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People of Korean Heritage

Chapter 17

EUN-OK IM

Overview, Inhabited Localities, and Topography OVERVIEW

This chapter focuses on the commonalities among people of Korean heritage, with historical reference to the mother country, South Korea. The word Korea limitedly refers to the Republic of Korea. Because some information may not be pertinent to every Korean, this chapter serves as a guide for health-care providers rather than as a man- date of facts. Differences in beliefs and practices among Koreans in Korea, the United States, and other countries vary according to the primary and secondary characteris- tics of culture as presented in Chapter 1. An understand- ing of Korean culture and history gives health profession- als the insight needed to perform culturally appropriate assessments, plan effective care and follow-up, and work effectively with Koreans in the workforce.

South Korea is a peninsula separated by North Korea to the north at the 38th parallel and surrounded by the for- mer Soviet Union to the northeast, the Yellow Sea to the west, and the Sea of Japan to the east. South Korea has a landmass of 98,480 square kilometers (38,031 square miles), which is about the size of the state of Indiana, and a population of 48 million (CIA, 2007). South Korea has 1 percent of the landmass of the United States, but has one- sixth as many people, making it 16 times more densely populated than the United States (Kohls, 2001). The mega-modern metropolitan area of Seoul, the capital, has a population of 10.3 million people (Asianinfo, 2007a). A new international state-of-the art airport is located in Incheon, 60 kilometers from the center of Seoul. Other large cities are Busan (Pusan) and Daegu (Taegu). Planes,

trains, and buses link all South Korean major cities, mak- ing travel easy and efficient. With the recent increase in the number of automobiles and the construction of high- ways, motorways are becoming more congested. Major industries are electronics, telecommunications, automo- bile production, chemicals, shipbuilding, and steel (CIA, 2007). South Korea is now well known as riding on the “hallyu movement” or the “Korean wave,” which is the globalization of Korean dramas throughout Singapore, Malaysia, Japan, China, and the United States. Since the 1990s, the entertainment industry of South Korea has grown explosively, producing Asia-wide successes in music, television, and film.

The continental and monsoon climate of Korea is fairly consistent throughout the peninsula, except during the winter months. North Korea has cold, snowy winters, with an average temperature in January of 17°F. South Korea is milder, with an average January temperature of 23°F. During the summer months, the monsoon winds create an average temperature of 80°F, with high humid- ity throughout the peninsula. Precipitation occurs mostly during the summer months and is heavier in the south. The peninsula is mountainous; only 20 percent of the ter- rain is located in lowlands. Such topography encourages the development of concentrated living areas. Most cities and residential areas are located along the coastal plains and the inland valleys opening to the west coast.

HERITAGE AND RESIDENCE

Korea is one of the two oldest continuous civilizations in the world, second only to China. Koreans trace their her- itage to 2333 B.C. In the 1st century A.D., tribes from cen- tral and northern Asia banded together to form this “Hermit Kingdom,” littering the countryside with palaces,

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pagodas, and gardens. Over the ensuing centuries, Mongols, Japanese, and Chinese invaded the Korean peninsula. Japan forcibly annexed Korea in the early 20th century, ruling it harshly and leaving ill will that persists to this day. As a result of the Potsdam Conference after World War II, the United States took over the occupation of South Korea, with the USSR occupying North Korea. By 1948, Korea’s new government was recognized by the United Nations, only to be followed by the North Korean Communist forces invading South Korea in 1950. The result was the Korean War, which lasted until 1953 and caused mass devastation, from which the country has made a remarkable recovery. Open aggression between North and South Korea again occurred in 1998 and 1999. In 2000, the two Koreas signed a vague, yet hopeful, agreement that the two countries would be reunited. However, North Korea’s recent resumption of its nuclear weapons program has set its neighbors and much of the rest of the world on edge (CNN, 2007).

In 1988, the year Seoul hosted the Olympic Games, elections were held, and relations were re-established with China and the Soviet Union. Intermittent corrup- tion among political officials has continued to surface, threatening internal relationships and the economy. In 1997, South Korea’s economy tumbled dramatically, resulting in economic and democratic reforms. With unwavering persistence, Koreans have rebuilt their major world economy, reflecting a 4 percent annual growth rate with moderate inflation (CIA, 2007). The United States continues to maintain a strong military presence throughout South Korea (Fig. 17–1).

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Koreans are one of the most rapidly increasing immigrant groups in the United States (Korean American Coalition, 2003). The first major immigration from Korea to the United States occurred between 1903 and 1905, when the Korean government prohibited further emigration: About 10,000 Koreans had entered Hawaii and 1000 reached the U.S. mainland. The U.S. Immigration Act of 1924 practi- cally closed the door to Japanese and Koreans. During the civil rights movements of the 1950s and 1960s, new immigration laws repealed the earlier limitations on Asian immigration. Koreans continue to immigrate to America to pursue the American dream, to increase socioeconomic opportunities, and to attend colleges and

universities. In addition, many Koreans and Americans marry, making both Korea and America their homes. Korea ranks fourth in the number of Asian immigrants to the United States, with 1.3 million, closely following the Philippines, China, and Vietnam (Shin & Shin, 1999). According to the 2003 Statistical Yearbook of the Immigration and Naturalization Service, 12,512 Koreans were admitted to the United States in 2003 (U.S. Department of Homeland Security, 2004).

EDUCATIONAL STATUS AND OCCUPATIONS

Most of the population pursues higher education, and South Korea has more citizens with PhDs per capita than any other country in the world. Owing to Confucian cul- tural influence, education is emphasized as a virtue of human beings (all human beings should be educated) and is highly valued in the Korean culture (Im, 2002).

Before the late 19th century, education was primarily for those who could afford it. State schools educated the youth from the yangban (upper class), focusing on Chinese classics in the belief that these contained the tools of Confucian morality and philosophy that also apply in politics. In the late 1800s, the state schools were opened to all citizens. Early Christian missionary work introduced the Western style of modern education to Korea. Initially, many Koreans were skeptical of the radi- cal curriculum and instruction for females, but the popu- larity of this style grew rapidly.

After the takeover of Korea by the Japanese in 1910, two types of schools emerged, one for Japanese and another for Koreans. The Korean schools focused on voca- tional training, which prepared Koreans for only lower- level positions. Japanese colonial education was designed to keep Koreans subordinate to ethnic Japanese in all ways (Sorensen, 1994). In 1949, South Korea allowed for the implementation of a educational system similar to that of the United States. This 6–3–3–4 ladder (6 years in elementary school, 3 years in junior high, 3 years in high school, and 4 years in college) continues today in con- temporary South Korea. Anti-Communism and morality are taught throughout elementary and secondary schools.

In the United States, many Koreans own their own small businesses, which vary from mom-and-pop stores and gas stations to grocery stores and real estate agencies to retail shops. Their reputation for hard work, indepen- dence, and self-motivation has given them the reputation of the “model minority.” However, this has caused a back- lash in some communities, such as Washington, DC, where they have been compared with other minority groups. The message has become: “If the Koreans can do it, why not other groups?” The turmoil and riots that took place in Los Angeles in April 1992 between the African American community and the Korean American mer- chants is another example of conflicts that arise from such labeling.

Many Korean small businesses are located in African American neighborhoods because of low capital invest- ment requirements and limited resources of the owners. Korean merchants begin dealing in inexpensive consumer goods as a practical way to start a business in a capitalistic society. Koreans often assist each other in establishing

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businesses by pooling their money and taking turns with rotating credit associations to provide each family with the opportunity for financial success.

Communication VIGNETTE 17.1

Ho Park and Ok Park, ages 58 and 57 years, immigrated to New York from South Korea in 1984. They arrived with their four children and lived with Ok’s sister and her family for 2 years. They saved their money and eventually moved into a small two-bedroom apartment where they lived for 10 years. Later, they moved into a three-bedroom house in New Jersey where they have now lived for the past 12 years. Ho is a col- lege graduate from one of the top universities in South Korea, and Ok is a graduate from a prestigious women’s college in South Korea. Despite their college degrees, they have been working as housekeepers in a hospital.

The three sons and one daughter have matured without any problem. The daughter, Teresha, is a nurse and works in Michigan. The oldest son, Eugene, is a military officer and lives with his wife in Maryland. The third son, Phyllip, is a graduate student in biology at the University of Minnesota. However, their second son, David, is not doing well. Since he graduated from high school, 3 years ago, he has lived with Ho and Ok without getting a job. He sits on the couch and spends most of his time watching TV or playing computer games and gaining weight. Ho and Ok are concerned about him, but are unsure how to help him.

Ok has developed allergies and has difficulty breathing when exposed to chemicals used in her cleaning job at the hospital. In addition, she is having serious backaches that she links to using heavy equipment. However, she can not quit her job because her husband’s salary will not meet their finan- cial needs, which include university tuition for Phyllip and a home mortgage. Despite her health problems, Ok takes full responsibility for household tasks such as cooking, dish- washing, and laundry.

With Ok’s health problems and David’s unemployment, Ho is thinking about opening a small Korean grocery store. However, he has heard many strories of Koreans who opened small businesses and went bankrupt or got killed by robbers. Considering that he is not a friendly person who easily smiles or welcomes customers, he believes that he would not be good at operating a Korean grocery store. Even thinking about the new business makes him smoke more than usual: He has smoked a pack of cigarettes daily for the past 30 years, and now smokes more than a pack a day. Recently, he is experiencing frequent coughing and short- ness of breath.

1. How does the Park family fit the “model minority” cul- ture and work ethic?

2. Identify three health concerns for the Park family and describe culturally congruent strategies for resolving them.

3. Identify how Korean traditional gender roles are affect- ing Ok’s health problems and family dynamics.

4. Describe Koreans’ traditional attitudes toward smoking and discuss interventions for Ho’s smoking.

DOMINANT LANGUAGE AND DIALECTS

The dominant language in Korea is Korean, or han’gul, which originated in the 15th century with King Se Jong, and is believed to be the first phonetic alphabet in East Asia. The Korean language belongs to the Ural-Altaic lan- guage family, which includes Turkic, Mongolian, and Tungusic as major branches (Comrie, Matthews, & Polinsky, 1996). Dialects do not exist in Korean, but slang terminology is characteristic of specific age groups and regions.

Korean language has four levels of speech that are determined based on the degree of intimacy between speakers. These varying levels reflect inequalities in social status based on gender, age, and social positions. Use of an inappropriate sociolinguistic level of speech is unac- ceptable and is normally interpreted as intended formal- ity to, disrespect for, or contempt to a social superior.

Chinese and Japanese have influenced the Korean lan- guage, which has 14 consonants and 10 vowels. During their annexation in the early 20th century, the Japanese forbade public use of the Korean language, requiring the use of the Japanese written and spoken language.

Most Koreans in the United States can speak, read, write, and understand English to some degree. However, some Americans may have difficulty understanding the English spoken by Koreans, especially those who learned English from Koreans who spoke with their native into- nations and pronunciations.

CULTURAL COMMUNICATION PATTERNS

The sharing of thoughts, feelings, and ideas is very much based on age, gender, and status in Korean society. Traditionally, the Korean community values the group over the individual, men over women, and age over youth. Those holding the dominant position are the deci- sion-makers who share thoughts and ideas on issues.

Koreans prefer indirect communication because they perceive direct communication as an indication of inten- tion or opinions as rude. Moreover, Koreans may agree with the health-care provider in order to avoid conflict or hurting someone’s feelings, even if something is impossi- ble (Im, 2002). Thus, it is important to read between the lines when working with these families and remember those growing up in the United States may adopt the dominant American communication style.

Koreans tend to avoid eye contact especially with older people, perceived authorities (e.g., health-care providers), and strangers. Avoiding direct eye contact with older peo- ple and perceived authorities indicates respect, and women’s avoiding direct eye contact with men shows modesty. Younger generations of Koreans educated in the United States may adopt the dominant communication style of eye contact. Koreans are usually comfortable with silence owing to Confucian teaching, “silence is golden.” Silence was traditionally emphasized as a virtue of edu- cated people. Even among Korean Americans, people who are silent, especially men, are viewed as humble and well- educated. However, the social fabric and cultural norms of Koreans are changing as they interact with Western societies and culture. Younger generations of Koreans,

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even in South Korea, are noted as being very sociable and kind to visitors (Asianinfo, 2007b).

Close personal space (less than a foot) is shared with family members and close friends, but it is inappropriate for strangers to step into “intimate space” unless needed for health care (Im, 2002). Visitors from America may be uncomfortable with Koreans’ spatial distancing in public spaces. Koreans stand close to one another and do not excuse themselves if they bump into someone on the street. This may be due to the high population density in the metropolitan areas of South Korea (1274 per square mile) and Koreans’ cultural attitudes toward strangers (e.g., they usually do not speak with strangers). Among family members and close friends, touching, friendly pushing, and hugging are accepted. However, among strangers, touching is considered disrespectful unless needed for care. Also, touching among friends and social equals of the same sex is common and does not carry a homosexual connotation as it might in Western societies. However, more social etiquette rules apply when it comes to touching older family members or those of higher social status. Hugging and kissing recently have become common among parents and young children as well as among young children and aunts or uncles.

Feelings are infrequently communicated in facial expressions. Smiling a lot shows a lack of intellect and disrespect. One would not smile to a stranger on the street nor try to joke during a serious conversation. Joking and amusement have their designated times. In Korea, men frequent bars after work and may express their sense of humor in this setting. Men and women alike appreciate and encourage jokes and laughter in appropriate settings. Koreans generally do not express their emotions directly or in public; expressing emotions in front of others, including family members, is regarded as shameful, espe- cially among men (Im, 2002). A common Korean belief related to men’s emotions is that men should cry only three times in their lives: (1) When they are born, (2) when their parents die, and (3) when their country per- ishes (Im, 2002). Given these cultural communication patterns, health-care providers should not interpret these nonverbal behaviors as meaning that Korean clients are not interested in, or do not care about, information pre- sented during health teaching and health promotion interventions.

TEMPORAL RELATIONSHIPS

Traditional Koreans are past-oriented. Much attention is paid to the ancestry of a family. Yearly, during the Harvest Moon in Korea, chusok (respect) is paid to ancestors by bringing fresh fruits from the autumn harvest, dry fish, and rice wine to gravesites. However, the younger and more-educated generation is more futuristic and achieve- ment oriented.

In Korea, palm readers are visited to determine the best home to purchase, the date for having a wedding, and when new businesses should open. The busiest time of the year for the palm reader is just before the Chinese New Year. Koreans are eager to know their fortune for the com- ing year. Many believe that misfortunes occur because ancestors are unhappy. During these times, families show

respect to ancestors by more frequent visits to their gravesites in the hope of appeasing the spirits. Shamans are also used in Korea to rid homes and new places of busi- ness from spirits, and they may be used by Koreans of all socioeconomic levels.

The Korean conception of time depends on the cir- cumstances. Koreans embrace the Western respect for time for important appointments, transportation connec- tions, and working hours, all of which are recognized as situations in which punctuality is necessary. Yet, socially, Korean Americans arrive at parties and visit family and friends within 1 to 2 hours later than the agreed-upon time. This is socially acceptable when the person or fam- ily is waiting at home. If the social meeting is being held in a public setting, a half-hour time span for arrival at the meeting place can be expected.

FORMAT FOR NAMES

The number of surnames in Korea is limited, with the most common ones being Kim, Lee, Park, Rhee or Yi, Choi or Choe, and Chung or Jung. Korean names contain two Chinese characters, one of which describes the gener- ation and the other the person’s given name. The sur- name comes first; however, because this may be confus- ing to many Americans, some Koreans in the United States follow the Western tradition of using the given name first, followed by the surname. Adults are not addressed by their given names unless they are on friendly terms; individuals should be addressed by their surname with the title Mr., Mrs., Ms., Dr., or Minister.

Given the diversity and acculturation of Korean Americans, health-care providers need to determine the Korean clients’ language ability, comfort level with silence, and spatial-distancing characteristics. In addi- tion, Koreans should be addressed formally until they indicate otherwise.

Family Roles and Organization VIGNETTE 17.2

Kay and Sook Lim, ages 55 and 57 years, immigrated from Korea in 1988 at the invitation of Kay’s brother who lived in Chicago. They came to Chicago with only $200 and began working as clerks in a Korean laundry. Owing to Kay’s excellent management skills and Sook’s diligent work ethic, they have been able to establish a real estate business. They now live in a prestigious home and regularly donate money to their church. Their fellow church members frequently tell them that they are role models for the many Korean immigrants in the area.

The Lims have two children: one daughter and one son. Their daughter, Grace, of whom they were very proud, was one of the top students in her high school and entered Cornell University, a special honor for them. However, she married a white man, became pregnant, and abandoned her studies. Kay and Sook had to accept her marriage because of her pregnancy, but they did not let other relatives and friends know about her marriage. Grace moved to Los Angeles with her husband and does not want to see her parents again

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because they do not heartily approve of her marriage and pregnancy.

Their son, John, has recently been a family concern. Until Kay and Sook received a telephone call from a policeman, they did not know that he had been skipping classes. In addi- tion, they were unaware that he was coming home very late at night because they also came home late at night. John was involved in a gang fight in which a victim was badly hurt, necessitating additional expenses for an attorney.

Because of the circumstances of both children, Kay became very depressed and could not go to work. Moreover, they could not get help from a health-care provider or emo- tional support from relatives or church friends because they did not want others to know about these unfortunate occur- rences with their children. Furthermore, whenever John comes home late at night, he and Sook quarrel, which fre- quently results in physical altercations. Thus Kay becomes more depressed and separates herself from others.

1. What cultural strategies can a public-health case man- ager employ for Kay’s depression?

2. If the Lim family were to seek health care, what type of care provider would they most likely seek?

3. What cultural barriers exist for the Lim family in seek- ing mental-health counseling and obtaining social sup- port?

4. Discuss traditional Korean prescriptive, restrictive, and taboo practices for adolescents and young adults. How does the Kim family vary from these traditional prac- tices and values?

HEAD OF HOUSEHOLD AND GENDER ROLES

Fundamental ideas about morality and the proper order- ing of human relationships among Koreans are closely associated with kinship values derived mainly from Confucian concepts of filial piety, ancestor worship, funer- ary rites, position of women, the institution of marriage, kinship groups, social status and rank, and respect for scholars and political officials. Although constitutional law in South Korea declares equality for all citizens, not all aspects of society have accepted this. Korean culture is largely based on patriarchal and Confucian norms that subordinate women (Im, 2002). In Confucian traditional Korean families, the father was always the head of the family; he had power to control the family, and the family had to obey any order from the father. Wives did not share household tasks with their husbands, so they tended to be physically overloaded and psychologically distressed. Wives’ exploitation was hidden under Confucian norms that praised women who sacrifice themselves for their families and nation (Im & Meleis, 2001). Also, the wife was confined to the home and bore the major responsibility for household tasks; the husband was the breadwinner.

Among Korean immigrants in the United States, women hold the family together and play a vital role in building an economic base for the family and commu- nity, often sacrificing themselves in the immigration process. The Korean immigrant woman may have started as a cleaning woman or seamstress, then worked at a fast food restaurant, and then in a small shop owned with her husband. However, the women’s financial contributions

to the family usually do not change the gender roles: Their husbands still occupy center stage, exercise the authority, and make the major family decisions (Im & Meleis, 2001).

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

In contrast to the Western culture, in which mothering is individually fashioned and relies on the expertise of health-care providers, in the highly ritualistic Korean cul- ture, mothering is molded by societal rules and informa- tion is less frequently sought from health-care providers. In this context, mothers tend to view infants as passive and dependent, and they seek guidance from folklore and the extended family (Choi, 1995). In Korea, children over the age of 5 years are expected to be well behaved because the whole family is disgraced if a child acts in an embar- rassing manner. Most children are not encouraged to state their opinions. Parents usually make the decisions.

Korean families have high standards and expectations for their children, and “giving a whip to a beloved child” is the basis for discipline of children (Im, 2002). Thus, the pressure of high performance in school and entering a highly ranked university is prevalent among Korean chil- dren and adolescents (Im, 2002). Usually, Koreans are not happy with very masculine girls or very feminine boys (Im, 2002).

“Teaching to the test” is also common in Korea, but the role of teachers is also to encourage self-study. The future of Korean students is determined by their teachers’ recommendations, and this pressure can be extremely intense for students who are not doing well. The teaching style is one in which students listen and learn what is being taught. Regardless of private doubts, a student rarely questions a teacher’s authority. Korean children in America must be taught the teaching style in American schools, in which questioning is positive and is valued as class participation. Even if Korean American students understand the style of teaching, it can be difficult to know the appropriate timing for asking questions.

The pressure of doing well in school and attending a university of high quality leaves Korean adolescents little room for social interactions. Activities that interfere with one’s education are considered taboo for adolescents. In Korea, students frequently attend study groups after school or special tutoring sessions paid for by their fami- lies in preparation for examinations to enter a university. Short coffee breaks or snacks at local coffee shops or noo- dle houses are permissible, but then it is “back to the books.”

Dating is uncommon among high school students in Korea, although it is allowed. Adolescent girls are usually not allowed to spend the night at their friends’ houses, virginity is emphasized, and sexual activities and preg- nancy at puberty stigmatize the family across social classes. Although talking about sexuality, contraception, or pregnancy in public is taboo, close girlfriends or boyfriends exchange information on these topics or get their information from women’s magazines. Neither the school system nor the family assumes responsibility for sex education. Girls in elementary school are given a class

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regarding their menstrual cycle, but no information is given about sexual relations.

Once young adults have entered a university, they receive their freedom and are then permitted to make their own decisions about personal and study time. Group outings are common for meeting the opposite sex. Dating may occur from these group meetings and consists of movies, dinner, and walks in the park.

Issues arise between the first-generation Korean immi- grant parents and the second-generation children in rela- tion to conflicting values and communication. With rapid acculturation, the second generation often takes on the values of the dominant society or culture. Thus, parents who are of the first generation in most cases are chal- lenged when their second-generation children do not accept traditional values and ideals that they may still hold dear. The different cultures between the first-genera- tion parents and the second-generation children are some- times the cause of domestic violence. Most of the first gen- eration of Korean immigrants were educated in Korea, and they have a strong stereotype of Korean patriarchal cul- ture. However, because the second generation is educated in the United States (some of them never visited Korea), most second-generation individuals feel a spirit of insub- ordination and often quarrel. For some, physical abuse might be involved if they do not follow orders (Kim, Cain, & McGubbin, 2006; Kim & Chung, 2003; Park, 2001).

FAMILY GOALS AND PRIORITIES

In Korea, the family is described as “corporate,” in which family members have specific rights and duties within their family. A Korean cannot belong to more than one corporate family, and a family member replaces the roles of another family member who dies. This traditional cor- porate family is dissolving among both Koreans and Korean Americans. Usually, both parents work to provide every opportunity possible for their family. As each fam- ily member learns to adjust to the changing roles, conflict can result. Children adapt most easily to the new culture and may even take on the dominant culture’s values.

Lee and Lee (1990) studied the adjustment of Korean immigrant families in the United States in relation to roles, values, and living conditions between husbands and wives and parents and children. The findings showed a transition from an independent family structure, in which the woman had little knowledge of the man’s activities outside the home, to a joint family structure. Many activities were carried out together with an inter- change of roles at home. Conflict centered on undefined role expectations. In Korea, the roles of men and women were very clear. However, upon immigrating to the United States, men and women were faced with conflict- ing roles in the new culture and had to struggle to rede- fine them. Other conflict areas were the couple’s ability to speak English, the woman’s inability to drive, the degree of acculturation, the limited social contact, and the stres- sors of living in a new culture.

In Korea, education is a family priority. The outcome of having a highly educated child was a secure old age for the parents. Because of the dependent relationship between parents and their children, parents were more willing to

make drastic sacrifices for the advancement of their chil- dren’s education. Today, status is achieved rather than inherited in Korea. Education in Korea is a determinant of status, independent of its contribution to economic suc- cess.

Traditionally in Korea, parents expected their children to care for them in old age. Hyo (filial piety), which is the obligation to respect and obey parents, care for them in old age, give them a good funeral, and worship them after death, was a core value of Korean ethics. The obligation to care for one’s parents is written into civil code in Korea. The burden was on the eldest son, who was obliged to reside with his parents and carry on the family line. Such an arrangement made the generations dependent on each other. The son felt obligated to care for his parents because of the sacrifices they made for him. Similarly, he made the same sacrifices for his children and expected them to provide for him and his wife in their old age. Many of these traditions in Korea have changed. Some of the eldest children emigrated, leaving the responsibility for their parents to the siblings who remained in Korea.

Some older Koreans were brought to the United States without their friends and with minimal or no English skills. They often felt obligated to assist the family in any way possible by preparing meals or taking care of the children when the parents were not home. Decision-mak- ing for older people was hampered in their new culture. Korean older people were frequently consulted on impor- tant family matters as a sign of respect for their life expe- riences. Older people’s roles as decision-makers in the United States have shifted with the younger generation of Korean Americans wanting the final decision-making authority in their young families.

Traditionally, Koreans give great respect to their older people. Old age begins when one reaches the age of 60 years, with an impressive celebration prepared for the occasion. The historical significance of this celebration is related to the Chinese lunar calendar. The lunar calendar has 60 cycles, each with a different name. At the age of 60, the person is starting the calendar cycle over again. This is called hwangap. This celebration was more significant in the past when life expectancy in Korea was much lower than it is today. Despite a change in the direct role of older people in their families, older Koreans are socially well respected in Korea. In public, an older woman is called Halmoni (grandmother), and those who are not blood rel- atives call an older man Harabuji (grandfather). Older peo- ple are offered seats on buses out of respect and honor.

Traditionally, the extended Korean family played an important role in supporting its members throughout the life span. With the break up of the extended family, Korean Americans support each other through secondary organizations such as the church. The church assists new immigrants with the transition to life in the United States. The church is a resource for information about child care, language classes, and social activities (Im & Yang, 2006; Tritto, 2004). Korean Americans without family support may seek other Korean Americans who live in the area. With Korean Americans dispersed throughout the United States; however, this task can be difficult.

Whereas some Koreans inherit social status, many have the ability to change their status through their education

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and professions. Traditional Korean culture espouses respect not only for older people but also for those of val- ued professions. In modern Korea, professors, bureaucrats, business executives, physicians, and attorneys receive a high level of respect. Historically, those with the highest education were handsomely paid. Even though the salary differences between university professors and other pro- fessions have narrowed significantly in recent years in Korea, the status of the intellectual remains high. Similarly, the bureaucratic officer has a high social status, wielding much respect and influence.

ALTERNATIVE LIFESTYLES

Alternative lifestyles are usually frowned upon in Korean culture. Women who divorce suffer social stigma, the degree of which depends on the situation. However, recent changes in the Family Law in South Korea now per- mit women to head a household, recognize a wife’s right to a portion of the couple’s property, and allow a woman to maintain greater contact with her children after a divorce (U.S. Department of State, 2006). Partially owing to the law change, South Korea now has one of the high- est divorce rates in the world, with 47.4 percent of mar- riages ending in divorce (U.S. Department of State, 2006). Yet, the stigma of divorce remains strong among Koreans in both South Korea and the United States, and there is little government or private assistance for divorced women (U.S. Department of State, 2006). Mixed mar- riages, between a Korean and a non-Korean, are highly disregarded by some, and the Korean government makes it very difficult for these marriages to occur. Korean women who have married American servicemen are often the objects of Korean jokes and are ridiculed by some.

Living together before marriage is not customary in Korea. If pregnancy occurs outside marriage, it may be taken care of quietly and without family and friends being aware of the situation. In the United States, preg- nancy outside of marriage may not carry such a great stigma among the more acculturated.

As in other Asian cultures, homosexuality has not been accepted in Korean culture (Kimmel & Yi, 2004). Also, Korean’s understanding and knowledge of homosexuality are ambigous and limited (Kim & Hahn, 2006): Koreans think that homosexuality is an abnormal and impure modern phenomenon. Despite the recent coming out of several Korean homosexual entertainers in South Korea, those who have relations with a person of the same sex still remain “in the closet.” Personal disclosure to friends and family usually jeopardizes the family name and may lead to ostracism. The community may stigmatize both the family and the individual, making it difficult to con- duct their personal lives.

Workforce Issues CULTURE IN THE WORKPLACE

Korean Americans come from a culture that places a high value on education. Many Korean immigrants are college educated and held white-collar jobs in Korea. Moreover, it

is difficult for Korean immigrants to obtain work in the United States commensurate with their experience because of language difficulties, restricted access to corpo- rate America, and unfamiliarity with American culture (Im & Meleis, 2001). The skills and work experiences they had in Korea are often not accepted by American busi- nesses, forcing them to take jobs in which they may be overskilled while they save money to start their own busi- nesses. Korean American women frequently need to find jobs to assist the family financially, which may cause role conflicts between more traditional husbands and wives.

Korean Americans have a strong work ethic. They work long hours each week for the advancement of family opportunities. Family is the priority for Korean Americans, but on the surface, this may not always be apparent when long hours are devoted to work. The goal is to save money for education and other opportunities, so the family can provide for their children in the future.

The number of Korean medical personnel working in the American health-care system is unknown. Significant num- bers of Korean nurses and physicians are practicing in the United States and Canada; many have received part or all of their education in the United States. Yi and Jezewski’s study (2000) of 12 Korean nurses’ adjustment to hospitals in the United States identified five phases of adjustment. The first three phases, relieving psychological stress, overcoming language barriers, and accepting American nursing practice, take 2 to 3 years. The remaining two phases, adopting the styles of American problem-solving strategies and adopting the styles of American interpersonal relationships, take an additional 5 to 10 years. Accordingly, orientation programs need to address language skills, practice differences, and communication and interpersonal relationships to help Koreans adjust to the American workforce. These same phases may occur with other Korean health professionals.

ISSUES RELATED TO AUTONOMY

Those in supervisory positions need to recognize the roles and relationships that exist between Koreans and their employers. A supervisor is treated with much respect in work and in social settings. Informalities and small talk may be difficult for Korean immigrants. For an employee to refuse an employer’s request is unacceptable, even if the employee does not want or feel qualified to complete the request. Supervisors should make an effort to promote open conversation and the expression of ideas among Korean Americans. Asking Korean employees to demon- strate procedures is better than asking them whether they know how to perform them. Those who have adjusted to the American business style may be more assertive in their positions, but an understanding of this work role gives supervisors the tools to more readily use Korean Americans’ skills and knowledge.

As with any new language, it is often difficult to under- stand American slang and colloquial language. Employers and other employees should be clear in their communica- tion style and be understanding of miscommunications. Ethnic biases are often directed at Korean Americans who speak English with an accent. Employers’ and coworkers’ preconceived notions of immigrants can also be a deter- rent to Korean Americans in the workforce.

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Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Koreans are an ethnically homogeneous Mongoloid peo- ple who have shared a common history, language, and culture since the 7th century A.D. when the peninsula was first united. Common physical characteristics include dark hair and dark eyes, with variations in skin color and degree of hair darkness. Skin color ranges from fair to light brown, with those residing in the southern part of South Korea being darker. Epicanthal skin folds create the distinctive appearance of Asian eyes.

DISEASES AND HEALTH CONDITIONS

Schistosomiasis and other parasitic diseases are endemic to certain regions of Korea. Therefore, health-care providers should consider parasite screening with Korean immigrants, when appropriate. South Korea continues to manufacture and use asbestos-containing products and has not taken the precautions necessary to adequately protect employees and meet international standards. Thus, Koreans emigrating to the United States need to be assessed for asbestos-related health problems (Johanning, Goldberg, & Kim, 1994).

The high prevalences of stomach and liver cancer, tuber- culosis, hepatitis, and hypertension in South Korea predis- pose recent immigrants to these conditions. High rates of hypertension lead to an increase in cardiovascular accidents and renal failure. The high incidence of stomach cancer is associated with environmental risks, such as diet and infec- tion (Helicobacter pylori), and in some cases, genetic predis- position (Kim, 2003). As with other Asians, a high occur- rence of lactose intolerance exists among people of Korean ancestry. Dental hygiene and preventive dentistry have recently been emphasized in health promotion in South Korea. Because of the high incidence of gum disease and oral problems, however, these conditions deserve attention.

VARIATIONS IN DRUG METABOLISM

Growing research in the field of pharmacogenetics has found variations in drug metabolism among ethnic groups. Studies suggest that Asian populations require lower dosages of psychotropic drugs (Levy, 1993). Other studies have shown variations in drug metabolism and interaction with propranolol, isoniazid, and diazepam among Asians in comparison with those of European Americans and other ethnic groups (Meyer, 1992). Although these studies pri- marily focus on people of Chinese and Japanese heritage, health-care professionals should be aware and attentive to the possibility of drug metabolism variations among Korean Americans (Munoz & Hilgenberg, 2005).

High-Risk Behaviors Because Koreans place great emphasis on education, many subject their children to intense pressure to do well in school. A survey conducted among middle and high

school students in Korea demonstrated such pressures. Three-quarters of the students reported having consid- ered running away or committing suicide because of their lack of success in school (Sorensen, 1994). Another study conducted at Seoul National University, the apex of uni- versities in South Korea, reported that 14 percent of the students admitted to the class of 1980 experienced ner- vous disorders, character blocks, or nervous breakdowns (Sorensen, 1994). Similar pressures have been seen in the United States, where suicide has occurred in Korean high school and college students because of intense pressure to do well in school.

Korea has a high incidence of alcohol consumption, up from 7.0 L in 1980 to 8.1 L per adult per capita, which is similar to that of the United States and Ireland at 7.8 L per adult per capita. However, among adult men in Korea, consumption is 18.4 L per capita, one of the highest rates of alcohol consumption in the world (Park, Oh, & Lee, 1998). Korean business transactions commonly occur after the decision-makers have had several drinks. Koreans believe that people let their masks down when they drink and that they truly get to know someone after they have had a few drinks. Socioeconomic changes in Korea have resulted in differences in alcohol-related social and health problems, with a change from drinking mild fermented beverages with meals to drinking distilled liquors without meals. In the United States, 62 percent of Korean American men and 39 percent of Korean American women drink alcoholic beverages, with beer the alcoholic beverage most commonly consumed (Yu, 1990b).

In Korea, women drink far less than men. Sons’ drink- ing patterns are similar to their fathers’ patterns. A sub- stantial generational difference exists among females, with daughters abstaining from alcohol less frequently than their mothers and drinking more, and more often, than their mothers (Weatherspoon, Park, & Johnson, 2001). In the United States and Korea, drinking and vehic- ular accidents among Koreans and Korean Americans are a cause for concern.

One-third of Korean Americans living in the Los Angeles area smoke, and Korean American men (37 per- cent) smoke more than Korean American women (20 per- cent) (Yu, 1990b). In their study, Lee, Sobal, and Frongillo (2000) found that bicultural Korean men were least likely to smoke, whereas acculturated and bicultural women were more likely than traditional women to smoke. In Korea, a few women do smoke, and for those who do, smoking in public, such as on the street, is con- sidered taboo.

Cho and Faulkner (1993) studied the cultural concep- tions of alcoholism among Korean and American univer- sity students. Students had to decide whether the person described in a vignette was an alcoholic or not and why. The results showed that American-born students tended to define alcoholism in terms of social and interpersonal problems related to drinking, whereas Korean-born stu- dents defined alcoholism in terms of physical degenera- tion and physiological addiction. The authors cautioned against the misuse of American concepts and diagnostic scales in the cross-cultural arena. Cultural factors should be examined closely in relation to the study, diagnosis, and treatment of alcohol problems.

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HEALTH-CARE PRACTICES

Seat belts are infrequently worn in South Korea, although there has been recent pressure to use them. Korean Americans understand the legal mandates in the United States and comply with seat-belt and child-restraint laws.

Hobbies such as hiking and golf are enjoyed in South Korea. Korean Americans do not identify hiking as a fre- quent pastime, either because of environmental con- straints or because of living situations. Golf remains a sig- nificant activity among those Korean Americans who are financially able to play the sport.

Nutrition MEANING OF FOOD

Food takes on a significant meaning when one has been without food. Many Koreans over the age of 50 who fought in the Korean War experienced a time when their next meal was not guaranteed. Because of a devastated economy and agricultural base, barley and kimchee, a spicy pickled cabbage, were dietary staples during the war.

COMMON FOODS AND FOOD RITUALS

Korean food is flavorful and spicy. Rice is served with 5 to 20 small side dishes of mostly vegetables and some fish and meats. The variety of seasonings in Korean cooking includes red and black pepper, garlic, green onion, ginger, soy sauce, and sesame seed oil. The traditional Korean diet includes steamed rice; hot soup; kimchee; and side dishes of fish, meat, or vegetables served in some varia- tion for breakfast, lunch, and dinner. Breakfast is tradi- tionally considered the most important meal.

Kimchee is made from a variety of vegetables but is pri- marily made from a Chinese, or Napa, cabbage (Fig. 17–2). Spices and herbs are added to the previously salted cab- bage, which is allowed to ferment over time and is served with every meal in a variety of forms. Some common Korean American dishes:

Beebimbap is a combination of rice, finely chopped mixed vegetables, and a fried egg served in a hot pottery bowl. Hot pepper paste is usually added.

Bulgolgi is thinly sliced pieces of beef marinated in soy sauce, sesame oil, green onions, garlic, and sugar, which is then barbecued.

Chopchae are clear noodles mixed with lightly stir- fried vegetables and meats.

Rice is usually served in individual bowls, set to the left of the diner. Soup is served in another bowl, placed to the right of the rice. Chopsticks and large soupspoons are used at all meals. Korean Americans may use forks and knives, depending on their degree of assimilation into American culture. Meals are frequently eaten in silence, using this opportunity to enjoy the food. When Koreans migrate to the United States, they increase their consumption of beef, dairy products, coffee, soda, and bread as well as decrease their intake of fish, rice, and other grains. However, incor- porating a larger quantity of Western foods does not make a less-healthy diet. They consume diets consistent with their traditional Korean food patterns, with 60 percent of calories coming from carbohydrates and 16 percent of calories from fat (Kim, Yu, Chen, Cross, & Kim, 2000). To increase compliance with dietary prescriptions, health teaching should be geared to the unique Korean American food choices and practices.

Understanding the ritual offering of food and drink to guests is important. Koreans offer a guest a drink on first arriving at their home. The guest declines courteously. The host offers the drink again and the guest again declines. This ritual can occur three to five times before the guest accepts the offer. This interaction is done out of respect for the hosts and their generosity to share with their guest and to express an unwillingness to impose on the hosts. Accepting an offer when first asked is consid- ered rude and selfish.

DIETARY PRACTICES FOR HEALTH PROMOTION

Most dietary practices for health promotion apply to pregnancy, discussed later in this chapter. Someone suf- fering from the common cold is served soup made from bean sprouts. Dried anchovies, garlic, and other hot spices are added to the hot soup, which assists in clearing a congested nose.

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

Kim, Yu, Liu, Kim, and Kohrs (1993) examined the nutri- tional status of older Chinese, Korean, and Japanese Americans. Along with a dietary interview and anthropo- metric measurements, a 24-hour recall technique was used to obtain dietary data. The results of the study showed that older Korean Americans had the poorest diets, partic- ularly with regard to inadequate amounts of vitamins A and C. Korean American women had a low intake of pro- tein. The results also suggested that older Asian Americans are at high risk for calcium deficiencies. The authors con- cluded that a large-scale national nutritional survey is needed for Asian Americans to plan health programs based on the specific needs of selected populations.

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FIGURE 17–2 Kimchee, a spicy pickled cabbage that is a staple of the Korean diet.

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A study by Park, Murphy, Sharma, and Kolonel (2005) indicated that the proportion of overweight or obesity was 31.4 percent in U.S.-born Korean women and 9.4 per- cent in Korean-born Korean women. They also reported that U.S.-born Korean women had higher intakes of total fat and fat as a percentage of energy and lower intakes of sodium, vitamin C, beta-carotene, and carbohydrate as a percentage of energy than Korean-born women. In addi- tion, Cho and Juon (2006) reported that of 492 Korean American respondents, 38 percent were overweight and 8 percent were obsese according to the World Health Organization for Asian populations. These findings sug- gest that acculturation of Korean immigrants affects dietary intakes in ways that may alter their risks of several chronic diseases.

Korean Americans, as with most other Asians, are at a high risk for lactose intolerance. Thus, milk and other dairy products are not part of the traditional Korean diet, emphasizing the need to assess them for calcium defi- ciencies.

Korean Americans living in or near large metropolitan cities have access to Korean markets and restaurants. When no Korean stores are available, Chinese or Japanese markets may contain some of the foods Koreans enjoy. When no Asian markets are available, the American gro- cery store suffices.

Pregnancy and Childbearing Practices

VIGNETTE 17.3

Jay and Sue Kim, ages 29 and 26 years and married for 2 years, immigrated from South Korea and settled in Los Angeles. They have lived in a small one-bedroom apartment since their arrival. Both of them graduated from the same Korean university with baccalaureate degrees in English liter- ature. They have one child, Joseph, age 1 year.

When they arrived in the United States, Jay was unable to find a job because of his poor proficiency in English, despite his major in English Literature. He eventually obtained a job with a moving company through a church friend. Sue is not working because of their son. Although the Kims did not attend a church before immigration, they are now regularly attending a Korean Protestant church in their neighborhood.

Sue is pregnant again, determined by a home pregnancy kit, with their second child and concerned about the medical costs. They did not use any contraceptives because she was breastfeeding. Because of financal limitations, Sue did not ini- tially have prenatal care with her first pregnancy. However, she did keep up with the Korean traditional prenatal practice, tae-kyo. Eventually, she received help from her church and delivered a healthy son. She is not sure whether she can get financial help from her church again but is confident that her second child will be healthy if she follows the Korean tradi- tional prenatal practices.

Jay is concerened about job security because he recently heard from colleagues that the moving company might soon go bankrupt. Although Jay has not been satisfied with his cur- rent job (he thinks that he is overqualified), this news is still a

cause for concern. Moreover, Sue’s recent pregnancy has made Jay more stressed, and he has started drinking alcohol.

Joseph cannot stand up by himself and still wants to be breastfed. Although Sue has tried to give foods such as oranges, apples, steamed rice, and milk (because she is now pregnant), Joseph refuses to eat them and cries for breastfeed- ing. Joseph’s weight is low normal for same-age babies.

1. How might Jay have improved his English langage skills to increase his opportunities to obtain a position for which his education qualifies him?

2. Describe the Korean cultural practice tae-kyo. Is this practice congruent with allopathic recommendations for prenatal care?

3. How do food choices among Koreans differ with preg- nancy and postpartum?

4. Describe cultural attitudes toward drinking among Koreans.

5. Identify two or three culturally congruent strategies for addressing Jay’s drinking.

FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

To curtail population growth in Korea, the government promotes the concept of two children per household. The government supported the use of contraception when a 10-year family planning program was adopted in the early 1960s, resulting in a mass public education program on contraception. When contraceptive devices became easily available in Korea, fertility control spread widely among married women. Contraceptive devices are cov- ered by the present national health insurance of Korea. Recently, South Korea’s fertility rate fell to a new record low in 2005 as more women engaged in economic activi- ties and got married at older ages (Hankyoreh, 2007). The average number of babies per woman of child-bearing age was 1.08 in 2005, down from 1.16 in 2004, and the num- ber of newborn babies fell by 38,000, or 7.9 percent, to 438,000 (Hankyoreh, 2007). As part of efforts to address those issues, the South Korean government is to spend a total of 30.5 trillion won (U.S. $432.8 billion) over the next 5 years to strengthen the country’s social safety net and boost its record-low birth rate (Hankyoreh, 2007).

Before the 1950s, abortion was illegal in Korea, although induced abortions were performed widely. Today, abortion is legal and is widely used in Korea. Abortion is not highly publicized in Korea, yet there is an unspoken acceptance of the practice. The government keeps a hands- off policy, which has not met with major opposition. Women are not expected to get their husband’s consent, nor are underage youth required to have their parents’ acknowledgment. The government does not pay for abor- tions; rather, patients pay a set price from personal funds.

Pritham and Sammons (1993) investigated Korean women’s attitudes toward pregnancy and prenatal care with regard to their beliefs and interactions with health- care professionals from the United States. The survey was conducted of 40 unemployed Korean women between the ages of 18 and 35 at an American military medical- care facility in a major metropolitan area of Korea.

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Attitudes toward childbearing practices and relationships with health-care providers were elicited. The results indi- cated that these women were happy about their pregnan- cies. Only one-third of the respondents agreed with the traditional preference for a male child. About 40 percent of the women reinforced strong food taboos and restric- tions and acknowledged the need to avoid certain foods during pregnancy. Twenty percent disagreed with the use of prenatal vitamins, and 25 percent indicated needing only a 10- to 15-lb weight gain in pregnancy. The women generally had sound health habits in relation to physical activity and recognized the harm of smoking while preg- nant. The study sample was homogeneous and small, lim- iting the ability to generalize about the findings.

Pregnancy in the Korean culture is traditionally a highly protected time for women. Both the pregnancy and the postpartum period have been ritualized by the culture. A pregnancy begins with the tae-mong, a dream of the conception of pregnancy. Once a woman is pregnant, she starts practicing tae-kyo, which literally means “fetus education.” The objective of tae-kyo is to promote the health and well-being of the fetus and the mother by hav- ing the mother focus on art and beautiful objects. If the pregnant woman handles unclean objects or kills a living creature, a difficult birth can ensue (Howard & Barbiglia, 1997). Some women wear tight abdominal binders begin- ning at 20 weeks’ gestation or work physically hard toward the end of the pregnancy to increase the chances of hav- ing a small baby (Howard & Barbiglia, 1997). In addition, expectant mothers should avoid duck, chicken, fish with scales, squid, or crab because eating these foods may affect the child’s appearance. For example, eating duck may cause the baby to be born with webbed feet (Howard & Barbiglia, 1997).

Kendall’s study (1987) in Honolulu supported the belief that Korean women attribute a variety of com- plaints to naeng (chill), a cold imbalance of the womb that brings on a heavy vaginal discharge and can make women who experience it sterile. The researcher empha- sized that an intimate condition such as naeng may be lost in translation in non-Korean contexts.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Ludman, Kang, and Lynn’s study (1992) explored the food beliefs and diets of 200 pregnant Korean American women. The food items most frequently consumed were kimchee (82.5 percent), rice or noodles (81.5 percent), and fresh fruit (79 percent). Foods avoided during pregnancy included coffee (19.8 percent), spicy foods (9.9 percent), chicken (6.9 percent), and crab (6.9 percent). A list of 20 food items was then given to the women, who were asked to respond whether they consumed the food or not and, if not, to indicate their reasons. A number of respondents indicated that they did not eat rabbit (91.5 percent), spar- row (91.5 percent), duck (89.5 percent), goat (84 percent), or blemished fruit (63 percent) because of dislike or lack of availability. The reason most frequently given for not eating blemished fruit was that it might produce a skin disease on the infant or cause an unpleasant face. The study showed that, although many Korean American

women were aware of traditionally taboo foods, they did not avoid consuming them. An awareness of these beliefs can give health professionals a basis for nutritional edu- cation for Korean American women.

Birthing practices among both Koreans and Korean Americans are highly influenced by Western methods. Women commonly labor and deliver in the supine posi- tion. After the delivery, women are traditionally served seaweed soup, a rich source of iron, which is believed to facilitate lactation and to promote healing of the mother. Bed rest is encouraged after pregnancy for 7 to 90 days. Women are also encouraged to keep warm by avoiding showers, baths, and cold fluids or foods.

The postpartum period is seen as the time when women undergo profound physiological, psychological, and sociological changes; this period is known as the Sanhujori belief system. In this dynamic process, postpar- tum women should care for their bodies by augmenting heat and avoiding cold, resting without working, eating well, protecting the body from harmful strains, and keep- ing clean (Howard & Barbiglia, 1997). In Western society in which they may lack extended family members from whom to seek assistance, Korean women may be faced with a cultural dilemma.

Park and Peterson (1991) studied Korean American women’s health beliefs, practices, and experiences in rela- tion to childbirth. Using structured questions, they inter- viewed in Korean a nonrandom sample of 20 female vol- unteers. Those interviewed subscribed to a holistic view, which emphasized both emotional and physical health. Only one-half of the women interviewed rated them- selves healthy. The authors related this to the stresses of immigration and pregnancy. Preventive practices were not found among members of this group. Only one woman regularly received Pap smears and did breast self- examinations. A common finding was that most women participated in a significant rest period during puer- perium. Those who did not rest lacked help for the home. All the women ate brown seaweed soup and steamed rice for about 20 days after childbirth to cleanse the blood and to assist in milk production. Because pregnancy is a hot condition and heat is lost during labor and delivery, some women avoided cold foods and water after childbirth to prevent chronic illnesses such as arthritis. The baby should be wrapped in warm blankets to prevent harm from cold winds. Herbal medicines are also used during puerperium to promote healing and health (Howard & Barbiglia, 1997).

Health-care professionals can improve the health of Korean American women by providing factual informa- tion about Pap smears and teaching breast self-examina- tion. Pregnant Korean American women should be asked about their use of herbal medicine during pregnancy so that harmless practices can be incorporated into biomed- ical care. Recommendations for improving postpartum care among Korean American women include (1) devel- oping an assessment tool that health-care providers can use to identify traditional beliefs early in a pregnancy, (2) developing a bilingual dictionary of common foods, (3) developing pamphlets with medical terms used in the U.S. health-care system, and (4) providing time for prac- ticing English skills (Park & Peterson, 1991).

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Death Rituals DEATH RITUALS AND EXPECTATIONS

Traditionally, in Korea, it was important for Koreans to die at home. Bringing a dead body home if the person died in the hospital is considered bad luck. Consequently, viewing of the deceased occurred at home if the individ- ual died at home and at the hospital if the person died at the hospital. Several days or more were set aside for the viewing, depending on the status of the deceased. The eldest son was expected to sit by the body of the parent during the viewing (Martinson, 1998). Friends and rela- tives paid their respects by bowing to a photograph of the deceased placed in the same room in which the body rested. The guests were then offered the favorite foods of the deceased. Today, most Korean Americans are not accustomed to viewing the body of the deceased. More commonly, relatives and friends come to pay their respect by viewing photographs of the deceased.

Although Korean Americans view life support more pos- itively than European Americans, the majority in one study did not want such technology (Blackhall et al., 1999). In addition, they were less likely to have made a prior decision about life support. Older and more educated Koreans were less likely to favor truth telling, believing that patients should not be told that they have a terminal illness.

An ancestral burial ceremony follows, with the body being placed in the ground facing south or north. Both the place and the position of the deceased are important for the future fortune of the living relatives. Koreans believe that if the spirit is content, good fortune will be awarded to the family. Unlike Western graves, a mound of dirt covers the gravesite of the deceased in Korea.

Cremation is an individual and family choice and is practiced more commonly in Korea for those who have no family or die at a young age. For example, when unmarried people die without any children to perform ancestral ceremonies, they are often cremated and their ashes scattered over a body of water.

Rice wine is traditionally sprinkled around the grave. Korean families bow two to four times in respect at the gravesite, and then the men, in descending order from the eldest to the youngest, drink rice wine. Some Korean Americans dedicate a corner of their home to honor their ancestors because they cannot go to the gravesite.

Circumstances in which “do not resuscitate” orders are an issue need to be addressed cautiously. Families trust physicians and may not question other options. Because death and dying are fairly well accepted in the Korean cul- ture, prolonging life may not be highly regarded in the face of modern technology. Korean hospitals focus on acute care. Families are expected to stay with family members to assist in feeding and personal care around the clock. Thus, many Korean Americans may expect to care for their hos- pitalized family members in health-care facilities.

RESPONSES TO DEATH AND GRIEF

Mourning rituals, with crying and open displays of grief, are commonly practiced and socially accepted at funerals, and they signify the utmost respect for the dead. The

eldest son or male family member who sits by the deceased sometimes holds a cane and makes a moaning noise to display his grief. The cane is a symbol of needing support. Health-care personnel may need to provide a pri- vate setting for Korean Americans to be able to grieve in culturally congruent ways.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

Confucianism was the official religion of Korea from the 14th to the 20th century. Buddhism, Confucianism, Christianity, shamanism, and Chondo-Kyo are practiced in Korea today. Chondo-Kyo (religion of the Heavenly Way) is a nationalistic religion founded in the 19th cen- tury that combines Confucianism, Buddhism, and Daoism. Among Korean Americans, the most recent esti- mates of organized religions include no affiliation, 46 per- cent; Christianity, 26 percent; Buddhism, 26 percent; Confucionism, 1 percent; and other, 1 percent, of which the majority are Chondo-Kyo (CIA, 2007). In the United States, the church acts as a powerful social support group for Korean immigrants (Im & Yang, 2006). Yu (1990a) speculated that with the growth of other organizations that facilitate the transition for Korean immigrants, they might have less need for churches as the major source of emotional support and practical information on life in the United States.

Kim (1990) studied Korean Christian churches in the Pacific Northwest in an attempt to prove the importance of the structure and function of the church as a secondary association for Korean immigrants in the United States. Many of the churches were young in terms of both years of operation and age of the membership. Most had been in operation between 5 and 10 years. Most of the churches were hierarchically organized, and only a couple of the churches reported having female pastors. A variety of services other than prayer meetings were offered, such as English and Korean language programs, income tax seminars, health education including AIDS prevention, information on U.S. citizenship and laws, driver’s licenses, job searches, and assistance with older family members. Kim reinforced the role of churches in preserv- ing Korean culture and, consequently, ethnic identity. Kim also stressed the importance of retaining one’s ethnic identity in the Korean culture. Korean immigrants experi- ence a dramatic transition and are frequently faced with the forces of racism and individualism.

Koreans in America might not pray in the same fash- ion as Westerners, but for many people, the spirits demand homage. Korean churches often have prayer meetings several times a week, some with early-morning prayers. Buddhist temples have spirit rooms attached to them. Although Buddhists believe the spirit enters a new life, the beliefs of the shamans are so strong that the Buddhist church incorporated an area of their church for those who believe that ancestral spirits need honoring and homage. With such a variety of spiritual beliefs, care- givers must assess each Korean client individually for reli- gious beliefs and prayer practices.

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MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

Family and education are central themes that give mean- ing to life for Korean Americans. The nuclear and extended families are primary sources of strength for Korean Americans in their daily lives. These concepts were previously covered under Family Roles and Organization and Educational Status and Occupations.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Shamanism is a powerful belief in natural spirits. All parts of nature contain spirits: rivers, animals, and even inanimate objects. The many religions of Koreans create numerous ideologies about what happens with the spirits of the deceased. Christians believe the spirit goes to heaven; Buddhists believe the spirit starts a new life as a person or an animal; and Shamanists believe the spirit stays with the family to watch over them and guide their actions and fortunes. Such a variety of faith systems pro- vides a great diversity in beliefs of the Korean people. Given this diversity of spiritual beliefs among Koreans, each client needs an individual assessment with regard to spiritual and health-care practices.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

Beliefs that influence health-care practices include reli- gious beliefs (see Dominant Religion and Use of Prayer) and dietary practices (see Nutrition). Health-care providers need to be aware that the theme dominating these beliefs is a holistic approach, which emphasizes both emotional and physical health.

Health-care practices among Koreans in America are primarily focused on curative rather than preventive mea- sures. Health promotion in Korea is a relatively new pub- lic-health focus. In Korea, education on dental hygiene, sanitation, environmental issues, and other preventive health measures is being encouraged. Visits to the physi- cian for an annual physical examination, Pap smears, and breast self-examination are uncommon. Among Koreans, traditional patterns of health promotion include har- mony with nature and the universe, activity and rest, diet, sexual life, covetousness, temperament, and appre- hension (Lee, 1993).

RESPONSIBILITY FOR HEALTH CARE

One American study reported that only 13.5 percent of Korean American men and 11.3 percent of Korean American women had a digital rectal examination (DRE) for occult blood. Regression analysis indicated that gen- der, education, knowledge of the warning signs of cancer, and length of residence in the United States were signifi- cantly related to having undergone DRE. The researchers determined that this group of Korean Americans did not see health-care providers or health brochures as valuable sources of information, and to target this group, efforts

should be coordinated with church and community lead- ers and enhanced by developing brochures in the Korean language (Kim, Yu, Chen, Kim, & Britnall, 1998).

Because of women’s modesty during physical examina- tions and their preferences that women perform intimate examinations, many Korean women defer having Pap tests or breast cancer screening tests (Lee, Fogg, & Sadler, 2006; Wismer et al., 1998). A recent study among Korean immigrant women reported that 78 percent of the partic- ipants had had a mammogram at some point and that 38.6 percent had had one in the previous year (Lee et al., 2006). This reluctance for undergoing Pap tests directly relates to cervical cancer’s rating as the number-one female cancer diagnosed among women in Korea (Lee, 2000). Modesty has also been associated with low rates of mammography among Korean Americans (Maxwell, Bastani, & Warda, 1998) as well as limited knowledge about breast self-examination and causes of breast cancer (Han, Williams, & Harrison, 2000).

Recent Korean immigrants come from a country in which universal health insurance was implemented in the late 1980s. A government mandate established employer-based health insurance for medium and large firms. Regional health insurance systems, subsidized by the government, were later established for small firms, farmers, and the self-employed. Yu (1990a) found that 55 percent of the Koreans surveyed in Los Angeles and Orange counties have medical insurance; however, the rates vary according to income, with higher rates among the high-income group and lower rates among the low- income group.

The use and availability of over-the-counter medica- tions vary tremendously between the United States and Korea. Many prescription drugs in the United States such as antibiotics, anti-inflammatory and cardiac medica- tions, and certain pain control medications can be pur- chased over-the-counter in Korea at any yak bang (phar- macy). For example, when feeling “tired” or “fatigued,” older people in Korea may perform home infusions of dextrose and water or albumin.

Self-medication with herbal remedies is also practiced. Ginseng is a root used for anything from a remedy for the common cold to an aphrodisiac. Seaweed soup is used as a medicine. Chinese herbs are used to control the degree of “wind” that may be in the body. Other herbal medica- tions are taken for preventive or restorative purposes, For example, haigefen (clamshell powder) has high levels of lead, which can cause abdominal colic, muscle pain, and fatigue (Markowitz, Nunez, Klitzman, & Munshi, 1994). Accordingly, health-care professionals should query their patients about their use of traditional Korean medicine and must be aware that herbal medicine may be used in conjunction with Western biomedicine.

FOLK AND TRADITIONAL PRACTICES

Hanyak, traditional herbal medicine used for creating harmony between oneself and the larger cosmology, is a healing method for the body and soul. Hanbang, the tra- ditional Korean medical-care system, works on the princi- ple of a disturbed state of ki, cosmological vital energy. Symptoms are often interpreted in terms of a psychological

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base. Treatments include acupuncture, acumassage, acu- pressure, herbal medicines, and moxibustion therapy. The therapeutic relationship between hanui (oriental medi- cine doctors) and their clients is genuine, spontaneous, and harmonious. Clients who use both Western and tradi- tional Korean practitioners may experience conflicts because of the lack of cooperation between hanui and bio- medical practitioners (Pang, 1989). In 1993 in Korea, a pharmaceutical act supported pharmacists in prescribing and dispensing herbal drugs, creating a lucrative business and increasing conflicts among hanui physicians and phar- macists (Cho, 2000).

Shamans are used in healing rituals to ward off restless spirits. Shamans originated with the religious belief of shamanism, the belief that all things possess spirits. A shaman, mundang, is usually a woman who has special abilities for communicating with spirits. The shaman is used to treat illnesses after other means of treatment are exhausted. The shaman performs a kut, a shamanistic cer- emony to eliminate the evil spirits causing the illness. Such a ceremony may take place when a young person dies to prevent his or her spirit from staying tied to the earth. Others believe a shaman can eliminate evil spirits that may be causing difficulty with financial transactions. Although shamans have been around for many years, Koreans con- sider them part of the lowest class. Health-care providers need to determine whether Koreans in America are using folk therapies and should include nonharmful practices with biomedical therapies and prescriptions.

BARRIERS TO HEALTH CARE

Because many Korean Americans use various options for healing, Western medical practices may be used in con- junction with acupressure, acupuncture, and herbal med- icine. Barriers for Koreans in America may result from the expense of non-Western therapies, because insurance companies often do not cover alternative therapies.

As for many other American residents, the lack of insur- ance creates barriers to health care. Paying for health care out-of-pocket is expensive and not feasible for many Korean American families. Language, modesty, cultural atti- tudes toward certain illnesses, and communication prob- lems also serve as impediments for access to health care.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

Perceptions of pain vary widely among Koreans. Some Koreans are stoic and are slow to express emotional dis- tress from pain. Others are expressive and discuss their smallest discomforts. Family and friends are useful resources for learning some of the historical coping mech- anisms of sick individuals. Nonverbal cues and facial expressions must be monitored for those who are stoic rather than expressive. Pain assessments should be con- ducted regularly, and patient education may be necessary for stoic individuals.

Mental illness is stigmatized in the Korean culture. Kim and Grant (1997) conducted a study of Korean American women and their reluctance to use mental-health profes- sionals in the United States. Their study concluded that these women experienced gender-role disruption, evidence

of depressive symptoms, and subsequent risk of substance abuse, suicide, battering, loss of employment, deficits in parenting, and low use of mental-health professionals. A study in Korea of 3711 respondents showed that 23.1 per- cent of men and 27.4 percent of women were at risk for depression, which is a higher rate than in the United States and other Western countries. In this study, female gender, less than 13 years of education, and disrupted marriage were significant predictors of severe, definitive symptoms of depression (Cho, Nam, & Suh, 1998). Pang (1990) explored the cultural construction of hwa-byung among a group of Korean immigrant women in the United States, using a convenience sample. Hwa-byung, a traditional Korean ill- ness, results from the suppression of anger or other emo- tions (Donnelly, 2001). Hwa means “fire and anger,” and byung means “illness.” All the women in the study knew the meaning of hwa-byung, and 80 percent reported having experienced it. The emotions they reported suppressing were sadness, depression, worry, anger, fright, and fear. Most of the emotions described were related to conflicts with close relatives or family, such as sons and daughters or significant others. These were expressed as physical com- plaints, ranging from headaches and poor appetites to insomnia and lack of energy. The complaints were chronic in nature, and a variety of remedies were used to alleviate the symptoms. Most of the women suggested that hwa- byung was difficult to cure and accepted the symptoms as inevitable. For these older Korean women, hwa-byung was a mode for constructing illness as a personal, social, and cul- tural adaptive response (Pang, 1990). These women expressed life’s hardships by channeling their emotional ill- nesses into physical symptoms.

A community study of Korean Americans addressed the prevalence, clinical significance, and meaning of hwa-byung (Lin, Lau, Yamamoto, Zheng, & Kim, 1992). The results indicated a high percentage of Korean Americans (11.9 per- cent) who identified themselves as suffering from hwa- byung. A strong association was shown between hwa-byung and major depressive disorders. Although hwa-byung is found predominantly among older Korean women with lit- tle education, this study’s findings did not support this con- clusion. The ability to generalize these findings, however, is limited because assignment to the study groups was not completely random and because the sample size was small.

Historically, the area of special education has not been well studied or researched in Korea. Families who have children with mental or physical disabilities often ques- tion what they have done wrong to make their ancestors angry. Families feel stigmatized for such a misfortune and cannot accept their children’s disfigurement or low intel- lect. Korea lacks social support to assist families in caring for children with mental or physical disabilities. Some families abandon these children in their desperate need for support with long-term care and expenses. Other chil- dren are kept from the public eye in the hope of saving the family from stigmatization.

Seo, Oakland, Han, and Hu (1992) explored the histor- ical and future needs of special education in South Korea. Korea is faced with high teacher-pupil ratios, a reliance on self-contained programs, negative attitudes toward the disabled, and lack of advocacy for them. Of the 600,000 children aged 6 to 17 years who were disabled, only 15

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percent received service in special private or public schools or classes. Negative attitudes toward the disabled influence the idea of mainstreaming mildly disabled stu- dents in South Korea. Korean Americans may hold these same views regarding the mentally and physically dis- abled and need special support in obtaining assistance.

In Korea, once hospitalized people are physically sta- ble, they are discharged to their homes to be with the family. Bowel training and physical therapy activities are not the responsibility of the hospital. The families must care for family members at home with the support of other family members. Long-term care for chronic prob- lems or for rehabilitation is rare in Korea. Thus, Korean Americans are familiar with the concept of family home care. Depending on their adaptation to the American health-care system, and families’ contact with American health-care professionals, some Korean Americans adjust their ideologies on the sick role.

BLOOD TRANSFUSIONS AND ORGAN DONATION

No beliefs held by Korean Americans prevent the accep- tance of blood transfusions. Organ donation and organ transplantation are rare, reflecting traditional attitudes toward integrity and purity. These issues need to be approached sensitively with Korean Americans because they may be influenced by the individual’s religious beliefs.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

In general, no taboos exist that prevent health-care prac- titioners from delivering care to the opposite gender. Female physicians are definitely preferred for maternity care and female problems because women feel more com- fortable discussing gynecological and obstetric issues with female physicians. However, more-traditional Koreans frequently prefer health-care providers who speak Korean, are older, and are of the same gender, although many will seek health care from others who do not meet these requirements if their preferred care provider is not available. Miller (1990) studied the use of traditional health practitioners, acupuncturists, and herbalists among a group of 102 Korean immigrants. The findings indicated that Korean immigrants with higher incomes were more likely to use traditional Korean practitioners.

The area of social work is new in Korea. The hospitals have no positions for such a role. A few educational pro- grams exist in Korea for social workers, but much devel- opment is needed in the area of social support. Because these roles may be new to many Koreans, health-care providers may need to encourage Korean Americans to use these services.

STATUS OF HEALTH-CARE PROVIDERS

Because traditional Korean culture accords high respect to men, older people, and physicians, the ideal physician is

an older man with gray hair. This shows that he has expe- rience and wisdom and is able to make the best decisions. With such a high status in Korea, physicians expect respect from all other health professionals. Usually, nurses are expected to carry out physicians’ orders explic- itly. This is not to say that the nurse cannot question orders, but great time and effort are spent consulting other nurses before questioning physicians in the most respectful way. However, as nurses are becoming more educated in Korea, they are becoming more assertive and more closely mirror Western practice patterns.

With an emphasis on increasing the educational level of nurses, they too are gaining stature and respect in Korean culture. Baccalaureate, masters, and doctoral pro- grams are available for nurses in Korea. Although exact numbers are not available, Korea has approximately 600 doctorally prepared nurses as of 2001.

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