family member has a certain position, role, and related responsibilities. ▪ All members are expected to work, make contributions, and strive to enhance the entire family’s reputation, social, and economic position. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Family Roles and Organization ▪ Individual concerns and personal fulfillment are afforded little consideration and sacrifices for the betterment of the family are expected. ▪ In most Polish families, the father is perceived as the head of the household. ▪ Depending on the degree of assimilation, the father may rule with absolute authority Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Family Roles & Organization ▪ Among some third- and fourth–generation Polish Americans and second- and third–wave immigrants, more egalitarian gender roles are becoming the norm. ▪ Historically, large families were commonplace. ▪ Polish women, following the Roman Catholic Church’s teachings, often experienced between 5 and 10 pregnancies. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Family Roles & Organization ▪ The most valued behavior for Polish American children is obedience. ▪ Taboo childhood behaviors include any act that undermines parental authority. ▪ Parents are quite demonstrative with children. ▪ Many parents praise children for self-control and completing chores. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Family Roles & Organization ▪ Little sympathy is wasted on failure but doing well is openly praised. ▪ Children are taught to resist feelings of helplessness, fragility, or dependence. ▪ For many, important family priorities are to maintain the honor of the family in the larger society, to have a good jobs, and to be good Catholics. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Family Roles & Organization ▪ Older people are highly respected. ▪ They play an active role in helping grandchildren learn Polish customs and in assisting adult children in their daily routine with families. ▪ For some families, one of the worst disgraces, as seen through the eyes of the Polish community, is to put an aged family member in a nursing home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Family Roles & Organization ▪ Third- and fourth–generation Polish Americans may consider an extended-care or assisted living facility. ▪ Extended family, consisting of aunts, uncles, and godparents, is very important to Poles. ▪ Longtime friends become aunts or uncles to Polish children. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Family Roles & Organization ▪ Alternative lifestyles are seen as part of assimilation into the blended American culture. ▪ Same-sex couples are frowned upon and may even be ostracized, depending on the level of assimilation. ▪ The Polish value for family solidarity is strong and divorce is truly seen as a last resort. ▪ When divorce does result, single heads of households are accepted. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Workforce Issues ▪ Polish Americans have extensive social networks and their strong work ethic enables them to gain employment and assimilate easily into the workforce. ▪ Some Poles entering America are underemployed and may have difficulty working with authority figures who are less educated than themselves. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Workforce Issues ▪ Poles are usually quick learners and work hard to do a job well. ▪ The Polish characteristic of praising people for their work makes Poles strong managers, but some lack sensitivity in their quest to complete tasks. ▪ Foreign-born Poles may have some difficulty understanding the subtle nuances of humor. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Workforce Issues ▪ Because Poles learn deference to authority at home, in the church, and in parochial schools, some may be less well suited for the rigors of a highly individualistic, competitive market. ▪ Polish immigrants who worked under a communist bureaucratic hierarchy may have some difficulty with the structure, subtleties, and culture of the American workplace. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Biocultural Ecology ▪ Most Poles are of medium height with a mediumto-large bone structure. ▪ As a result of foreign invasions over the centuries, Polish people may be dark and Mongol looking or fair with delicate features with blue eyes and blonde hair. ▪ Poles consider themselves tough and be able to tolerate pain from injuries, illness, and disease. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Biocultural Ecology ▪ In 1986, the Chernobyl radiation incident in Russia contaminated the land and water systems of eastern Poland. ▪ The full impact of this disaster on the incidence of cancer in Poland, as well as for Poles emigrating to other parts of the world, remains unknown. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Biocultural Ecology ▪ Health conditions common among Poles include cardiovascular disease, stroke, obesity, and cervical cancer. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish High-Risk Behaviors ▪ Alcohol misuse, with its subsequent physiological, psychological, and sociological effects and its related financial impact, continues to be an ongoing concern among Polish Americans. ▪ Illicit drug use is becoming more commonly used by Polish urban residents. ▪ Cannabis is the most popular illicit drug. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Nutrition ▪ Most Poles extend the sharing of food and drink to guests entering their homes. ▪ Eating and/or drinking with the host is perceived as social acceptance. ▪ Polish foods and cooking are similar to German, Russian, and Jewish practices. ▪ Staples of the diet are millet, barley, potatoes, onions, radishes, turnips, beets, beans, cabbage, carrots, cucumbers, tomatoes, and apples. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Nutrition ▪ Common meats eaten are chicken, beef, and pork. ▪ Traditional high-fat entrees include pigs’ knuckles and organ meats such as liver, tripe, and tongue. ▪ Kapusta (sauerkraut), golabki (stuffed cabbage), babka (coffee cake), pierogi”(dumplings), and chrusciki”(deep-fried bowtie pastries) are common ethnic foods. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Nutrition ▪ The Polish American diet is frequently high in carbohydrates, sodium, and saturated fat. ▪ Except for individuals living near the Baltic Sea in northern Poland who consume fish regularly, Poles are in danger of developing nutritional problems related to the lack of iodine in their diet. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Pregnancy & Childbearing Practices ▪ Because family is very important, most Poles want children. ▪ In Poland, the Catholic Church strongly opposes abortion, which is the prevailing attitude of many Poles in America. ▪ Fertility practices are balanced between the needs of the family and the laws of the Church. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Pregnancy & Childbearing Practices ▪ Pregnant Polish Americans are expected to seek preventive health care, eat well, and rest adequately to ensure a healthy pregnancy and baby. The emphasis is on “eating for two”. ▪ Many consider it bad luck to have a “baby shower.” Polish grandmothers may be reluctant to give gifts until after the baby is born. Birthing is typically done in the hospital. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Pregnancy & Childbearing Practices ▪ Pregnant women usually follow the physician’s orders carefully. ▪ The birthing process is considered the domain of women. ▪ Newer Polish immigrants may feel uncomfortable with men in the birthing area or with family-centered care. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Pregnancy and Childbearing Practices ▪ Women are expected to rest for the first few weeks after delivery. ▪ For many, breastfeeding is important. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Death Rituals ▪ Most Poles have a stoic acceptance of death as part of the life process and a strong sense of loyalty and respect for their loved ones. ▪ Family and friends stay with the dying person to negate any feelings of abandonment. ▪ The Polish ethic of demonstrating caring by doing something means bringing food to share, caring for children, and assisting with household chores. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Death Rituals ▪ Most Polish women are quick to help with the physical needs of the dying. ▪ Home hospice care is acceptable to most Poles. ▪ Polish American family members follow a funeral custom of having a wake for 1 to 3 days, followed by a Mass and religious burial. ▪ Most Poles honor their dead by attending Mass and making special offerings to the Catholic Church on All Souls Day, November 1. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Spirituality ▪ The Catholic Church requires attendance at Mass on all Sundays and holy days of obligation and is an integral part of the lives of most. ▪ There are “holy days” in almost every month of the year in addition to the rituals of baptism, first holy communion, confirmation, marriage, sacrament of the sick, and burial. ▪ Birthdays are important religious events. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Spirituality ▪ One very popular song is “Sto Lat,” which conveys wishes that the celebrant live 100 years. ▪ Primary spiritual sources are God and Jesus Christ, the Virgin Mary, saints, and angels to ward off evil and danger. ▪ Honor and special attention is paid to the Black Madonna or Our Lady of Czestachowa Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Spirituality ▪ Many older Polish people believe in the special properties of prayer books, rosary beads, medals, and consecrated objects. ▪ Polish Americans commonly exhibit devotions to God in their homes, such as crucifixes and pictures of the Virgin Mary, the Black Madonna, and Pope John Paul II. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practices ▪ Most Poles put a high value on stoicism and doing what needs to be done. ▪ Many only go to health-care providers when symptoms interfere with function; then they may consider the advice provided carefully before complying. ▪ Many Poles are reluctant to discuss their treatment options and concerns with physicians and routinely accept the proposed care plan. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practices ▪ If Poles believe they are unable to pay the medical bill, they may refuse treatment unless the condition is life-threatening. ▪ Many have a strong fear of becoming dependent and resist relying on charity. ▪ Since many Poles consider Medicare, Medicaid and managed care as forms of social charity, they are reluctant to apply for them. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practices ▪ Poles usually look for a physical cause of disease before considering a mental disorder. ▪ If mental health problems exist, home visits are preferred. ▪ Talk oriented interventions/therapies without pharmaceutical or suitable psychosocial strategies are dismissed unless interventions are action oriented. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practices ▪ Given the continuation of limited access to care and the strong work ethic of this cultural group, health promotion practices are often undervalued by Polish Americans. ▪ Older Polish Americans and newer immigrants commonly smoke and drink, engage in limited physical exercise outside of work, and receive poor dental care. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practices ▪ Attention to health promotion practices among Polish American women may be complicated by their sense of modesty and religious background. ▪ Breast self-examination and Pap smear tests are poorly understood by many women, depending on the assimilation into American culture. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practices ▪ The Polish ethic of stoicism discourages the use of over-the-counter medications unless a symptom persists. ▪ Most Poles refuse to take time off from work to see a health-care provider until self-help measures have proven ineffective. ▪ Herbs and rubbing compounds may also be used for problems associated with aches, pains, and inflammation from overworked joints. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practices ▪ Being unable to speak and understand English, the cost of health care, and the complexity to navigate the US system are the greatest barriers to health care for Polish immigrants. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practices ▪ Due to their strong sense of stoicism and fear of being dependent upon others, many Polish Americans use inadequate pain medication and choose distraction as a means of coping with pain and discomfort. ▪ When asked, many Poles either deny or minimize their pain or level of discomfort. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practices ▪ Few Poles turn to psychiatrists or mental health providers for help. Those who seek help from mental health professionals do so as a last resort. ▪ Many individuals choose their priest or seek assistance from a Polish volunteer agency before going to a health professional for psychiatric help. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practices ▪ Given the ethic of being useful, independent and a good Catholic influences one to refrain from using extraordinary means to keep people alive. ▪ The individual or family determines what means are considered extraordinary. Receiving blood transfusions or undergoing organ transplantation is acceptable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practitioners ▪ Immigrant Poles often assess health-care providers by their demeanor, warmth, and displays of respect. ▪ Health advice may be sought from chiropractors and local pharmacists as well as neighbors and extended family. ▪ Biomedical advice is sought when a symptom persists and interferes with daily functions of life. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practitioners ▪ Physicians are held in high regard in Polish communities. ▪ Poles may change physicians if they believe their recovery is too slow or if a second opinion is needed. ▪ Educated Poles are more willing to follow medical orders and continue with prescribed treatment than those less educated. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Polish Health-care Practitioners ▪ Polish women are modest and self-conscious. They may refuse health care when asked to disrobe in front of a male health-care provider. ▪ In some cases, it may be critical to request a female provider. ▪ Poles expect health-care providers to appear neat and clean, provide treatments as scheduled, administer medications on time, and enjoy their work. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian American Culture Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Overview/Heritage ▪ This presentation focuses on Russians who are immigrants to the United States. ▪ The Russian Federation, the largest country in the world, is composed of 21 republics and covers parts of two continents, Asia and Europe. ▪ Under communism all media were controlled, disseminating only information that the government wanted people to know. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Overview/Heritage ▪ Under Communism, everyone could attend higher education institutions, resulting in a welleducated population. ▪ Many scientists, physicians, and other professionals who have immigrated to the United States find difficulty in continuing to practice their profession, necessitating employment in occupations that lower self-esteem. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Communication ▪ The official language of Russia is Russian. ▪ Most educated Russians in the United States speak English to some extent because professional literature in Russia was printed in English. ▪ Many do not understand medical jargon and have difficulty communicating abstract concepts. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Communication ▪ Many older Russian Jewish immigrants speak Yiddish. ▪ Younger Jewish immigrants usually do not speak Yiddish because it was strongly discouraged in Russia. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Communication ▪ Punctuality is the norm, and many arrive early. ▪ Temporality is toward present and future orientation. ▪ In Russia, many people concerned themselves with having food and other necessities, not just for that day, but also for the following days and weeks ahead. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Communication ▪ Direct eye-to-eye contact is the norm among family, friends, and others without distinction between genders. ▪ Some may avoid eye contact when speaking with government officials, a practice common in Russia where making eye contact with government officials and other people in hierarchal positions could lead to questioning. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Communication ▪ Most individuals accept touch regardless of age and gender. ▪ Vocal volume may be loud, extending to those nearby who are not part of the conversation. ▪ Russians do not appreciate when others stand with their hands inserted into pockets, cross arms over their chests, and slouch. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Communication ▪ Until trust is established, many Russians stand at a distance and are aloof when speaking with health-care providers. ▪ Many educated women keep their maiden names when they marry. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Family Roles & Organization ▪ Family, children, and older adults are highly valued. Russians, accustomed to extended family living in their home country, continue the practice when they emigrate. ▪ Decision-making among current immigrants is usually egalitarian with decisions being made by the parents or by the oldest child. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Family Roles and Organization ▪ While parents work, grandparents care for grandchildren. ▪ Older people live with their children when selfcare is a concern. ▪ Nursing homes are rare and are of poor quality in Russia; thus, children may fear placing parents in long-term care facilities. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Family Roles & Organization ▪ Children of all ages are expected to do well in school, go on for higher education, help care for older family members, and tend to household chores, according to traditional gender roles. ▪ Teens are expected not to engage in sexual activity. ▪ Sex and contraceptive education are not traditionally provided. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Family Roles & Organization ▪ Single and divorced relationship statuses are accepted without stigma. ▪ Gay and lesbian relationships are not recognized or discussed and are still stigmatized by a large part of the population. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Workforce Issues ▪ The concept of teamwork is new to Russian nurses as is critical thinking and sensitive caregiving. ▪ When communicating in the workplace, Russians promote the value of positive politeness, a technique that employs rules of positive social communication. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The nurse is conducting an intake assessment on a 76 year old Russian immigrant. She does not maintain eye contact with the nurse. The lack of eye contact is most likely due to a. Respect for the nurse. b. Lack of trust. c. Does not want to tell the truth. d. Most Russians do not maintain eye contact when conversing. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: B Many older Russian immigrants do not maintain eye contact with governmental officials or people in hierarchal positions because they could not be trusted. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Workforce Issues ▪ The employee, using positive politeness, will say nice things that show that the person is accepted, while simultaneously providing support, empathy, and avoiding negative discourse with coworkers. ▪ When negotiating compromise, Russians express emotion and invest considerable time and effort into supporting decisions. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Workforce Issues ▪ With colleagues and friends, Russians communicate directly, which is considered a sign of sincerity. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Biocultural Ecology ▪ Russians in the US are predominately white making them prone to skin cancer. ▪ Common health conditions of Russians include alcoholism, depression, gastrointestinal disorders, respiratory diseases, cardiovascular diseases, cancer due to radiation, dental disease, tuberculosis, diabetes mellitus, and hyperlipedemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Biocultural Ecology ▪ Many who come from Eastern Europe were exposed to the radiation effects of the Chernobyl disaster in 1986, resulting in a high incidence of cancer among this immigrant group. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian High-Risk Behaviors ▪ Both men and women have high smoking rates. ▪ Domestic violence is common and is related mostly to high rates of alcohol consumption. ▪ Domestic violence support services are not available in Russia; thus, patients are reluctant to report or seek help for domestic violence in the United States. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Nutrition ▪ Common foods include cucumbers in sour cream, pickles, hard-boiled eggs as well as eggs served in a variety of other ways, marinated or pickled vegetables, soup made from beets (borscht), cabbage, buckwheat, potatoes, yogurt, soups, stews, and hot milk with honey. ▪ Cold drinks are not favored. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Nutrition ▪ Meat choices include pickled herring, smoked fish, anchovies, sardines, cold tongue, chicken, ham, sausage, and salami. ▪ Bread is a staple with every meal. ▪ The diet overall is high in fat and salt. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Pregnancy and Childbearing Practices ▪ Many new immigrants may not be aware of different methods of fertility control. ▪ Abortion is very common in Russia, and some may choose this option in the United States. ▪ Russian condoms are made of thick rubber, discouraging their use by men. ▪ Pregnant women have regular prenatal checkups, which are mandatory in Russia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Pregnancy and Childbearing Practices ▪ During pregnancy, women are discouraged from heavy lifting and from engaging in strenuous physical activities; they are also protected from bad news that can be harmful to the fetus. ▪ They are encouraged to eat foods that are high in iron, calcium, and vitamins. ▪ Strawberries, citrus fruits, peanuts, and chocolate are avoided to prevent allergies in the newborn. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Pregnancy and Childbearing Practices ▪ As labor approaches, women take laxatives and enemas to facilitate delivery. ▪ Traditionally in Russia, husbands and relatives could not participate in the delivery or visit the hospital postpartum. ▪ There are no cultural restrictions for fathers or female relatives not to participate in delivery. ▪ The delivery room should not have bright lights because many individuals believe that bright lights will harm the newborn’s eyes. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Pregnancy and Childbearing Practices ▪ Many women breast-feed until the infant reaches the toddler stage. ▪ Many women believe the breasts must be kept warm during feeding lest the mother get breast cancer later in life. ▪ Peri-care with warm water is important, and a binder is worn to help the mother’s figure return to its state prior to pregnancy. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Pregnancy and Childbearing Practices ▪ In Russia, women were accustomed to 8 weeks of maternity leave before delivery and up to 3 years leave following delivery. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Death Rituals ▪ Families want to be notified about impending death first, before the patient is told. ▪ Most families prefer to have the dying family member cared for at home. ▪ Do-not-resuscitate orders are appropriate; many families want their loved one to die in comfort. ▪ Few believe in cremation; most prefer interment. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Death Rituals ▪ Both men and women may wear black as a sign of mourning. ▪ Black wreaths are hung on the door of the deceased’s home. ▪ Expression of grief varies greatly. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Spirituality ▪ Most who practice a religion are Eastern Orthodox or Jewish, with smaller numbers of Molokans, Tartar Muslims, Seventh Day Adventists, Pentecostals, and Baptists. ▪ Sixty percent of Russian people are nonreligious. ▪ The state-controlled Russian Orthodox Church was the only accepted religion in Russia (other religions were prohibited) until perestroika and glasnost. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Spirituality ▪ Russian Americans pray in their own way, which may be different from that of the dominant religion with which they identify. ▪ Because Judaism was forbidden in Russia, many Jewish Russian in the US are unfamiliar with many of the Jewish religious practices. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Health-care Practices ▪ Because health care is free at the point of entry in Russia, newer immigrants might not be aware of the need for insurance in the United States. ▪ Hospital stays in Russia average 3 weeks. Some clients may expect this in the United States. ▪ Unmarried women are not accustomed to Pap tests because in Russia only married women get them. Mammography is uncommon in Russia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Health-care Practices ▪ Many individuals are preoccupied with remaining warm to prevent colds and other illnesses. ▪ Most do not want breezes from fans or drafts from an open window to blow directly on them. ▪ They may also be reluctant to apply ice at the recommendation of a health-care provider. ▪ Most Russians are stoical with pain and may not ask for pain medicine. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Health-care Practices ▪ Some individuals may be reluctant to wash their hair for fear of catching a cold if the room is not warm or has a draft. ▪ Because of high radiation in parts of Russia, many fear having an x-ray. ▪ Clients are not accustomed to being told about cancer, terminal illnesses, or grave diagnoses; many believe it makes the condition worse. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Health-care Practices ▪ A primary treatment for a variety of respiratory illnesses is cupping. ▪ A small glass cup, a bonzuk or bonki, has alcohol-saturated cotton or other materials in it. ▪ The material is lighted and then the cup is turned upside down on the patient’s back. The skin is drawn into the cup, leaving round ecchymotic areas when it is removed. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Health-care Practices ▪ Common cultural practices include taking vodka with sugar for a cough; soaking one’s feet in warm water for a sore throat; aromatherapy for a variety of respiratory illnesses; mud and mineral baths to promote healing; and herbs and teas for fever, colds, and minor ailments. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Health-care Practices ▪ People are accustomed to not telling healthcare providers about depression or any other emotional or mental health concerns because mental illness carries a significant stigma and mental health facilities are very poor in Russia. ▪ Inadequate screening of blood in Russia creates fear of contracting HIV from blood transfusions. ▪ Most do not believe in organ donation. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Russian Health-care Practitioners ▪ Health-care providers are respected. ▪ Because nurses function in higher roles in the United States than in Russia, they may be mistaken for physicians. ▪ Men and women are accustomed to living together in very small physical quarters; thus, most do not have a problem with privacy. ▪ Gender is not generally a concern in care. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck A 42 year old Russian immigrant has been ordered a chest x-ray suspected pneumonia. He is very reluctant to have the x-ray. A probably reason for his reluctance is a. High radiation in some parts of Russia. b. He is unaware of the procedure. c. He is modest and does not want to disrobe. d. The physical environment is cold. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: A Many Russians, especially recent immigrants, are fearful of x-rays because of high radiation levels in parts of Russia. 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 1 Chapter 36 People of Thai Heritage Ratchneewan Ross and Jeffrey Ross Overview, Inhabited Localities, and Topography Overview Siam, the land of the musical The King and I, is the former name of Thailand, a country in Southeast Asia well known for its cuisine and exotic culture. Thailand today is composed of a unique blend of traditions reaching back to its origins as a mixture of Southeast Asian peoples, its background in Buddhism, and its profound influences inherited from the cultures of both India and China. For providers of health care to Thai patients, the beliefs and practices that stem from these combined traditions can present both opportunities and challenges. Thailand began a tradition of emulating Western political, economic, and cultural ideas in the late 19th century. In the closing decades of the 20th century, Thailand—like several other Asian “economic tigers”— began a period of explosive economic growth. Thailand’s growth continues today, but it has also been interrupted by periods of political conflict and economic instability: Since the Asian financial crisis of 1997 to 1999, Thailand has endured a weakening of its currency and investor confidence as well as outbreaks of severe acute respiratory syndrome (SARS), the tsunami of 2004, and the continuation of violent insurrections in its predominantly Muslim southern provinces (Warr, 2009). Also, regarding Thailand’s central government, the bloodless coup of 2006 was followed in 2010 by alarming clashes of violence between “yellow shirt” and “red shirt” competing political factions, and these conflicts have further strained Thailand’s economic and cultural stability (Kane, 2010). Indeed, the political opposition of these two factions can be said to reflect a deeper and broader cultural divide in Thailand between the urban elite of the city and the poor of the country, thus challenging Thailand’s “national capacity for creative compromise” and—at least in some sense— contributing to a kind of “collective anxiety” among the Thai population (McCargo, 2008). Yet, most visitors to Thailand continue to be impressed by the unique ways with which the Thai people manage a precarious balance between the contrasts of the old and the new, between the rich traditions of their past and the frenetic influences of modern economic competition, all amid a continually shifting global culture. Concerning health care, this balance can often play out as a tension between older cultural beliefs (and sometimes superstitions) and more modern concepts of medicine grounded in empirical research. These tensions need to be understood in general by healthcare providers for their positive and negative potentials for care and, in particular, for how these may vary from individual to individual. Thailand is located north of Malaysia, west of Cambodia, south and west of Laos, and east of Myanmar (formerly Burma). Further to the north lies the once-sleeping giant of China, now dramatically influencing Thailand’s political and economic spheres. Thailand’s land mass (513,115 km2, 198,115 mi2) and population of 67 million people are roughly equivalent to those of France (U.S. Department of State, 2011). Over 10 million people live in the regions of greater Bangkok, the capital of Thailand. Once called the “Venice of the East” because of its historic canal system, Bangkok today is the vast and vibrantly pulsating hub of the country. More than anywhere else, it embodies the contrasts between the old and the new in the country. Thailand has several important rivers. The main river, the Chao Praya, irrigates the fertile soil of the central plains. The Mekong River in the north and northeast marks the boundary between Thailand and Laos before flowing further southeast to Vietnam. The Ping, Wang, Yom, and Nan rivers are located in the north (Hoare, 2004). Thailand is divided into 77 provinces within four different regions: north, northeast, central, and southern. Each region is unique in its geographic and cultural characteristics. Northern Thailand is the most 1 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 2 2 Aggregate Data for Cultural-Specific Groups beautiful region geographically with high mountains, deep valleys, rivers, forests, and waterfalls. The “Golden Triangle” in the north, where drug and opium smugglers have sought asylum, lies at the junction of three countries: Thailand, Laos, and Myanmar (Hoare, 2004). In general, Thailand has a tropical climate with three seasons. The summer, or hot season, runs from March to June. The rainy season lasts from July to November, and the cool season from December to February. Many Thais, with their good sense of humor, will tell you that the country’s three seasons are called “hot, hotter, and hottest” (Hoare, 2004, p. 12). For visitors from a temperate climate, the weather throughout most of the year in Thailand will seem very humid and hot, with some relief from the heat only during the weeks of late December and early January. Thais love the beauty of their land and are adjusted to the weather, yet many who see snow for the first time in another country experience great joy at such a moment. Heritage and Residence In terms of its history, Thailand is the only Southeast Asian country that has never been colonized by Westerners. The earliest knowledge of what today is Thailand is shrouded in lost histories of the ancient peoples of Southeast Asia. New cultures arose as kingdoms shifted through the centuries. The Dvaravati (1st century BC to the 11th century AD) were strongly influenced by Indian culture so that even today the Rama legends of Indian mythology form an integral part of Thailand’s belief system (Hoare, 2004). The present king of Thailand is the ninth of the Rama kings, and the Thais’ perception of their king’s divinity can also probably be traced to Indian origins. The first people culturally considered as “Thais” probably migrated from the south of China. Sukhothai, founded in the 13th century AD, is considered the first kingdom of Siam (or Thailand). Its most famous king was Ramkhamhaeng, who is credited with developing the first Thai alphabet. Sukhothai had a profound influence on the development of Buddhist theology and classical art in Thai culture (Hoare, 2004). The Sukhothai period was eclipsed in 1350 by the extremely powerful kingdom of Ayutthaya on the Chao Praya River. The kings of Ayutthaya further embodied the essence of divine kingship as an inheritance from Indian philosophy. Although Ayutthaya eventually met its tragic demise when the Burmese sacked the city in 1767, it still represents a magnificent blossoming of artistic and cultural expression in the history of Siam (Hoare, 2004). After an interval known as the Thonburi period, the present Rattanakosin period of Rama kings began in 1782 with its seat in Bangkok. Rama I undertook building Bangkok from a sleepy little village into what eventually became the great city of the Grand Palace (Hoare, 2004). Especially in the 18th, 19th, and 20th centuries, policy makers of Thailand remained independent of European colonial powers by steering a political course as a strategic buffer zone between British Burma (today Myanmar) to the west and French Indochina (Cambodia, Laos, and Vietnam) to the east (Hoare, 2004). Thais are very proud of their independence. In 1939, the name of the country was changed from Siam to Thailand, which literally means “The land of the free.” This name change reflected a fundamental shift from supreme monarchy to constitutional monarchy as a governing system (Hoare, 2004). In 1932, Thailand appointed its first prime minister. Thereafter, the king no longer served in any critical decision-making capacities (Hoare, 2004). Still, the lineage of Thai kingships continues, and the Thai people continue to love and deeply revere their king. This intimate relationship between royalty and the people is intertwined with Thai Buddhism and the Thai peoples’ perception of their king as divinely ordained. The king is usually not directly involved in Thai politics, but if a strong moral issue arises, he generally helps in addressing the problem guided by his peace and wisdom (Hoare, 2004). In 2006, the Thais celebrated their beloved King Rama IX’s 60th anniversary. His monarchy is now the oldest in the world. Any criticism of the king and his family is not at all acceptable to Thais and is even forbidden by law. Yet, Thailand’s present constitutional monarchy is a democratic form of government built around the actual governing authority of the prime minister and the parliament. Reasons for Migration and Associated Economic Factors Approximately 70 percent of all Thais (120,000 Thais) in the United States live in Los Angeles (Wikipedia, 2011a). Los Angeles is thus often referred to as Thailand’s most recent province and “home to the world’s first and only ‘Thai Town’” (Wikipedia, 2011a). Coincidentally, both Bangkok’s and Los Angeles’s names mean the “City of Angels.” However, Thai communities are spread throughout the United States. Other cities with sizable Thai populations include New York City, Houston, and Chicago. The first two Thai immigrants in the United States were Eng and Chang, the famous Siamese twins who captured the world’s attention because of their conjoined chests and whose career was a public exhibition. They settled in North Carolina in 1839, later changed their Thai last name to Bunker, and got married to American women (Wikipedia, 2011b). The first Thai student in the United States came with an American missionary in 1871. His name was Mr. He Thien, and he graduated from a medical college in New York. He later became the father of the former prime minister of Thailand, Pote Sarasin (Wikipedia, 2006). 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 3 People of Thai Heritage During the Vietnam War, many Thai women married American GIs and immigrated to the United States (Bao, 2005). Immediate family members of these American Thais often followed them and settled in the new country. From 1968 to 1976, many Thai professionals such as physicians, pharmacists, and engineers immigrated to the United States to further their studies under scholarship programs, and many of them never returned to Thailand (Wikipedia, 2006). They found professional careers and remained in the United States. In general, Thais have continued in their migration to the United States in search of better opportunities. Educational Status and Occupations In Thailand, education is compulsory for at least 9 years (grades 1 through 9) (Fig. 36-1). However, the Thai government provides free education to all Thais who go to government schools up to grade 12. The literacy rate in Thailand was 92.6 percent in 2002 (CIA World Factbook, 2011). The system of higher education is well developed in Thailand, with government universities perceived as being of higher quality than private universities. Government universities are competitive, however, because of their difficult entrance examination requirements. Those students who are not accepted in government universities can still opt to enroll in the more expensive private schools. In 2002, 27.4 percent of Thais aged 17 to 24 years enrolled in college (Thailand Investor Service Center, 2004). Many Thais with graduate degrees work in the United States in professional fields such as medicine, nursing, and engineering. Others own Thai restaurants or grocery stores and provide work for other Thais. Communication Dominant Language and Dialects The standard Thai dialect is derived from Pali and Sanskrit (ancient South Asian languages) and is the 3 official language in Thailand. The Thai language is a fixed tonal language having five tones. Thus, the same phonetic sound can have different meanings depending on the tone. The written alphabet is a complicated system of 44 letters with over 33 vowels or vowel combinations. English is used in international schools, tourist places, and sometimes among Thai elite society. Although English is taught in Thai schools, the English proficiency of Thai people in general is not very high, especially when compared with certain other Southeast Asian countries such as Malaysia or Singapore. This may be due in part to Thailand’s having never been colonized. The north, northeast, and southern regions of Thailand are all areas with unique dialects of their own. The dialect in northern Thailand is Pasah Nua, literally “the northern language.” Thais in the Northeast speak Pasah Isaan, “the northeast language,” which is a mixture of Laotian and other dialects. Pasah Isaan usually sounds very foreign to the ears of people in other regions of Thailand. The dialect of southern Thailand is Pasah Dai, “the southern language,” and is the fastest-sounding among the dialects. A recent trend, however, has been that many parents in the northern or northeastern regions choose not to teach their children their regional dialects, in part, because they believe that the dialects do not sound modern or cultured. Cultural Communication Patterns Age and status in Thailand contribute greatly to how Thais communicate with one another. According to the Thai culture, a younger person is expected to show respect for an older person through his or her gestures and language. A Thai female uses the word “Kah” and a Thai male uses “Kraab” at the end of a sentence to add politeness in a conversation. Looking in a person’s eyes and conversing quietly reflects respect and politeness. A distance of 11/2 to 2 feet between two speakers is preferable. In terms of body language, kisses and hugs between a male and a female are not traditional in the Thai culture. Thais usually greet each other with the “Wai” motion—putting the palms of both hands together in a prayer-like gesture and bowing the head slightly. This gesture is used by both men and women of all age groups. Respect for older people, an important aspect of Thai culture, is always signaled by a younger person gesturing with the “Wai” to the older person first. Temporal Relationships Figure 36-1 A grade school in Thailand. Traditional Thai families are nuclear in nature. Today, however, single families are becoming more common in Thailand. In any case, it is not uncommon for a single Thai to live with her or his sibling(s), cousin(s), 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 4 4 Aggregate Data for Cultural-Specific Groups aunt(s), uncle(s), grandparent(s), or parent(s). A friendship between two individuals who are not biologically related can often evolve into a family-like relationship. Thus, a Thai may become like a brother, a sister, an aunt, an uncle, a parent, or a grandparent to a friend. As mentioned previously, respect for seniority is crucial among Thais. Visiting and bringing along a present or giving money to elders during the Thai New Year is an important role obligation for younger Thais. When the elders in a Thai family become too old to take care of themselves, younger members are morally required to care for them. Only in very rare circumstances do elderly Thais live alone. Format for Names Most Thais have long first and long last names. A Thai is usually referred to by his or her first name, even in an official setting like school or work. The names usually have clear meanings in Thai. The first name is often given by a Buddhist monk or fortuneteller based on the date, day of the week, and time of a newborn’s birth. But often parents name their children themselves. More recently, some parents have begun to give their children Western first names, such as John, Matthew, or Amy. In general, when a woman marries she usually takes her husband’s last name. A couple’s children also take their father’s last name. A recent Thai law, however, regulates that a married woman does not have to use her husband’s last name if she prefers not to, thus legally sealing an already existing cultural shift. When Thai names are transcribed in English, the spelling is merely a kind of phonetic translation from its spelling in the Thai alphabet. Because Thai is a tonal language, however, the correct pronunciation of names cannot be ascertained from their spelling in English. For health-care providers in the West, the best course is to ask Thai patients how to pronounce their names and do the best one can in approximating it. Importantly, almost all Thais have a short nickname used by their family and close friends and often by colleagues at work. Nicknames normally have no relationship with first names. They are often humorous to Thais themselves. Nicknames are usually either Thai or English words. They might be derived from names of colors, body types, fruits, or any number of other things. Health-care providers should feel free to ask their patients if they wish to be called by their nickname. The client may well prefer it. Family Roles and Organization Head of Household and Gender Roles Gender is another important aspect in Thai families. A man is the head of the household in a traditional Thai family, usually being the breadwinner and managing important tasks. This view is reflected in an elder’s teaching on a wedding day: “The man is the front step of an elephant. The woman is the hind step.” In most Thai families, responsibilities involving household chores and taking care of children belong to a woman. If a woman works outside the home, a maid is sometimes hired to help with the household chores and babysitting. Many Thai men have much more leisure time than Thai women, regardless of the employment status of a woman. However, more Thai families today have begun to divide household chores between men and women. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Thai children are taught to respect elders. Talking back to elders is discouraged. The role of children as students in school is very important. Many Thai parents choose a career deemed suited to their child’s abilities and characteristics. The degree to which children assist with household chores depends upon a family’s economic status; the poorer the family, the more chores children do. Thai female adolescents have traditionally been expected to protect their virginity until marriage. Dating with a chaperone present is preferable to parents. However, more and more Thai adolescents date on their own today. Social attitudes are changing rapidly in Thailand, and those of the youth culture are strongly influenced by global trends related to music, entertainment, and social mores. These are often challenging to older traditions and can conflict with those inherited through Buddhist theology. Family Goals and Priorities Children are the center of the family for Thais (Fig. 36-2). Many Thai children, therefore, sleep with their parents from birth until some point in time before they reach adolescence. Thai parents do not feel comfortable leaving their infants in a separate bedroom. Often, children are spoon-fed by adults until they are 6 to 7 years old. This can sometimes appear unusual to Westerners. Most Thai parents hope their children will go to college. They will pay whatever they can for tuition fees and support even through graduate school. Education is so vitally important for Thais that Westerners are often amazed when a Thai spouse will leave his or her partner or children behind for years to further studies aboard. Marriages in Thailand used to be mainly arranged by the parents. Today, young Thais have more freedom to select a spouse. Nevertheless, sometimes parents may make the final decision as to whether or not a bride or groom is acceptable. However, in this context, younger Thais are clearly expected to care for older people, including older in-laws, when they are in need. 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 5 People of Thai Heritage 5 deemed very important for Thais, in many circumstances, especially for economic reasons, work comes before family (Fig. 36-3). For instance, a husband and his wife in Thailand often work in different provinces. A good number of the Thai couples reunite once a month. Taking a leave from work for a major surgery or a death or dying of family members besides one’s spouse, child, or parent may not be supported by Thai agencies. In general terms, Thai Americans tend to socialize among themselves rather than mix with Americans or people from other cultures. Therefore, some Thai Americans may not deeply understand American culture. However, other Thai Americans relate well to their surrounding culture, especially first-generation American-born Thais who tend to help change or adaptation come more easily to their parents (Advameg Inc., 2011). Issues Related to Autonomy Figure 36-2 A Thai family photo. Alternative Lifestyles Gays and lesbians in Thailand are more accepted today than in the past. Before the mid 1980s, commercial lounges and bars were the main or the only places for gays and lesbians for social gatherings. Since the mid 1990s, Thai gays and lesbians have had more venues to meet and advance a positive lifestyle. These new places include launched boutiques, hotels, restaurants, karaoke clubs, pubs, and spas (Utopia, 2011). The first Thai lesbian organization was founded in Bangkok in 1986 by a popular Thai singer. Eight years later, the first Southeast Asian gay and lesbian center was established. The center is a resource for gays and lesbians to find books and presents. Both of the organizations have at least two common goals, which include a movement for lesbian and gay rights and efforts to combat HIV/AIDS (Utopia, 2011). At present, gay marriage is not supported by Thai laws. Like many other American Asians, Thai Americans respect their supervisors because seniority is strongly valued in their culture. Thus, they might not be assertive at work. Therefore, supervisors may be wise to provide open discussions and expression of opportunities for their Thai American colleagues. As mentioned previously, English proficiency among some Thais is low. Therefore, with Thai Americans who are learning English as their second language, the language used in the workplace should be clear. Slang expressions should be avoided. If used, slang expressions need to be clarified. Biocultural Ecology Skin Color and Other Biological Variations An estimated 75 percent of the population in Thailand are pure “Thai”; 14 percent are Chinese; and the rest (11 percent) are Malay, Lao, Mon, Cambodian, Vietnamese, Asian Indian, Caucasian, or hill-dweller Workforce Issues Culture in the Workplace Most Thais usually try to avoid personal conflicts at work and are hard workers. Although the family is Figure 36-3 Selling noodles at the floating market in Thailand. 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 6 6 Aggregate Data for Cultural-Specific Groups tribes—Karen, Lisu, Ahka, Lahu, Mien, and Hmong (Fig. 36-4) (CIA, 2011). Some Thais in northeast Thailand (Isaan) emigrated from Laos or Cambodia. In general, Isaan Thais have darker skin color (dark brown) than other Thais who live in the north and central regions. The facial profile of Isaan Thais is akin to that of Laotians, with a relatively flat nose and broad prominent cheekbones (Fig. 36-5). Some Thais in the north immigrated to Thailand from China or Burma. They tend to have finer skin texture and lighter skin color than other Thais in the country. Their noses are a little longer and their cheekbones narrower than those of Isaan Thais. Central Thais generally have medium skin color compared with that in the rest of the country. Their facial profile is a mixture of Isaan Thais and northern Thais. Southern Thais, some of whom migrated from Malaysia, are likely to have darker skin color. Their facial profile is similar to that of Malay. Other Thais have combined Thai and Chinese, Vietnamese, Malaysian, Laotian, or other heritage, with skin color and facial profiles representing mixtures of such racial combinations. Overall, regardless of skin color or facial profile, the Thais’ size and body structure are usually much smaller than those of Caucasians. Diseases and Health Conditions Thai scientists in collaboration with scientists from Riken Yokohama Institute in Japan and Yale University in the United States successfully identified a genetic pattern common to Thais by analyzing blood samples from 280 Thais from all four regions of the country (National Center for Genetic Engineering and Biotechnology [BIOTEC], 2006). This breakthrough, hopefully, will help scientists to better understand Figure 36-5 Isaan dance. Thais’ responses to a variety of antigens, drug metabolism, and genetic disorders. Glucose-6-phosphate dehydrogenase deficiency (G-6-PD) is the most common genetic disorder among humans. Sixty-five percent of Thai newborns’ jaundice is caused by this deficiency (Nuchprayoon, Sanpavat, & Nuchprayoon, 2002). Usually, the enzyme regulates how red blood cells function. When a person lacks the enzyme, her or his red blood cells can be hemolyzed by certain medications, foods, or infections. The condition is called “hemolytic anemia.” In most cases, when the cause of the anemia is removed, symptoms disappear. In rare cases, people with G-6-PD deficiency have persistent anemia and need to be monitored on a regular basis (Nuchprayoon et al., 2002). Thalassemia is another genetic disorder prevalent among Thais. Thirteen percent of Thais have inherited this disorder, and 50 percent of those who are affected by the disorder come from Isaan, or the northeast of Thailand (Fucharoen et al., 2006). Symptoms among Thais with thalassemia range from asymptomatic to severe anemia (Fucharoen et al., 2006). When Thai patients show anemic symptoms, they should be tested for thalassemia and identified for care if necessary. Variations in Drug Metabolism Figure 36-4 An interracial boy (American Thai) in front of a vendor’s wagon in Thailand. Different ethnic groups may have different pharmacokinetic functions (Bjornsson et al., 2003). Recent literature reporting some variations in drug metabolism between Thais and non-Thais is mostly associated with antiretroviral medications. For example, a study 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 7 People of Thai Heritage revealed that using indinavir/ritonavir dose (400 mg/ 100 mg) as a combined antiretroviral drug among Thais is more preferable than using indinavir/ritonavir dose (600 mg/100 mg) as used among Caucasians owing to the smaller body size of the Thais (Cressey et al., 2005). This lower-dose medicine results in fewer side effects and greater adherence for Thais than the higher-dose medicine. Although the lower-dose medication provided lower plasma concentrations among the Thai participants, the low dose seems to be effective as evidenced by a suppression of viral replication through 48-week follow-ups (Cressey et al., 2005). Therefore, when treating Thai patients, dosing recommendations derived from Caucasian patients may not be appropriate. As a general rule, a lower dose may be more beneficial for Thais, possibly resulting in fewer severe side effects and greater adherence to the medications. High-Risk Behaviors Health-Care Practices The Thai Ministry of Public Health (2008) examined the most significant major health problems among the Thais by age group. These examinations were conducted during 2005 and 2007. Results are presented below: ≤14 years old: Low birth weight and perinatal asphyxia 15 to 29 years old: HIV/AIDS, road traffic injuries, drug abuse, schizophrenia, and alcohol abuse 30 to 59 years old: HIV/AIDS, road traffic injuries, diabetes, and liver cancer ≥60 years old: Cerebrovascular diseases, emphysema, and diabetes In this section, we will pay particular attention to working-aged Thais (15 to 59 years old). Since HIV/ AIDS is the major health problem and cause of death in this age group, information regarding HIV/AIDS is presented first. Information on alcohol consumption, a significant behavior associated with HIV infection, follows. HIV/AIDS HIV/AIDS History in Thailand The first patient with AIDS in Thailand, reported in September of 1984, was a Thai gay man who studied in the United States and moved back to Thailand. Since that year, incidences of HIV infection have been reported throughout the country. HIV infection rates in Thailand peaked at 4 percent in 1991, with over 140,000 new cases in that year. Rates declined to 1.5 percent by 2003, partly due to the 100 percent condom use campaign promoted among high-risk groups by the Thai government (Ministry of Public Health, 2005). In the past, high-risk groups included female commercial sex workers (CSWs) and injection drug users 7 (IDUs). HIV-positive rates among Thai female CSWs climbed to over 33 percent in 1994 but fell to 4 to 8 percent in 2004, also mainly due to the 100 percent condom use campaign. The extent to which high-risk behavior among homosexual men played a part in the early spread of HIV and AIDS in Thailand is difficult to ascertain due to a lack of reliable information. However, a recent survey revealed that 17 percent of gay men who did not frequent CSWs were HIV-positive (Cairns, 2004). Thailand has been commended for its general response to HIV/AIDS. However, Thailand has in large measure ignored the problems of HIV/AIDS among homosexual men. Adding to complications, the problem is interrelated with Thailand’s commercially successful male sex industry. Young male sex workers sell their services—negotiating with sex, condoms, work, and social stigma while living with the ever-present danger of an HIV infection (Mutchler, 2005). Today, the situation for gay men in Asian countries is similar to that in the West in the mid 1980s (Cairns, 2004). Recent HIV/AIDS Statistics It is estimated that 600,000 HIV-positive individuals lived in Thailand in the year 2009 (UNAIDS, 2011), with the prevalence rate of 1.4 percent among adult Thais (U.S. Department of State, 2011). In 2009, the number of total deaths in Thailand due to AIDS was reported at 28,000 (UNAIDS, 2011). The most severe HIV rates are found to be in some Northern provinces (e.g., 3 percent in Payao and Uttaradit) and tourist areas (e.g., 2 percent in Phuket, Cholburi, Trad, and Samut Songkram) (National AIDS Prevention and Alleviation Committee, 2010). Thai Men’s Sexual Behavior and Prostitution At present, the major route of HIV transmission in Thailand is through sexual activity (>85 percent in 2004), particularly because many Thai males frequent female or male CSWs without using a condom (Centers for Disease Control and Prevention [CDC], 2006). Even though prostitution is illegal in Thailand, the country has over 200,000 overall sex workers at any given point in time (Manopaiboon et al., 2003). Only 27 percent of Thai customers use a condom when they visit female CSWs in Thailand, whereas 52 percent of other Asian customers and 76 percent of Western customers use a condom (Buckingham & Meister, 2003). The number of CSWs in Thailand has not decreased since 2005, while the number of nonbrothel settings potentially related to sexual activity (spas, parks, Internet, and informal social networks) has increased dramatically (Rongkavilit, 2010). These nonbrothel settings are five times more likely to precipitate new HIV cases than brothel settings because they are overlooked by the Thai government’s formal HIV prevention program and thus do not receive preventative interventions and HIV and STI information (National AIDS Prevention and Alleviation Committee, 2010). 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 8 8 Aggregate Data for Cultural-Specific Groups Many men in Thailand have sex with women other than their wives. A study revealed that 92 percent of Thai husbands had multiple sexual partners during the last 5 years of their marriage. Among the men in this study, approximately 85 percent had frequented female CSWs without using a condom. Furthermore, over half of the wives were not aware of their husbands’ promiscuity (Bennetts et al., 1999). It should be noted that this pattern of sexual behavior among Thai men in Thailand may or may not be generalized to those living in the United States, Canada, or other countries in which cultural patterns are different. New Groups of HIV Cases At present, newer and more prominently high-risk groups for contracting HIV include Thai youth, Thai men who have sex with men, seafarers, amphetamine users, and people who are intoxicated from alcohol (National AIDS Prevention and Alleviation Committee, 2010). Most alarmingly, the fastest-growing population of new HIV cases in Thailand is composed of very young adolescents, young pregnant women, and young adults aged 15 to 24 years old (National AIDS Prevention and Alleviation Committee, 2010). Higher HIV rates among these groups are accounted for by an increase in premarital sex among youth and overall promiscuity in the Thai society (National AIDS Prevention and Alleviation Committee, 2010; Rongkavilit, 2010). More and more Thai youth have casual sex at a younger age. Since the mid 1980s in Thailand, the youngest age for first-time sexual intercourse has fallen from 16 to 9 years old (Fongkaew, 2004). A report shows that only 20 to 30 percent of sexually active young Thais use condoms consistently (United Nations Development Programme, 2004). Moreover, research among HIV-positive Thai youth (male and female 16 to 25 years old) reveals that consistent condom use was found to be low (55 to 58 percent) among the sample during the 3-month study period (Rongkavilit, Naar-King, Cheunyam, Wang, Wright et al., 2008). Sexual promiscuity among Thai youth has also contributed to an increased risk for other sexual transmitted infections (STIs) and unwanted pregnancies. In 2008, it was reported that 20 percent of all pregnancies in Thailand belonged to women under 20 years old (National AIDS Prevention and Alleviation Committee, 2010). Within the last decade, there has been more openness about homosexual orientation in Thailand. Homosexual behavior has been found to be increasing by age brackets in Thai society. A study in Thailand in 24 provinces found homosexual behavior at 0.3 percent among high school students, 2 to 3 percent among vocational school students, and 4.7 percent among men in the military, with only 50 percent of men having sex with men using condoms consistently (National AIDS Prevention and Alleviation Committee, 2010). HIV rates among men who have sex with men are reported to be highest (17 to 31 percent) in large tourist cities like Bangkok, Chiang Mai, and Phuket, and this is becoming a great concern for health professionals and the Thai government (National AIDS Prevention and Alleviation Committee, 2010). Seafarers, highly mobile and working on boats far from land, have become a newly vulnerable group prone to contract HIV. Most of them are single, young Thai or immigrant (from Myanmar or Cambodia) men who stay out to sea for weeks or months at a time. When they return to land, they often drink heavily and have sex with female CSWs without condom use. Their HIV-positive rate is strikingly high at 15.5 percent (Entz, Ruffolo, Chinveschakitvanich, Soskolne, & van Griensven, 2000). After contracting sexually transmitted diseases, they tend to treat themselves by using over-the-counter medicine (Entz, Prachuabmoh, van Griensven, & Soskolne, 2001). A qualitative study found that many migrant seafarers in Thailand feel vulnerable to HIV infection; yet, they are pressured by peers to drink alcohol and visit CSWs after returning to land (Ford & Chamratrithirong, 2008). Condoms were used with brothel CSWs by participants in this study but not other types of CSWs. Amphetamine users and drinkers of alcohol tend to have sex while they are high or intoxicated, which puts them at increased risk for having unsafe sex. An estimated 600 million tablets of amphetamines are consumed annually in Thailand (Newton et al., 2003). Thai names for amphetamines are Yaa Bah (literally meaning “crazy drug”) or Yaa Mah (literally meaning “horse drug,” because of the horse emblem on the tablet) (Newton et al., 2003). Amphetamines are usually taken by young people as a stimulant so that they can work for hours or days without feeling exhausted. An overuse of amphetamines can cause a person to become agitated and harm oneself or others. Withdrawal from amphetamine use generally leads to excessive sleeping and hypoglycemia (Newton et al., 2003). Among northern Thai men, the use of amphetamines is found to be associated with the use of other types of drugs (seven times more likely with heroin and approximately six times with thinner, opium, and marijuana) and also to be associated with different STIs besides HIV, such as gonorrhea and genital warts (Melbye et al., 2002). HIV-Positive Pregnant and Postpartum Women and Family Relations Among Thais, the family and ex- tended family members are all considered within the Thai culture to be a whole unit. When any member in the greater family suffers from HIV/AIDS (or any other hardship/illness), it affects every member of the family. Moreover, every family member has the responsibility to support a suffering member, either through emotional, financial, or other tangible means (Ross, Sawatphanit, Suwansujarid, & Draucker, 2007a). Thus, one family member’s actions, whether negative 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 9 People of Thai Heritage or positive, belong to the whole family. The family’s unique oneness in the Thai culture can work either positively or negatively for a Thai family member with HIV/AIDS. For example, the concept of oneness can generate all kinds of support from the family. The parents and siblings of sick members are clearly expected to care for them. Also, maternal grandparents are expected to care for the sick member’s children if the member were to pass away because of AIDS (Rende Taylor, 2005). Yet, the patient with HIV/AIDS can also be abandoned due to fears in the family of viral transmission and of family disgrace (Bechtel & Apakupakul, 1999; Bennetts et al., 1999). Approximately 210,000 women and 1 to 2 percent of pregnant women in Thailand have contracted HIV (UNAIDS, 2011). Studies report that almost 80 percent of HIV-positive pregnant (n = 127) and postpartum Thai women (n = 85) experience depressive symptoms to some degree; those with higher selfesteem and social support report fewer depressive symptoms (Ross, Sawatphanit, & Zeller, 2009; Ross, Sawatphanit, Mizuno, & Takeo, 2011). Research shows that when family support is not available, critical emotional support from nurses can increase HIV-positive pregnant Thai women’s self-esteem and decrease their depressive symptoms, thus saving their lives (Ross et al., 2007a; Ross, Sawatphanit, & Suwansujarid, 2011; Sawatphanit, Ross, & Suwansujarid, 2004). Therefore, health-care professionals should assess and offer emotional support for their Thai HIV/AIDS patients, especially when family support for these patients does not exist. Summary of HIV Impact Overall, more incidences of HIV infection have begun to appear among Thai youth. HIV infection can cause severe financial, physical, emotional, and social disruption for Thai patients and their families. Although the Thai government is planning to provide free antiretroviral medications to all HIV cases who need such help, Thailand’s present HIV/AIDS medical care cost is over US$420 million nationally (National AIDS Prevention and Alleviation Committee, 2010) and around $600 per year per family. In the perspective of the Thai economy, the gross national income per capita in Thailand is US$3,760 (ranked 122nd in the world), as opposed to US$46,360 in the United States (ranked 18th in the world) (World Bank, 2010). Thus, the long-term burdens posed by high rates of HIV/AIDS among Thais need to be studied, especially at the community level. To prevent new HIV cases, the Thai government must invent new strategies. Besides existing HIV prevention campaigns, such as promoting condom usage among some groups of Thais (e.g., sex workers, HIV-positive individuals, etc.), strategies to enhance self-esteem and abstinence should also be promoted, particularly among Thai youth. Also, traditional aspects of Thai culture which cherish abstinence and 9 virginity before marriage should be encouraged within the larger Thai society. Otherwise, Thailand may fall too deeply to be bailed out from an impending and serious HIV crisis, considering that more than 1.2 million Thais with an HIV infection are now projected for the year 2020, along with 18,000 deaths from AIDS in that same year (Ministry of Public Health, 2008). Nutrition Meaning of Food “We should eat to live, not live to eat” is a famous saying not only in Latin but also in Thai, reflecting the central importance and meaning of food in the Thai culture. Many Thais live their lives by following such a saying. In general, an individual portion of a Thai dish is about one-third to one-fifth of a typical U.S. dish in terms of volume. As a result, most Thais are slim owing to these smaller portions and also the types of food they eat. Thais believe that foods containing adequate essential nutrients help to maintain life and growth and delay illness later in life (Kosulwat, 2002). A Thai balanced diet usually includes low-fat/low-meat dishes with a large percentage of vegetable and legumes. Rice and fish are main staples (Kosulwat, 2002). Common Foods and Food Rituals In general, rice is the main source of carbohydrates in Thai dishes, but noodles are also found in many favorite recipes. Vegetables and meats are usually fried or grilled and prepared in many combined variations to supplement rice. Overall, pork or chicken is eaten more than beef. All meats are consumed more sparingly in proportion to vegetables when compared with a Western diet. Fish and other forms of seafood are also regularly enjoyed. Thailand has a long coastline, especially in the south, with an old and rich tradition of fishing as an important industry. Communal eating is an essential part of the Thai culture. Friends and families eat seated together either on the floor or at a table. Either way, when rice is part of the meal, Thais will begin with a large amount of rice on their plates and reach to central communal plates of combined meat and vegetable recipes to add to their rice. This is done by all in a free fashion throughout the meal, with some families using a serving spoon to take from the communal dishes and others using their individual tablespoons. The tablespoons are the main instruments for eating, with the fork used only as a guide; knives are not often used because the meats in Thai recipes are usually precut. Noodle recipes are much loved by Thais and prepared with the noodles already mixed in with meats and vegetables. For all foods, seasonings are critical to the Thai artistry of accommodating different palettes. Fish and oyster sauces are very often combined with soy sauce as 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 10 10 Aggregate Data for Cultural-Specific Groups a basic starting point for many recipes. Thai chili pepper is the basic ingredient added to control the degree of spiciness in foods. Many Thais love very spicy food, but not all. Tom-Yum is a traditional spicy Thai soup that is gaining popularity worldwide (Fig. 36-6). It has been found to have positive effects on people’s health because of its ingredients, which include lemon grass, galangal roots, kaffir lime leaves, hot chilies, red onions, and garlic (Siripongvutikorn, Thummaratwasik, & Huang, 2005). Tom-Yum’s antioxidant effects are the result of the ingredients mentioned previously. The soup’s antimicrobial effects come from its chilies, onions, and garlic (Siripongvutikorn, Thummaratwasik, & Huang, 2005). Onions and garlic can function against diabetes and hypercholesterolemia. Fresh garlic, used as an ingredient in Som-Tum and many other Thai dishes, has been identified as an antifungal, antiparasitic, and antiviral agent (Siripongvutikorn, Thummaratwasik, & Huang, 2005). Som-Tum is a famous spicy Thai salad originating from the northeast of Thailand. Its ingredients include fresh shredded papaya, cut tomatoes, tamarind juice, fish sauce, salt, sugar, fresh crushed garlic, and hot chilies. Sometimes, cooked or raw fermented fish is added. Som-Tum is usually served with hot sticky (sweet) rice, which is a favorite in the Northeast. Sources of protein, such as Thai beef/pork jerky and grilled chicken are often served with Som-Tum and sticky rice. Overall, this course of Som-Tum, sticky rice, and sources of protein is considered an enjoyable delicacy by Thais in all areas of society. In the past, many Thais became sick and died from eating raw fermented fish, which contains Opisthorchis viverrini, a liver fluke, found to cause cholangiocarcinoma in humans (Watanapa & Watanapa, 2002). Today, because of increased health education provided by nurses and other health professionals, Thais are more knowledgeable about the dangers of eating raw fish. Nevertheless, some Thais may persist in eating raw fermented fish because of entrenched eating habits and their attraction to its taste and smell. An assessment regarding any preference for eating raw fermented fish could be helpful. A study conducted in Thailand revealed that many healthy Thai dishes are being replaced by foods containing a high quantity of fat and meat, related to the country’s evolution from an agricultural to a newly industrialized country. Food produced in Thailand is now more important for exportation purposes and the economy than for domestic consumption (Kosulwat, 2002). Thai families have less time to cook. They tend to eat at Western-style restaurants serving foods high in fats, meat, and sugar content. As a result, obesity rates among Thai children and adults have risen dramatically since the mid 1980s (Kosulwat, 2002). A study revealed that Thai children with obesity have low self-esteem and are often ridiculed by their peers (Phakthoop & Ross, 2006). In a study among 102 Thais in the United States, 79 percent changed their food intake habits when living in the United States (Siripongvutikorn et al., 2005). They skip more meals and consume more Western foods and snacks such as white bread, salty items, fruit juice, soft drinks, and sweets. When they dine out, they tend to go to American or Chinese restaurants. Forty percent of the participants indicated that their diet has become less healthy owing to a lack of time for food preparation and the unavailability of some Thai ingredients and food choices (Siripongvutikorn et al., 2005). An analysis of this study, as based on the Food Guide Pyramid, reveals that most Thai participants living in the United States consume enough fruits and vegetables; not enough bread and milk; and too much meat, fats, oils, and sweets. Health professionals in the United States should assess their Thai patients’ food intake habits and encourage them to consume more fruits and vegetables. If needed, advice about an increase of bread and milk intake and limiting meat, fats, oils, and sweets should also be provided (Siripongvutikorn et al., 2005). Dietary Practices for Health Promotion For Thais, hot or warm foods or drinks are considered healthier than cold ones. This idea is based in part on a belief in “cold and hot” or “Yin and Yang,” inherited from Thailand’s profound Chinese influence. Many types of herbs are considered to promote health and work against cancer development. Some herbs are considered a panacea. Therefore, Thai dishes usually contain some kind of herbs, particularly garlic and hot chilies. Positive effects of some herbs have already been described. Nutritional Deficiencies and Food Limitations Figure 36-6 Tom-Yum Koong with lemon grass. Iodine deficiency (IDD) used to be a major health concern in Thailand. In 1953, IDD was first identified in the northeastern and northern regions of Thailand, where there is no sea outlet. Aware of the problem, in 1965, the Thai government initiated a pilot project of salt iodization in a northern province. Owing to its 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 11 People of Thai Heritage success, the project has been further expanded. The first IDD survey, conducted until 1988, was completed in 15 provinces of two regions of Thailand, showing an IDD prevalence rate of 19.3 percent. In 1993, the salt iodization project was expanded nationwide, resulting in further success with an IDD rate of 1.3 percent in 2003. At present, the Thai government examines goiter rates among schoolchildren in 15 northeast and northern provinces and uses them as the Thai IDD indicator (Ministry of Public Health, 2005). Despite the salt iodization program’s success, at the 2004 Review of Progress toward Sustainable Elimination of Iodine Deficiency held in Thailand, the Thai Ministry of Public Health indicated that only 51 percent of Thai households consumed enough iodized salt (Network for Sustained Elimination of Iodine Deficiency, 2004). This was well below the international target of at least 90 percent set for the end of the year 2005. More than 34 million Thais do not consume enough iodized salt, and 375,000 newborns may suffer from IDD. However, the Thai Ministry of Industry and the U.S. Food and Drug Administration have begun working with salt producers to manage salt iodization programs. Together they brought the goiter prevalence rate in Thailand down to 2.2 percent in 2008 (as compared to rates for the same year in other countries: 19.4 in Australia, 17.9 in India, 30.0 in Turkey, and 14.5 in Switzerland) (Network for Sustained Elimination of Iodine Deficiency, 2011). In Thailand, only seven cases of anorexia nervosa have been reported (Jennings, Forbes, McDermott, Hulse, & Juniper, 2006). However, evidence exists that young Thais in particular are increasingly becoming susceptible to developing eating disorders. A study among 101 Thais in Thailand, 110 Caucasian Australians, and 130 Asian Australians found that the Thai participants reported the highest scores on eating disorder attitudes and psychopathology (Jennings et al., 2006). Recently, pressure to be thin has become more extreme in Thailand than in Australia. The evidence suggests that eating disorders may not be limited to Westerners, as we used to believe. Such disorders will become more prevalent among Thais in the near future. Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy Thai women view pregnancy as a special time in their lives when they need extra care physically and emotionally (Nigenda et al., 2003). They acknowledge that this is a time when their moods can be unstable. Ideally, the age of 20 years is the optimal time for pregnancy owing to the women’s physical and emotional maturity. Thai women want their husbands and their mothers to be supportive of their pregnancies. Some women state that the most common side effects of 11 pregnancy are excessive white vaginal discharge, frequent urination, and morning sickness (Nigenda et al., 2003). Owing to modesty, especially during a vaginal examination, Thai women prefer female health-care providers over their male counterparts. They do not feel comfortable exposing their bodies to male providers (Nigenda et al., 2003). Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family The descriptions in this section are based on literature review and the authors’ experience working with pregnant and postpartum Thai women. During the childbearing period, Thai women basically receive advice from their mothers about what to do or not do. Their mothers are the most significant persons who direct their practices during this time. Some of the practices presented herein are not stereotypical among all Thais; rather, they reflect some general practices or beliefs of some Thais in some particular areas of the country. During pregnancy, the mothers of some pregnant Thai women may discourage their daughters from particular practices or behavior. For example, pregnant women are advised not to complain or get upset so that newborns will be happy and stay happy for the rest of their lives. They may also be advised not to sit on stairs or doorsills to avoid a difficult labor and delivery. When a pregnant mother blocks other people from going up and down stairs or in and out of a doorway, the unborn baby could be blocked inside the mother’s uterus. Astrology and animism play major roles in many Thais’ lives. In general, Thai pregnant women are discouraged from visiting a hospitalized person (regardless of the kind of sickness), attending a funeral ceremony, or visiting a house where there has been a death (Kaewsarn, Moyle, & Creedy, 2003a). Such practices are believed to prevent the pregnant woman and her unborn baby from catching any illness or getting haunted by a spirit or ghost. In northeast Thailand, some women believe that eating eggs may result in having smelly newborns (Nigenda et al., 2003). Some avoid drinking coconut juice, believing that it can cause too much vernix caseosa (fat on the newborn’s skin), whereas others drink a lot of the juice, believing that it will help their newborns to have smooth and beautiful skin texture. Some believe that drinking chocolate milk, eating chocolate, or drinking coffee will cause their newborns to have a darker skin color. Most Thais view lighter skin as more favorable. Pregnant women from the central region of Thailand are often seen with a safety pin on their outfit over their belly. The pin works against a kind of ghost who always wants to steal the unborn baby from a 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 12 12 Aggregate Data for Cultural-Specific Groups mother’s womb. Also, pregnant Thai women, especially those with Chinese descendents and their families, may ask their obstetric physicians to perform selective cesarean sections, believing that the date and time of their babies’ births can greatly affect their children’s future as based on the Chinese Zodiac calendar and fortune-telling (Ross et al., 2007a). Like many other Southeast Asian women, postpartum Thai mothers practice the concept of “Yin” and “Yang” (cold and hot) (Kaewsarn et al., 2003a). After a child is born, the mother is left cold and wet. Therefore, the mother should gain some heat to dry out her body, especially her uterus (Kaewsarn et al., 2003a). To gain heat, some Thai mothers practice Yue Fai, which literally means “being with fire.” There are a couple of ways to perform Yue Fai. The new mother lies down either on a bed above a bonfire or on a wooden plank nearby. The fire is tended for as long as the mother is supposed to be near the fire, which may be from 1 to 30 days. Reasons given by Thai mothers for practicing Yue Fai include desiring an increase of milk, faster involution of the uterus, and illness and bone ache prevention (Kaewsarn et al., 2003b). Some drawbacks of this ritual, however, include inconvenience, discomfort, and complications, such as heat rashes, sweating, dehydration, and minor burns (Kaewsarn et al., 2003b). To be able to perform Yue Fai, space is needed and a family member must keep tending the fire. Without enough space and a 24/7 support person, Yue Fai is not possible. When Yue Fai, the ultimate practice for gaining heat during the postpartum period, is not possible, Thai mothers are advised by their mothers or nurses to use a combination of practices, including a perineal heat light, a hot Sitz bath, sauna heat belts, and warm showers (Kaewsarn et al., 2003b). Warm and hot drinks and foods are consumed; ice chips or ice cubes are avoided. In general, all Thai mothers are allowed by their mothers to drink warm and hot nonalcoholic liquids. However, there is no consensus about the types of protein, vegetable, and fruit the postpartum mothers should consume. Whereas some mothers are encouraged to eat certain food items, others are not (Kaewsarn et al., 2003b). Many postpartum Thai women are not restricted to proteins, vegetables, and fruit, but some are. Sources of protein include pork, chicken, fish, eggs, milk, catfish, internal organs, beef, water buffalo meat, and shrimp (Kaewsarn et al., 2003b). However, some mothers might be advised to not eat eggs, chicken, or buffalo meat, believing that the new mothers’ perineum may not heal. On many occasions, the first author has heard the mothers of postpartum Thai mothers’ give their reason as to why chicken is a taboo food for women after delivery: They stated that usually a chicken likes to scratch the ground to look for food. The chicken meat, therefore, could scratch open the perineum. Eggs are avoided by some mothers, believing that they could cause a big scar on the perineum. Water buffalo meat is tough and cheap and, therefore, seen as unhealthy by Thais. Based on this belief, it is thought that the healing process of the new mother’s perineum could be jeopardized by its consumption. Vegetables eaten by postpartum mothers may include lettuce, banana flower, lemon grass, onion, ginger, cabbage, hairy melon, snake beans, chili, peppers, and bamboo shoots (Kaewsarn et al., 2003b). Acceptable fruits after the postpartum period may include oranges, bananas, tamarind, watermelon, jack fruit, and durian, an oval fruit with a hard spiny rind (Fig. 36-7). However, some women avoid durian because of its strong smell. For traditional Thai families, especially those from rural Thailand, the new mother might be restricted to a few items of food for the first few weeks. For example, she might be allowed to take only rice soup with salt without any protein or fruit. Some postpartum Thai women drink Ya Dong, a Thai nonalcoholic or alcoholic drink infused with herbs. Herbs used in Ya Dong may include ginseng, galangal, peppermint, cinnamon, Spirulina, and plant roots. As perceived by many Thais, Ya Dong is famous for its medicinal qualities. When used by postpartum women, the drink helps with blood production and drying out the uterus quickly. Expecting Thai fathers, like those of many cultures today, have for their part also begun to participate more in the childbearing experience. They tend now to desire more strongly, for example, to protect the unborn baby and to become more involved with the mother in preparing for postpartum care (Sansiriphun et al. 2010). Particular regional cultural practices may influence how some Thai fathers respond to society’s changing expectations for them. Moreover, Buddhist theology has been found, in general, to be “embedded in the beliefs and strategies” of expecting Thai fathers (Sansiriphun et al., 2010). Figure 36-7 Beautiful Thai fruits at a commencement ceremony. 2780_BC_Ch36_001-018 03/07/12 10:05 AM Page 13 People of Thai Heritage Death Rituals Death Rituals and Expectations Because most Thais are Buddhists, only the funeral rites in connection wit…
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