Understanding the Culture of Chinese Children and Families

Abstract

Providing appropriate health care to a client can be accomplished only in an environment that is sensitive to the cultural values and beliefs of the client. As the population of first-and second-generation Chinese immigrants increases in the United States, the need to develop culturally sensitive health care becomes significant. Chinese immigrants and their families have become an important part of American society, including the school setting. The school nurse, who regularly works with students and families, should work in a manner that allows Chinese immigrants to maintain their cultural values and beliefs, while providing appropriate care for the student. The Chinese culture is unique and holds values and beliefs that contrast with those of the Western culture. A school nurse who understands and incorporates the Chinese culture will be better able to develop a positive interaction with the family and make arrangements for culturally appropriate care.

Keywords

children Chinese culture health care school nurse

Introduction

More than 1 billion people live in China today, and many additional Chinese people live in other countries, making the Chinese the most populous ancestry in the world (Jayne & Rankin, 2001). It is estimated that by the year 2010, 35% of the children in the United States will be non-White. Currently, first- and second-generation immigrant children under age 15 are the fastest-growing group in the United States (Chen & Rankin, 2002). Twenty-five percent of the 12 million Americans who report themselves as being of Asian descent are under the age of 18 (Yu, Huang, & Singh, 2004).

Schools in the United States serve a diverse population of children of Asian origin, both new immigrants and second-generation immigrants whose parents are from other countries. Many studies have discussed the importance of culturally sensitive care for patients in hospitals, but few have emphasized such care for nurses working in schools and the community (Fralicx & Bolster, 1997; Haffner, 1992). Because Chinese Asian immigrant children are coming to the United States in increasing numbers, it is important for school nurses to be aware of the students’ cultural differences.

In demographic representations of communities, Asians are commonly categorized as one culture or ethnicity. However, families and communities of Asian origin are in fact quite different from one another, depending on the country of origin, and where in the country they are from, such as north or south, east or west, urban or rural. For example, cultural practices are different among Asians from Hong Kong, Taiwan, or mainland China. Perhaps no other professional group in society has recognized the impact of cultural diversity as much as the health profession (Pur-nell & Paulanka, 1998). “Nurses constitute the biggest group of health care providers who can potentially deliver culturally competent care to large populations of diverse patients” (DiCicco-Bloom & Cohen, 2003, p. 26). Acknowledgment of and respect for these differences are needed to provide culturally sensitive care. As school nurses encounter more Chinese families, they will have an opportunity to increase their knowledge of families of Chinese descent while heightening their respect for and valuing of the culture. Providing some basic features that are relevant in the Chinese culture and facilitating understanding of the differences within the culture will enhance the ability of school nurses to incorporate more receptive interactions with these families as they deliver health care in the school setting.

Chinese people may speak a variety of different languages and dialects. There are seven major language groups, each with many dialects.

Language

Chinese people may speak a variety of different languages and dialects. There are seven major language groups, each with many dialects. The national language, putonghua, which means “common speech,” is also called Mandarin (Chinese Languages, 2004). Over 2 million Americans speak Chinese regularly at home, making it second to Spanish as the most common foreign language spoken in the United States, according to the 2000 census (Fetto, 2003; U.S. Census Bureau, 2000). A study of the effects of Chinese residents’ income, language, and citizenship status found that fluency in English can strongly affect health care access for this population (Jang, Lee, & Woo, 1998). For Asian children, health issues are compounded by the problem of adaptation to an unfamiliar culture, particularly for children with limited English. In addition, a study of Asian adolescents revealed significant psychosocial deficits in school and a lack of parental support among those who do not speak English at home (Yu et al., 2004). Health professionals’ unfamil-iarity with another culture can affect interpretation of important health data. For example, the practitioner may misinterpret a client's pain because of differing personal cultural practices. With such a large number of people in the United States speaking Chinese, advocating for a trusted interpreter may be helpful in overcoming language barriers that may arise when communicating with Chinese community members.

Communication Practices

Traditional Chinese communication practices differ from Western communication practices, which may lead to misunderstanding. Chinese people tend to be more passive, polite, and attentive, with a friendly demeanor. The Chinese believe this type of behavior is virtuous and reflective of practicing and demonstrating Confucian principles. These principles play an important role in forming Chinese character and behavior. Their purpose is to achieve harmony, the most important social value. It is interesting that there is no Chinese equivalent for the word self.

Chinese people tend to be subtle when explaining or discussing something, whereas Westerners appreciate more direct and clear explanations. This is an example of the Confucian principle of behavior in which one is to avoid raising issues unless the other party does so. In addition, one is not to tell the other party things that may upset him or her (O'Keefe & O'Keefe, 1997). Because of this principle, some Chinese families might avoid sharing a health concern such as a chronic illness, mentioning a health practice that they adhere to, or consulting with unfamiliar health professionals about a specific health issue. Because of the lack of access to and understanding of the U.S. health care system, many Chinese immigrant families do not benefit from needed services that may be available in their community (Yu et al., 2004). School nurses can assist such families in accessing care and educating them about the U.S. health care system.

Because Westerners are willing to openly give and accept comments and rebukes, they assume that everything is all right when Chinese people give no response.

Many Westerners may not understand Chinese communication practices and may misinterpret them. Westerners might become upset because they consider Chinese communication to be indirect and offensive. Westerners handle issues directly, whereas the Chinese may find being direct offensive and insulting. Because Westerners are willing to openly give and accept comments and rebukes, they assume that everything is all right when Chinese people give no response. When speaking openly, the Chinese may be reluctant to offer their opinion if someone will be embarrassed as a result (O'Keefe & O'Keefe, 1997). To prevent misunderstandings, it is important for school nurses to be aware of these differences.

Another difference in behavior that Chinese people may display that Westerners may misinterpret relates to taking initiative. Chinese people tend to avoid taking initiative because this behavior would not maintain harmony and peace. Westerners may see this behavior as being negligent and avoiding responsibility. Westerners also tend to think ahead and act independently, whereas the Chinese view this proactive independence as showing disrespect to the group and being too individualistic (O'Keefe & O'Keefe, 1997).

The Chinese defer to authority. As a collectivist society, each person's duty is to conform. Clients or their caregivers may not verbalize their anxiety or doubts about the care they receive. The Chinese want to avoid conflict and will not challenge anyone whom they regard as an expert. For example, if a doctor prescribes a medication incorrectly, instead of saying something, Chinese people will accept the doctor's prescription but not follow the order (Chen, 2001). As a result, they may be perceived as noncompliant in following the prescribed treatments. By nodding during the instructions given by a health care professional, the Chinese American may be deferring to authority rather than actually understanding and agreeing with the instructions, because disagreement with health care professionals is considered disrespectful and distrustful (Chen & Rankin, 2002). Not challenging the professional may also be perceived as a manner of saving face for both the client and the health care provider.

Chinese people tend not to discuss their concerns with health care professionals. They consider their concerns to be personal, to be shared only with the family. As school nurses provide the family with support and treat them with honesty, compassion, and respect in a manner consistent with the family's culture, nurses can discover the family's concerns in a more personal way. Parents are very concerned about their child's future when the child has a chronic illness. Trust and empathy can bring the bond between nurse and family closer, enhancing compliance with treatment plans. Reassuring families that it is appropriate to ask the nurse or physician questions will help ease family members’ concerns regarding health care provided during the course of illness (Chen & Rankin, 2002).

Holism and Caring

Holism is a valued concept in the Chinese culture. Incorporating this concept can be challenging to nurses who work according to the biomedical or task-based model of care (Wong & Pang, 2000). There have been many studies over the past two decades examining how different cultures conceptualize holism and caring. Having knowledge in this area is helpful in establishing nurse–client interactions. According to Wong and Pang, holism and caring influence every aspect of the health care culture of the Chinese. Health is perceived from the viewpoint that a human being is a dynamic entity. The person is in dynamic interaction with the world, and “illness is perceived as disharmony at the individual or social level” (Wong & Pang, p. 13). For example, while caring for a student with a stomachache, the school nurse would also address the emotional aspect of the student's not being in balance with the environment.

Because illness is seen as an imbalance between the person and the natural and social environments, both curative and caring processes are important to return the client to optimal health.

Because illness is seen as an imbalance between the person and the natural and social environments, both curative and caring processes are important to return the client to optimal health. The manner in which people are cared for is important to helping them achieve health. A common belief among the Chinese states that “thirty percent of healing depends on curative means and seventy percent on nursing care” (Wong & Pang, 2000, p. 14). Therefore, caring is seen as more important than medicine among Chinese families. The nature of nursing parallels the Chinese concept of caring. Although the Western culture might view nursing as a servant's work, nurses cherish “treating the patient as their own family member.” School nurses provide holistic care as they focus on the student and the family as the unit of care, based on the knowledge that health includes physical, psychological, social, and spiritual well-being.

Importance of Family Relationships

The family is the basic unit of society for the Chinese. People practice Confucian principles within the family, and these Confucian principles are the basis for Chinese values and lifestyles (Xing, 1995). There are five hierarchical relationships, those between (a) father and son, (b) ruler and ruled, (c) husband and wife, (d) elder brother and younger brother, and (e) friend and friend. For example, one principle is to make family needs a priority over the needs of oneself, and children are expected to make sacrifices for the needs of their parents. Traditional Confucian roles and responsibilities are taught and passed to younger generations through stories and proverbs told by mothers in the family (Holroyd & Mackenzie, 1995).

Chinese women have other teachings by which they abide. The “Four Books for Women” teach women their duties and responsibilities. Women are taught to be submissive to their husbands; to be obedient to parents and parents-in-law; to work hard at cooking, cleaning, and sewing; and to avoid public affairs (Zhan, 2002). Women's moral behavior is viewed as a symbol for the well-being of community and state. Women can be subject to serious penalties if they do not abide by these teachings and societal expectations. Women's crimes against men are punished much more severely than men's crimes against women. With the women being expected to obey and maintain a lower status than men, the power of the patriarchal society or culture will remain stable (Zhan 2002). Gender roles were promoted in pre-modern China, and still apply in some cultures today. Boys are expected to play with other boys and do school work, while girls are expected to help the mother with household chores (Zhan 2002). Because the family structure is patriarchal, girls are valued less than boys.

Most problems among family members are handled within the family and controlled by the extended family, because social and legal structures recognize the family as a unit, but not individuals (Zhan, 2002).

The extended family also plays a role in ensuring that its members behave properly. Most problems among family members are handled within the family and controlled by the extended family, because social and legal structures recognize the family as a unit, but not individuals (Zhan, 2002). Personal integrity is determined by the way a person treats his or her family. It is a moral obligation to care for a family member, and this care cannot be performed by someone outside the family (Wong & Pang, 2000). The obligation of family members to care for each other, especially children and those who are ill, is fundamental in the Chinese culture (Chen & Rankin, 2002; DiCicco-Bloom & Cohen, 2003). School nurses working with Chinese families need to keep this concept in mind and develop nursing interventions and teachings that pertain to the family as a unit and not solely to the children.

The Home Visit

School nurses may make home visits from time to time, especially to a child who is chronically ill. Therefore, it is important to be aware of cultural differences in the home environment. DiCicco-Bloom and Cohen (2003) observed nurses in 14 home visits and found that even though some nurses attended to the family's cultural needs, none integrated the family's lifestyle into the actual care provided. Acknowledging cultural differences and integrating these differences into the nursing care plan can improve the quality of care. Because the home environment is the main living environment, it is most likely that school nurses who visit the child's home will develop insights about the family's cultural practices and assess the child and family holistically. Assessment of the child's and family's concept of health is valuable, because knowledge of clients’ concepts of health is necessary. This knowledge allows the nurse to plan interventions that are acceptable and meaningful to the family and the child (Hwu, Coates, Boore, & Bunting, 2002).

Family Needs during a Child's Illness

The Chinese culture is a collectivist culture, shunning individualism for the more important collective groups, such as family and society. When a child is ill, parents and healthy children may keep information from one another to avoid causing anxiety and distress. This behavior is characteristic of a selfless culture that displays its roots in Buddhism and Taoism. Buddhist teachings emphasize “face,” or dignity. When something wrong happens to a family member, he or she brings shame to the family. Therefore, the individual may not admit having health problems, especially mental health problems, because it would bring shame to the family.

In contrast, the United States is more of an individualistic culture in which the individual is seen as more important than the collective group, family, or society. Individualism and individual accomplishment are revered in the United States. This can lead to cultural struggles between Chinese American children and their immigrant families, in which one group is in need of being individualistic, whereas their families are more sensitive to the culture and value the emphasis on the family unit.

When something wrong happens to a family member, he or she brings shame to the family. Therefore, the individual may not admit having health problems, especially mental health problems, because it would bring shame to the family.

The family is the primary social unit in the Chinese culture. Any decisions that affect the family are made with the family, either by the father, who is the household leader, or by the elder son. Roles are based on “the proper way” or “Li.” In this system, great value and importance are placed on emotional control, obedience, conformity, and “face” (McLaughlin & Braun, 1998; Ow & Katz, 1999). Face is a mutually protective behavior that enables all individuals involved to end any potentially embarrassing situation with no loss in prestige. The immediate family loses face if a family member does something that is considered “wrong.” The actions taken to save face are important in the resolution of problems. This is especially true within the family's interpersonal relationships in saving one's own face or another's face, and by enhancing one's own face or another's face. The interaction can also be negative, with actions causing the loss of one's own face or hurting another's face. The Chinese may withhold information or keep secrets in order to save face and to protect family members (Ow & Katz, 1999).

When parents keep the diagnosis of an ill child confidential from other siblings or family members, it is because the parents do not want siblings to worry about the situation that parents and trusted family members are attempting to resolve (Ow & Katz, 1999). In addition, outsiders are not told about the illness, because a loss of face would occur by showing a weakness or bringing shame to the family because of the flawed health of the child. This practice also relates to karma, in that it is considered unlucky to talk of illness or death for fear that it may occur (McLaughlin & Braun, 1998). Saving face must be respected when working with a Chinese family who have a chronically ill child. The family does what is necessary to protect both the child and the family while making health care decisions. School nurses must work with the family in the same fashion so that they suffer no loss of prestige or status.

Yiu and Twinn (2001) reported that Chinese parents have a great need for information when their child has a chronic illness. They experience anxiety from lack of resources and social support, especially if they are faced with a language barrier. It is important for nurses to assess the depth of their language ability and to consider obtaining a qualified interpreter when needed. Determining the extent of communication to other siblings regarding a child's illness is also essential if nurses are to avoid frustration and stress from disclosing information to inappropriate members of the family. School nurses need to be sensitive to each individual family group, because there may be differences within the same culture. Understanding the family system makes it possible to provide help in dealing with the stress of coping with an illness in the family and to assist the family members to meet their needs.

Self-Care

In any cultural group, when a child becomes ill, regardless of whether it is an acute or chronic illness, both parents might need to take time off from work to care for the child. Missing work can affect family income and increase stress levels. As mentioned earlier, it is important to know that in Chinese families, parents and family members provide care for each other's illnesses as an obligation to show respect. However, encouraging children with a chronic illness to learn self-care can reduce financial burdens as well as the “physical, emotional, and economical burdens of the disease” (Luo, 2003, p. 82). Orem's self-care theory is appropriate in the Chinese culture, because many families have more than two children and need to divide their attention among the children; the oldest children might be expected to perform self-care and be more proficient compared with the younger siblings. Luo's study of 66 school-age children with ne-phrotic syndrome revealed that high levels of self-care were seen in the majority of the children.

Because the family may limit the amount of information shared with outsiders about the ailing child, they may not have enlisted all the services available to the child or the family.

Hwu and colleagues (2002) examined the concept of health among Chinese people with chronic illness. These individuals described “health” as relating to factors of independence, physical functioning, and the ability to interact socially. Questions on topics relating to independence included: (a) being able to move freely to perform most activities of daily living, (b) being able to take care of oneself, (c) not being sick enough for hospitalization, and (d) not relying on others. School nurses who work with Chinese children should encourage and foster the highest level of self-care possible.

Because the family may limit the amount of information shared with outsiders about the ailing child, they may not have enlisted all the services available to the child or the family. A culturally knowledgeable social worker could help establish support services for the family. Not only the child with the illness, but the siblings and family members may receive services that will help resolve the family issues related to the illness, as well as increase the health care services available to the child. Resources may be limited because of communication barriers and limited support networks.

Health Practices and Medicine

In identifying the health practices and medicine used by the Chinese American community, there is a need to identify some of the health problems that may affect this ethnic population. Even as a child with a specific illness is treated, health care professionals need to be aware of other family members with illnesses or conditions that may affect the recovery of the child or those members who may be negatively affected by the child's illness. In Chinese American women aged 65 and older, depression is widespread. The suicide rate among Chinese American women is three to seven times the rate of suicide in European American women. Also, in the elder Chinese American population, vascular dementia is prevalent. Although alcoholism tends to be low in prevalence among the Chinese, it, along with depression, is probably underestimated (Tom, 1999).

Hepatitis B and tuberculosis have higher incidence rates in the Chinese American population than in the overall population of the United States, with hepatitis B affecting 1 in 10 Asian Americans. Because of the high incidence of hepatitis B in Chinese Americans, this ethnic group also has the highest rate of liver cancer. Other cancers of significance in the Chinese American population are nasopharyngeal cancer, breast cancer, prostate cancer, colon cancer, and lung cancer. According to the Centers for Disease Control (n.d.) statistical data in 2001, rates of tuberculosis were dramatically higher for Asians/Pacific Islanders (32.7 per 100,000), African Americans (13.8 per 100,000), Hispanics (11.9 per 100,000), and American Indians/Alaska Natives (11.0 per 100,000) than for Whites (1.6 per 100,000). Making sure that Chinese American students receive the complete series of hepatitis B vaccinations, assessing for any risks for tuberculosis, and following up on positive skin tests should be a priority for school nurses. Referring families to screening resources and providing appropriate health education is another important responsibility of the school nurse.

As with the general population, there is a trend toward the increase of diabetes mellitus and cardiovascular disease (Tom, 1999). The striking rise in type 2 diabetes diagnoses is a concern in ethnic immigrant groups that have undergone lifestyle changes and live in industrialized nations. It is estimated that more Chinese people living in the United States are diagnosed with type 2 diabetes than Chinese people living in China (Jayne & Rankin, 2001).

The health practices among Chinese Americans vary with the generation of acculturation in the United States. Individuals born in China are more likely to follow the traditional health practices, such as the concept of yin and yang, and be more skeptical of Western medicine than those Chinese individuals who were born in the United States. Yin and yang have a basis in the five fundamental concepts: metal, wood, fire, water, and earth, and qi or chi concepts (Feng, 2002). Yin and yang are opposing forces. Yin is identified as female, negative energy, and cold. Yang is identified as male, positive energy, and hot. It is the balance of yin and yang forces that sustains the body and maintains the health of the individual; a hot or cold imbalance brings about illness. An excess of yin (cold) results in fever and dehydration. An excess of yang (hot) results in gastric and other disorders. Yang represents the external organs, including the small intestine and stomach. Yin represents the internal organs, including the lungs and spleen (Feng). Foods are described as “hot” or “cold.” For example, meats, seafood, and fried foods are “hot,” whereas vegetables and fresh fruits are “cold.” Climates and seasons may require adjustments in food choices. For example, parents may not recommend “cold” foods to their child after surgery, because the child needs to rebuild the warmth of the body because of the blood loss (Chen & Rankin, 2002). In the school setting, a student may eat particular foods for lunch that have been packed or prepared by the parents with respect to the weather or health situation.

Qi or chi is the vital energy flowing in the person. When it is absent, the body dies. Chi can be gained from three sources: genetics, air, and food. It can be lost through aging and neglect. When chi is in balance, it promotes the function of the heart and lungs. To maintain the chi balance, tai chi, a series of slow, precise, specific exercises, is performed, nourishing all body parts by improving the blood flow (Feng, 2002).

Acupuncture is a common Chinese practice based on the principles of yin and yang and chi. Modern acupuncture may include the use of lasers or electricity. Moxibustion, the practice of applying heat to the acupuncture points, treats conditions such as asthma, arthritis, and bronchitis (Feng, 2002). Chinese people use several other traditional healing methods or practices during illness. Cupping is used to decrease stress and congestion by placing heated cups on parts of the body. This rids the body of unwanted chi by bringing it to the surface of the body and then letting it diffuse away. These therapies work against the imbalances that are thought to cause the illness rather than reducing the symptoms as in Western medicine. Her-bology, the use of plant and animal matter, stimulates chi in the body to treat ailments. Meditation helps relax the body to reduce stress (Tom, 1999). Although underestimated in scientific medicine, meditation enables people with chronic illnesses to maintain a total sense of mind, body, and spirit (Bonadonna, 2003).

For over 40 years, the Chinese government has required an integrated practice of Western and Chinese medicine in their medical schools. Combined Western and Chinese therapies have in some cases been more effective than either practice alone. Chinese herbs and radiation therapy boost the immune response and inhibit developing tumors more effectively than either therapy by itself (Feng, 2002). Chinese Americans may have different physiologic and psychological responses to Western medicine (Tom, 1999). Some medications, such as psychotropic medicines, are required in lower doses. This is because of smaller body size and differences in the metabolism or clearance of the medication by Chinese Americans. Psychotherapy may make Chinese patients anxious or uncomfortable and subject to somatization (Tom, 1999).

Implications for School Nursing Practice

School nurses have a unique opportunity to work with culturally diverse populations, based on the fact that the number of immigrant children is increasing each year. School nurses consistently interact with children and their families, many of whom have contrasting views and cultural beliefs about health care. Because these values, beliefs, and practices may vary even in families from the same country of origin, an assessment of their culture and family system at the beginning of a nurse–family interaction is an important initial step of the nursing process.

School nurses have a unique opportunity to work with culturally diverse populations, based on the fact that the number of immigrant children is increasing each year.

School nurses need to be aware of major concepts in the Chinese culture such as holism and the Confucian teachings. Awareness of Chinese cultural beliefs will benefit the child and the family, as well as the school nurse. Understanding and respecting the Chinese culture supports the delivery of meaningful and satisfying health care in the school setting.

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