People of Russian Heritage. People of Polish Heritage. People of Thai Heritage. 800 words minimum

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People of Russian Heritage

Chapter 19

LINDA S. SMITH

Overview, Inhabited Localities, and Topography

OVERVIEW

Russians are blessed with a rich and beautiful language and culture. Russia, also known as the Russian Federation, is nearly twice the size of the United States, covers 11 time zones, and is a democratic federation of 89 republics. The climate ranges from temperate and humid to arctic in the polar north. With 6.9 million square miles, it is the largest country in the world. Ethnically, 80 percent of those liv- ing in Russia are Russian, 3.8 percent are Tatars, 2 per- cent are Ukrainian, and 14.4 percent are other smaller groups. Owing to over 7 decades of religious suppression under communist rule, a large number of Russians are either nonreligious or nonpracticing. Between 15 and 20 percent of Russians are Russian Orthodox, 10 to 15 per- cent are Muslim, and 2 percent belong to other Christian groups. Only about 500,000 Russians are Jews. Russia enjoys one of the highest literacy rates in the world at 99.6 percent, with men and women equally literate. The population of Russia at 143 million is declining with 1.5 deaths for each birth (CIA, 2006). This high death rate is related to high-risk behaviors such as sexual promiscuity, smoking, and alcoholism plus traffic accidents and heart disease. The life expectancy of Russian men is 58 years, and of Russian women, 73. Adding to this population decline is a low fertility rate of 1.1 (replacement level is considered to be 2.1 children per woman of reproductive age) (CIA, 2006; Library of Congress, 2005; Marquez, 2005). The two largest cities—Moscow, Russia’s capital, and St. Petersburg—have 10 million and 4.5 million peo- ple, respectively. Although major cities are heavily popu-

lated, 27 percent of Russians live in very rural areas (Library of Congress, 2005).

In 1917, the imperial Czar was overthrown and Vladimir Lenin took power, followed by Josef Stalin. The overthrow was partly due to the horrific defeat of the Russian armies during World War I and resulted in rioting and discontent. After Lenin left power, Stalin further strengthened and unified Communist rule over the Soviet Union, which comprised 15 republics, the largest of which was the Republic of Russia. These 15 republics are ethnically and culturally diverse. On August 24, 1991, Russia gained independence when the Soviet Union col- lapsed. Each of the 15 republics of the Soviet Union devel- oped into independent nations. Russia adopted a consti- tution in 1993. Unfortunately, Russia’s poverty rate is 17.8 percent with an 11.5 percent inflation rate (CIA, 2006), with a large number of adults unemployed (7.6 percent) or underemployed. In January 2007, one Russian ruble was worth 3.7 cents (US$0.0037) (OANDA, 2007). By contrast, in 1989, 1 Ruble was worth US$6.

Economically, Russia has some of the most abundant natural resources, including rich deposits of oil, natural gas, coal, timber, and minerals such as diamonds, nickel, aluminum, and platinum. Russia has over 20 percent of the world’s forests. Regrettably, during the Soviet rule under Stalin and others, water, land, and air pollution prevailed (Energy Information Administration [EIA], 2004). In addition, after 1991, economic and social reform was plagued by high crime rates (police have low pay, low status, and high corruption) and political bribery and corruption. At present, there are three branches of government, the executive, the legislative, and the judi- ciary, but Russia’s president has formidable powers and has used these powers to turn back some of the important democratic reforms made in the 1990s.

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HERITAGE AND RESIDENCE

During the Soviet rule between 1917 and 1991, Soviet cit- izens moved between and among republics, often leaving their own culture and birthplace. Since the fall of the Soviet empire, a return migration to the republic and cul- ture of birth has been occurring (Aroian, 2003).

Russians have also left their homelands and settled in the United States. Russian Americans are one of the fastest-growing ethnic groups in the United States. According to the U.S. Bureau of the Census (2000), over 2.6 million Russians live in the United States. Between 1996 and 2000, the average number of new Russian immigrants to the United States was 15,411 per year (U.S. Department of Homeland Security, 2005b). The Russian- speaking population in the United States increased 254 percent between 1990 and 1998. During the year 2005, 4652 Russian children were adopted by U.S. citizens (U.S. Department of Homeland Security, 2005c).

Of the 18,083 Russians who came to the United States in 2005, the largest number (2786) relocated in New York state, followed by California, Illinois, Florida, and the Pacific Northwest (U.S. Department of Homeland Security, 2005a). Almost 90 percent of Russian Americans live in urban areas such as New York City and the Tri-State area (24 percent), Boston, Philadelphia, Baltimore, Miami, Atlanta, Cleveland, Chicago, Detroit, Denver, Houston, Los Angeles, San Diego, San Francisco, Seattle, and Portland, Oregon (Allied Media Corp., 2006). In Canada, Russians primarily live in Toronto, Vancouver, and Montreal (Aroian, 2003).

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Since 1917, four major waves of migration from Russia to the United States have occurred. Three of these com- prised ethnic and national minority groups, the largest from Russia being the Soviet Jews. This emigration was primarily due to the persecution experienced as well as their refugee status (Aroian, 2003). Soviet Jews were one of the few groups allowed, and in some cases encouraged, to leave Russia under Communist rule. The last wave of Russian immigrants has occurred since 1993 and has resulted from much more freedom to immigrate, harsh economic conditions, political turmoil, and greater overtly expressed Russian nationalism and anti-Semitism. U.S. immigration rules such as quotas, job requirements, and sponsorships apply (Aroian, 2003). During and after the transition from Communism to a free-market sys- tem, teachers, scientists, and physicians were the hardest hit. Salaries were fixed and well below poverty levels, causing a desperate migration in hopes of an improved quality of life for themselves and their children (Wikipedia, 2006).

Prior to 1991, people who came to the United States from Russia were unhappy with the oppression of free thought imposed by the Communist regime. Ethnic minorities were often tortured for their beliefs. More recently, however, Russians came to the United States to reunite with families and loved ones (Bistrevsky, 2005).

EDUCATIONAL STATUS AND OCCUPATIONS

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The average age for U.S. Russian immigrants is 42 years, with nearly one-fourth of the total U.S. Russian popula- tion being 65 years of age or older. Of adults over age 25, one million have at least a bachelor’s degree, and this high level of education is reflected in the median house- hold income of $59,950 (U.S. Bureau of the Census, 2000). Nearly 64 percent are married, with 1.6 children per couple. They are ambitious professionals and over 18 percent have graduate degrees. Thus, the average adult Russian in the United States works in a professional area, is well educated, and has a better-than-average income (Allied Media Corp, 2006).

Education is highly valued and strongly promoted for both genders. Russian extended families frequently pool their financial resources, and even work additional hours, to provide a good education for their children. Good grades are an expectation. Men look for well-educated wives who are intelligent, critical thinkers. Women are an important part of the workforce in Russia, although the roles of mother and homemaker are also valued. Even though Russian women pursue education and careers, the expectation remains that they fulfill home and child-care responsibilities (Aroian, 2003).

Teaching/learning systems in Russia are rigid, com- pared with U.S. standards. Until recently, however, learn- ing English was not a priority in Soviet schools, which presents a very real language barrier for Russian immi- grants, especially older people, who came to the United

V I G N E T T E 1 9 . 1

Vera (34 years old) and Alexander Sarkisova (38 years old) are ethnic Russians living in Chicago, Illinois. They were both born in Moscow, Russia, and immigrated to the United States 41⁄2 years ago. Vera and Sasha (short for Alexander) came to Chicago to be with Alexander’s parents and two brothers. As they prepared for their relocation to the United States and awaited their visas, Vera and Alexander took a year of English language classes at Moscow State University. In Russia, Vera was trained as an optometrist and Alexander was an electrical engineer. Even though they knew some English upon arrival, both were dismayed by their lack of ability to understand spo- ken English. Vera and Sasha work in Chicago—Vera cleans offices at night and Alexander drives a taxi cab. They live in the basement of the home of Alexander’s brother. Fortunately, they both have health insurance through Alexander’s employ- ment but this insurance covers only a portion of the real health-care costs.

1. How does this couple’s immigration profile compare with other Russian immigrants over the last 100 years?

2. What health risks can be identified for Vera and Alexander Sarkisova considering their immigration expe- rience?

3. What barriers might this couple experience in securing health-care services?

4. Name four nonverbal behaviors that might offend the Sarkisovas?

5. How should Russian Americans be addressed?

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States during the first three immigrant waves. Recently, English has grown more popular in Russia owing to media, film, music, and Western advertising.

Not all Russian immigrants are financially secure. Sixty percent of those receiving public assistance in one California area had an annual household income of less than $10,000, and 28 percent of the families had an income between $10,000 and $30,000. Importantly, most Russians receiving public assistance have a college educa- tion (Hobbs, 2002).

Employed Russians receiving public assistance work half time in areas such as computer hardware and soft- ware, retail, elder and child care, and education. In Russia, these individuals all worked—and were employed in fields such as engineering, math, medicine, computer sci- ence, education, and other professions. Unfortunately, these positions are not often open to them in the United States owing to language, licensing, and credentialing problems. Over half (58 percent) of the employed Russians receiving assistance report that their jobs come without medical benefits, sick leave, or retirement plans. When Russian Americans start their own small busi- nesses, the biggest barriers are language, unfamiliar legal regulations, and unfamiliar start-up processes such as securing business loans (Hobbs, 2002). In contrast, more recent Russian immigrants tend to be less well educated and more likely to pursue technical and service occupations (Minnesota Department of Employment and Economic Development [MDEED], 2006).

Communications DOMINANT LANGUAGE AND DIALECTS

Russian is a uniquely rich, expressive, and beautiful liv- ing language. The primary language for over 150 million people, it is one of the world’s major languages (Rendaxa Software, 2007; Wikipedia, 2007) and the most pervasive of all Slavic languages. Russian is one of the six official languages of the United Nations. Russian, official lan- guage of the Russian Empire, unified the 15 Soviet republics and the Soviet-controlled satellite nations, although each had its own language and culture. School children in these satellite countries were required to take many years of Russian language courses.

Importantly, not all Russian speakers in the United States are ethnic Russians. Prior to the Soviet collapse in 1991, most Russian speakers in North America were Russian-speaking Jews (Wikipedia, 2007). Therefore, for these families, languages of Yiddish and Ladino (the Spanish dialect spoken by some Sephardic Jews but writ- ten in Hebrew script) may be spoken in the home; how- ever, younger Russian Jews, although they may under- stand spoken Yiddish, may not be fluent in the language (MDEED, 2006). According to the U.S. Bureau of the Census (2003), 706,242 persons over age 5 spoke Russian at home. Of these, only 43 percent reported speaking English very well, 29 percent spoke English well, 21 per- cent spoke English “not well,” and 6 percent could not speak English at all. Often of limited English proficiency, Russian immigrants can read and write English better

than speak it, and most Russians, with the exception of Russian older people, learn and become proficient in English. Many large urban centers of Russian speakers have their own newspapers and self-maintained commu- nities, especially when these communities primarily include Russian immigrants who arrived prior to 1991. Therefore, immigrants from the former Soviet Union speak both Russian and their own native languages (e.g., Ukrainian, Georgian), but may have very limited English proficiency.

Two main Russian dialects, Northern and Southern, have distinct tone, pronunciations, and even grammar characteristics. Standard Russian, based in Moscow, has characteristics of both Southern and Northern dialects (Culture tips, 2000). Written Russian uses the Cyrillic alphabet, derived from but not the same as the Greek alphabet. Russian is considered phonetic, and even children as young as 5 years of age can read the classics. Russian language includes five vowels and numerous con- sonants that are considered hard or soft. Russian language experts have identified 350,000 to 500,000 words (Wikipedia, 2007). Interestingly, Russian does not include articles (e.g., “the”) and is often called a house green lan- guage (“the” and “is” are omitted).

CULTURAL COMMUNICATION PATTERNS

Russians enjoy intellectual conversations that focus on political, economic, cultural, and social issues. Word of mouth among Russian speakers is a strong influencing factor for Russians making decisions regarding health care and major purchases (Allied Media Corp, 2006). Russians seek emotional support from their spouses, relatives, and friends and report not being free to trust religious advi- sors, teachers, social services workers, or community lead- ers. They did report a willingness to talk with physicians and other health-care workers, especially when these workers are able to speak Russian (Hobbs, 2002).

Russians tend to speak loudly, even during socially pleasant communications (MDEED, 2006). They have great insight into their own and another’s feelings and may communicate on an emotional level. Russians make eye contact, nod their head in a gesture of affirmation or approval, and are, mostly, respectful in their verbal and nonverbal behaviors toward older people and persons of perceived rank or authority (Culture tips, 2000; MDEED, 2006).

Between men, Russians appreciate a firm handshake, and this symbol of agreement is considered more binding than paper documents. Shaking hands with a female stranger is not appropriate, unless the woman is a health- care professional. The doorway of the home of a Russian is considered the center of the house spirit, and it is a bad omen to shake hands over the threshold. Remove shoes prior to entering the home (MDEED, 2006).

Behavior in public must be respectful. Russians do not appreciate gestures such as standing with hands inserted into pockets or arms crossed over the chest; neither do they appreciate slouching postures when being inter- viewed or seeing the soles of shoes when sitting across from someone who is crossing their legs. Russians also do not appreciate the crossing and stretching of arms behind

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the head. Making the nonverbal sign for “OK” may be considered an obscene gesture. Shaking a fist shows anger or disagreement, and pointing with the index finger is considered rude (Hobbs, 2002; MDEED, 2006).

Russians freely touch friends and family members. Greetings that include kisses on each cheek, with close friends, are common. Furthermore, Russians often require less personal space than most other North Americans. Russians are social diplomats and will “bend” the truth for the sake of politeness or for the purpose of softening bad news (Birch, 2006).

Russians perceive themselves as spontaneous and emo- tional, able to be extremely empathetic toward the suffer- ing of others. They are emotionally strong and have a long and distinguished history of enduring great hard- ship and adversity. Thus, Russians may present a perva- sive attitude of endurance with comments such as “we have overcome many troubles and we can overcome these troubles because we are strong . . . we are Russians.” They look to others for the same level of respect and recognition of social order as they give. Thus, Russians have a sense of duty, self-sacrifice, and genuine caring toward others (Culture tips, 2000).

TEMPORAL RELATIONSHIPS

Russians who have immigrated to other countries tend to be both present and future oriented. This is not the case, however, among nonimmigrants. Russians living in Russia have shared their need to live within the present, “because we have no future.”

Russians are punctual and value this attribute. For appointments, Russians will arrive either early or right on time.

FORMAT FOR NAMES

Russians use titles such as Mr., Mrs., Dr., Professor, aunt, and grandfather to show the appropriate respect (Culture tips, 2000; Hobbs, 2002). Even when friendships are established, they often ask to be addressed by their first name plus their patronymic. The patronymic is the first name of their father with either a feminine or a masculine ending, depending on the person’s gender. An example of a preferred name format might be Oleg Vasiliovitch (Oleg, son of Vaslav).

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

In Russia, younger adults and youth lean and depend on the wisdom of their parents and grandparents whenever important decisions need to be made. In the United States, especially owing to the English language barrier, older Russians tend to depend on their children and grandchildren to guide decision-making. This is especially true when older Russians live within Russian-language communities, purchasing food and supplies from Russian retailers. Such communities provide little incentive to learn English. Importantly, Russians will be reluctant to

sign consent forms and other documents without first consulting their family members (Keefe, 2006). In addi- tion, family members will often attend health-care appointments in order to provide cognitive as well as affective support (Aroian, 2003). Different from other immigrant groups, Russian immigrants arrived in the United States in multigenerational family units. Thus, older Russians may not have left their Russian homes completely by choice.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

Russian children are taught to obey their parents and older people, as well as to achieve high grades in school and complete a university education. The expectation of children is to care for family members who are ill and in need of care (Culture tips, 2000). Older people are expected to raise their grandchildren, especially if both parents are employed.

Sexual topics such as contraception and sex education are not thought to be appropriate public discussion top- ics. Sexual activity outside of marriage is not sanctioned, and if teen girls get pregnant, abortion is the primary intervention (Aroian, 2003). Older Russian immigrants tend to be more modest (Aroian, 2003) and loathe public displays of affection.

FAMILY GOALS AND PRIORITIES

Russians have great cultural pride and sense of family; they have a strong family and group focus, and the fam- ily or group is more important than the person. Thus, they depend upon and trust the influence of a network of family, neighbors, friends, and colleagues. Historically, collectivism was part of Russian society for centuries, with the communal good holding higher value than individ- ual needs. Russians have great love for their extended family members and a strong and cohesive sense of the importance of family. Therefore, during crises, Russians pull together with their family, seeking their love and support. Consequently, Russians report amazement with the American value for individualism and independence. Spouses consult each other (Culture tips, 2000), and to a Russian, friends are considered close and important. Most Americans reserve those close, intimate ties for immediate family members.

Russian young people are expected to have and com- plete household chores, which are gender specific, with girls doing tasks such as cooking and cleaning and boys doing more physical labor—except for grocery shopping, which is a task for both boys and girls. Although educa- tion and a good job are considered important for Russian women, finding a good husband is even more important and being an “old maid” is socially frowned upon (Aroian, 2003).

Domestic violence is a rising concern in Russia. Therefore, for Russian immigrants, especially women, who may not trust police and social/mental health ser- vices, domestic violence is seldom reported (Aroian, 2003). Moreover, Russian women will only rarely admit to and report being raped.

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ALTERNATIVE LIFESTYLES

Divorce rates in Russia are high, and small families are also typical owing to economic hardships. Russian immi- grants have small families and high divorce rates, perhaps because Russian American women grow more indepen- dent as they acculturate, stress increases owing to immi- gration, and Russian women wait to reach their new country prior to ending an unhappy marriage (Aroian, 2003). Recent Russian immigrants tend not to be religious owing to the influence and antireligion dogma of Communism. Therefore, among Russian immigrants, divorce does not negatively affect social status. Divorced men in Russia are never awarded child custody, and although they pay child support, they do not remain active in their children’s lives (Aroian, 2003). This ten- dency is also noted with Russian immigrants.

Although Russian women are expected to marry by age 25 and have children, they are also expected to continue to pursue education and career paths. This is possible because the mothers and grandmothers become primary caregivers for young children; men are seldom expected to fulfill child-care responsibilities. Importantly, Russian women with fertility problems are not considered desir- able spouses (Aroian, 2003).

Following a survey in Russia that reflected answers to questions related to the Russian culture (Russians who, 2005), 65 percent of Russians favor the death penalty and 56 percent oppose adoption of Russian children by for- eigners. They also believed that Russian women who mar- ried foreigners should forfeit their citizenship. These strong beliefs are likely due to the resurgence of a strong Russian identity separate from Western influences.

Public displays of affection between same-sex couples are extremely rare in Russia. Overtly expressed antigay graffiti is commonly seen on the streets and buildings of downtown Moscow. Homosexuality is no longer a crime with the new Russian Penal Code effective on January 1, 1997. The age of consent is set at 16 years, regardless of sexual orientation. In July 1997, the first gay and lesbian pride festival occurred in Moscow. However, alternative lifestyle choices are still stigmatized by a large part of the population (News about gay Russia, N.D.). Traditional Russian Americans may not accept same-sex relation- ships; therefore, gay and lesbian Russians in the United States are likely to remain closeted unless significant trust is developed with their health-care providers. Same-sex behavior should not be disclosed to family members or friends.

Workforce Issues CULTURE IN THE WORKPLACE

The concept of employed persons with disabilities may be difficult for Russians to grasp. Russians believe that dis- abilities and negative health events are caused by some- thing the person did not do and should have or did do and should not have. For example, Russians agree that eating well and keeping warm are important for good health (MDEED, 2006).

Russians believe that members of health-care profes- sions should work hard to create membership that reflects the diversity of the communities in which they work. With an ever-increasing Russian immigrant population in North America, it is essential that Russian-trained health- care providers, with their values for holistic health care, earn credentials in their new countries.

Russian immigrant nurses work hard and have as their practice motto the relief of suffering. With nurses and physicians in short supply in the United States, the skills of Russian-trained nurses and physicians are greatly needed. However, the concept of teamwork is new to Russian nurses, as are critical thinking and sensitive care giving. In addition, the idea of lifelong learning is diffi- cult in an authoritarian work environment (Alaniz, 2001). Russian nursing education has been likened to that of the American Licensed Practical Nurses (Alaniz, 2001).

When communicating in the workplace, Russians have a very different value system. For example, Russians will perform and promote the value of positive politeness. Positive politeness is a technique that employs rules of positive social communication. The employee using posi- tive politeness will say nice things that show that the per- son is accepted, while simultaneously providing support and empathy and avoiding negative discourse with coworkers. When negotiating compromise, Russians express more emotion and invest more time and effort into supporting decisions and requests. With colleagues and friends, Russians communicate directly, which is con- sidered to be a sign of sincerity. Russians expect to be specifically asked for information (Bergelson, 2003).

ISSUES RELATED TO AUTONOMY

In the United States, nurses and physicians work as a unit, as a team, yet each member maintains independence. In Russia, the physician makes the decisions and performs the problem-solving processes. Thus, the nursing profes- sion carries limited status and respect from the Russian- speaking public (Alaniz, 2001). One Russian immigrant explained, “What do we expect from nurse? We don’t expect anything—we only expect something from doctor. Nurse is just someone who obeys” (Smith, 1996).

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Ethnic Russians are primarily Caucasians. Cultural assim- ilation is considered easier when the immigrants’ skin color is the same as or similar to the majority group. Stature and skin color for ethnic Russians are similar to other North American groups, with the exception of high rates of obesity among Russian immigrants. Researchers Dubrova, Kurbatova, Kholod, and Prokhorovskaya (1995) retrospectively reviewed documents from a Moscow maternity hospital over a 40-year time period. Between 1930 and 1949, they found the age of menarche decreased at a rate of 12 months per decade, with a parallel increase in maternal height by 1.8 cm per decade—significantly

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greater gains than those for women in Western European countries. These increases ended during the second half of the study. The infants’ weight, length, and head and chest circumferences showed changes—assumed to be related to increases in the mother’s stature.

DISEASES AND HEALTH CONDITIONS

Common health disorders seen in Russian immigrants include hypertension, coronary disease, gastrointestinal disorders, and diabetes. Common disabilities include the results of diabetes (sensory impairment), alcoholism, chronic health disorders, hypertension, psychosocial dis- orders, arthritis, lung diseases such as asthma and chronic obstructive pulmonary disease (COPD), and cancer (Keefe, 2006; MDEED, 2006; Shpilko, 2006). Alcoholism is far less prevalent among Russian Jews and women (Aroian, 2003).

Russian Jews who immigrated to Israel between 1989 and 1992 reported, from a list of 11 disease states, an aver- age of 3.5 chronic diseases—a much higher rate than that reported among immigrants from other countries. The highest age-specific disease prevalence rates were in mus- culoskeletal diseases, ischemic heart diseases, gastroin- testinal diseases, and high blood pressure. Women in this study reported higher rates than men for all disease states. The researchers suggest that health-care facilities need to be aware of and prepared for higher rates of disease and disability among this immigrant group (Rennert, Luz, Tamir, & Peterburg, 2002).

Many Russians prefer to somatize psychological disor- ders, especially depression, rather than to admit to them. For example, clinical depression is a very real concern for many older Russian immigrants, but these individuals present with vague complaints of skeletal or gastrointesti- nal problems.

Depression among Russian immigrants was studied by Tran, Khatutsky, Aroian, Balsam, and Conway (2000). Health status among older Russian-speaking immigrants was also studied. These researchers found that when Russian older people lived alone, they were more likely to experience a much greater level of depression than when they lived with family or friends. In addition, those older Russians with better English skills had better health and less depression. Older Russian immigrants who spoke lim- ited or no English exhibited a poorer health status and more depression. These researchers recommended sup- portive health services for this immigrant group as well as sensitivity to the living arrangements and family circum- stances of older Russian immigrants.

In a study by Vadlamani et al. (2001), Russian-speaking Jewish immigrants had a much higher than average rate of polyps. Therefore, these researchers suggest more aggressive colorectal cancer screening for this patient population. Perhaps related to these findings are those of Mehler, Scott, Pines, Gifford, Bigerstaff, and Hiatt (2001) in their study of the incidence of cardiovascular risk fac- tors among Russian immigrants. In their study (N ! 204), Russian immigrants had a greater incidence of hyperlipi- demia and hypertension (56 percent). Nearly half of their study participants had two or more cardiovascular risk factors. Most were overweight, but surprisingly few

reported alcohol or tobacco use, probably owing to the influence of religion (Jew and Pentecostal Christians) on these practices. Different from the findings of other stud- ies on Russian immigrants, Mehler et al. did not note increased rates of diabetes.

VARIATIONS IN DRUG METABOLISM

Gaikovitch (2003) extensively investigated drug metabo- lism properties that make medications more water-soluble and thereby more readily excreted in the urine. She exam- ined genetic polymorphism variations in the metabolism of many drugs. She writes that, “the frequency of func- tionally important mutations and alleles of genes coding for xenoobiotic metabolizing enzymes shows a wide eth- nic variation . . . ” (para. 1). Her purpose in doing the research was to provide a foundational pharmacogenetic information databank for Russians, the largest Slavic group. Gaikovitch found that the allele distribution of “. . . important drug and xenobiotic metabolizing enzymes among Russians shows that the allele frequency is similar to that of other Caucasians. Therefore, it may be expected that drug side effects and efficacy problems due to an indi- vidual’s genetic background are similar when compared to those in other European populations” (para. 1).

The metabolism of alcohol may be the exception. According to Gabriel (2005), Russians inherited, via the Mongolian invaders to their country, a genetic character- istic that prevents the processing of ethanol derived from fruit or potatoes. He believes that this genetic trait makes Russians more susceptible to alcoholism, especially when the preferred alcoholic beverage is cognac or vodka.

High-Risk Behaviors Russians’ reluctance to immunize may be considered a high-risk behavior. In Russia, immunizations are available but have been and continue to be of poor quality. Furthermore, reports of hepatitis- and HIV-positive–cont- aminated immunization needles have created fear and distrust among Russian parents. Therefore, Russians do not immunize their children in order to avoid these risks. Another high-risk behavior is the common practice Russian immigrants have of sharing left-over medications with family and friends (Aroian, 2003).

Russia has an alcohol problem. Russians drink hard liquor, mostly vodka and cognac at family gatherings and celebrations. Worthy of note, the typical Russian toast translates as “to your health” (Culture tips, 2000). Heavy alcohol consumption is a part of daily life for this popula- tion, partly owing to the sustained indifference to address the problem by Russian authorities. Russian statisticians estimate that over 30 percent of deaths in Russia are directly related to alcohol (Nemtsov, 2005; Nicholson, Bobak, Murphy, Rose, & Marmot, 2005).

Smoking is also prevalent; Russia is one of the few countries that currently do little or nothing to curb tobacco use. Nearly 63 percent of Russian men and 15 per- cent of Russian women smoke, and this number increases by about 2 percent per year. Although 60 percent of current smokers want to quit, no state-supported programs exist

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to help them do so. For this and other reasons, the male life expectancy in Russia is just above 58 years (Parfitt, 2006). Although Russian immigrants do not demonstrate the same level of smoking and drinking behaviors as their native counterparts, more recent Russian immigrants engage in these behaviors at higher rates than previous groups (Hasin et al., 2002).

High-risk sexual behaviors among Russia immigrant adolescent girls were investigated by Jeltova, Fish, and Revenson (2005). The results highlight the importance of maintaining emotional ties with the traditional Russian culture. They found that the more acculturated to the American culture the girl is, the greater the incidence of risky sexual behavior.

HEALTH-CARE PRACTICES

Russians define health as the absence of illness. Importantly, Russian immigrants generally adhere to health-care appointments, treatment regimens, and medication use (Aroian, 2003). Russians may, however, distrust physi- cians and choose to combine the prescribed treatments with homeopathic remedies. Mental illnesses are consid- ered a disgrace in Russia; so Russian immigrants may not provide answers to questions regarding any family or per- sonal history of mental illness (University of Michigan Health System, 2007).

When Russian-speaking immigrant women of all ages were asked about their U.S. health-care practices and uti- lization, the women asserted that they preferred female physicians but believed male doctors to be more skilled and competent (Ivanov & Buck, 2002). They wanted always to be able to see their own physicians and expressed frustration when that was not possible. These Russian women also expressed dissatisfaction with family physicians owing to their perceived lack of professional- ism. They were dissatisfied with the general appearance of health-care professionals and how difficult it is to distin- guish between the nurse and the janitor. Not surprisingly, they stated that language, in addition to cost, was a major barrier to health care and, therefore, chose to receive their health information from their mothers and grandmoth- ers. These Russian women valued massage and herbal remedies and would access medical care when these reme- dies were ineffective. However, access to care was primar- ily only for illness, not for preventive care such as Pap smears and mammograms. They want the physician to refer them for preventive services and to inform them about everything they need to know to stay well (Ivanov & Buck, 2002).

Russians often self-diagnose and therefore seek out and read Russian-language health articles related to their disorders. One important method of receiving health- care information is through the mass media and Internet. Through a website called RussianDoctor.com, users can access a list of Russian-speaking dentists and physicians by specialty and location (city/state). Rulist.com is a search engine that provides a kind of Russian yellow pages with information on health and wellness. Russian immigrants may also subscribe to the Russian health magazine. The publishers of this maga- zine profess a strong commitment to increase the med-

ical awareness of Russian speaking people in the United States.

Nutrition MEANING OF FOOD

For Russians, and most especially for Russian Jews, food and nutritional practices are considered essential ingredi- ents for health and healing (University of Washington Medical Center, 2005). Food also carries ritual and cere- mony. When entertaining, Russians often use food as a demonstration of their love and respect for their visitors. They often spend days purchasing and preparing food for their most-treasured guests.

Russian immigrants eat three meals a day, with their largest meal at noon. Russians enjoy snacks and tea, water, and fruit juices without ice. Russian Jews do not eat pork or shellfish (Hobbs, 2002). Russian immigrants have reported little interest in American food.

COMMON FOODS AND FOOD RITUALS

Nutritional issues are believed to be a major contributing factor toward the chronic diseases experienced by Russian immigrants. Heart disease, diabetes, and hypertension are related to nutritional habits such as high-salt, carbohy- drate, and fat intake (Keefe, 2006).

DIETARY PRACTICES FOR HEALTH PROMOTION

When Russians are ill, they love soup and broths, bland foods, chicken, potatoes, fruit and vegetables, and yogurt. Tea with honey and milk is considered medicinal (Hobbs, 2002).

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

Russian diets contain high levels of saturated fat (and hydrogenated vegetable fats), salt, and carbohydrate (Keefe, 2006). This contributes to the over 60 percent of Russian adults with high blood cholesterol as well as the high rates of obesity and hypertension (Marquez, 2005). Although fresh fruits and vegetables are not routinely consumed in Russia owing to limited availability and high cost, Russians enjoy eating them and Russian immi- grants enjoy them with their meals whenever possible.

Pregnancy and Childbearing Practices

PEOPLE OF RUSSIAN HERITAGE • 331

V I G N E T T E 1 9 . 2

Vera and Sasha Sarkisova want to have at least two children but Vera has had great difficulty sustaining the last two preg- nancies. Eight years ago in Moscow, Vera had an abortion, which resulted in a painful infection that took months to clear. Joyfully, Vera believes she is now, once again, 3 months’ pregnant. Upon the advice of an American coworker, she

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FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

Russians delay marriage and childbearing until age 20. Childbearing and child rearing are expectations, and infertility is perceived by Russians as a health problem, disappointment, and even punishment for some femi- nine wrongdoing (Aroian, 2003).

Contraception for Russian women is allowed without sanctions or taboos. Even so, many Russian immigrants are afraid of birth control pills and refuse to take them. One possible reason for this reluctance was the poor quality and the high dosage of oral contraceptives in Russia. To compound this problem, condoms in Russia were poorly made, and many jokes have evolved about the routine breakage of Russian-made condoms. Furthermore, Russian men believe that condoms hinder sexual pleasure and, therefore, refuse to wear them. Most Russian men also refuse vasectomies (Aroian, 2003). Consequently, abortion was and is one of the most com- mon forms of birth control in Russia. Russia has the world’s highest abortion rate, with the average woman having three or more abortions in her lifetime; self- induced abortions are not uncommon. In 1990, there were 1972 abortions per 1000 live births. In 2002, this number dropped to 1276 (World Health Organization [WHO], 2005). Thus, Russian immigrant women have high rates of infertility, and these infertility issues may lead to marital discord and divorce.

Russian women are responsible for contraception and often make contraception decisions without consulting their male partners. These decisions often relate to access and cost. Young Russian women are discouraged from strenuous exercise, including swimming, while menstru- ating (Aroian, 2003).

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Pregnant Russian women do not engage in heavy lifting and often commit to bed rest if it is prescribed. Russian women who are pregnant receive more respect. When born, boys are dressed in blue and girls in pink (Aroian, 2003). Breastfeeding is encouraged, and nursing women are told to drink tea with milk and eat nuts to improve their milk supply (Aroian, 2003).

Owing to religious beliefs, Russian Jews circumcise their male infants. Ethnic Russians do not circumcise their newborn boys.

Death Rituals DEATH RITUALS AND EXPECTATIONS

Flowers are used to beautify caskets and funeral services, and even Russian Jews have open caskets. Food and beverages are usually served during wakes and funerals. Friends and family come to pay their respects for 7 days postmortem, but the expected total period of official mourning is 1 full year, after which time, a surviving spouse may remarry. Close rel- atives of the deceased dress in black. Russians do not hes- itate to cry and sob at funerals (Aroian, 2003), but overt wailing is often confined to the home of the deceased.

Family will hold vigil day and night if their loved one is dying. All relatives and friends are expected to visit a dying patient and often sit with the person for hours. If a part of their religious practices, the placing of hands on the ill person’s forehead may be noted, as a kind of ritual blessing gesture. In addition, religious symbols may be placed at the ill person’s bedside, and at the time of death, a spiritual advisor should be present. Also at the time of death, all mirrors may be covered with black fabric and the dead person’s mouth and eyes closed (University of Washington Medical Center, 2005).

If the patient and family are Russian Orthodox, crema- tion is unlikely (University of Washington Medical Center, 2005). Spiritual leaders from the Russian Orthodox religion institute a special prayer vigil, called panikhida, over the deceased. This is a special time that includes chants, prayers, singing of hymns, and gospel readings (Yehieli, Lutz, & Grey, 2005).

Russian Jews bury the dead within 24 hours except during holidays, on Saturday, or if awaiting the arrival of additional friends and family (University of Washington Medical Center, 2005). For Russian immigrants, cremation is far less common than burial. However, Russian immi- grants may chose cremation so that the deceased’s ashes can be shipped back to “Mother” Russia (Yehieli et al., 2005).

RESPONSES TO DEATH AND GRIEF

Russian Orthodox followers believe that life and death are connected and that they will, if they live and worship appropriately, enjoy eternal life in heaven (Yehieli et al., 2005). Therefore, the death of a loved one is a family affair whereby large numbers of extended family members pay vigil to the terminally ill and deceased person. They con-

332 • CHAPTER 19

reluctantly visits the women’s health clinic and is seen by a nurse practitioner specializing in women’s care. Vera tells her about the unusual drainage she’s been having. Vera is exam- ined vaginally by the nurse practitioner, after which she receives two prescriptions, one for vitamins and the second for her “morning sickness.”

That night, Vera experiences yet another miscarriage. She blames the miscarriage on the examination performed by the nurse as well as on the medication she took for nausea. Vera feels confused and alone. Sasha wants children and has threatened to leave her if she is unable to fulfill his wishes. Vera and Sasha are not religious but believe in the strong spir- itual bonds of family; therefore, having children is essential to them both.

1. What would a culturally competent health-care provider do to help Vera during this time of crisis?

2. How might typical Russian beliefs regarding the role of the nurse affect Vera’s perceptions of the etiology of her miscarriage?

3. Why might Vera be susceptible to fertility problems? 4. Where might the nurse or social worker get assistance

for Vera?

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nect in prayer and ask the heavens to show mercy on the soul of their deceased loved one (Yehieli et al., 2005).

Perhaps as a mechanism of diplomacy, Russians are loathe to disclose to patients the critical nature of their ter- minal illness (Birch, 2006; MDEED, 2006; Norman, 1996) and tend to be cheery and happy in the presence of a dying person. Norman (1996) found that the rationale for this reluctance was due to the belief that the stress of such bad news would cause increased morbidity and even death. Moreover, the dying person would lose hope and succumb to the illness, the physicians could be making an incorrect diagnosis, and the family, responsible for the care of their members, needed to do everything that was possible to protect that person from psychological turmoil. Russians and some Russian Americans believe that talking about death is a bad omen. Therefore, it is important to carefully and diplomatically talk with the family first, prior to dis- closure of bad news to the patient (MDEED, 2006).

Related to their sense of community and family, Russians believe that a problem for one family member is a problem for the entire family. In addition, the physician needs to identify the lead family spokesperson and work with him or her. Family members generally do not openly grieve in front of a sick or dying loved one, but the dying person is allowed to express her or his own sadness and grief. However, taking morphine or other analgesia may be perceived as a last resort in a hopeless situation. Administration of potent narcotics is also perceived as patient abandonment (University of Washington Medical Center, 2005). Requests for Living Wills or Durable Powers of Attorney, as well as consents for withholding or withdrawing treatment, are usually declined by Russian patients and family members (University of Washington Medical Center, 2005).

Spirituality RELIGIOUS PRACTICES AND USE OF PRAYER

Preferred religious practices for Russian immigrants vary, depending upon the chosen spiritual beliefs. Some Russians, having lived within the antireligious confines of the former Soviet Union, will deny religious affiliations. Conversely, Russian Jews and those who are Russian Orthodox will practice accordingly. Prior to the over- throw of Czarist Russia, ethnic Russians were predomi- nantly Russian Orthodox. During the Soviet era, however, religious practices of all types were condemned and, in many cases, severely punished. With the resurgence of Russian nationalism, the Russian Orthodox Church has again taken a major role in the life and politics of Russian people. As evidence of this renewed emphasis, once crum- bling, decaying Russian Orthodox Churches are now being carefully restored, perhaps symbolic of the restora- tion of the Russian Orthodox faith and practices.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

Ethnic Russians may not believe in an afterlife, but self- professed atheism has had a dramatic decline since 1991.

Russian immigrants gain spiritual strength, stability, and meaning through their associations with family and friends.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Seriously ill patients and family members who are reli- gious (e.g., Russian Orthodox, Russian Jew) consider prayer as an essential and powerful tool toward health and healing (University of Washington Medical Center, 2005). Members of the Russian Orthodox faith believe in the heavenly position of saints as well as religious miracles.

Health-Care Practices

PEOPLE OF RUSSIAN HERITAGE • 333

V I G N E T T E 19.3

Sasha Sarkisova smokes two packages of cigarettes a day, loves high-fat food, and drinks “occasionally.” He has been diagnosed with hypertension and is going to a traditional healer for “Russian” medicine and massage treatments. His allopathic physician has prescribed three medications for his cholesterol and hypertension.

1. How should Alexander’s medical case manager approach the long-term nature of his hypertension?

2. How might the health-care professional utilize this couple’s sense of family to improve health outcomes?

3. What interventions might improve medication adher- ence and health-care utilization for Alexander?

4. What specific food choices would you expect from Sasha? How might these food choices be altered in a culturally congruent manner?

HEALTH-SEEKING BELIEFS AND BEHAVIORS

Among Russian immigrants, health is defined as the absence of disease. They feel alienated from the American health- care system and, therefore, may fail to seek the health care needed. Older Russian immigrants do not adhere well to preventive health practices (Benisovich & King, 2003).

Homeopathic and traditional herbal remedies, how- ever, are used and valued by Russian immigrants. Russians historically have known and implemented homeopathic remedies for centuries, and often, as in Russia, these remedies are used simultaneously with those of Western medical science. Russians, and especially Russian older people, may use herbal teas, tinctures, (Yehieli et al., 2005), mud baths, massage (with and without oils), saunas, and other alternative medicines and healing prac- tices. Russians want to know the cause of their health problems and will expect their health-care providers to holistically diagnose the etiology of any health concerns. Many believe that Western medicine places too much emphasis on medications and laboratory results and not enough on clinical diagnosis and holistic care.

Many Russian immigrants believe that ill health may be the direct result of family and economic stress.

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Although they avoid being chilled and seek warmth when ill, they firmly believe in the value of fresh air, sunlight, and good nutritious food.

Although Russian immigrants believe in the value of good food, some have a very different view of obesity when compared with the dominant U.S. culture. Stevens et al. (1997) compared attitudes and behaviors related to body size and other parameters among black, white, and Russian adolescents. Russian teen girls were found to be less likely than black and white adolescent girls to iden- tify obese and overweight status as a concern.

RESPONSIBILITY FOR HEALTH CARE

Regardless of age, most Russians take an active role in their health and health care, and using alternative and homeopathic remedies; they commit to self-care. Russian immigrants may even bring health kits with them to the clinics and hospitals. Health kits contain a variety of remedies for the treatment of indigestion, headache, and infection (Yehieli et al., 2005). These medicines are avail- able for direct purchase at Russian pharmacies.

During focused interviews with Russian immigrants, Ivanov and Buck (2002) learned that these women believed the physician to be responsible for any and all preventive information and referrals. The expectation is that they would be told exactly what to do and how to do it to get or stay well.

FOLK AND TRADITIONAL PRACTICES

Russian immigrants may implement the treatment called “cupping,” a technique whereby the inside of a glass “cup,” a bonzuk, is heated and then placed on a person’s back, shoulder, or chest in order to remove sickness and evil. Cupping practices are especially popular when patients have respiratory problems such as bronchitis and asthma. In Russia, physicians and nurses go to patients’ homes to perform cupping. In addition to cup- ping, home and folklore illness remedies include rubbing of oils and ointments, enemas, saunas and whirlpools, mineral water (for soaking as well as drinking), herbal teas, hot and cold soups, liquors, and mud plasters (Bistrevsky, 2005).

BARRIERS TO HEALTH CARE

Awareness and Attitudes

Respect and trust focused on health-care professionals must be earned. Russians do not appreciate being spoken to with disrespect, and they expect their health-care providers to look and act professional. Russian immi- grants also expect health-care professionals to respect the self-treatments they have used prior to seeking medical care. Russians are also very involved with the care of their family members, most particularly children, and will not appreciate the patient-only individual approach of some providers. Owing to social and political sanctions against psychiatric illness in Russia, Russian immigrants may also be reluctant to disclose mental health issues and family

histories of mental disorders. Therefore, providers need to approach the subject carefully and with full assurances of confidentiality.

In addition, Russians are unaccustomed to the concept of “gatekeeper.” They want direct access to the health- care specialist of their choice, and when this is not possi- ble, they believe the additional step to be expensive, wasteful, and unhealthy. Recent Russian immigrants may also be unfamiliar with concepts such as defensive health care and medical malpractice.

Affordability

In the former Soviet Union, health care was free. Therefore, concepts of private pay, co-pay, and insurance premiums are difficult to understand. Russian immigrants need help and support in their efforts to comprehend U.S. health-care systems, including Medicaid and Medicare programs. During Ivanov and Buck’s (2002) focus inter- views with Russian immigrants, they learned that although most of the interviewees had some form of health insurance, they still believed that health-care costs were a major health-care barrier and, therefore, preferred to use home remedies and Russian-made medications. Russian participants mentioned that after paying for food and other household essentials, little or no money was left for medicines and physician services.

About 85 percent of Russian immigrants carry some kind of health insurance coverage including employer- based private insurance as well as government plans such as Medicaid, Medicare, and Tri-Care (military) (Ethnic population, 2003). Even so, health care is perceived as far too expensive. An additional confusion may be that Russians are egalitarian and believe in an equal distribu- tion of health-care benefits (Culture tips, 2000).

Language Proficiency

Although English-competent family members agree to step in as interpreters, the use of relatives for interpretive services is ill advised. Russian immigrants strongly prefer Russian-speaking health-care professionals and will actively look for them. Unfortunately, many Russian- trained physicians and nurses are not appropriately cre- dentialed in the United States, yet they choose to diag- nose and treat without licensure, using medications and treatments sent from Russia.

Related to language is also lack of relevant health-care information, which has also been identified as a barrier (Shpilko, 2006). Not surprisingly, Russians with only lim- ited English proficiency report feeling isolated and alone and experience greater morbidity and mortality.

Accessibility

When Benisovich and King (2003) asked older Russian immigrants about health-care barriers, they stated that health care needed to be convenient and transportation to and from their appointments needed to be provided for them. Transportation is also perceived as being too expensive.

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CULTURAL RESPONSES TO HEALTH AND ILLNESS

In a study of Russian children and the prevalence of men- tal health disorders as measured with reliable and valid assessment tools, Goodman, Slobodskaya, and Knyazev (2005) found that psychiatric disorders were nearly 70 percent higher in this population compared with those in Great Britain. The two most common categories were emotional and behavioral disorders. The most predictive factors in this study were the child’s school performance, the mother’s mental health, a close relative with alcohol addiction, and the witnessing of domestic violence. Obviously, Russian children are at risk.

Long-term case management may be a difficult con- cept for Russian immigrants. Russians are unaccustomed to the role of primary-care providers in the United States and may have an unrealistic, cure-oriented expectation of U.S. health-care professionals.

When one physician is unable to meet the Russian immigrant’s expectations, it is likely the patient will seek the services of others. Prescribed treatments may not be dis- closed to other care providers, and therefore, concerns over polypharmacy may surface (Aroian, 2003). Furthermore, Russians are accustomed to health-care professionals plac- ing a greater emphasis on treatment than prevention. Being familiar with long in-patient hospitalizations, Russian immigrants are quite dismayed by the very short hospital stays in the United States.

BLOOD TRANSFUSION AND ORGAN DONATION

Requests for organ donations are usually declined (University of Washington Medical Center, 2005). Most Russians believe that the human body is sacred and are thus reluctant to allow organ donations and autopsies (Hobbs, 2002). Owing to contaminated blood supplies in Russia and the former Soviet Union, health-care profes- sionals may have a difficult time convincing Russian immigrants to consent to giving or receiving human blood products.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL CARE

In Russia, the majority of physicians are female. However, male physicians are more likely to hold positions of authority. Therefore, Russian women generally do not hold preference regarding the physician’s gender but believe male physicians to be more skilled and compe- tent. For women, this lack of gender bias seems to also hold true for other health-care professionals (Ivanov & Buck, 2002).

STATUS OF HEALTH-CARE PROVIDERS

Of all health-care professionals, physicians are considered to be the most knowledgeable and “in charge” of any health teaching or service. In Russia, for every 1000 people, there are 4.25 physicians, 0.32 dentists, and 8 nurses. When comparing these numbers with the United States (2.56,

1.63, and 9.37, respectively) (WHO, 2006), Russian immi- grants may perceive U.S. health-care professionals as being far less accessible. Russian traditional healers are afforded respect by Russian immigrants using their services.

Importantly, the Russian American Medical Association (RAMA) and the Russian American Dental Association have been established. RAMA was founded in 2002 and is based in Willoughby, Ohio. Dr. Nikolay Vasilyev is editor-in-chief of their peer-reviewed journal. They also have a website with information relevant to all Russian-speaking health-care professionals. For example, their website contains a link with an important descrip- tion of all levels of nursing in the United States. The site also contains links for members, programs, RAMA Journal, job search, practice, and students/residents (RAMA, 2007).

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337

People of Polish Heritage

Chapter 20

HENRY M. PLAWECKI, LAWRENCE H. PLAWECKI, JUDITH A. PLAWECKI, and MARTIN H. PLAWECKI

Overview, Inhabited Localities, and Topography

OVERVIEW

Over 9 million people in the United States and 800,000 people in Canada identify their ancestry as Polish (Statistics Canada, 2001; U.S. Bureau of the Census, 2004). Poland, officially the Republic of Poland, occupies 312,683 square kilometers, or roughly 120,727 square miles. Poland is approximately the size of New Mexico (121,599 square miles) (New Mexico Tourism Department, 2006). Poland has its capital in Warsaw. Located in Central Europe, Poland, with a population of about 38,111,000 in 2003, was the eighth largest country in Europe, accounting for 5.3 percent of the entire European population (Republic of Poland, 2003). In 2001, females were 51.4 percent of Poland’s total population and males were 48.6 percent. Consequently, there were 106 women for every 100 men in Poland. There were more females than males in both its urban and its rural populations; however, the disporportion of females to males was larger in the towns. Women accounted for over 52 percent of the urban population, and nearly 48 percent were men. Thus, there were about 110 women for every 100 men in the urban areas. In the rural areas, 50.1 percent were female and 49.9 percent male, reflecting 100.4 women for every 100 men (Republic of Poland, 2002f). The life expectancy in Poland has been increasing. By 2025, the life expectancy is projected to continue to increase for men from 69 to 74 years and for women from 78 to 81 years. The average Pole is nearly 35 years of age—37 years for women and 33 years for men. Over 56 percent of

Poles are below the age of 40, 27 percent are between 40 and 59 years of age, nearly 17 percent are above 60, and 2 percent are 80 or above (Republic of Poland, 2002a).

Poland shares its western border with Germany. To the south, Poland is bordered by Slovakia and the Czech Republic. Ukraine, Belarus, Lithuania, and Russia all share eastern and northeastern borders with Poland. The Baltic Sea borders the majority of the northernmost part of the country. Poland is a relatively low-lying country, with nearly 92 percent of its land mass situated at an altitude of less than 300 meters below sea level (Republic of Poland, 2002h). Most of the country is a plain without any natural boundaries except the Carpathian Mountains in the south and the Oder and Neisse rivers in the west (Republic of Poland, 2002b).

The year A.D. 966 marks Poland’s origin as an indepen- dent, Christian, centralized state. Over the centuries, Poland survived a difficult and tumultous history of fre- quent invasions, division, and rule by others. Through a series of agreements made between 1772 and 1795, Russia, Prussia, and Austria partitioned Poland among themselves. From 1795 to 1918, Poland ceased to exist as an independent country and its land was divided among Prussia, Russia, and Austria (Library of Congress, 1992a; Republic of Poland, 2002c). The nonexistence of Poland and its re-emergence after 120 years demonstrated the Polish people’s strong ties to its culture, language, and religion. Throughout this period, the people’s tenacity, determination, and dedication to the Catholic Church played a significant role in enabling the Poles to maintain their language, culture, and heritage. After World War I (WW I), between 1920 and early 1939, Poland once again existed as a separate, self-governing country (Library of

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Congress, 1992b). In 1939, Hitler’s Nazi forces invaded Poland. Displaying fierce patriotism, courage, and deter- mination 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 (Library of Congress, 1992c). Between the 1939 Nazi invasion and the end of World War II (WW II) in 1945, nearly six mil- lion Poles, over 15 percent of Poland’s total population, perished. This number included many Polish Jews who were exterminated by the Nazis in the Holocaust, prison- ers killed in concentration or forced labor camps, soldiers, and civilians (Library of Congress, 1992d). After WW II, Stalin, Churchill, and Roosevelt determined Poland’s future borders at the Peace Conferences in Yalta and Potsdam. The decisions made at these conferences resulted in Poland losing 10,000 square miles to the east and 50,000 square miles to the west. In total, Poland lost some 20 percent of its pre–WW II territory (Republic of Poland, 2002e). However, it did remain a separate, identi- fiable country, although it became a satellite of the United Soviet Socialist Republic (USSR).

In 1947, elections officially brought the Communist Party to power. The Stalinist model was implemented until 1956. 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. Walesa headed Solidarnosc (Solidarity), the first free trade union in Eastern Europe. Solidarnosc was created because of the Communists’ violent repression of the workmen of Radom in 1976 and a second strike at the Gdansk shipyards in 1980, the result of the government’s raising food prices (Centreurope.org, 2006).

In addition to the events cited previously, the 1978 election of the Polish Cardinal, Karol Wojtyla, as Pope John Paul II, led to unprecedented social and political changes in Poland. The 1980 emergence of Solidarity and the election of the Polish Pope rekindled a religious rebirth in the Poles, an increased sense of self, social iden- tity, and the realization of their collective strength. Solidarity became a major social movement and phenom- enon unheard of within the Soviet bloc’s political system. Despite negotiations, confrontations, and ultimately, repressive military operations by the ruling Polish Communist Party, the Solidarity movement survived as its influential unofficial opposition. Ultimately, the Polish Communist Party recognized that the people’s massive opposition reduced their ability to govern. In 1988, for- mal negotiations between the Polish Communist Party leaders and the unofficial opposition, called the Round Table talks, resulted in partially free Parlimentary elec- tions. Solidarity won a landslide victory in the June 1989 elections. In July 1989, the newly elected Parliament changed the country’s name and consititution, establish- ing the Third Republic of Poland and a democratic system of government (Republic of Poland, Ministry of Foreign Affairs, 2002g; von Geldern & Siegelbaum, 2003).

Polish immigrants and their descendants who immi- grated to America for many generations have maintained their ethnic heritage by promoting their culture, attend- ing Catholic churches, attending parades and festivals, maintaining ethnic food traditions, speaking the Polish

language, and promoting interest in their home country through media events as well as economic and political channels. For newer immigrant Poles, maintaining ethnic heritage meant learning English and obtaining a good job (Erdmans, 1998). Newer immigrants are less concerned with raising consciousness over Polish American issues than they are with financially helping families who remained in Poland and raising concerns over the politi- cal and economic climate in their homeland.

HERITAGE AND RESIDENCE

The first contribution of the Poles to the development of American democracy occurred during the American Revolutionary War. Benjamin Franklin, an American statesman, went to Europe and recruited experienced Polish leaders and soldiers. Two prominent Poles recruited to assist the colonists in their fight for indepen- dence were Count Kazimierz (Casimir) Pulaski and Tadeusz Kosciusko. General Pulaski, a valiant cavalryman, led soldiers by courage and example. His many heroic actions on behalf of the colonists lead to naming him the Father of the American Cavalry (Polish American Center, 1997). In 1929, recognizing his contributions to the American Revolution, Congress designated October 11th as Pulaski Day and authorized the U.S. Postal Service to issue a commemorative stamp in his honor. General Kosciusko served the American Revolution as both an engineer and a field commander. Kosciusko developed the defenses used in the major battles at Saratoga and West Point, New York, and then organized the blockade of Charleston, South Carolina, which led to the end of the South’s resistance. After the defeat of the British in 1784, Kosciusko was promoted to the rank of Brigadier General, given American citizenship, and presented the Cincinnati Order Medal by George Washington (Wilde, 2001). Both Pulaski and Kosciusko contributed significantly to the colonists’ victory and were recognized as heroes of the new republic. Many American towns, counties, parks, and other memorials bear the names of these Polish heroes.

The Poles’ dedication to the welfare of the United States was summarized by the motto of the first Polish American political club, the Kosciuszko Club, established in 1871, which states “A good Pole is a good American cit- izen” (Jarczak, N.D.). Immigrants, regardless of their country of origin, leave their homeland for a variety of reasons that include avoiding ethnic, religious, and polit- ical persecution; seeking a better lifestyle; and/or provid- ing a means of support for family and relatives who remained in the homeland. Once in the United States, they may be incapable, unprepared, or unwilling to dras- tically change their homeland’s culturally influenced pat- terns of behavior. Like any other group that perceives themselves as unaccepted, displaced, and different, the Polish immigrants established a geographically and socially segregated area called a Polonia, the medieval name for Poland. Polonia allowed members of the immi- grant group to experience social comfort, speak their native language, and openly practice the customs of their homeland.

The initial migration of about 2000 Polish immigrants occurred between 1800 and 1860. This group consisted of

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intellectuals and nobles who were motivated by political insurrections. The first substantive Polish settlement in America was founded in 1854 by Father Leopold Moczygemba and 100 Polish immigrant families in Panna Maria, Texas (Panna Maria, 2006). Even though most Poles preferred living in agrarian communities, they grav- itated to cities where work for laborers was plentiful.

Between the early 1800s and the beginning of WW II, over 5 million Polish immigrants came to the United States. Many of these immigrants perceived America only as a temporary home. This first major immigrant group was called za chlebem or “for-bread” immigrants. These immigrants came to earn money and then return to Poland. Polish immigration to America continues today. A new generation of immigrants recently freed from for- eign domination are now coming to the United States seeking better lives (Library of Congress, 2004).

The predominant residence for Polish immigrants in the United States is north of Ohio and east of the Mississippi River. The states of New York, Illinois, Michigan, Pennsylvania, New Jersey, and Wisconsin have the largest numbers of self-reported Poles and Polish Americans (U.S. Bureau of the Census, 2004). However, Polish communities with retirees and new immigrants are growing in Florida, Texas, and California.

At the peak of Polish migration, Chicago was consid- ered the most well-developed Polish community in the United States (Pacyga, 2004). The first Polish immigrants to Chicago were primarily nobles who fled Poland after the Polish-Russian war of 1830 to 1831. They came with plans of establishing a “New Poland” in Illinois (Pacyga, 2004). Chicago’s Polish community grew rapidly after 1850. By the beginning of the Civil War, approximately 500 Poles had established a small enclave on Chicago’s northwest side. Peter Kiolbassa, who served as a captain in the Sixth Colored Cavalry during the Civil War, emerged as a local leader. Kiolbassa organized the first Polish Society of St. Stanislaus Kostka in 1864. This organization prepared the community for the development of the city’s first Polish Roman Catholic parish. Located along the north branch of the Chicago River, the residents of Polonia initally attended a German parish church. Facing hostility from some of the Germans, who discouraged their priest from ministering to the Polish religious needs, the Polish community established its own Roman Catholic parish, St. Stanislaus Kostka. The parish was cen- tral to the creation of Polonia, because the establishment of ethnic Catholic parishes provided the community with a stable institutional base and served as a status symbol for the new immigrant colony. St. Stanislaus Kostka parish became the first of approximately 60 Polish parishes in the Chicago archdiocese.

The traditional Polish community in Chicago, a highly organized ethnic settlement that developed after the Civil War, matured and reached almost-complete institutional self-sufficiency before WW I. This community published major Polish-language newspapers, established the foun- dation for a parochial school system, and provided a layer of ethnically based social service insititutions, such as St. Joseph’s Home for the Aged, St. Hedwig’s Orphanage, the Polish Welfare Association, and St. Adalbert Cemetery, as well as a well-developed business enterprise (Pacyga,

2004). In addition, a thriving Polish and Eastern European Jewish business community developed in these neighborhoods.

The Polish community’s development allowed them to actively participate in the labor movement, which along with their involvement with fraternal groups, led to the development of neighborhood organizations. By 1980, Hispanics and African Americans had largely replaced Poles in the inner-city core neighborhoods. Polish Chicagoans left the old neighborhoods, moving to the suburbs. Chicago’s Polonia played a crucial role in the political, religious, educational, business, institutional, and cultural life of Chicago. Pulaski Street, Solidarity Drive, the Copernicus Center, and a number of other landmarks bear Polish names symbolizing Chicago’s Polish heritage (Pacyga, 2004).

More than one million Poles live in the Chicago met- ropolitean area, northwestern Indiana, and suburban Illinois. This number represents the largest Polish com- munity outside of the home country; only Warsaw has a larger Polish community (Bolzen, 2006). The city of Chicago and its suburbs is home to more Polish immi- grants and their extended families than any other city outside of Poland (USA Weekend.com, 2005).

Polonia was also the name given to Polish communities found in northeastern and midwestern cities after 1945 (Best, 2004). Members of these communities kept Polish nationalism alive by speaking their native language, pre- serving customs, and attending the local Catholic Church run by Polish clergy and the Felician Sisters. Because Poland was partitioned until 1919, Poles coming to America during the 1800s and early 1900s were unable to report Poland as their emigrating country, but they tena- ciously worked to ensure the survival of the Polish cul- ture. Over time, the 120-year partition of Poland and its absence from the world map significantly reduced the number of immigrants who could identify Poland as their emigrating country. Therefore, the partition ultimately led to an undercount of the actual number of Americans with Polish ancestry.

Polonias were very well organized. Establishing resi- dence in a Polonia isolated the immigrants and allowed them to avoid dealing with unfamiliar written and spo- ken languages and different cultural perspectives. For many older Poles, the neighborhood is their community. Polonias, especially in urban ethnic communities, pro- vide a sense of belonging, reduce alienation, and enhance the people’s ability to solve problems and maintain the motivation to address modern-day frustrations. “The assumption of voluntary Americanization continues to exist in spite of the behaviors of past generations who resisted the assimilation process and have, in fact, reestab- lished their pre-immigration cultures in multiple volun- tarily segregated ethnic enclaves/communities” (Plawecki, 2000, p. 7). Many Eastern European immigrants, such as the Poles, have the same demographic characteristics as the majority of Americans. As a consequence, their unique cultural perspectives have been ignored by both society and those responsible for providing health care. Immigrants from Eastern European cultures, including those from Poland, need to have their cultural beliefs, attitudes, and values considered if health-care providers

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are to provide sensitive, appropriate, and acceptable health care.

Culture has generally been defined as a socially trans- mitted behavior pattern that is based upon the accep- tance of the beliefs, attitudes, language, and practices that are typical of a community of individuals at a given time. The geographic, economic, and social segregation of any ethnic or racial group reinforces the culturally influenced behavior patterns. Consequently, the segregated group develops communication styles, cultural beliefs, and interactive behaviors that are socially accepted within their community but are different than those expected by the general populace (Plawecki, 1992, p. 4).

The Polish immigrants established religious and volun- tary organizations dedicated to the support of schools, organized trade, established banks, and initiated political and social activities designed to mirror those in Poland. Many of these Polish organizations still exist today and have used their influence to name monuments, statues, historical sites, major roadways, and bridges dedicated to Polish Americans and Polish nationals. These symbols of Poland’s contribution to America can be found in many towns and cities settled by Polish immigrants.

Poles are a heterogeneous group. As such, they were slow to assimilate into multicultural America. Much of the variation within this ethnic group is due to the pri- mary and secondary characteristics of culture (see Chapter 1).

Polish Americans were well represented in the WW II war effort of the United States. Significant numbers of Polish Americans, both native and immigrant, joined the U.S. military. Thousands of Polish Americans were killed defending America. Even after displaying that sense of duty, honor, and patriotism, Polish Americans often expe- rienced discrimination during and after the war. Poles were passed over for jobs because they had difficulties speaking English and their names were difficult to pro- nounce or spell. As a reaction to this discrimination, name changes became common for upwardly mobile Polish Americans. The shortening and changing of names were intended to decrease discrimination and promote greater acceptability in the job market as well as increase social acceptance. 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. However, the attitudes toward the Poles have improved since the Solidarity movement in the 1970s and 1980s, the election and activities of Pope John Paul II (the first Polish pope and the first non-Italian pope since 1523), Poland’s 1999 admission to the North Atlantic Treaty Organization (NATO), its 2004 entry into the European Union, and its leadership and involvement with the United States in Iraq as well as with Euro- Atlantic countries in antiterrorist activities (Republic of Poland, 2004).

V I G N E T T E 2 0 . 1

Cylka and Marcin Majda, both 90-year-old first-generation Polish Americans, painstakingly decorate their home with symbols of Catholicism, patriotic statues, an American flag,

and related memoriabilia on the 4th of July and September 11th. As the September 11th anniversary approached, Mrs. Majda asked her grandson, Larry, to accompany them to the memorial services at St. Adalbert’s parish. Puzzled by his grandparents’ activities related to September 11th, Larry asked them about their reasons for observing this anniversary. Mrs. Majda responded that her only brother, Anthony, died for this country when he was killed in World War II. She stated that when she was a little girl living in Chicago’s Polonia, her parents taught her that she was “an American first, a Pole sec- ond, and a Catholic third.”

Upon arrival at the Church, the choir was singing “God Bless America.” The priest ordered the choir to stop singing “God Bless America.” Although nothing was said at the time, Mr. and Mrs. Majda were furious.

1. Why did Mr. and Mrs. Majda become furious? 2. What cultural values are Mr. and Mrs. Majda demon-

strating? 3. Why would the priest act in such a manner? 4. What priorities will determine the actions taken by the

Majdas?

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Polish immigration to the United States occurred in three major waves. The first wave of immigrants, arriving in the early 1800s through 1914, came to America primarily for economic, political, and religious reasons. Many immi- grants were illiterate, peasants, or unskilled laborers (Grocholska, 1999). They took low-paying jobs and lived in crowded dwellings just to make a meager living.

The second major wave of immigration occurred after WW II. During the war, Poland lost over 6 million of its 35 million people (Brogan, 1990). Proportionally, Poland lost more people than any other nation during WW II. The country’s infrastructure was devastated, resulting in unbearable living conditions in post–WW II Poland. The nearly complete destruction of Poland prompted the post–WW II wave of Polish immigrants to come to America. This group primarily included political prison- ers, dissidents, and intellectuals from refugee camps all over Europe. These immigrants, who both were educated and had a basic knowledge of English, assimilated more eas- ily into American culture than those from the first wave. They consciously separated from Polonia and aligned themselves with other middle-class and professional groups in America. The upwardly mobile and middle-class aspira- tions of this group differed from the working-class orien- tation of the first- and second-generation descendants of the first wave (Grocholska, 1999).

The current third wave of immigrants, often called the Solidarity immigrants, began arriving in 1978 (Grocholska, 1999). These Solidarity immigrants reflect the ideologies of the first two waves—that is, they want to work and to speak freely about political and intellectual issues. Two types of third-wave immigrants came to America. The first came to work without any initial interest in permanently relocating. They entered this country on a visitor’s visa and left their families in Poland. These immigrants

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frequently lived in low-income housing, shared rooms with other immigrants, and worked hard to send money to their families in Poland. Networking with other Poles was their primary source of job contacts. They quickly took any job available, particularly as laborers, domestics, and unskilled farm workers. Because many of these immi- grants were sending money to their families in Poland, they often overstayed their visitor visas. In 2006, illegal immigration became a serious political issue in the United States, attributed primarily to the vast number of illegal immigrants from Mexico. In addition to those indi- viduals, it has been estimated that Polish immigrants account for a large segment (once estimated at the ninth largest) of illegal immigrants in the United States.

Immigrants save money on food by eating nutrition- ally inadequate diets and seek care only when a health problem becomes serious. Because many of these immi- grants have been abused and taken advantage of by unscrupulous Poles and others, they distrust strangers, bureaucrats, and even health-care providers whom they fear may report them and, ultimately, cause their depor- tation. When Polish immigrants are deported, they must wait at least 7 years before they can apply for another visa to return to America.

The second type of third-wave Polish immigrants chose to come to America for political and economic rea- sons. This group typically consists of well-educated pro- fessionals and small-business owners. They consciously decided to leave Poland forever and bring their families with them. This group epitomizes the Polish characteris- tics of hard work, determination, and frugality. Although many in this group are underemployed, they actively use English and integrate into their new country, recognizing that this may be a necessary first step to assimilation.

Many second- and third-wave immigrants avoid Polish communities because they believe that American ethnic Polonias are different from those in Poland. The concerns and issues of political representation and discrimination of established immigrants living in America are irrelevant to this wave of immigrant Poles. In addition, many older Polonias are located in diverse, changing inner-city neigh- borhoods, and the upwardly mobile Polish Americans, like other successful groups, have begun to leave the cities for the suburbs.

EDUCATIONAL STATUS AND OCCUPATIONS

Educational priorities and their desire to assimilate into American culture vary widely among Polish immigrants. The educational status, socioeconomic levels, and cul- tural philosophy often depend upon the time frame when the family emigrated from Poland.

In 1999, Poland initiated a reform of the educational system designed to raise educational levels and adapt to current labor market requirements. Since 2002, at least 90 percent of the students have completed their upper sec- ondary education. Only about 46 percent of those aged 25 to 64 have attained at least upper secondary education (Organization for Economic Cooperation and Development [OECD], 2005). In 2003, 99.8 percent of the total popula- tion aged 15 and over was able to read and write (CIA, 2006).

Until Poland’s decision to reform education in 1999, most Poles generally had limited education. In the mid- 1990s, nearly 34 percent of the Polish population had completed only primary education, whereas almost 7 per- cent had either incomplete or no primary education. In addition, slightly over 50 percent of the Poles completed secondary education, whereas fewer than 10 percent attained post-secondary or higher education (Republic of Poland, 2002d). Since 2002, following the educational reform, at least 90 percent of Poland’s younger generation has completed upper secondary education.

Until the 1950s and 1960s, many Polish families were slow to recognize the value of education for their chil- dren. Before WW II, most Polish children went to Catholic schools, where they learned about their culture, its language, and Catholicism. After WW II, parents felt an acute responsibility to have their children learn English. Subsequently, the Polish language was elimi- nated from the curriculum of many schools, and its use was restricted to the home.

For first-wave immigrants, work was more important than education. The value of hard work and material goods was easily understood. Illiterate first-wave Poles ini- tially had difficulty with unionized labor; however, once they understood what was at stake, they became staunch union supporters. A family’s “union” loyalty influenced many children to follow in their fathers’ footsteps by working in similar jobs. They worked in meat-packing houses in Chicago, steel mills and oil refineries in north- western Indiana, assembly lines in Detroit, and coal mines in Pennsylvania. Because young Poles followed in their parents’ occupational footsteps, upward mobility was slower for Poles than for some other ethnic minori- ties (Lopata, 1994).

The second wave of Polish immigrants placed a high value on education and culture. Educated, cultured Poles were expected to read widely and speak several languages. Cultured Poles have great pride and respect for Poland’s most famous people, such as composer Frederic Chopin, two-time Nobel laureate scientist Marie Curie, novelist Joseph Conrad, astronomer Nicolaus Copernicus, and Karol Wojtyla, better known as Pope John Paul II. Poles are known for epic works in prose and poetry. Major themes in Polish literature are nationality, freedom, exile, and oppression.

In the 1950s, the Polish communities in America had a renewed interest in scholarly and cultural endeavors. The Polish Institute of Arts and Sciences began publishing The Polish Review, a scholarly journal, devoted to the works of Polish scholars. The Kosciusko Foundation encourages cultural exchanges between Poland and America and pro- vides scholarships to Polish American students. Once the Polish community recognized the value of education for their children, Poles became one of the highest repre- sented ethnic groups in institutions of higher learning. “The proportion of young people who finished college was more than double that of older Polish Americans, and the proportion of young people who attended college was at least triple” (Lopata, 1994, p. 149).

After WW II, many Polish Catholics were blue-collar workers who perceived hard work as honorable. Many feared that education and its resultant mobility were a

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threat to their family, religious, and community life. For women, education was seen as even less necessary because of the value placed upon their staying at home and raising their children. Television helped change the character of ethnic communities forever as it brought the outside world into both the community and the home. The descendants of immigrants who did go to college val- ued obedience and self-control, respected authority, and exhibited determination (Bukowczyk, 1987). Young Poles tend to study and work, become preoccupied with their careers, run their own businesses, and appear to increas- ingly postpone marriage and starting families (Republic of Poland, 2002a).

Communication DOMINANT LANGUAGE AND DIALECTS

The Polish language was influenced by the countries sur- rounding Poland and by the Latin of 11th- and 12th-cen- tury kings. Depending on the regional and cultural back- ground of the speaker, Polish may sound German, Russian, or French. The Polish language has a lyrical qual- ity that is pleasant to the ear, even if one has difficulty understanding the words. Poles are an animated group, and facial expressions generally convey the tone of the conversation.

The dominant language of people living in Poland is Polish, although there are some regional dialects and dif- ferences. Generally, most Polish-speaking people can communicate with one another. Recently, a resurgence of interest in learning to speak the Polish language has occurred among Polish Americans. Both adults and chil- dren are learning Polish in church-affiliated language schools, cultural centers, and colleges. Polish radio sta- tions help keep an ongoing interest in the language, music, and culture.

CULTURAL COMMUNICATION PATTERNS

Poles use touch as a form of personal expression of caring. 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 con- sidered rude. Most Poles feel comfortable with close per- sonal space, but distances increase when interacting with strangers.

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, kiss- ing 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.

To Poles, love is expressed through covert actions and displayed easily in the form of tenderness to children. However, loving phrases are uncommon among adult Polish Americans. Poles praise each others’ deeds and good work, but they may be reluctant to acknowledge how they feel about one another. These behavioral varia-

tions may have persevered through generations of assim- ilated Poles.

Acknowledging the hostess is important when Poles visit each other’s homes; bringing flowers or candy is always in good taste. Normally, guests are discouraged from assisting the hostess in the kitchen or with cleanup after meals. After the event, thank-you letters and greet- ing cards should be sent to demonstrate an appreciation for the host’s hospitality.

Many Polish Americans 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?” Although the first expression might sound awkward, the latter expression may be considered impo- lite and too informal, especially if the person being asked is older.

A health-care provider is Pani Doktor, literally trans- lated as “Lady Doctor” instead of “Doctor.” 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.

When interacting with others, Poles consider age, gen- der, and title. For example, when a group is walking through a door, an unspoken hierarchy requires the per- son of lower standing to hold the door for a woman or those of a higher title. To many Americans, this behavior may seem excessive, but for Poles, it shows respect and courtesy. Polish Americans also 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 ordi- nary.

Most Poles enjoy a robust conversation and have a keen sense of humor. Polish humor sometimes has an openness and bawdiness that may be unnerving to those unaccustomed to it. Cultural nuances may make it diffi- cult to understand the underlying meaning of some transactions or exchanges. Because Poles in Poland have been censored for centuries, they have raised satire and political savvy to an art form.

Poles, as a group, tend to share thoughts and ideas freely, particularly as part of their hospitality. A guest in a Polish home is warmly welcomed and may be over- whelmed by the outpouring of generosity. Americans talk of sports while Poles speak of their personal life, their jobs, families, spouse, aspirations, and misfortunes.

TEMPORAL RELATIONSHIPS

Punctuality is important to Polish Americans. To be late is a sign of bad manners. Depending upon the status of the person for whom they are waiting, Poles may be intoler- ant of lateness. Even in social situations, people are expected to arrive on time and stay late.

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. Polish parents very much want their children to have a better life than the one they have experienced.

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FORMAT FOR NAMES

Many Polish peasants did not have surnames until the 1600s. The use of surnames appeared in the first half of the 18th century. After 1850, the practice of creating sur- names had ended.

Traditional Polish names are often a description of a person (e.g., John Wysocki, meaning “John the tailor”), a profession (e.g., the surname Recznik, meaning “butcher”), a place (e.g., Sokolowski, meaning “one came from a town named Sokoly or Sokolka”), or even a thing. Many factors caused this rather logical process to become somewhat confusing. Historical, linguistic, and political factors also directly affected the structure of Polish sur- names. First of all, the partition of Poland for almost 120 years made it impossible for any emigrant at that time to claim Poland as their homeland. Consequently, names may have been “adjusted” to sound more like those of the dominant ethnic group (e.g., Russian, Prussian, or Austrian) controlling that part of Poland at the time. Second, changes in surnames may have been made dur- ing 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 (Generations Network, 2007).

Some examples of common Polish names include Kowal meaning “blacksmith.” Numerous suffixes, such as “icz,” “czyk,” “iak,” and “czak,” which mean “son of,” can be added. One of the most common suffixes is “ski,” which originally was added to many names because it was associated with nobility. Over time, it was retranslated to mean “son of.” The suffix “cki” became the phonetic ver- sion of “ski.” Surnames ending in “y,” “ow,” “owo,” and “owa” are usually derived from names of places. The “ak” suffix is typical of western Poland, whereas “uk” is found in the east.

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

Life in the Polish culture centers on family. Each family member has a certain position, role, and related responsi- bilities. All members are expected to work, make contri- butions, and strive to enhance the entire family’s reputa- tion and social and economic position. Individual concerns and personal fulfillment are afforded little con- sideration, and sacrifices for the betterment of the family are expected. The family structure is interwoven with strong beliefs and traditions. In the United States, the Polish family has maintained itself as a strong economic unit.

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 in first-, second-, and even third-generation Polish American families. Depending on circumstances, only the Church may have greater authority than the father. For example, if a child wants to leave home and attend

college, the priest may help in convincing the family that it is an appropriate thing to do. However, among some third- and fourth-generation Polish Americans and sec- ond- and third-wave immigrants, more-egalitarian gender roles are becoming the norm. In addition, the father, as head of the house, worked as many hours a day in a mine or a factory as was permitted. He assumed responsibility of finding jobs for both offspring and newly immigrated friends and relatives.

Historically, large families were expected and com- monplace among Poles. Polish women who followed the Church’s teachings had many children, often experienc- ing between 5 and 10 pregnancies. Although women were pregnant a good deal of their early married lives, the wife began the workday well before dawn, and her responsibil- ities included cooking, caring for the children, laundering the clothes, and cleaning the house. If necessary, the wife also worked outside the home for additional income. Although the husband was the final authority in most matters, it was the woman who ran the house, disciplined the children, and cared for elderly family members.

In the early 1990s, Polish women married at the age of 22, whereas in the mid-1990s, the age of marriage was closer to 23, and in 2002, it was 24. Currently, most women become mothers between the ages of 25 and 29, whereas in the early 1990s, motherhood came between 20 and 24. The better the women are educated, the more frequently they postpone having children until their late 20s. The number of unmarried women is also increasing. Unmarried women represent about 20 percent of the pop- ulation, as compared with 5 percent in the early 1990s. Although the most common family model found remains 2 + 2 (2 parents and 2 children), it is becoming increas- ingly common for couples to have only one child (Republic of Poland, 2002a).

In 2001, Szaflarski used the data from the 1994 Polish General Social Survey to estimate the structural and psy- chosocial effects on self-reported health, risk behaviors, and social participation between the genders. Employment status was identified as improving the health of men, whereas marital happiness increased the probability of better health for women. Marital status was identified to influence social interactions. Married women were found to socialize less than unmarried women, whereas marital status had no effect on men’s socialization. Smoking was found to decline with the educational level among men but not among women, whereas excessive drinking increased for unhappily married men. Religiosity was determined to enhance and protect the health of both men and women (Szaflarski, 2001).

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

The most valued behavior for Polish American children is obedience. Taboo child behaviors include anything that undermines parental authority. Parents are quite demon- strative with young children, but they resist showing much affection toward them once they are older than toddler age. This is the parents’ way of teaching children to be strong and resilient. Many parents praise children for self-control and completing chores. Little sympathy is

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wasted on failure, but doing well is openly praised. Children are taught to resist feelings of helplessness, fragility, or dependence.

FAMILY GOALS AND PRIORITIES

Traditional family values and loyalty are strong in most Polish households. Children are valued in the Polish American family. For many first-wave immigrants, mar- riage is an institution of respect and economic solidarity and may not necessarily include romance. In the past, husbands owed their wives loyalty, fidelity, and financial support; whereas wives owed their husbands fidelity and obedience. Children owed their parents emotional and financial support before and after marriage. An important family priority for many is to maintain the honor of the family in the larger society, have a good job, and be a good Catholic.

The elderly are highly respected in most Polish fami- lies. They attend church regularly and carry on Polish tra- ditions. The Polish ethic of contributing to the family and enhancing its status extends to the aged as well. The elderly 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. Third- and fourth-generation Polish Americans may consider an extended-care or assisted-living facility because of work schedules and demands of care, but first- generation immigrants rarely perceive this as an option. If Polish people are to assimilate into a nursing home, the use of the Polish language and rituals may be crucial. Thus, health-care providers should assist clients in orga- nizing these types of events for their family members or should help them select nursing homes that offer these cultural advantages.

The quality of life for elderly immigrants is an excel- lent area for research (Berdes & Zych, 2000). Immigrants who arrived before the age of 21 adjusted to aging much better than their elderly counterparts who arrived in America well into maturity. If the elderly Pole moved to America and was actively embraced by family and friends, adjusting to old age in America was less difficult. However, if the move to America was a forced choice, the adjustment was more difficult.

Extended family, consisting of aunts, uncles, and god- parents, is very important to Poles. Long-time friends become aunts or uncles to Polish children. Numerous family rituals surround holidays, and family gatherings— such as for births, marriages, and name dates (calendar date of the patron saint for whom one is named)—are times to socialize and solidify relationships.

The goals of the family are to work, make economic contributions, and strive to enhance the position of the family in the community. The family unit comes together to help deter behaviors that might cause them shame or lower prestige in the eyes of the community. As Poles assimilate into the culture, the American value of success may prevail. Most Poles expect their children to have an education and a well-paying job and to provide for them in their old age.

ALTERNATIVE LIFESTYLES

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. Older second- and third-generation Poles have one of the lowest divorce rates of ethnic groups (Lopata, 1994), but patterns are changing with succeeding generations as they assimilate into the American lifestyle. Marital problems do exist, but the Polish value for family solidarity is strong and divorce is seen as truly a last resort. When divorce does result, single heads of households are accepted in the Polish American community.

Workforce Issues CULTURE IN THE WORKPLACE

Most Polish Americans are more socially segregated than other ethnic groups. In the past, many Poles never rose above the level of foreman or supervisor. Polish American immigrants of the 1800s maintained group solidarity and could always be counted on to help their families. Because men were semiliterate and had low-level skills, they gravitated to industrial cities, such as Chicago, where they could work long hours as laborers and earn overtime pay. Because Poles were active in trade unions and maintained a sense of loyalty to the group, they were stronger supporters of unions than many other American- born workers of the 1930s and 1940s.

Polish Americans have extensive social networks, and their strong work ethic enables them to gain employment and assimilate easily into the workforce. It is still possible to spend one’s entire life in the same house, be employed in the same factory, and have the majority of your social contacts inside the boundaries of Polonia. Whereas this may have helped immigrants in the past, it now acts as a deterrent to assimilation. The cultural tradition of hard work has caused employers to take advantage of this atti- tude. For example, Polish workers are being exploited as modern-day slave labor in Italy. Since 2000, Polish migrant workers have been recruited to the Italian coun- tryside to harvest crops. Responding to advertisements promising well-paying contracts, the Poles paid for bus rides from Warsaw for this work opportunity. However, gangs of Polish, Italian, and Ukranian criminals held the migrant workers without pay or lodging and provided only infrequent meals of bread and water (Spolar, 2006).

ISSUES RELATED TO AUTONOMY

Some Poles entering America are underemployed and may have difficulty working with authority figures who are less educated. Poles quietly comment that they are disrespected for their educational background and that they must endure decreased status to stay in America (Lopata, 1994). Poles are usually quick learners and work hard to do a job well. The Polish characteristic of prais- ing people for their work makes Poles strong managers, but some lack sensitivity in their quest to complete tasks.

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Even though nursing in Poland is considered a profes- sion, newer immigrants may be unprepared for the level of sophistication and autonomy of American nurses. Only since the 1980s has nursing entered the university setting in Poland. Most Polish nursing education is still completed in 1- to 2-year postsecondary education pro- grams. As with many other professionals coming to America, if Polish nurses are willing to complete the extra courses to become registered or practical nurses, their employment as a nurse can be continued. A problem for many foreign nurses is that they may not receive credit for their work experiences in their home country. A nurse with 10 years of foreign nursing experience may have to start with the schedule, salary, and status of a new gradu- ate. Poland’s nursing students express fundamental val- ues that are significantly influenced by a society charac- terized by strong religious conviction (Wronska, 2002). In the United States, nursing education’s multireligious atti- tudes defer any discussion of religious beliefs.

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, com- petitive market. For Poles living in a country with a strong religious tradition, the American work culture may be very difficult for them to understand. Nevertheless, the strong Polish work ethic, exhibited as volunteering for overtime, being punctual, and rarely taking sick days, is valued by employers.

Native-born Polish Americans have little, if any, diffi- culty with the English language. Foreign-born Poles fre- quently have some difficulty understanding the subtle nuances of humor. Less-educated Poles tend to seek jobs as domestics or choose to perform manual labor because they are reluctant to rely on their English language and communication skills. Recent Polish immigrants, who had experience working under a Communist bureaucratic hierarchy, may have some difficulty with the structure, subtleties, and culture of the American workplace. New- wave Poles may be very naïve in acclimating to the American work culture and, therefore, may become frus- trated with what is considered an acceptable work ethic.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Most Poles are of medium height with a medium-to-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, blue eyes, and blonde hair. Those with fair complexions are predisposed to skin can- cer and other illnesses related to exposure to environ- mental elements. Health-care providers must be aware of these conditions when assessing Polish clients and pro- viding health teaching.

DISEASES AND HEALTH CONDITIONS

Poles consider themselves to be a tough people with an ability to tolerate pain from injuries, illness, and disease.

Poles believe that suffering hardens individuals; there- fore, they value that experience and perceive it to be good. In the Polish culture, a common belief is that enduring pain without complaining or asking for relief demonstrates virility in men and self-control in women. Young boys are taught at an early age that they can con- trol illness, pain, or discomfort without the help of medi- cine and, thus, improve their inner strength. Another cul- tural belief is that taking medications weakens the entire system, which results in the decrease in family status. Fathers live vicariously through their children, especially their sons, and any weakness in the child is believed to reflect directly on them.

Risk factors for newer Polish immigrants are connected with their employment in industries in their homeland. Heavy industry in Poland produced prolonged, significant air pollution and environmental neglect. Living in pol- luted environments led to an increase in premature deliv- eries, low-birth-weight children, diseases of the pulmonary and circulatory systems, and various forms of cancer. The problem of occupational lead poisoning from 1970 to 1996 in Poland was documented by Szeszenia-Dabrowska and Wilczynka in 1998. Between 1972 and 1976, 8414 cases of lead poisoning, an occupational disease, were registered. A diminishing number of occupational lead poisoning cases was observed in the 1990s (Szeszenia-Dabrowska & Wilczynka, 1998). In 2005, Trzcinka-Ochocka, Jakubowski, and Razniewska published the results of their study assess- ing the current occupational exposure to lead and evaluat- ing the competence of laboratories responsible for the monitoring and analysis of health risks in workers exposed to lead. The data indicate that occupational exposure to lead is still a problem and that neither the recommenda- tions of 1996, reinforced by the Minister of Health in 2004, or the European Union directive, are universally followed. In addition, the study found that the competencies of the majority of the analytical laboratories were insufficient to evaluate the workers’ exposure to lead. Another decree was issued by the Minister of Health in April 2005 that man- dates accreditation of all laboratories by January 1, 2008 (Trzcinka-Ochocka et al., 2005).

In Poland, air pollution remains a serious problem because of sulfur dioxide emissions from coal-fired power plants. In addition to the air pollution problems, Poles have had a long history of excessive smoking. “At the end of the 1980s, Poland had the highest cigarette consump- tion in the world” (Zatorski, 2003, p. 97). In 1990, the Cancer Center and Institute, under the honorary patron- age of Lech Walesa and in collaboration with the International Union Against Cancer and the American Cancer Society, hosted a conference, “A Tobacco-free New Europe.” Public-health leaders from Eastern Europe were targeted; the participants heard comprehensive scientific evidence on the magnitude of health damage caused by cigarette smoking in the region. Ultimately, this confer- ence provided the basis for health-related tobacco control legislation, which dramatically reduced the consumption of cigarettes (Zatorski, 2003).

The World Health Organization (WHO)/Europe (2004) reported that among young people, 10 percent of 13-year- olds and 21.5 percent of 15-year-olds smoke at least once a week. Unfortunately, Polish Americans have a higher

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rate of smoking than other European Americans. Forty percent of all Polish men and 25 percent of all women older than 15 years smoke. Thus, approximately 32 per- cent of the Polish adult population are smokers.

Obviously, miners and workers in heavy industry are at an increased risk for the development of pulmonary diseases. Water pollution from industrial and municipal sources and disposal from industrial waste have also become environmental problems. Once these industrial establishments comply with the current European Union codes, the pollution levels should decrease (CIA, 2006). The factors cited previously have contributed to the significant incidence of respiratory disease and lung and other cancers.

In the late 20th century, the Chernobyl incident in Russia created a concern that radiation had 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.

In 2000, cardiovascular diseases (CVD) caused 56 per- cent of all deaths in Poland. Ischemic heart disease was the cause of 141 Polish deaths per 100,000 population, whereas cerebrovascular diseases led to 103 deaths per 100,000 population. Twenty percent of the adult popula- tion suffers from hypertension (WHO/Europe, 2004). The long-term effects of hypertension in the Polish popula- tion needs to be addressed, and awareness needs to be increased through patient education efforts (Niewada, Skowronska, Ryglewicz, Kaminski, & Czlonkowska, 2006). Zdrojewski et al. (2006) conducted individual and collective CVD risk assessments and developed individual and collective risk profiles of political and opinion leaders participating in the Polish Hygiene Society Congress. The researchers examined high blood pressure, overweight and obesity, and smoking as risk factors for those attend- ing the conference. These results were presented to the participants, and the cumulative results were compared with the nation’s current epidemiological burden caused by CVD (Zdrojewski et al., 2006). This strategy appears to be an effective way of impressing on the leaders the importance of these risk factors and improving the aware- ness, education, and lobbying efforts needed to establish a long-term educational program aimed at reducing the incidence of CVD risk factors.

In Poland, 10 percent of hospitalizations are attibuted to cancer or other malignant neoplasms. In 2000, cancer caused 216 deaths per 100,000 Poles. In Poland, the death rate from cervical cancer is more than triple the European Union (EU)-15 average (WHO/Europe, 2004).

VARIATIONS IN DRUG METABOLISM

Documentation on the pharmacodynamics of drug metabolism in Polish individuals is limited. The health- care literature has yet to report any pharmacological stud- ies specific to people of Polish descent.

High-Risk Behaviors Alcohol abuse, with its subsequent physiological, psycho- logical, and sociological effects and its related financial

impact, continues to be an ongoing concern among Polish Americans. In Poland, a study by Manwell, Czabala, Ignaczak, and Mundt (2004) found high rates of depression among heavy drinkers in the primary-care population. In addition, Cherpitel, Moskalewicz, and Swiatkiewicz (2004) reported that drinking patterns and subsequent injuries among males affected the number of emergency services utilized, suggesting a high recidivism for alcohol-related injuries. These results suggest that the patient’s acknowledgment of the role of alcohol in the injury may be an important factor used in developing individualized intervention strategies (Cherpitel et al., 2004).

In Poland, a high rate of alcoholic psychosis, cirrhosis of the liver, and acute alcohol poisoning exists. Other alcohol-related illnesses include cancer of the gastroin- testinal tract, peptic ulcers, accidents, and suicide. An esti- mated 1 million Poles are dependent upon alcohol, and another 3 million are alcohol abusers. Cumulatively, 4 million of Poland’s estimated 38 million people are either alcohol dependent or abusers (Manwell, Ignaczak, & Czabala, 2002). These researchers estimated that approxi- mately 30,000 male deaths per year are considered alco- hol-related, and nearly 80 percent of all cirrhosis-related deaths in men are associated with alcohol abuse (Manwell et al., 2002).

Alcohol abuse is an important part of the history of Poland. For some immigrants, alcohol was a way of reliev- ing boredom, frustrations, and severe hardships. For other immigrants, alcohol was a way of mitigating the painful memories of WW II and reducing depression and the symptoms of post-traumatic stress syndrome. Alcohol still influences family patterns of behavior for many Polish immigrants.

Because Poles place a high value on hospitality in both Poland and America, drinking among Poles is an accepted part of the culture. Part of being a good hostess or host is to have enough alcohol for every guest. For newer immi- grants and older Polish Americans, vodka is the alcohol of choice. Upper socioeconomic groups drink wine, whereas beer is consumed by all socioeconomic levels. In a study on drinking patterns of American and Polish college stu- dents, Polish students drank more than their American counterparts (Eng, Slawinska, & Hanson, 1991). Wine was the preferred drink of Polish students, and beer the pre- ferred drink of American students.

During 2000, the average Polish adult consumed 6.6 L of pure alcohol. This amount has decreased since the 1980s, but serious concerns remain about the system of recording and the problem of underreporting (WHO/ Europe, 2004). Because alcohol use and cigarette smoking are prevalent among many Poles, health-care providers must assess individual clients for abuse and provide coun- seling and referral for those who express an interest. Children of immigrants should especially be targeted for counseling regarding the health effects of smoking and alcohol consumption.

Illicit drug use is becoming more common among Polish urban residents. Cannabis is the most popular illicit drug. WHO/Europe (2004) reported that up to 25 percent of all Poles between 18 and 50 years of age have experimented with marijuana at least once.

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HEALTH-CARE PRACTICES

As with their U.S. counterparts, the behaviors of the Polish immigrants are directly associated with their level of edu- cation, income, and lifestyle. Those with higher levels of education are very interested in weight control, preven- tive health behaviors, and exercise. Health-care providers need to include interventions specific to the individual’s social environment (Stelmach, Kaczmarczyk-Chalas, Bielecki, & Drygas, 2005). Many Poles continue their established health-related activities after immigration.

For Poles just entering the United States, obtaining var- ious medical benefits has often been confusing and infor- mation facilitating access to the health-care system lim- ited. This frequently resulted in Polish people treating themselves, delivering babies at home using a lay midwife, taking folk medicines and herbal remedies, and even set- ting their own broken bones when necessary. The mother’s or grandmother’s responsibility was to know how to care for the family and their medical problems. Some additional common cultural practices included treating the symptoms of colds with herbs or poultices made from goose grease or fat. Gunpowder was ingested to promote emesis for an upset stomach. A boil was healed by soaking the heel of a loaf of white bread in milk and then placing it on the boil to draw out the core. Poor cir- culation or back pain was relieved by placing heated, alco- hol-swabbed shot glasses, called banki, on the affected area. The heated banki were placed on the back or over the painful areas, causing circular, swollen areas on the skin. The Poles believed that this painless, raised area increased the circulation and reduced overall pain. Therefore, the health-care provider obviously needs to individually assess the cultural health behaviors of their Polish patients.

Health-care providers should carefully screen Polish immigrants for diseases common in their home country. Hypertension, CVDs, respiratory conditions, alcoholism, cancer (particularly leukemia), and thyroid disorders are endemic diseases of Poland that are also found in the United States. Culturally congruent health teaching strate- gies associated with the risk factors for these diseases must be implemented when working with this population.

Nutrition MEANING OF FOOD

Another rather common depiction of cultural values is sometimes displayed on a wallhanging in a Polish home. The wallhanging often features a likeness of God with the inscription Gosc W Dom, Bog W Dom, which means “Guest in the House, God in the House.”

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. Three impor- tant considerations influence Poles regarding food. First, Poland is primarily a land-based country with short sum- mers and very cold winters. Thus, the major agricultural products in Poland include potatoes, vegetables, wheat, poultry, eggs, pork, and dairy products (CIA, 2006). Second, the cold weather discourages outdoor activities, while also creating a craving for hot stews, soups, and

foods that produce a feeling of satiety. Unfortunately, these foods are high in carbohydrates, fat, and sodium. Meats and vegetables are cooked for a very long time, resulting in the destruction of B and other vitamins. Third, the strong Catholic influence is evidenced by attending many food-laden celebrations, festivals, and rit- uals, each of which has its own traditional high-calorie foods. Many Poles continue these routine dietary prac- tices after emigrating. Health-care providers need to assess how the Polish clients’ dietary habits influence their weight, blood pressure, and overall health status and then structure a diet that is culturally acceptable, promotes healthy food choices, and is sustainable.

COMMON FOODS AND FOOD RITUALS

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, apples, and wild mush- rooms. Common meats 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 pas- tries) are common ethnic foods. As mentioned previously, hot soups and stews are favored during the bitterly cold winters, and cold soups are preferred during the summer.

The meal plan for many Poles consists of a hearty breakfast of coffee, bread, cheese, sausage, and eggs. A midmorning snack comprises a sandwich and tea or cof- fee. The main meal in midafternoon includes soup, meat, potatoes, a hot vegetable, and dessert. In the evening, cold cuts, eggs, butter, sour cream, bread, and grains are com- mon. This diet is modified depending on the availability of the food, the growing season, and the family’s finances. Dill, paprika, garlic, and marjoram (used in kielbasa) are common herbs. Many foods may be pickled or canned for storage, which also increases their sodium content. Table 20–1 lists a variety of traditional Polish foods.

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T A B L E 20.1 Polish Foods

Common Name Description Ingredients

Babka Coffee cake Yeast bread Barszcz Beet soup Served plain or with sour

cream Bigos Hunter’s stew Stew with game, sausage,

sauerkraut Chrusciki Polish bowties Fried egg dough Golabki Cabbage rolls Cooked cabbage stuffed

with chopped meat and rice in tomato sauce

Kielbasa Sausage Sausage Ogorki smietanie Sour cream Sour cream,

cucumbers cucumbers Pierogi Boiled Dumplings filled with

dumplings potatoes, cheese, or sauerkraut

Sledzie Herring Pickled fish

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DIETARY PRACTICES FOR HEALTH PROMOTION

The Polish American diet is frequently high in carbohy- drates, sodium, and saturated fat. Assessing clients for increased blood sugar and cholesterol levels and high blood pressure should be routine. Interventions that require significant dietary modifications to their cultur- ally based menus may be difficult.

Like many other economically developing countries, Poland’s efforts to examine the health status of its citi- zens has become increasingly important. One disease with dramatic long-term consequences is insulin-depen- dent diabetes. Over the years, an increased incidence of this disease in Poles has been documented. Sobel- Maruniak, Grzywa, Oriowska, and Staniszewski (2006) reported the results of their study to compare the long- term trend in the incidence of insulin-dependent dia- betes over 20 years (1980–1999). Their results showed a significant growth in the incidence of insulin-dependent diabetes among people aged 0 to 29 years in the Rzeszow Province. The male incidence of 6.7 significantly exceeded the 5.5 per 100,000 population rate in females. The group aged 0 to 14 years had a higher incidence (6.4/100,000) than the 15- to 29-year-old age group (5.8/100,000). Boys aged 10 to 14 had the highest inci- dence at 11.5 per 100,000. Obviously, there has been a increased incidence of insulin-dependent diabetes in the subjects over the 20-year observation period (Sobel- Maruniak et al., 2006). Health-care providers should be especially alert to the symptoms of diabetes in younger Polish immigrants.

V I G N E T T E 2 0 . 2

John Jagojinski came to America as a young boy in the 1940s and has lived in the same Polonia and worked in a nearby steel mill his entire life. He married his neighborhood girl- friend, Sophie, and they had two children. John is proud of his family, but dislikes the idea that their adult children moved to the suburbs 15 years ago.

Until recently, John was a heavy drinker who smoked one pack of cigarettes daily for 30 years. He quit smoking 10 years ago because he felt “winded.” He stopped drinking about 5 years ago because “I just couldn’t hold it like I used to.”

John has been feeling ill for the past month and told his wife he was drinking so much water that he was going to the bathroom all the time. John was concerned that he could barely hold his water (urine) when going to the bathroom.

A complete physical examination revealed that John’s legs were swollen and that he was having trouble breathing. John was given prescriptions to treat his condition and advised to reduce his dietary sodium intake.

After 1 week, John insisted on returning to the steel mill and asked Sophie to make him his customary lunchmeat sandwiches to take to work. After 3 weeks, the swelling in his legs has worsened and his wife said she should call the doc- tor for an appointment. John got angry.

1. What are the most likely clinical problems that John has developed?

2. What cultural considerations must the health-care provider keep in mind when advising John and Sophie?

3. How can John’s lunch be modified to reduce his sodium intake?

4. Why should Sophie or their adult children be included in managing John’s condition?

5. What health promotion activities should John be encouraged to perform?

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

Unfortunately, most of the land and water in Poland con- tains low levels of iodine. Iodine does not develop natu- rally in specific foods unless it is present in the soil or water. Iodine penetrates the foods that are grown in the soil, and their ingestion supplies it to the consumer. Ocean water also contains adequate amounts of iodine; thus, eating fish or other nutrients from the sea is likely to furnish sufficient amounts. Unfortunately, consuming fish on a regular basis has failed to become a part of the traditional diet in Poland.

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. Iodine is an essential compo- nent for the thyroid’s hormonal function, and its defi- ciency results in the underproduction of thyroxine and triiodothyronine. Disorders related to the inadequate pro- duction of these hormones may include (1) mental retar- dation, (2) neurological system defects, (3) goiters (e.g., enlarged thyroid), (4) sluggishness, (5) growth retarda- tion, (6) reproductive failure, and (7) increased childhood mortality. Fortunately, this nutritional problem is being monitored and addressed.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

Because family is very important, most Poles want chil- dren. In an agrarian society, and for early immigrants, children were considered important because they brought happiness and status to the family and were an economic necessity. In Poland, the Catholic Church strongly opposes abortion, which is the prevailing attitude of many Poles in America. However, during the years of war, poverty, and Communist rule, abortion and child spacing were considered necessities.

In 2006, the estimated birth rate was 9.85 per 1000 people, whereas the rate of death was 9.89 per 1000. The estimated fetal fertility rate for 2006 was 1.25 children born per woman (CIA, 2006), which is less than the 2.0 children required to sustain the current population. In Poland, women receive fully paid maternity leave for 90 days, and longer with partial payment, but many women are unable to take the entire leave owing to trying eco- nomic circumstances. Fertility practices are balanced between the needs of the family and the laws of the Church.

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PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Pregnant Polish Americans are expected to seek preven- tive health care, eat well, and get adequate rest to ensure a healthy pregnancy and baby. Immigrant families who have experienced poverty, famine, and inadequate health care are more likely to pay attention to prenatal care. The emphasis on food and “eating for two” is a common phi- losophy. Health-care providers must pay special attention to ensure that pregnant Polish American women restrict their weight gain during pregnancy.

Because the process of childbirth was poorly under- stood by an undereducated society, folk beliefs, magicore- ligious explanations, and taboos continue to surround the process. Many consider it bad luck to have a baby shower, and even now, many Polish grandmothers may be reluctant to give gifts until after the baby is born. Birthing is typically done in the hospital. Midwives may be used if there is a community feeling that they are “just as good as the doctor.”

Pregnant women usually follow the physician’s orders carefully. In America, Polish women seek prenatal clinics when they are unable to afford private fees. 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.

Women are expected to rest for the first few weeks after delivery. For many, breastfeeding is important. Health- care providers may need to provide active lactation coun- seling and education about appropriate care during breastfeeding (e.g., proper techniques) and to help the woman understand the balance between diet, rest, and exercise after delivery.

Death Rituals DEATH RITUALS AND EXPECTATIONS

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.

Most Polish women are quick to help with the physical needs of the dying. Home hospice care is acceptable to most Poles. Health-care providers may encounter diffi- culty in convincing the family that the dying member may choose to refuse food as a result of the illness rather than because of stubbornness or the caretaker’s cooking. Polish women may tend to hover. Health-care providers need to help families understand that it is important for the dying person to conserve energy.

RESPONSES TO DEATH AND GRIEF

In early Poland, individuals were buried within 24 hours of their deaths. Historically, immigrant Poles continued the practice of burying the deceased from the home and

having home burial ceremonies, which included a wake or vigil in which family members prayed and repeated the rosary over the dead person. Today, Polish American fam- ily 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 Church on All Souls’ Day, November 1. Families may continue tending the gravesite for years.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

The Catholic Church, with its required attendance at Mass on Sundays and holy days, is an integral part of the lives of most Polish people. There are “holy days” in almost every month of the year, in addition to the rituals of Baptism, confirmation, marriage, sacrament of the sick, and burial. Christmas and Easter are the two biggest holi- days requiring both special foods and rituals. On Christmas Eve, depending on the affluence of the family, up to 13 meatless dishes are served with the oplatek (simi- lar to a large communion wafer) that everyone shares at the table. On Christmas Day, the main meal consists of kielbasa, goose, ham, or turkey. The Easter holiday may begin with women bringing food to the church on Easter Saturday to be blessed by the priest. On Easter Sunday, lamb or kielbasa and boiled eggs are served. A table orna- ment, usually a lamb made of salt or butter, is often dis- played. Like many Americans of various ethnic back- grounds, Polish Americans have had a renewed interest in their ethnic roots. For example, their attendance at lan- guage classes, festivals, and Polish Catholic churches has become very widespread.

Religious ceremonies are a major part of maintaining Polish culture. Poles are very concerned that churches continue to act as a vehicle of Polish culture. Birthdays and name days are important religious and family events for Poles. One very popular song is Sto Lat, which con- veys wishes that the celebrant live 100 years. Polish wed- dings are legendary. This is the time when family and friends get together and two families unite. One folk practice is to bring chlebem i sola (bread and salt) as a symbol of hospitality. Guests always receive plenty of food and drink, listen to music, and dance. In America, Polish weddings may last only 1 day, but plenty of food and alcoholic beverages are considered essential to the joyous occasion.

Primary spiritual sources are God and Jesus Christ, with many Polish immigrants praying to the Virgin Mary, saints, and angels to ward off evil and danger. Honor and special attention are paid to the Black Madonna or Our Lady of Czestachowa (Fig. 20–1). Czestachowa, a town in central Poland, displays a picture of the Virgin Mary with two scratch marks on her darkened face. Every year, many Poles join a walking pilgrimage to see the Madonna. The United States has several settings honoring the Black Madonna. During times of illness and serious family con- cerns, one might hear a Pole evoking Matka Boska, which literally translated means “Mother of God.”

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Many older Polish people believe in the special proper- ties of prayer books, rosary beads, medals, and conse- crated objects. Polish Americans commonly exhibit devo- tions to God, such as crucifixes and pictures of the Virgin Mary, the Black Madonna, and Pope John Paul II, in their homes.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

Most Polish Americans have a strong work ethic and pride themselves on being fastidious and punctual. They are loyal to friends and family, have a strong sense of Catholic ideals, are self-disciplined, and are concerned about respect and honor. Most Polish Americans enjoy music, such as the works of Chopin and other classical composers, and dancing, including the jovial Polish polka, the waltz, or polonaise. Liturgical music may be important to older and more religious Poles.

After years of living under Communist censorship, newer immigrants value freedom, independence, being respected for their work, and having status in the com-

munity. Most Polish Americans find meaning in family loyalty and show great generosity to friends and extended family. Like all cultural groups, Polish Americans want to be shown respect.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Among the early immigrants, religion had both a folk tra- dition and a formal Catholic element. Most believed in mythological beings, water spirits, and house ghosts. Killing or any useless slaughter of animals was con- demned. All life had meaning, and if an experience was unexplainable, mysterious, or magical, folk beliefs and/or religion provided the answer.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

Most Poles put a high value on stoicism and doing what needs to be done. Many go to health-care providers only when symptoms interfere with function; then they may carefully consider the advice provided before complying. Describing anxiety and expecting nurturance are unchar- acteristic of most Polish adults and children. Many Poles are reluctant to discuss their treatment options and con- cerns with physicians and routinely accept the proposed care plan. If Poles believe they are unable to pay the med- ical bill, they may refuse treatment unless the condition is life-threatening. Many have a strong fear of becoming dependent and resist relying on charity. Because many Poles consider Medicare, Medicaid, and managed care as forms of social charity, they are reluctant to apply for them. Any action that lowers their social status in their community is generally considered unacceptable. The health-care provider must describe the intent of these financial programs carefully or Poles may perceive them as charity and, therefore, unacceptable options.

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 interven- tions and therapies without pharmaceutical or suitable psychosocial strategies are dismissed unless interventions are action oriented. In addition, Poles consult other fam- ily members and the community to assess the appropri- ateness of treatments. Polish Americans often seek self- help groups such as Alcoholics Anonymous before seeing a health-care provider. Assimilated Poles respect the health-care system and tend to seek specialized care when necessary.

In Poland, health care is subsidized by the state. In accordance with the National Health Fund Act of 2003, Poland has a compulsory health insurance scheme (WHO/Europe, 2004). To many immigrant Poles, the U.S. health-care system is complex, confusing, and overpriced. They perceive access to health care as difficult, and many people who can afford to pay higher fees to see a private physician are unaware of how to gain access. Some Poles return to Poland to have medical or surgical procedures

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FIGURE 20–1 The Black Madonna or Our Lady of Czestachowa is an object of devotion to millions of native and immigrant Polish peo- ple. (From The Marian Library/International Marian Research Institute, Dayton, OH. http://www.udayton.edu/mary/resources/blackm/ blackm03.html)

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performed because these are more understandable, avail- able, and/or affordable in their homeland.

RESPONSIBILITY FOR HEALTH CARE

Given the continuation of limited access to care and the strong work ethic of this cultural group, health promo- tion practices are often undervalued by Polish Americans. In fact, older Polish Americans and newer immigrants commonly smoke and drink, engage in limited physical exercise outside of work, and receive poor dental care. Partial and complete dentures are common in older Poles. A number of secondary teeth are often found missing in Polish American immigrant children. This frequently sur- prises nurses who may be unaware of the limited number of dentists in Poland.

Attention to health promotion practices among women may be complicated by Polish American women’s sense of modesty and religious background. Breast self-examina- tion and Pap smear tests are poorly understood by many women. Health promotion practices vary greatly and are dependent on the woman’s assimilation into American culture.

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 proved ineffective. Few Poles use vitamins unless these are sug- gested by a physician or a trusted family member; even then, their extrinsic value is compared with the cost.

FOLK AND TRADITIONAL PRACTICES

When a Pole is asked to undress for a physical examina- tion, the health-care provider should pay special atten- tion to any medals pinned to the patient’s undergar- ments. Most of these medals have special religious significance to the wearer and should, if possible, remain on the garment. In addition, Polish Americans may use certain remedies to cure an illness, such as tea with honey and spirits to “sweat out” a cold. Herbs and rubbing com- pounds may also be used for problems associated with aches, pains, and inflammation from overworked joints and muscles. Because of individual differences, every client must be assessed personally and asked specifically about their use of home remedies and over-the-counter medications.

BARRIERS TO HEALTH CARE

Being unable to speak and understand English and the cost of health care and its complexity are the greatest bar- riers to health care for Polish immigrants. In addition to overcoming the language barrier, health-care providers need to understand Polish family values. Health-care providers also must consider that Poles often filter infor- mation through the extended family and neighborhood before accepting the recommended health-care regimen. Polish Americans who have learned English as a second language may have some difficulty with the nuances of health-care jargon and terminology.

Inadequate or miscommunication can result in tragic consequences for the client. To negate the deleterious effects of miscommunications, the Department of Health and Human Services’ Office for Civil Rights issued a 1998 memorandum regarding the prohibition, under Title VI of the Civil Rights Act of 1964, against discrimination on the basis of national origin that affects people with lim- ited English proficiency. This memorandum asserts that the denial or delay of medical care owing to language bar- riers constitutes discrimination. It also requires that recip- ients of Medicare or Medicaid funds provide adequate language assistance to patients with limited English profi- ciency (Flores, 2006). Unfortunately, most of the states with the greatest number of patients with limited English proficiency have not complied with the memorandum, sometimes citing cost concerns. Although, in 1993, the Office of Civil Rights issued guidelines that appear to per- mit health-care facilities to avoid providing language ser- vices by citing burdensome costs, Title VI provides no such exception (Flores, 2006).

Health-care providers may need to employ primary- care or case management and/or assistance to obtain a cultural bilingual health provider and interpreter from the Polish American community to help decrease the number of barriers to health care. If an interpreter is required, the Polish community can usually help provide someone. Poles are polite to authority figures and avoid offending a health-care worker by disagreeing with them. Thus, they may be reluctant to ask for clarifications on questionable issues. In addition, many Poles are primarily concerned about how a disease affects daily functioning rather than about individual survival rates.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

Owing to their strong sense of stoicism and fear of being dependent upon others, many Polish Americans use inad- equate 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. Poles with chronic illnesses may have similar attitudes; thus, persevering with pain is common. The health-care provider should use a visual analog scale to assess pain, assist clients with distraction techniques, and help Poles to accept pain medication when needed.

Premigration stresses (e.g., losses, catastrophic experi- ences, anxiety, and internment) may be combined with postmigration stressors (e.g., language difficulty, loss of relationships, cultural pride, lack of support systems) to cause mental health problems (Fenta, Hyman & Noh, 2004). Social and geographic isolation within one’s own ethnic neighborhood are common, albeit somewhat restrictive, reactions to this situation. Many immigrants are able to overcome the initial shock of moving to a for- eign country, but they fail to have adequate coping skills to get through the stressors of total adjustment. Lack of language skills, feelings of unfamilarity, and fear of the unknown are some of the reasons given by those who fail to leave their Polonia. In these self-segregated cultural communities, children often become the go-betweens for their parents and the larger community. As children mature, they leave their parents and the Polonia to start

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their own families. Thus, the parents’ avoidance of the acculturation process, even 25 years later, creates stressors leading to feelings of abandonment, loneliness, and dis- placement. These feelings may become significant and lead to major physical and/or mental illnesses.

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 individu- als choose their priest or seek assistance from a Polish volunteer-run agency before going to a health profes- sional for psychiatric help.

Immigration to America failed to change the Pole’s concerns about the delivery of appropriate health care. Immigrants are taught from infancy to resist asking for help or assistance from others but to bear the burdens of life independently.

Successful adaptation to the new homeland requires the immigrant to voluntarily progress through the process of assimilation and acculturation. Assimilation requires the individual to gradually adopt and incorpo- rate the characteristics of the prevailing culture into their own lives. Acculturation mandates that the immi- grants willingly modify their own culture as an accomo- dation to their transition to accepting the general values and attitudes of their new culture and homeland. The process of acculturation may affect the association between migration and health. The bidimensional approach describes acculturation as a process of adaptation to the mainstream culture while maintaining the inherited eth- nic identity (Ryder, Alden, & Paulhus, 2000).

Aroian (1992) described three types of social support needed by Polish immigrants. During the first 3 years, immigrants need help finding housing and jobs and information about getting through the system; that is, learning English, buying groceries, and learning American customs. During the next 3 to 10 years, help is required to secure credit, obtain loans, and assimilate into American life. Finally, immigrants in America for more than 10 years need support in honoring their Polish her- itage through networks of other immigrants while main- taining an American support system. After immigrants are comfortable with resettlement, feelings of grief and loss begin to be acknowledged. “The psychological adap- tation to migration and resettlement requires the dual task of mastering resettlement demands and grieving and removing the losses left in the homeland” (Aroian, 1990, p. 8).

V I G N E T T E 2 0 . 3

Chester and Kathryn Jusczak immigrated to the United States during the 1980s. They settled in the Chicago Polonia and adjusted to a comfortable life in the neighborhood. Chester works long hours in the oil refinery, while Kathryn focused on raising their four children. After completing school, all of the children left Polonia. Chester and Kathryn remained in their neighborhood, socializing with their Polish friends.

Recently, Chester began experiencing severe right flank back pain. When the pain became unbearable, he visited his primary-care physician, Dr. Gajewski, who diagnosed a kid- ney stone. After it had passed, Dr. Gajewski advised the

Jusczaks that Chester should go on a restricted-protein and low-sodium diet and drink more water. In addition, he gave Chester a prescription for a pain medication to take in case of another episode. After leaving the office, Chester dismissed the need for filling the prescription with the statement, “It wasn’t that bad; I can handle the pain.” The Jusczaks were told that the nurse would visit their home to help them structure the recommended diet.

1. How can the nurse present the dietary restrictions to Chester and Kathryn so that they are acceptable and will be implemented?

2. Why did Chester resist filling the pain medication pre- scription?

3. Why should the nurse request that one or more of the Jusczaks’ children be present during the discussion of their diet regimen?

BLOOD TRANSFUSIONS AND ORGAN DONATION

The ethic of being useful, independent, and a good Catholic influences one to refrain from using extraordi- nary means to keep people alive. The individual or family determines what means are considered extraordinary. Receiving blood transfusions or undergoing organ trans- plantation is acceptable. However, it is important for a family to know the extent to which a patient will be able to function following organ transplantation. Cost is always an important consideration. Most Poles resist becoming a burden on their family’s physical or financial resources and may attempt to convince the family that the procedure is too costly. Poles do consider it their duty to care for a sick member at home.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

Immigrant Poles often assess health-care providers by their demeanor, warmth, and show of respect. Health advice may be sought from chiropractors and local phar- macists as well as neighbors and extended family. Generally, professional biomedical advice is sought when a symptom persists and interferes with daily life.

Newer immigrants may fail to realize that many patients are discharged from the hospital before they have totally healed and are fully recovered. Poles may assume this practice is related to charity care, disrespect, or their financial status. Early discharges should be explained to the client and family.

STATUS OF HEALTH-CARE PROVIDERS

When caring for Polish clients, particularly the elderly, all health-care providers should make every attempt to address individuals by their surname. Although this may be difficult, many names can be phonetically pronounced. Attempting to pronounce the names demonstrates

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respect for the client. As a group, Poles are fiercely inde- pendent, relying on themselves or family members for almost every aspect of their social status, health, and livelihood. Nurses need to focus on the Polish client’s background and upbringing and take into consideration how health care becomes accepted or rejected. Illness or being sick is considered weakness for male family mem- bers. Polish women consider it their role to care for the family members without asking for help. It is also impor- tant to consider that Polish women are modest and self- conscious and may refuse health care when asked to dis- robe in front of a male health-care provider. In some cases, it may be critical to request a female provider.

When it becomes evident that only professional help will resolve a problem, the affirmative act of seeking assis- tance is a major decision. Communication, considera- tion, displaying respect, and demonstrating cultural sen- sitivity will help to improve the Poles’ attitudes toward the health-care provider. The health-care professional will need to introduce changes in ways that are appropriate and acceptable and can be integrated into an established, culturally dominated lifestyle.

Nurses will need to understand their own cultural val- ues, beliefs, and practices in order to avoid or prevent alienating the Polish client and family about the diffi- culty, complexity, and conseqences of any recommended interventions. Using an authoritarian approach to gain compliance will cause conflict. Based upon their history, Poles have a tradition of survival, sometimes through stubborness, pride, warmth, or genuineness. Therefore, being perceived as an amiable, respectful, and knowledge- able provider is integral to changing attitudes and subse- quent behaviors. Communicating through the use of a bilingual family member as a liaison and finding agree- ments on cultural health beliefs and practices may be the best initial strategy for change when dealing with elderly immigrants or more-traditional Polish Americans.

A person’s culture influences their perceptions of health and illness. How a client accepts help or allows care to be rendered depends upon their previous experi- ences, understanding, and trust in the provider. Respect, patience, and acceptance are important components of health care. Thus, nurses need to compassionately com- municate with their clients through their professional appearance, words, actions, gestures, inflections, and pos- tures. Clients of Polish descent interact with health-care providers, whom they perceive as authority figures, in very distinctive ways. Polite listening may determine how compliant a client may be with the recommended regi- men. Nurses need to focus specifically on cultural norms when dealing with older clients if they are to meet their needs. It is often the tone or how something is said as well as the body language that accompanies it that communi- cates whether the nurse respects the client. Being cultur- ally sensitive to the Polish American client will be accepted as a gift from a stranger and will be reciprocated with appreciation, genuineness, and respect.

Physicians are held in high regard in Polish communi- ties. Poles typically follow medical orders carefully. Poles may change physicians if they believe their recovery is too slow or if a second opinion is needed. Educated Poles are more willing than those less educated to follow

medical orders and continue with prescribed treatment. Poles with less education tend to change physicians if the disease fails to subside quickly enough. Poles respect physicians but need to understand the purpose of the medical treatment.

Poles expect health-care providers to appear neat and clean, provide treatments as scheduled, administer med- ications on time, and enjoy their work. Immigrant Poles may be unfamiliar with the advanced roles of the American nurses, who are expected to know about, plan, and be directly involved in the clients’ care. Thus, many Poles may still want only the physician to explain all aspects of their care.

The World Wide Web and computer access have facili- tated the production of materials that may assist the nurse and provide the client with culturally appropriate materi- als. McCarthy, Enslein, Kelley, Choi, and Tripp-Reimer (2002) analyzed 75 bi- and multilingual health sites avail- able on the Internet. Such sites may be very useful for dis- seminating information to groups with limited English- language skills. Ethnic communities could significantly benefit from having Internet-based information about specific health conditions translated into Polish and other languages and distributed to appropriate client groups.

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355

People of Thai Heritage

Chapter 21

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 a unique blend of traditions that reach back to its origins as a blend of Southeast Asian peoples, a background in Buddhism, and profound influences from the cultures of both India and China. For providers of health care to Thai patients, beliefs and practices that stem from these com- bined traditions can present both opportunities and chal- lenges.

Thailand began a tradition of emulating Western polit- ical, economic, and cultural ideas in the late nineteenth century. In the later decades of the twentieth century, Thailand (like several other Asian “economic tigers”) began a period of explosive economic growth that con- tinues today but that has been interrupted at times by political and economic instability. A recent example was the bloodless coup that took place in the fall of 2006. Visitors to Thailand, and especially those who learn to love and study its culture, are always impressed with the unique ways in which the people of Thailand manage an often precarious balance between contrasts of the old and the new—between the rich traditions of the past and the frenetic influences of modern economic competition and a global cultural influence.

In the context of health care, this balance very often plays out as a tension between older cultural beliefs (and sometimes superstitions) and more modern concepts of medicine grounded in research. These tensions need to be

understood by providers in both their positive and their negative potentials for health care as to how they vary from individual to individual.

Thailand is located north of Malaysia, west of Laos and Cambodia, 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 (511,770 km2) and population (over 64 million people) are similar to those of France (CIA, 2006). 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 pul- sating 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 fur- ther southeast to Vietnam. The Ping, Wang, Yom, and Nan rivers are located in the north (Hoare, 2004).

Thailand is divided into 76 provinces within four dif- ferent regions: north, northeast, central, and southern. Each region is unique in its geographic and cultural char- acteristics. Northern Thailand is the most 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 asy- lum, 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,

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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). Indeed, 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 usually experience overwhelming 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 eleventh century AD) were strongly influenced by Indian culture so that even today the Rama legends of Indian mythology form an inte- gral part of Thailand’s belief system (Hoare, 2004). The pre- sent king of Thailand is the ninth of the Rama Kings, and the Thais’ perception of their king’s divinity can also prob- ably be traced to Indian origins.

The first people who are culturally considered “Thais” probably migrated from the south of China. Sukhothai, founded in the thirteenth century AD, is considered the first kingdom of Siam (or Thailand). Its most famous king was Ramkhamhaeng, who is credited with develop- ing 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 AD 1350 by the extremely powerful kingdom of Ayutthaya on the Chao Praya River. The kings of Ayutthaya in particular 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 build- ing Bangkok from a sleepy little village into what even- tually became the great city of the Grand Palace (Hoare, 2004).

Especially in the eighteenth, nineteenth, and twenti- eth centuries, policymakers of Thailand remained inde- pendent of European colonial powers by steering a politi- cal 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 gov- erning system (Hoare, 2004).

In 1932, Thailand appointed its first prime minister. Thereafter, the king no longer served in any critical deci-

sion-making capacities (Hoare, 2004). Still, the lineage of Thai kingships continues, and the Thai people con- tinue to love and deeply revere their king. This intimate relationship between royalty and the people is inter- twined with Thai Buddhism and the Thai peoples’ per- ception 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 address- ing 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 for- bidden by law. Yet, Thailand’s present constitutional monarchy is a democratic form of government built around the actual governing authority of the prime min- ister and the parliament.

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Over 150,000 Thais live in the United States (U.S. Census Bureau, 2000). In 2004, approximately 4300 Thais became U.S. citizens (U.S. Census Bureau, 2006). Approximately 66 percent of all Thais in the United States live in Los Angeles. Los Angeles is therefore often referred to as “Thailand’s 77th province.” Coincidental and interesting to note is that both Bangkok and Los Angeles are known as the “City of Angels.” However, Thai communities are spread throughout the United States. Other cities with siz- able Thai populations include Houston and Philadelphia (Wikipedia, 2006).

The first two Thai immigrants in the United States were Eng and Chang, the famous Siamese twins who cap- tured the world’s attention because of their conjoined chests and whose career was a public exhibition. A num- ber of medical examinations were performed on them to learn about the true nature of their condition (Wikipedia, 2006). 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 med- ical college in New York. He later became the father of former prime minister of Thailand Pote Sarasin (Wikipedia, 2006).

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 coun- try. 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 con- tinued 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 1–9) (Fig. 21–1). However, the Thai government provides free education to all Thais who go to government

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schools up to grade 12. The literacy rate in Thailand was 92.6 percent in 2002 (CIA, 2006).

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 require- ments. Those students who are not accepted in govern- ment 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 official lan- guage in Thailand. The Thai language is a fixed tonal lan- guage 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 a unique dialect 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 Thais is Pasah Dai, “the southern language,” and is the fastest-sounding among the dialects.

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 reflect respect and politeness. A distance of 11⁄2 to 2 feet between two speakers is prefer- able.

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

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), aunt(s), uncle(s), grandparent(s), and/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 last names. A Thai is usu- ally referred to by her or his first name, even in an official setting like school or work. Their names usually have clear meanings. A first name is often given by a Buddhist monk or a fortune-teller based on the date, day of the week, and time of a newborn’s birth. Sometimes, parents name their children themselves. When married, a woman usually uses her husband’s last name. A couple’s children also use their father’s last name.

When Thai names are written in English, the spelling is merely a kind of phonetic translation from its real spelling in the Thai alphabet. Because Thai is a tonal lan- guage, the pronunciation of names cannot be ascertained

PEOPLE OF THAI HERITAGE • 357

FIGURE 21–1 A grade school in Thailand.

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from their spelling in English. For health-care providers in the West, the best course is to ask Thai clients how to pronounce their name and do the best one can in approx- imating it.

Importantly, almost all Thais have a short nickname used by their family and close friends and often by col- leagues at work. A nickname normally has no relation- ship with the first name. They are often humorous to Thais themselves. Nicknames are usually either Thai or English words. They might be derived from names of col- ors, body types, fruits, or any number of other things. Health-care providers should feel free to ask their clients 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 teach- ing 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 house- hold 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 charac- teristics. The degree to which children assist with house- hold 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, entertain- ment, 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. 21–2). 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 impor- tant 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, includ- ing older in-laws, when they are in need.

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, 2007).

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FIGURE 21–2 A Thai family photo.

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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 move- ment for lesbian and gay rights and efforts to combat HIV/AIDS (Utopia, 2007). At present, gay marriage is not supported by Thai laws.

Workforce Issues CULTURE IN THE WORKFORCE

Most Thais usually try to avoid personal conflicts at work and are hard workers. Although the family is deemed very important for Thais, in many circumstances, especially for economic reasons, work comes before family (Fig. 21–3). For instance, a husband and his wife in Thailand often work in different provinces. A good num- ber 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, Thai Americans tend to socialize among themselves rather than be exposed to Americans or peo- ples from other cultures. Therefore, Thai Americans may not deeply understand American culture. Language barri- ers often occur in the workplace. In order to help them adjust to an agency in the United States, an orientation program focusing on cultural differences may be helpful.

ISSUES RELATED TO AUTONOMY

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 dis- cussions 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 lan- guage used in the workplace should be clear. Slang expres- sions 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 tribes—Karen, Lisu, Ahka, Lahu, Mien, and Hmong (Fig. 21–4) (CIA, 2006).

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. 21–5). 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 nose is a little longer and their cheekbones are 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 north- ern 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 usu- ally much smaller than those of Caucasians.

PEOPLE OF THAI HERITAGE • 359

FIGURE 21–3 Selling noodles at the floating market in Thailand.

FIGURE 21–4 An interracial boy (American Thai) in front of a ven- dor’s wagon in Thailand.

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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 pat- tern 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 Thais’ responses to a variety of antigens, drug metabolism, and genetic disorders.

Glucose-6-phosphate dehydrogenase deficiency (G6PD) 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 G6PD deficiency have persistent ane- mia 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

Different ethnic groups may have different pharmacoki- netic functions (Bjornsson et al., 2003). Recent literature reporting some variations in drug metabolism between Thais and non-Thais is mostly associated with antiretrovi- ral medications. For example, a study 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 concentra- tions among the Thai participants, 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 recom- mendations 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 (2005) examined the most significant risk factors (during 2001–2004) nega- tively affecting the lives of Thai people. Results showed that unsafe sex (12.7 percent) is the leading factor, fol- lowed by smoking (6.9 percent), alcohol consumption (5.3 percent), hypertension (4.8 percent), nonuse of hel- met while driving motorcycle/motorbike (4.2 percent), high body mass index (3.7 percent), illicit drug use (2.7 percent), high cholesterol (2 percent), inadequate veg- etable and fruit consumption (1.5 percent), occupational injuries (1 percent), poor sanitation and malnutrition (1 percent), physical inactivity (1 percent), and pollution (0.8 percent).

As stated, unsafe sex is the number one health-behav- ior concern in Thailand. Because unsafe sex is related to high rates of HIV infection and AIDS in Thailand, infor- mation regarding these in connection with certain Thai sexual behaviors is presented in the next section.

HIV/AIDS

In September of 1984, the first patient with AIDS (a Thai gay man who studied in the United States and moved back to Thailand) was reported in Thailand. Since then, incidences of HIV infection have been reported through- out 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 commer- cial sex workers (CSWs) and injection drug users (IDUs). HIV-positive rates among Thai female CSWs climbed to

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FIGURE 21–5 Isaan dance.

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over 33 percent in 1994 but fell to 4 to 8 percent in 2004, mainly due to the 100 percent condom use cam- paign (Sunthrajarn, Wongkongkateph, Onnom, & Amroncichet, 2005). 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 owing 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 response to HIV/AIDS. However, Thailand has in large measure ignored the problems of HIV/AIDS among homosexual men. Adding complication, the problem is interrelated with Thailand’s commercially successful male sex indus- try. Young male sex workers sell their services—negotiat- ing with sex, condoms, work, and social stigma while liv- ing 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).

Over 600,000 HIV-positive individuals live in Thailand, with over 20,000 new cases each year (Ratanasuwan, Anekthanoanom, Techasathit, Rongrungruang, Sonjai, & Suwanagool, 2005). More recently, over 80 percent of Thai HIV-positive individuals are 20 to 39 years old, and the ratio of males to females with HIV is 2:1, as opposed to 6:1 in the early 1990s (Sunthrajarn et al., 2005).

At present, the major route of HIV transmission in Thailand is through sexual activity (!85 percent in 2004). This is because many Thai males frequent female or male CSWs without using a condom (Centers for Disease Control and Prevention [CDC], 2006; Sunthrajarn et al., 2005). Even though prostitution is illegal in Thailand, the country has over 200,000 sex workers at any given point in time (Manopaiboon et al., 2003). Only 27 percent of Thai customers use a condom, whereas 52 percent of other Asian customers and 76 percent of Western cus- tomers use a condom when they visit female CSWs in Thailand (Buckingham & Meister, 2003).

Many men in Thailand have sex with women other than their wives (Sunthrajarn et al., 2005). 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, approximate 85 percent had frequented female CSWs without using a condom. Over half of the wives were not aware of their husbands’ promiscuity (Bennetts, Shaffer, Phophong, Chaiyakul, Mock, Neeyapun, et al., 1999). 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.

Approximately 200,000 women and 1 to 2 percent of pregnant women in Thailand have contracted HIV (Joint United Nations Programme on HIV/AIDS, 2005; United Nations Children’s Fund, 2005). Furthermore, one study reported that at least 80 percent of Thai pregnant women with HIV experience depression (Ross & Srisaeng, 2005). Only 76 percent of HIV-positive Thai pregnant women receive antiretroviral medications as mother-to-child transmission prophylaxis, whereas all HIV-positive preg-

nant women in the Unites States receive the medications if there is no contraindication (United Nations Children’s Fund, 2005).

At present, newer and more prominently high-risk groups for contracting HIV include young Thai men who have sex with men, seafarers, amphetamine users, and drinkers (Sunthrajarn et al., 2005). 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 (Fongkaew, 2004). Moreover, a report shows that only 20 to 30 per- cent of sexually active young Thais use condoms consis- tently (United Nations Development Programme, 2004). Among Thai men who have sex with men, it is reported that 17.3 percent were HIV-positive in 2003 (Thanprasertsuk et al., 2005), but the rate went up to 28.3 percent in 2005 (CDC, 2006). Approximately 25 percent of these men also had sex with women without using condoms consistently (Thanprasertsuk et al., 2005).

Seafarers, highly mobile and working on boats far from land, have become a newly vulnerable group 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 sex- ually transmitted diseases, they tend to treat themselves by using over-the-counter medicine (Entz, Prachuabmoh, van Griensven, & Soskolne, 2001).

Amphetamine users and alcohol drinkers tend to have sex while they are high, which puts them at risk for hav- ing unsafe sex (Sunthrajarn et al., 2005). An estimated 600 million tablets of amphetamines are used annually in Thailand (Newton, Chierakul, Ruangveerayuth, Abhigantaphand, Looareesuwan, White, 2003). Thai names for amphetamines are Yaa Bah (literally means “crazy drug”) or Yaa Mah (literally means “horse drug,” from the horse emblem on the tablet) (Newton et al., 2003). The drug is 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 be agitated and harm oneself or others. Withdrawal from amphetamine use generally leads to excessive sleeping and hypoglycemia (Newton et al., 2003).

Overall, incidences of HIV infection cause severe financial, physical, emotional, and social disruption for Thai patients and their families. The medical care cost for one HIV infection in Thailand is over U.S. $600 per fam- ily per year (Sunthrajarn et al., 2005). In perspective, the gross national income in Thailand is U.S. $440, as opposed to U.S. $43,740 in the United States (World Bank, 2006). The long-term burdens posed by high rates of HIV/AIDS among Thais need to be studied, especially at the community level.

For Thais, family and extended family members are all considered within the Thai culture as a whole unit. Thus, when any member in the greater family suffers from HIV/AIDS (or any other hardship/illness), it affects each and every member in the family. Moreover, every family

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member has a responsibility to support a suffering mem- ber, through either emotional, financial, or other tangible means (Ross, Sawatphanit, Suwansujarid, & Draucker, 2007). One family member’s actions, whether negative 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 with HIV/AIDS. On the one hand, the concept of oneness can help to receive all kinds of sup- port from one’s family. For instance, the parents and sib- lings of sick persons are definitely expected to care for them. Also, maternal grandparents are expected to care for the sick person’s child if the child’s parents were to pass away owing to AIDS (Rende Taylor, 2005). On the other hand, the patient with HIV/AIDS can be abandoned owing to fears in the family of viral transmission and fam- ily disgrace (Bechtel & Apakupakul, 1999; Bennetts et al., 1999).

Studies show that when family support is not avail- able, critical emotional support from nurses can save HIV- positive pregnant Thai women’s lives and increase their self-esteem (Ross et al., 2007; Sawatphanit, Ross, & Suwansujarid, 2004). Therefore, health-care professionals should assess and offer emotional support for their Thai patients with HIV/AIDS, especially when family support for these patients does not exist.

SMOKING AND ALCOHOL CONSUMPTION

Smoking and alcohol consumption follow unsafe sex as the second and third most common risk factors found in the behavior of Thai people. Thailand has low smoking rates compared with those in other countries. From 1981 to 2004, smoking rates among Thais declined from 35.2 to 19.5 percent. Among Thai males, smoking rates fell from 63.2 to 37.2 percent, and among Thai females from 5.4 to 2.1 percent (Thailand Health Promotion Institute, 2006). These declining rates result from government cam- paigns that limit cigarette advertisements. Government campaigns also employ Thai celebrities as role models for nonsmoking (Ministry of Public Health, 2005).

Conversely, alcohol consumption has been an ever- increasing problem in Thailand. Alcohol consumption rates among adult Thais climbed from 26 percent in 1985 (Institute of Population and Social Research, 1985) to 32.7 percent in 2002 (Public Health Statistics, Ministry of Public Health, 2006). A report in 2003 showed that more than half of Thai drinkers consumed alcohol at least twice a week (Ministry of Public Health, 2005). The amount of alcohol consumed by Thais is found to be higher than that consumed by French, Americans, Japanese, and Filipinos.

In general, Thai men drink more alcohol than Thai women. Traditionally, Thai men have always used alcohol and smoked more than Thai women, in part due to dif- ferent social expectations between men and women (Assanangkornchai, Conigrave, Saunders, 2002). Owing to factors such as globalization and the imitation of other cultures, such expectations have been changing. The number of Thai female drinkers rose from 1 percent in 1996 to over 5 percent in 2003.

The highest rates for drinking are found among young Thais, aged 15 to 24 years, one third of whom engage in

drinking alcohol (Ministry of Public Health, 2005). One study found that the most common cause in the 1990s for first-time drinking among young Thais was peer pressure, followed by “wanting to try” and the socializing effects (Assanangkornchai et al., 2002). A more recent survey revealed that the number one factor causing young Thais to drink for the first time is socialization, followed by peer pressure and “wanting to try” (Ministry of Public Health, 2005).

Drinking is highly associated with road accidents around the world. In Thailand, over half of road accidents are caused by driving under the influence (DUI). In gen- eral, Thai rates for deaths from accidents are composed mostly of road accidents. The rate for deaths resulting from all accidents in 1984 was 5.74 deaths per 100,000 people. The rate had increased dramatically to 20.97 deaths per 100,000 people by 2002 (Ministry of Public Health, 2005).

The first law to specify a blood-alcohol limit for drivers in Thailand was passed several years ago, yet incidences of DUI continue to escalate (Ministry of Public Health, 2005). Clearly, there is a need for the Thai government to pass a stronger law that punishes drivers for incidences of DUI.

Nutrition

V I G N E T T E 2 1 . 1

Boon, a 25 year-old Thai man, is seeing a doctor at a free mobile clinic in California. Boon came to the United States a few years ago and now works as a cook at a Thai restaurant. His English is broken, and it is hard for the doctor to under- stand him. The doctor calls a Thai nurse who lives in town to be an interpreter. Through the interpretations, the doctor learns that Boon has some pain in his abdomen. He comes from the northeastern region of Thailand, or Isaan; he loves to eat spicy food, especially Som-Tum, with fermented fish as one of the ingredients. Boon is worried about his liver because his father died in Thailand from liver cancer.

1. What additional information regarding his food intake should be obtained from Boon? Why?

2. How can the nurse tell whether Boon’s pain is related to his stomach, his liver, or both?

3. How important is it to have a bilingual Thai-English interpreter at a clinic when a Thai American patient is not proficient in English?

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

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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 supple- ment rice. Overall, pork or chicken is eaten more than beef. All meats are consumed more sparingly in propor- tion 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 cul- ture. 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 com- munal dishes and others use 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 veg- etables.

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 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. 21–6). 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 ingre- dients mentioned previously. The soup’s antimicrobial effects come from its chilies, onions, and garlic (Siripongvutikorn et al., 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 eat- ing raw fermented fish, which contains Opisthorchis viver- rini, 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 contain- ing a high quantity of fat and meat, related to the coun- try’s evolution from an agricultural to a newly industrial- ized 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 chil- dren 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/or 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 con- sume enough fruits and vegetables; not enough bread and milk; and too much meat, fats, oils, and sweets. Health

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FIGURE 21–6 Tom-Yum Koong with lemon grass.

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professionals in the United States should assess their Thai clients’ 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

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 iodiza- tion in a northern province. Owing to its success, the pro- ject has been further expanded. The first IDD survey, con- ducted 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 gov- ernment examines goiter rates among school children in 15 northeast and northern provinces and uses them as the Thai IDD indicator (Ministry of Public Health, 2005).

Despite the salt iodization program success, at the 2004 Review of Progress towards 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 is 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 ingest enough iodized salt, and 375,000 newborns may suffer from IDD. However, no evidence exists that the Thai Ministry of Industry and the U.S. Food and Drug Administration are working with salt pro- ducers in monitoring salt iodization activities (Network for Sustained Elimination of Iodine Deficiency, 2004).

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 psy- chopathology (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 emotion- ally (Nigenda, Langer, Kuchisit, Romero, Rojas, Al-Osimy, 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 pregnancy are excessive white vaginal dis- charge, frequent urination, and morning sickness (Nigenda et al., 2003). Owing to modesty, especially dur- ing 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

V I G N E T T E 2 1 . 2

Nin, a 35-year-old Thai, comes to the prenatal clinic. She shows a nurse a safety pin over her belly on her maternity cloth. She also states that postpartum, she will need to follow her mother’s advice regarding beliefs of “hot” and “cold.” When informed by her doctor about her gestational diabetes and hypertension diagnoses, Nin looks worried and states that she probably got the disorders from her “Karma.”

1. What additional information should the nurse obtain from Nin regarding her “hot” and “cold” practices after delivery?

2. What should be the response of the nurse when Nin shows him or her the safety pin?

3. What should the nurse ask Nin about her belief in “Karma” and her illness?

The descriptions in this section are based on literature review and the authors’ experience working with preg- nant and postpartum Thai women. During the childbear- ing 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

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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 dis- couraged 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, 2003b). 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 eat- ing eggs may result in having smelly newborns (Nigenda et al., 2003). Some avoid drinking coconut juice, believ- ing 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 mother’s womb. Also, pregnant Thai women, especially those with Chinese descendents and their families, may ask their obstetric physicians to perform selective cesarean sec- tions, 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., 2007).

Like many other Southeast Asian women, postpartum Thai mothers practice the concept of “Yin” and “Yang” (cold and hot) (Kaewsarn, Moyle, & Creedy, 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 ill- ness and bone ache prevention (Kaewsarn et al., 2003a). Some drawbacks of this ritual, however, include inconve- nience, discomfort, and complications, such as heat rashes, sweating, dehydration, and/or minor burns (Kaewsarn et al., 2003a). 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 per- son, Yue Fai is not possible.

When Yue Fai, the ultimate practice for gaining heat during the postpartum period, is not possible, Thai moth-

ers are advised by their mothers and/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., 2003a). Warm/hot drinks and foods are consumed; ice chips or ice cubes are avoided.

In general, all Thai mothers are allowed by their moth- ers to drink warm/hot nonalcoholic liquids. However, there is no consensus about the types of protein, veg- etable, and fruit the postpartum mothers should con- sume. Whereas some mothers are encouraged to eat cer- tain food items, others are not (Kaewsarn et al., 2003a). Many postpartum Thai women are not restricted to pro- teins, 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., 2003a). However, some mothers might be advised to not eat eggs, chicken, or buf- falo 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 rea- son 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, cab- bage, hairy melon, snake beans, chili, peppers, and bam- boo shoots (Kaewsarn et al., 2003a). 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. 21–7). 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

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FIGURE 21–7 Beautiful Thai fruits at a commencement ceremony.

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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.

Death Rituals DEATH RITUALS AND EXPECTATIONS

Because most Thais are Buddhists, only the funeral rites in connection with Buddhism are addressed here. Like other Buddhists, Thai Buddhists believe that after a person dies, the person will be reborn somewhere else based on that person’s Karma (Dhammanada, 2002). “Karma means ‘action’ and . . . refers to the process by which a person’s moral behavior or actions have consequences for the per- son’s future, either in the present or later life” (Ross et al., 2007, p. 4).

In general, Thai Buddhists follow the custom of cre- mating the bodies of the deceased because, when the Buddha passed away, his body was cremated. According to the Buddha’s teaching, a funeral ceremony should be simple. Unfortunately, many Thai Buddhists (and some other Buddhists) have transformed what was a tradition- ally simple cremation ceremony into one that is overly extravagant.

“The consciousness or mental energy of the departed person has no connection with the body left behind . . . . A dead body is simply an old rotten simple house which the departed person’s life occupied. The Buddha called it ‘a useless log.’ Many people believe that if the deceased is not given a proper burial or if a sanctified tombstone is not placed on the grave, then the soul of the deceased will wander to the four corners of the world and weep and wail and sometimes even return to disturb the relatives. Such a belief cannot be found in Buddhism” (Dhammanada, 2002, p. 246).

In the funeral ceremony, often Buddhist monks are invited to chant verses to the dead and the family (Fig. 21–8). Food and candles are offered to the monks. Many

Thai Buddhists believe that such chanting will benefit the spirit of the dead, regardless of Buddha’s teaching about the unbound relationship between the body and the spirit. The ashes from the cremation are buried at a ceme- tery. Sometimes, a portion of the ashes is sprinkled in a river. If possible, when the family of the dead returns home after a sojourn away from Thailand, some of the ashes may be sprinkled again in a river or near the deceased’s hometown.

RESPONSES TO DEATH AND GRIEF

During the funeral ceremony, the family gets together. The sons of the deceased are expected to be ordained for a short period of time, ranging from a week to 3 months. The ordination is believed to help the dead go to heaven. Female relatives normally wail quietly. The family mem- bers pray quietly to the dead before the cremation to ask for forgiveness and wish the dead to be reborn in a happy and peaceful home. Often, in their prayer, family mem- bers wish for themselves to be reborn in the same family with the same relation to the dead in their next life.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

Approximately 95 percent of the Thais are Buddhist; the rest are Muslim (4.6 percent), Christian (0.7 percent), and Hindu or other (0.1 percent) (CIA, 2006). In the United States, over three million people are Buddhist, most com- ing from Asian countries, including Thailand (Eck, 2001). Buddhism is an exceptionally tolerant religion with its roots in Hinduism. Although precepts grounded in Buddhism (as discussed later) are fundamental to the spir- itual make-up of most Thais, animistic beliefs generally have equal meaning for them and play a parallel role in their belief system.

Although not in agreement with all other religious beliefs, Thai Buddhists are free to incorporate any other religious values and/or animism to their beliefs and prac- tices when deemed good. Most Thais in all socioeconomic strata to some degree incorporate animism, fortune- telling, and astrology. Studies have shown that ancient spirits are prayed to by many Thai patients (or their care- givers) and fortune-telling plays a major role in how Thais deal with illnesses (Ross et al., 2007; Rungreangkulkij & Chesla, 2002).

Many families in Thailand have a spirit house where they believe that the ancient spirits of the land (Pra Poom) dwell: Two little statues of the Pra Poom (one male and one female) are placed inside a unique little abode that rests on a post or column. This house is usually at least as high as the eye level of an adult so as to indicate the respect of the family for the Pra Poom. Their abode can be either very simple or quite decorative, depending upon how much the family can afford, and faces either north or east (in the belief that these two directions are superior to the south and west). Miniature figures of a couple of horses and elephants are often placed in front of the Pra Poom figures to accompany them. Fresh flowers, food, and

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FIGURE 21–8 A Buddhist funeral.

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drink are placed in tiny plates, bowls, and cups as offer- ings. These may be placed everyday, or about once a month. The family members pray to the Pra Poom as often as they wish. Usually, the family prays and gives offerings to the Pra Poom more often when asking for blessings and faster healing of an ill family member.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

For most Thais, family support along with Buddhism is a crucial source of strength. In the Thai culture, parents are obliged to care for their ill children, regardless of a child’s age or type of illness (Rungreangkulkij & Chesla, 2002; Sunthrajarn et al., 2005). Children or the unborn babies of HIV-positive pregnant Thai women have been identi- fied as a major source of strength for their mothers (Jirapaet, 2001; Ross et al., 2007).

In a study among Thai mothers of schizophrenic adult children, the mothers practiced “Thum-jai” as a way to cope with a situation perceived to be unchangeable (Rungreangkulkij & Chesla, 2002). Thum-jai means “let it be” or “whatever will be, will be.” By practicing Thum-jai, a person will be able to accept the reality of a challenge or problem and try to move on in his or her life with calm- ness and peace. The mothers in Rungreangkulkij and Chesla’s study (2002) stated that when their sick children misbehaved, they smoothed their own heart with “water.” For the Thai, a metaphor of “water versus fire” indicates “calmness versus anger/frustration.” The “fire” should be put out by “water” in a person’s heart to defeat a crisis situation. The mothers in this study offered that calmness and gentle speech usually worked better than scolding in calming down their schizophrenic children (Rungreangkulkij & Chesla, 2002).

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Buddhism significantly pervades the life of many Thais (Burnard & Naiyapattana, 2004). When coping with diffi- culties or illnesses, many Thai lay people and health-care professionals follow Buddha’s teaching (Ross et al., 2007; Sunthrajarn et al., 2005). Like most Buddhists, the ulti- mate goal for a Buddhist Thai is to reach Nirvana. This is the end of reincarnation or the cycle of rebirths. When there is no rebirth, there is no suffering. Either they are happy or suffering. “Peace” is the ultimate goal (Dhammanada, 2002). Results from a study reflect this belief by reporting that the ultimate goal of HIV-positive postpartum Thai women (alongside goals for their chil- dren) is to live with their HIV infection in peace. The women thus stated that they followed the Buddha’s teachings through their beliefs in Karma, the Five Precepts, and the Four Noble Truths in order to live in peace with HIV (Ross et al., 2007).

As mentioned earlier, Karma is strongly associated with belief about rebirth. Many Thai patients (or caregivers) believe that unwholesome Karma from their past life has caused them to become ill in the present life. They believe that the illness can be improved by following the Five Precepts so that their present or next life (or the lives of

their loved ones) will be improved (Ross et al., 2007). Merit making—a way to decrease selfishness and greed and a way to be hopeful for a better present and future life—is performed by many Thais. Merit making includes activities such as freeing animals or birds, donating money to the poor or temple, offering food to monks, and tangibly helping those in need, emotionally, or finan- cially (Ross et al., 2007; Tongprateep, 2000).

The Five Precepts are comparable with half of the Christian Ten Commandments and stress abstinence from killing, stealing, lying, sexual misconduct, and illicit drugs and alcohol consumption (Smith, 1994). A study with seven HIV-positive postpartum Buddhist Thai women revealed that the participants all decided to carry their pregnancies to term instead of ending them. They all stated that ending a pregnancy is a type of killing, which is considered a sin. Furthermore, all of the women in this study believed that such unwholesome action would follow them in their next reincarnation as bad Karma (Ross et al., 2007). In another study, it was found that the Five Precepts are observed by older Thai people to help them feel happy and peaceful (Tongprateep, 2000).

The Four Noble Truths reflect tenets about life, suffering, and the cessation of suffering. The First Noble Truth main- tains that life is suffering, and that suffering as such is found in four unavoidable life moments; namely birth, illness, aging, and death. The Second Noble Truth main- tains that the cause of all suffering is Tanha, or personal desire. The Third Noble Truth is a belief that overcoming Tanha is attainable. The Fourth Noble Truth outlines paths to end suffering (Smith, 1994).

A qualitative study reported that the Four Noble Truths were followed by HIV-positive pregnant Thai women to cope with their infection (Ross et al., 2007). The women stated that they began dealing with their illness by accepting the truth that everyone dies anyway at some point in life (The First Noble Truth) and that their suffering came from their personal desire (The Second Noble Truth). In other words, their desire arose by thinking of them- selves as a real existence in the world rather than as an illusion. “Self” is like a mirage, or an imagined being (Flanagan, 2005). Therefore, when a person becomes self- less, the person is freed from suffering (Smith, 1994). The women in the study tried to think that their body and soul were not theirs, but instead imagined elements. To overcome desire, the participants tried to focus on uni- versal life (The Third Noble Truth) by thinking about their infants instead of themselves and by meditating and praying. They also tried to follow the Middle Way, or a path between the two extremes of self-pleasure and self- mortification (Dhammanada, 2002), as a means to end their suffering. In accordance with the Buddha’s teaching that any extremes of thoughts, behavior, or speech are not wholesome, they reported trying not to feel too badly about themselves in order to be peaceful.

Meditation and prayer are ways for many Thais to cope with an illness. Studies revealed that both Thai pregnant and nonpregnant women meditated and prayed to the Buddha and supreme beings in order to help them cope with HIV/AIDS (Dane, 2000; Jirapaet, 2001; Ross et al., 2007). Meditation is a means for Thai older people to enhance their self-awareness, peace of mind, sleep, and

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physical health (Tongprateep, 2000). For Thai older peo- ple in the United States, meditation and prayer also help them feel peaceful, perceive life as valuable, value tran- quil relationships with family and friends, and experience meaning and confidence in death. For Thais, health and spirituality are intertwined and are important aspects of life (Pincharoen & Congdon, 2003).

In conclusion, the spiritual concepts of Karma, Nirvana, the Five Precepts, the Middle Way, and the Four Noble Truths are all important for Buddhist Thais. Ideally, when health professionals in the United States are aware of Buddhist concepts in caring for their sick or healthy Thai clients, the quality of care can be significantly enhanced.

Health-Care Practices

V I G N E T T E 2 1 . 3

Wan, a 60-year-old married Buddhist Thai American, diag- nosed with cervical cancer, has been coming to a hospital for chemotherapy since her diagnosis. Today, Wan is being admitted to the hospital for the therapy. While Wan’s nurse is entering her room, Wan is closing her eyes with the palms of her hands put together and facing a little Buddha image she brought with her from home.

1. If you were the nurse, what would you do at that moment?

2. What additional information would you want to get from Wan in terms of her Buddha image in relation to her illness?

3. Identify a culturally related mental health problem for Wan related to her illness.

4. Identify helpful culturally congruent interventions regarding Wan’s spiritual beliefs.

HEALTH-SEEKING BELIEFS AND BEHAVIORS

In Thailand, most Thais rely on government health-care facilities, especially in the northeast region, or Isaan. People in Isaan hold strong traditional beliefs and prac- tices. They tend to be poorer and less educated than the rest of the country. In the Isaan area, statistical rates of gynecological problems are relatively low, yet, Isaan women’s self-reports show high rates of gynecological complaints associated with vaginal discharge and pain “in the uterus” (Boonmongkon, Nichter, & Pylypa, 2001). This contrast is often explained by a lack of comprehen- sion among some Isaan women who do not understand clearly the physiological changes of their menstrual cycle and the amount of vaginal discharge. Some of the pain “in the uterus” with which they are concerned may well be related to physiological pain during ovulation.

Boonmongkon and colleagues (2001) reported that Isaan women’s complaints and concerns about vaginal dis- charge and pain in the uterus may have an extreme impact on their lives. The women believe that such problems will turn into cervical cancer. This belief causes them to visit health-care facilities often, self-treat by relying on small doses of inappropriate antibiotics, be unhappy with their

sexual relationship with their husband, and suffer from worries of their “ailments” (Boonmongkon et al., 2001).

Most Isaan women in Boonmongkon and colleagues’ study (2001) believed that their sustaining problems of vaginal discharge and pain “in the uterus” stemmed from their inappropriate practices after postpartum or signifi- cant past events. For instance, over 25 percent of the women stated that their chronic symptoms resulted from their inadequate practices of “lying by fire” and this caused their uterus to stay wet. Examples of other past experiences that the women believed caused their sustain- ing gynecological problems include hard work in youth, abortion, pushing too hard during delivery, and steriliza- tion. Some women in the study indicated that they did not receive adequate information about their problems from health professionals but did not feel like asking ques- tions for fear of being scolded. Therefore, U.S. health-care professionals should bear in mind that Thai women, espe- cially from Isaan, may need more information regarding physiological changes related to their menstrual cycle and may need encouragement to ask any questions they have regarding their gynecological concerns.

RESPONSIBILITY FOR HEALTH CARE

Health promotion and disease prevention behavior among the Thais is very limited. Although all Thais are covered by some kind of health insurance, including the Universal Coverage of Health Care Scheme (75-cent health care), only 5.3 percent of the population used health promotion services, which include immunization, prenatal care, family planning, postpartum care, yearly check-ups, den- tal care, and some other services (Ministry of Public Health, 2005). Among those who did use such services, one-third went to urban health centers, 28.7 percent to community hospitals, and 11.3 percent to general/ regional hospitals. One-third of the services used were yearly check-ups and one-third included immunization (Ministry of Public Health, 2005).

FOLK AND TRADITIONAL PRACTICES

Folk practices are common among less educated, rural Thais. Many Thais believe that bad Karma and/or negative supernatural power causes mental illness. Therefore, folk therapies from traditional healers are the first resource for many Thai families. When such therapies do not seem to work, they go to contemporary medical facilities as their second resource. Folk therapies may include healing cere- monies, using shamans (as a mediator) to converse with supernatural beings (such as black magic, evil beings, and/or ancient/natural spirits), negotiating with them that the sick person might be released from their illness. In such ceremonies, holy water or oil is usually used to anoint the sick (Rungreangkulkij & Chesla, 2003).

Khwan is a Thai concept about the “power inside,” or the “life spirit.” Thais believe that Khwan enters the new- born’s anterior fontanel during delivery. Khwan is differ- ent from self-esteem; it is thought of as a “life force” that can vanish when people are in a stage of shock, mental ill- ness, or far away from home (Burnard & Naiyapattana, 2004). In a Khwan ceremony, fresh flowers are offered by

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the sick or the person who has lost her or his Khwan. A monk or an older person then ties a blessed white thin string around a person’s wrist, believing that the blessed string will tie the Khawn again to the person’s body (Burnard & Naiyapattana, 2004).

BARRIERS TO HEALTH CARE

For Buddhists, when one is too extreme in one’s speech, thoughts, or behavior, it is considered unwholesome, as based on their belief in the Middle Way (Dhammanada, 2002). In this sense, some Buddhist Thais may not seek health care until their symptoms become severe. In addi- tion, stigmatization attached to mental illness and beliefs in animism and Karma tend to prevent some Thais from seek- ing professional help when mental health problems arise. Some may not seek assistance from health-care profession- als until they realize that traditional healers, Shamans, can- not help them (Rungreangkulkij & Chesla, 2003).

CULTURAL RESPONSES TO HEALTH AND ILLNESS

Adhering to their belief in the Middle Way, many Thais may appear stoic in trying to withhold expressions of pain or suffering from their illness. Health-care profes- sionals may need to rely more on nonverbal clues for pain or some psychological-emotional distress when assessing their Buddhist Thai patients.

Many Thais, and even some health professionals, equate depression with psychosis (Ross et al., 2007). Thus, when clinical depression is diagnosed, health-care professionals should make extra efforts to encourage depressed Thai patients to get help and treatment, along with assuring them that depression and psychosis are different disorders.

BLOOD TRANSFUSION AND ORGAN DONATION

No religious beliefs against blood transfusion exist for Thais. However, donating and receiving organs is another matter. Although acceptable among many Thais, belief in their rebirth might prevent some from donating their organs, believing that they might not have the organ when needed in the next life.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONER

Like Hindus, Thais in the United States and elsewhere tend to consult their family and friends first when they feel ill or have medical problems. Thai women usually seek female practitioners for childbearing care and gyne- cological problems owing to their modesty and their cul- ture. However, if female practitioners are not available, they are generally willing to accept male practitioners. Traditional healers, or Shamans, in relation to Thai patients are discussed earlier.

STATUS OF HEALTH-CARE PROVIDERS

Respect for seniority is a strong cultural value among Thais. Thus, less-experienced health professionals in

Thailand are expected to respect those with more experi- ence in the same profession. In general, when comparing physicians, head nurses, and junior nurses, Thai physi- cians receive the most respect, followed by the head nurses and junior nurses (Fig. 21–9). In some cases, very senior head nurses receive the same level of respect as physicians (Burnard & Naiyapatana, 2004).

Based on a concept of “Thainess” as expressed by many Thais, and especially in terms of being Buddhist, Thai nurses reported that they often incorporate Buddhist ideas and beliefs in caring for their chronically ill patients (Burnard & Naiyapattana, 2004; Sawatphanit et al., 2004).

Like many other patients in developing countries (Withell, 2000), some Thai patients, especially those with lower socioeconomic status, are typically passive in voic- ing their needs and requesting care and services from health-care providers (Jirapaet, 2001). Therefore, health professionals, in North America or elsewhere, are advised to evaluate the level of passivity among their Thai patients so that their needs can be addressed with an eye toward optimal quality care.

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