Complete the following:
- Chinese case study #1
- Japanese case study #1
- answer question at the end of each case study and include a introduction and conclusion . 1000 to 2000 words
Assignment: Complete the following: Chinese case study #1Japanese case study #1answer question at the end of each case study and include a introduction and conclusion . 1000 to 2000 words
Case Studies AFRICAN AMERICAN CASE STUDY #1 Robert Collins is a 49-year-old African American. He resides in the inner city of Detroit, Michigan, with his extended family. He has a 43-year-old wife and five children, aged 26, 18, 16, 14, and 10. His wife, his elderly mother, three of his children (aged 16, 14, and 10), two grandchildren, and his sick sister-in-law represent the household membership. Mr. Collins completed the 11th grade and maintains employment in a steel factory. Although he works more than 40 hours a week, his income places him at the poverty level. He cannot afford to purchase health insurance. Mr. Collins’s 18-year-old daughter, Chloe, is pregnant for the third time and is a single parent. Mr. Collins is caring for her other two children. Chloe is going to night school to complete her high school education. The Collins family goes to church every Sunday and is actively involved in the church. Mrs. Collins was diagnosed with cancer, and she is receiving spiritual healing from her pastor and church for this illness. Mr. Collins is extremely concerned about his wife’s health and has increased his tobacco use. Study Questions 1. Name one occupation-related disease for which Mr. Collins is at risk. 2. Identify one family member who is likely to be caring for the younger children in the family. 3. Describe three cultural beliefs that Chloe may have regarding her pregnancy. 4. Discuss the role of spirituality in this family. 5. Identify two religious or spiritual practices in which Mrs. Collins may be engaging. 6. Because Mrs. Collins has cancer, discuss possible cultural thoughts she may have regarding death and dying. 7. Identify two diseases common among African American men. 8. Identify the high school dropout rate among African American teens in the inner city. 9. Name one tobacco-related disease found in the African American population. 10. Name two dietary health risks for African Americans. 11. Identify five characteristics to consider when assessing the skin of African American clients. 12. Name two skin conditions common among African Americans. AFRICAN AMERICAN CASE STUDY #2 Mr. and Mrs. Evans are an African American couple who retired from the school system last year. Both are 65 years of age and reside on 20 acres of land in a large rural community approximately 5 miles from a Superfund site and 20 miles from two chemical plants. Their household consists of their two daughters, Anna, aged 40 years, and Dorothy, aged 42 years; their grandchildren, aged 25, 20, 19, and 18; and their 2- year-old great-grandson. Anna and Dorothy and their children all attended the university. Mr. Evans’s mother and three of his nieces and nephews live next door. Mr. Evans’s mother has brothers, sisters, other sons and daughters, grandchildren, and great-grandchildren who live across the road on 10 acres of land. Other immediate and extended family live on the 80 acres adjacent to Mr. Evans’s mother. All members of the Evans family own the land on which they live. Mrs. Evans has siblings and extended family living on 70 acres of land adjacent to Mr. Evans’s family, who live across the road. Mr. and Mrs. Evans also have family living in Chicago, Detroit, New York, San Francisco, and Houston. Once a year, the families come together for a reunion. Every other month, local family members come together for a social hour. The family believes in strict discipline with lots of love. It is common to see adult members of the family discipline the younger children, regardless of who the parents are. Mr. Evans has hypertension and diabetes. Mrs. Evans has hypertension. Both are on medication. Their daughter Dorothy is bipolar and is on medication. Within the last 5 years, Mr. Evans has had several relatives diagnosed with lung cancer and colon cancer. One of his maternal uncles died last year from lung cancer. Mrs. Evans has indicated on her driver’s license that she is an organ donor. Sources of income for Mr. and Mrs. Evans are their pensions from the school system and Social Security. Dorothy receives SSI because she is unable to work any longer. Mr. Evans and his brothers must assume responsibility for their mother’s medical bills and medication. Although she has Medicare parts A and B, many of her expenses are not covered. Mr. and Mrs. Evans, all members of their household, and all other extended family in the community attend a large Baptist church in the city. Several family members, including Mr. and Mrs. Evans, sing in the choir, are members of the usher board, teach Bible classes, and do community ministry. Study Questions 1. Describe the organizational structure of this family and identify strengths and limitations of this family structure. 2. Describe and give examples of what you believe to be the family’s values about education. 3. Discuss this family’s views about child rearing. 4. Discuss the role that spirituality plays in this family. 5. Identify two religious or spiritual practices in which members of the Evans family may engage for treating hypertension, diabetes, and mental illness. 6. Identify and discuss cultural views that Dorothy and her parents may have about mental illness and medication. 7. To what extent are members of the Evans family at risk for illnesses associated with environmental hazards? 8. Susan has decided to become an organ donor. Describe how you think the Evans family will respond to her decision. 9. Discuss views that African Americans have about advanced directives. 10. Name two dietary health risks for African Americans. 11. Identify five characteristics to consider when assessing the skin of African Americans. 12. Describe two taboo views that African Americans may have about pregnancy. AMISH CASE STUDY Elmer and Mary Miller, both 35 years old, live with their five children in the main house on the family farmstead in one of the largest Amish settlements in Indiana. Aaron and Annie Schlabach, aged 68 and 70, live in the attached grandparents’ cottage. Mary is the youngest of their eight children, and when she married, she and Elmer moved into the grandparents’ cottage with the intention that Elmer would take over the farm when Aaron wanted to retire. Eight years ago, they traded living space. Now, Aaron continues to help with the farm work, despite increasing pain in his hip, which the doctor advises should be replaced. Most of Mary’s and Elmer’s siblings live in the area, though not in the same church district or settlement. Two of Elmer’s brothers and their families recently moved to Tennessee, where farms are less expensive and where they are helping to start a new church district. Mary and Elmer’s fifth child, Melvin, was born 6 weeks prematurely and is 1 month old. Sarah, aged 13, Martin, aged 12, and Wayne, aged 8, attend the Amish elementary school located 1 mile from their home. Lucille, aged 4, is staying with Mary’s sister and her family for a week because baby Melvin has been having respiratory problems and their physician told the family he will need to be hospitalized if he does not get better within 2 days. At the doctor’s office, Mary suggested to one nurse, who often talks with Mary about “Amish ways,” that Menno Martin, an Amish man who “gives treatments,” may be able to help. He uses “warm hands” to treat people and is especially good with babies because he can feel what is wrong. The nurse noticed that Mary carefully placed the baby on a pillow as she prepared to leave. Elmer and Mary do not carry any health insurance and are concerned about paying the doctor and hospital bills associated with this complicated pregnancy. In addition, they have an appointment for Wayne to be seen at Riley Children’s Hospital, 3 hours away at the University Medical Center in Indianapolis, for a recurring cyst located behind his left ear. Plans are being made for a driver to take Mary, Elmer, Wayne, Aaron, Annie, and two of Mary’s sisters to Indianapolis for the appointment. Because it is on the way, they plan to stop in Fort Wayne to see an Amish healer who gives nutritional advice and does “treatments.” Aaron, Annie, and Elmer have been there before, and the other women are considering having treatments, too. Many Amish and non-Amish go there and tell others how much better they feel after the treatments. They know their medical expenses seem minor in comparison to the family who last week lost their barn in a fire and to the young couple whose 10-year-old child had brain surgery after a fall from the hayloft. Elmer gave money to help with the expenses of the child and will go to the barn raising to help rebuild the barn. Mary’s sisters will help to cook for the barn raising, but Mary will not help this time because of the need to care for her newborn. The state health department is concerned about the low immunization rates in the Amish communities. One community-health nurse, who works in the area where Elmer and Mary live, has volunteered to talk with Elmer, who is on the Amish school board. The nurse wants to learn how the health department can work more closely with the Amish and also learn more about what the people know about immunizations. The county health commissioner thinks this is a waste of time and that what they need to do is let the Amish know that they are creating a health hazard by neglecting or refusing to have their children immunized. Study Questions 1. Develop three open-ended questions or statements to guide you in your understanding of Mary and Elmer and what health and caring mean to them and to the Amish culture. 2. List four or five areas of perinatal care that you would want to discuss with Mary. 3. Why do you think Mary placed the baby on a pillow as she was leaving the doctor’s office? 4. If you were the nurse to whom Mrs. Miller confided her interest in taking the baby to the folk healer, what would you do to learn more about their simultaneous use of folk and professional health services? 5. List three items to discuss with the Millers to prepare them for their consultation at the medical center. 6. If you were preparing the reference for consultation, what would you mention about the Millers that would help to promote culturally congruent care at the medical center? 7. Imagine yourself participating in a meeting with state and local health department officials and several local physicians and nurses to develop a plan to increase the immunization rates in the counties with large Amish populations. What would you suggest as ways to accomplish this goal? 8. Discuss two reasons why many Old Order Amish choose not to carry health insurance. 9. Name three health problems with genetic links that are prevalent in some Amish communities. 10. How might health-care providers use the Amish values of the three-generational family and their visiting patterns in promoting health in the Amish community? 11. List three Amish values to consider in prenatal education classes. 12. Develop a nutritional guide for Amish women who are interested in losing weight. Consider Amish values, daily lifestyle, and food production and preparation patterns. 13. List three ways in which Amish express caring. APPALACHIAN CASE STUDY #1 William Kapp, aged 55 years, and his wife, Gloria, aged 37, have recently moved from an isolated rural area of northern Appalachia to Denver, Colorado, because of Gloria’s failing health. Mrs. Kapp has had pulmonary tuberculosis for several years. They decided to move to New Mexico because they heard that the climate was better for Mrs. Kapp’s pulmonary condition. For an unknown reason, they stayed in Denver, where William obtained employment making machine parts. The Kapp’s oldest daughter, Ruth, aged 20, Ruth’s husband, Roy, aged 24, and their daughter, Rebecca, aged 17 months, moved with them so Ruth could help care for her ailing mother. After 2 months, Roy returned to northern Appalachia because he was unable to find work in Denver. Ruth is 3 months’ pregnant. Because Mrs. Kapp has been feeling “more poorly” in the last few days, she has come to the clinic and is accompanied by her husband, William, her daughter Ruth, and her granddaughter, Rebecca. On admission, Gloria is expectorating greenish sputum, which her husband estimates to be about a teacupful each day. Gloria is 5 ft 5 in. tall and weighs 92 pounds. Her temperature is 101.4°F, her pulse is regular at 96 beats per minute, and her respirations are 30 per minute and labored. Her skin is dry and scaly with poor turgor. While the physician is examining Mrs. Kapp, the nurse is taking additional historical and demographic data from Mr. Kapp and Ruth. The nurse finds that Ruth has had no prenatal care and that her first child, Rebecca, was delivered at home with the assistance of a neighbor. Rebecca is pale and suffers from frequent bouts of diarrhea and colicky symptoms. Mr. Kapp declines to offer information regarding his health status and states that he takes care of himself. This is the first time Mrs. Kapp has seen a health-care provider since their relocation. Mr. Kapp has been treating his wife with a blood tonic he makes from soaking nails in water; a poultice he makes from turpentine and lard, which he applies to her chest each morning; and a cough medicine he makes from rock candy, whiskey, and honey, which he has her take a tablespoon of four times a day. He feels this has been more beneficial than the prescription medication given to them before they relocated. The child, Rebecca, has been taking a cup of ginseng tea for her colicky symptoms each night and a cup of red bark tea each morning for her diarrhea. Ruth’s only complaint is the “sick headache” she gets three to four times a week. She takes ginseng tea and Epsom salts for the headache. Mrs. Kapp is discharged with prescriptions for isoniazid, rifampin, and an antibiotic and with instructions to return in 1 week for follow-up based on the results of blood tests, chest radiograph, and sputum cultures. She is also told to return to the clinic or emergency department if her symptoms worsen before then. The nurse gives Ruth directions for making appointments with the prenatal clinic for herself and the pediatric well-child clinic for Rebecca. Study Questions 1. Describe the migration patterns of Appalachians over the last 50 years. 2. Discuss issues related to autonomy in the workforce for Appalachians. 3. Identify high-risk behaviors common in the Appalachian region. 4. Describe barriers to health care for people living in Appalachia. 5. What might the nurse or physician do to encourage Mrs. Kapp to comply with her prescription regimen? 6. What would your advice be regarding each of the home remedies that Mrs. Kapp is taking? Would you encourage or discourage her from continuing them? 7. What might the nurse have done to help ensure that Ruth would make the appointments for herself and her daughter? 8. What advice would you give Ruth regarding the home remedies that she and her daughter are currently taking? Would you encourage or discourage their use? 9. Do you think Mrs. Kapp will return for her appointment next week? Why? What would you do if she did not return for her appointment? 10. Do you think that Ruth will make and keep appointments for herself and her daughter? 11. What would you do to encourage Mr. Kapp to consent to a health assessment? 12. What additional services could you suggest to assist the Kapp family at this time? 13. What additional follow-up do you consider essential for the Kapp family? 14. What advice would you give Ruth regarding her daughter’s frequent bouts of diarrhea? APPALACHIAN CASE STUDY #2 Leona Sperry, aged 74 years, lost her husband, a preacher, to emphysema 2 months ago. Since that time, she has been living alone on a limited income from her husband’s Social Security. Mrs. Sperry states that she has lived in the same West Virginia community all of her life, just like her parents and grandparents. She is known in the community as Miss Leona and is respected for her knowledge of folk medicine and “deliverin’ babies,” which she has done as long as she can remember, just like her mother and grandmother. All but one of her nine children live within 50 miles. Miss Leona does her own cooking, bakes biscuits and bread twice a week, and makes large pots of meat stew so she does not have to cook every day. A farmer neighbor supplies her with milk, eggs, and meat in trade for using the land from her small farm to pasture his cattle. Even though she only went to the third grade, she enjoys reading stories in the Reader’s Digest, which she keeps on her bedside table. She also enjoys talking on the telephone with her children and sister, who lives about 5 miles away. Miss Leona lives on top of a hill and has to cross a footbridge to get to her home. Her driveway ends at the footbridge, requiring her to carry her groceries up a steep incline with many steps. Sometimes, a neighbor or the postman delivers her groceries when her children are unable to bring them to her. Miss Leona’s granddaughter, a nurse who lives out of the area, called the Visiting Nurse Association and requested that someone see her grandmother. Miss Leona tells the visiting nurse that she has had arthritis in her hands, hips, and knees for many years. She has also suffered from “low blood” all her life. Now, she has other health problems as well, and some chest congestion, which is not responding to her usual treatment. Her most recent health concern, she says, is “heart problems,” which her physician, Dr. Adi, tells her is from her high-fat diet. However, Miss Leona believes her heart problems were brought on by her husband’s death, because she did not have them until after he died. Her physician also gave her a jar of salve to put on a leg wound caused by an insect bite, which became infected when she scratched it in her sleep. On her last visit to her physician a month ago, he referred her to a heart specialist at a medical center 50 miles from her home. He also wanted her to make an appointment with an arthritis specialist. So far, she has not made an appointment with either specialist because she does not know when one of her children will be available to take her to the medical center. Besides, she says, her children have their own families and jobs, and she does not like to bother them with her problems. In addition, she tells you that she is looking forward to her 16-year-old granddaughter, who is 3 months’ pregnant, coming to live with her in a couple of months. After all, she misses being a midwife. She admits not using the salve given to her by Dr. Adi because he told her to apply the salve according to the instructions on the jar. She has been drinking the brine from her home-canned pickles for her “low blood,” drinking ginseng tea for her arthritis, and applying a poultice made from bacon grease on the leg wound. She tells you that she does not want to return to Dr. Adi because she cannot understand him, he does not listen to her, and he did not help her when she last saw him. She explains that she is a good “Christianwoman,” has lived right all her life, and does not interfere with her neighbors’ lives. She rarely misses Sunday church services because all her neighbors go to the same Baptist church and she “allus” has plenty of volunteers to carry (take) her to the church. Study Questions 1. Why do the members of her community call Mrs. Sperry by the name Miss Leona? 2. What can the nurse do to assist Miss Leona to decrease the barriers to needed health care? 3. What might Dr. Adi do to ensure a more-trusting relationship with Miss Leona? 4. What historical precedence is there for distrust of “outsiders” in Appalachia? 5. What evidence do you see of the “ethic of neutrality” in this case study? 6. What is the difference between a minister and a preacher, as practiced by Baptists in Appalachia? 7. What do Appalachians mean by the term “low blood”? What are some folk treatments for this condition? 8. What advice would you give Miss Leona about her folk remedies? 9. What might you do to encourage Miss Leona to make appointments with the specialists recommended by Dr. Adi? 10. How might you help Miss Leona eat a more-nutritious diet? 11. What strategies might you encourage for Miss Leona to cope with her “heart problems” that began after her husband died? 12. What kind of prenatal advice would you give the granddaughter when she comes to live with Miss Leona? ARAB CASE STUDY Mrs. Ayesha Said is a 39-year-old Muslim Arab housewife and mother of six who immigrated to the United States from a rural town in southern Iraq 2 years ago. Her mother-in-law and her husband, Mr. Ahmed Said, accompanied her to the United States as participants in a post–Gulf War resettlement program, after they spent some time in a Saudi Arabian refugee camp. Their relocation was coordinated by a local international institution that provided an array of services for finding employment, establishing a household, enrolling the children in public schools, and applying for federal aid programs. Mr. Ahmed, who completed the equivalent of high school, works in a local plastics factory. He speaks some English. He plans to attend an English-language class held at the factory for its many Iraqi employees. Mrs. Ayesha, who has very little formal schooling, spends her day cooking and caring for her children and spouse, with the assistance of her mother-in-law. She leaves their home, a three-bedroom upper flat in a poor area of the city, only when she accompanies her husband shopping or when they attend gatherings at the local Islamic center. These events are quite enjoyable because most of those using the center are also recently arrived Iraqi immigrants. She also socializes with other Iraqi women by telephone. Except for interactions with the American personnel at the institute, Mr. Ahmed and Mrs. Ayesha Said remain quite isolated from American society. They have discussed moving to Detroit because of its large Arab community. Four of the Said children attend public elementary schools, participating in the English as a Second Language (ESL) program. Mr. Ahmed and Mrs. Ayesha are dismayed by their children’s rapid acculturation. Although Muslims do not practice holidays such as Halloween, Christmas, Valentine’s Day, and Easter, their children plead to participate in these school-related activities. Mrs. Ayesha is being admitted to the surgical unit after a modified radical mastectomy. According to the physician’s notes, she discovered a “lump that didn’t go away” about 6 months ago while breast-feeding her youngest child. She delayed seeking care, hoping that inshallah, the lump would vanish. Access to care was also limited by Mrs. Ayesha’s preference for a female physician and her family’s financial constraints—that is, finding a female surgeon willing to treat a patient with limited financial means. Her past medical history includes measles, dental problems, headache, and a reproductive history of seven pregnancies. One child, born prematurely, died soon after birth. As you enter the room, you see Mrs. Ayesha dozing. Her husband, mother-in- law, and a family friend, who speaks English and Arabic and acts as the translator, are at her bedside. Study Questions 1. Describe Arab Americans with respect to religion, education, occupation, income, and English-language skills. Compare the Said family with Arab Americans as a group. 2. Assess the Said family’s risk for experiencing a stressful immigration related to their isolated lifestyle. 3. Describe the steps you would take to develop rapport with Mrs. Ayesha and her family during your initial encounter. Include nonverbal behavior and social etiquette as well as statements or questions that might block communication. 4. Identify interventions that you would employ to accommodate Mrs. Ayesha’s “shyness” and modesty. 5. You notice that, although Mrs. Ayesha is alert, her husband and sometimes her mother-in-law reply to your questions. Interpret this behavior within a cultural context. 6. Although Mrs. Ayesha is normothermic and states her pain is “little,” Mr. Ahmed insists that his wife be covered with several additional blankets and receive an injection for pain. When you attempt to reassure him of his wife’s satisfactory recovery, noting as evidence of her stable condition that you plan to “get her up” that evening, he demands to see the physician. Interpret his behavior within a cultural context. 7. Discuss Arab food preferences as well as the dietary restrictions of practicing Muslims. If you filled out Mrs. Ayesha’s menu, what would you order? 8. When you give Mrs. Ayesha and her family members discharge instructions, what teaching methods would be most effective? What content regarding recovery from a mastectomy might most Arab Americans consider “too personal”? 9. Identify typical coping strategies of Arabs. What could you do to facilitate Mrs. Ayesha’s use of these strategies? 10. Discuss predestination as it influences the Arab American’s responses to death and bereavement. 11. Discuss Islamic rulings regarding the following health matters: contraception, abortion, infertility treatment, autopsy, and organ donation and transplant. 12. Describe the Arab American’s culturally based role expectations for nurses and physicians. In what ways do the role responsibilities of Arab and American nurses differ? 13. What illnesses or conditions are Arab Americans unlikely to disclose because of Islamic prohibitions or an attached stigma? 14. Compile a health profile (strengths versus challenges) of Arab Americans by comparing beliefs, values, behaviors, and practices favoring health and those negatively influencing health. BALTIC CASE STUDY Mr. Antanas Butkauskas, aged 61, and his wife, Birut, aged 58, live in an eastern suburb of Cleveland, Ohio. He works in a tool and die shop, and she works as a seamstress in a shirt factory. They have three grown children, none of whom live with them. They have lived in the United States since 1949, when they emigrated from Germany. They escaped from Lithuania just before World War II ended. Both lost touch with siblings who were deported to Siberia by the Soviets. Fearing for their own lives, Mr. and Mrs. Butkauskas took their then-small children and fled their country, leaving behind their farm and remaining relatives. Both Mr. and Mrs. Butkauskas worked hard, saved money for a small house, and put all three children through college. Mrs. Butkauskas has had arthritis in her hands and hip joints for a number of years and symptoms of congestive heart failure since her late 40s. Mr. Butkauskas has had high blood pressure for about 12 years. Both have been on medication for their physical problems. They were encouraged to diet, lose weight, and decrease their sodium intake. Mrs. Butkauskas has followed the medication regimen faithfully. She has decreased salt and fat intake and has lost about 15 pounds. Mr. Butkauskas initially lost 8 pounds but does not follow his diet closely. He eats salami and other salty foods for lunch when he is tired of what his wife prepares. The Butkauskas have a small backyard garden where they grow tomatoes, cucumbers, carrots, onions, beets, and beans. They enjoy being outdoors together in their small garden. They also enjoy listening to their ethnic music. Both are beginning to think about retirement and continue to be frugal, saving for their old age. This past winter, Mr. Butkauskas was laid off. Even though his foreman told him that this was temporary, Mr. Butkauskas is extremely worried about paying the bills and not being able to save as much as he wants. He has difficulty sleeping and is having tightness in his chest with pain radiating down his arm. He does not want to worry his wife, so he does not tell her about this until the pain and discomfort become severe. His wife takes him to their family physician, who has cared for him for years. Study Questions 1. Identify the cultural aspects of health to be considered for this family when performing a cultural health assessment. What physical symptoms need immediate attention? 2. Identify this family’s expectation of care should Mr. Butkauskas need hospitalization. 3. List stress-management techniques appropriate for family members of this culture. How could they be used? 4. List alterations in diet and related interventions appropriate in this situation. 5. Discuss how the nurse might act with cultural sensitivity if Mrs. Butkauskas insists on doing the nursing for her husband while he is in the hospital. 6. Mrs. Butkauskas wants to bring in homemade wine one evening. How might the nurse intervene with cultural sensitivity? 7. Mrs. Butkauskas brings gifts of home-baked goods for the nursing staff each time that she visits. Discuss a culturally conscious response. 8. Identify two major health problems of Baltic Americans and how these relate to this particular family. 9. Discuss interventions appropriate to Mr. Butkauskas’s cardiac problems. 10. Identify strategies to reduce Mr. Butkauskas’s stress about being laid off that would be acceptable to him. CHINESE CASE STUDY #1 An elderly, Asian-looking man is admitted to the emergency room with chest pain; difficulty breathing; diaphoresis; vomiting; pale, cold, clammy skin; and apprehension. Three people, speaking a mixture of English and a foreign language to one another, accompany him. The nurse tries to speak English with the man, but he cannot understand anything she says. Accompanying the elderly man are two women (one elderly and very upset and one younger who stands back from the other three people) and one younger man. The younger man states that the elderly man, whose name is Li Ying Bin, is his father; the elderly woman, his mother; and the younger woman, his wife. The son serves as the translator. Li Ying Bin comes from a small village close to Beijing. He is 68 years old, and he has been suffering with minor chest pain and has had trouble breathing for 2 days. He is placed in the cardiac room, and the assessment continues. Mr. Li is on vacation, visiting his son and daughter-in-law in the city. His son and daughter-in-law have been married for only 1 year, but the son has lived in the West for 7 years. Mr. Li’s daughter-in-law looks Chinese but was born in the United States. She does not speak very many words of Chinese. Further physical assessment reveals that Mr. Li has a history of “heart problems,” but the son does not know much about them. Mr. Li had been to the hospital in Beijing but did not like the care he received there and returned home as soon as possible. He goes to the local clinic periodically when the pain increases, and the health-care provider in China used traditional Chinese medicine, herbs, and acupuncture. In the past, those treatments relieved his symptoms. Medications are ordered to relieve pain, and Mr. Li undergoes diagnostic procedures to determine his cardiac status. The studies reveal that he did sustain massive heart damage. Routine interventions are ordered, including heart medications, anticoagulants, oxygen, intravenous fluids, bedrest, and close monitoring. His condition is stabilized, and he is sent to the cardiac intensive-care unit. In the cardiac unit, the nurse finds Mrs. Li covering up Mr. Li until he sweats, and Mrs. Li argues with the nurse every time her husband is supposed to dangle his legs. She complains that he is too cold and brings in hot herbal beverages for him to drink. She does not follow the nurse’s and physician’s orders for dietary restrictions, and she begins to hide her treatments from the staff. Her son and daughter-in-law try to explain to her that this is not good, but she continues the traditional Chinese medicine treatments. Mr. Li is a very quiet patient. He lies in bed and never calls for help. He frequently seems to be meditating and exercising his arms. When he does talk to his son, he speaks of the airplane ride and the problems of being so high. He believes that may have caused his current heart problem. Mr. Li also wonders if Western food could be bad for his system. Mr. Li’s condition gradually deteriorates over the next few days. Nurses and physicians attempt to tell the family about his condition and possible death, but the family will not talk with them about it. Mr. Li dies on the 5th day. Study Questions 1. If you were to go to China on a business trip, how would you design your name card so that the Chinese would not be confused? 2. If you wished to have a meeting with a Chinese delegation of health-care providers, would you expect them to be on time? Why? 3. If the meeting included a meal with Chinese food, what kinds of food would you expect to be served? How would it be presented? If something were served that you do not like, would you eat it anyway? 4. Compare and contrast the Chinese meaning of life and way of thinking with the Western meaning of life and way of thinking. 5. What are the common health risks for the development of chronic obstructive pulmonary disease among Chinese people? 6. What are some of the reasons that Mr. Li waited so long to enter the hospital? 7. Mr. Li did not complain of chest pain in the cardiac intensive-care unit. Is this a common behavior? Why? 8. True or False: The Chinese family will expect health-care providers at the hospital to provide most of the care for Mr. Li. 9. Why must the physician be careful with the amounts of medication ordered? 10. Mrs. Li is curt, demanding, and disagreeable toward her daughter-in-law. Why does she act this way? 11. Explain why Mr. Li blames the airplane ride and the Western food for his heart attack. Why does he meditate and do exercises? 12. Is Mr. Li’s stoicism during dying surprising? Why do the family members refuse to discuss his health and possible death? 13. What is the preferred method for handling the remains of a deceased Chinese person? 14. Describe common mourning rituals for the Chinese. 15. Describe bereavement in a Chinese family. 16. Describe a common view of death among Chinese. CHINESE CASE STUDY #2 Mr. Chen, aged 30, and his wife, aged 28, have three children, aged 7, 5, and 2. Many of their extended families also live in the United States near them. Mr. Chen and his parents own several Chinese restaurants. Mr. Chen, an extremely important member in this family, was diagnosed with end-stage renal disease (ESRD) in 1996. The entire family has been under stress for a variety of reasons: the uncertain outcomes of Mr. Chen’s illness, three young children, living in a foreign country and in a different cultural environment, and barriers to accessing health care effectively. Mr. Chen immigrated to the United States in the early part of 1988 to join his parents and work in their successful Chinese restaurant in New York City. His fiancée immigrated to the United States in late 1988, and they married in 1990. The Chen family and Mr. Chen’s parents moved to Albany, New York, and eventually opened three new restaurants before he became ill. His wife cared for their children at home. Mrs. Chen’s parents remained in New York City, where her father is a minister in the Chinese Christian Church. In December 1995, Mr. Chen felt extremely sick with fatigue, nausea, vomiting, and weight loss. At that time, he did not have health insurance. Because of language barriers and the high cost of health care in the United States, he returned to China for medical care. In China, Mr. Chen was diagnosed with ESRD. His physician recommended a kidney transplant. Mr. Chen’s parents also returned to China because of the seriousness of their son’s health. Mr. Chen sold his three restaurants to obtain money for his medical expenses. In May 1996, Mr. Chen received a cadaver kidney transplant in China and recuperated without complications. In July 1996, he returned to the United States with a fully functioning kidney. Mr. Chen continued taking antirejection immunosuppressive agents prescribed by the Chinese physician until October 1996, 5 months’ post-transplantation. At that time, he saw an American physician to obtain a prescription for refilling his antirejection medication. The physician told him that he did not need to continue the medication. He questioned the physician because the Chinese physician had told him that he needed to continue the medication for the rest of his life. Again, he was told that his condition was stable, and he stopped taking the medication. After 20 days, kidney rejection occurred, and he began long-term hemodialysis under Medicare. Hemodialysis left him feeling exhausted and unable to work outside his home. His diet was limited, and he suffered a number of complications, including hepatitis B and liver failure. In December 1997, he suffered a seizure while visiting friends. After Mr. Chen became ill, Mrs. Chen began working as a waitress in a friend’s restaurant and became the sole financial provider for the family. To reduce rent expenses and to be closer to his wife’s work, they moved to a four-bedroom house, which they shared with two other Chinese families, who were close friends. Also, Mr. Chen initiated the extensive application process for disability and Medicaid and long-term hemodialysis. The language barrier made this process even more complicated. He felt frustrated because he was unable to care for his family. However, he is still hopeful and plans to someday return to China for another kidney transplant. His extended family is very supportive, and they are saving money to help pay for his second kidney transplant. Study Questions 1. Initially, what were the main reasons why Chinese people immigrated to the United States? How does this differ from their current reasons for immigrating? 2. How did Americans treat the Chinese in the early 1800s? 3. How do Chinese Americans form networks to support one another? 4. What are some effective ways for Western health-care providers to communicate with Chinese clients who may have difficulty understanding English? 5. Compare and contrast the Chinese meaning of life and ways of thinking with the Western cultural perceptions of the meaning of life and ways of thinking. 6. Why did Mr. Chen initially not seek health-care providers in the United States? 7. What are some of the difficulties that Mr. Chen might have as a long-term hemodialysis patient with a Chinese cultural background? 8. If you were Mr. Chen’s health-care provider, what might you do to improve the quality of life for the Chen family? 9. How might the Chen family go about seeking a kidney transplant in the United States? 10. How might the extended family be more involved with the Chen family? 11. Would you suggest to Mr. Chen that he ask his extended family to be tested for compatibility for being a kidney donor for him? 12. Explain the relationship of yin and yang. CUBAN CASE STUDY Mrs. Demetilla Hernandez is a 63-year-old Cuban woman who seeks consultation at the Liberty health-maintenance organization (HMO) clinic because of weakness, lethargy, and fatigue that she has experienced for the last 2 months. A week ago, while cooking dinner at her daughter, Mariana’s house, she momentarily lost her balance and slipped on the kitchen floor. Although Mrs. Hernandez sustained only a mild bruise on her leg, her daughter insisted on taking her to the clinic for a check-up because of her persistent symptoms. Mrs. Hernandez, widowed 4 years ago when her husband died of a heart attack, lives with Mariana, aged 40. Mariana is divorced and has three children: Luis, aged 15; Carolina, aged 10; and Sofia, aged 7. Since moving into Mariana’s house, Mrs. Hernandez has been managing the household while Mariana is at work. Mrs. Hernandez prepares the family’s meals, attends to the children when they come home from school, and performs light housekeeping chores. Mariana is employed full-time as a supervisor at the local telephone company. The family, originally from Cuba, has been living in Miami for 12 years. Carolina and Sofia were born in Miami, but Luis came from Cuba with his parents when he was 3 years old. Mrs. Hernandez, who does not speak English, converses with her daughter and grandchildren in Spanish. Although the children and their mother occasionally speak English among themselves, the family’s language at home is Spanish. At the Liberty HMO clinic, Mrs. Hernandez was diagnosed with essential hypertension and non–insulin-dependent diabetes mellitus. The physician prescribed an oral hypoglycemic drug and advised Mrs. Hernandez to exercise daily and to limit her food intake to 1500 calories a day. Mrs. Hernandez was concerned because she usually prepares traditional Cuban meals at home and was not sure whether she could tolerate being on a diet. Besides, she explained to Mariana, she thought the dishes she prepares are very “healthy.” Proof of that, she stated, is that her three grandchildren are plump and nice-looking. Mrs. Hernandez told her daughter that, instead of buying the prescribed medicine, perhaps she should go to the botanica and obtain some herbs that would help lower her blood sugar. Study Questions 1. As a health-care provider, what are the typical Cuban communication patterns you need to be aware of in dealing with Mrs. Hernandez? 2. Describe the traditional Cuban food patterns. How would you assist Mrs. Hernandez in developing a plan for a 1500-calorie diet and regular exercise? 3. Would you encourage Mrs. Hernandez to go to the botanica to purchase some herbs? How would you approach her desire to use herbs instead of the prescribed oral hypoglycemic agent? 4. Discuss some common folk practices that Cuban families may use to maintain health or cure common ailments. 5. Explain how time orientation may influence Mrs. Hernandez’s compliance with follow-up clinic visits. 6. Formulate three important goals in teaching Mrs. Hernandez and her family about health care. 7. Identify the typical family and value structure among Cuban Americans. 8. List three major health problems among Cuban Americans. 9. If you were the health-education specialist at the clinic, what would you teach the staff about Cuban culture to help them provide culturally comptent care? 10. Discuss traditional child-rearing practices among Cuban Americans. FILIPINO CASE STUDY #1 In 1990, Jose Bisigan, aged 87, and his wife, Carmen, aged 85, sold their small restaurant and immigrated to Los Angeles from a small town in the Visayan region. They came to join their first-born daughter, Felicia, aged 54, a nurse; her husband; and their three children, aged 10 to 18. Mr. Bisigan speaks limited English and is in a poststroke rehabilitation unit. Since the stroke, he has had mild aphasia, mild confusion, and bladder and bowel continence problems. His hypertension and long-standing diabetes are controlled with medication and diet. His wife, daughter, and grandchildren have been supportive of him during this first hospitalization experience. Mr. Bisigan’s family has cooperated with the health team, often agreeing with minimal resistance to the prescribed treatment management. The rehabilitation team recommended subacute rehabilitation treatment as part of the discharge plan. As a businessman and the elder in the family household, Mr. Bisigan is looked to for counsel by the immediate and extended family. Mr. Bisigan’s status, however, has caused friction between Felicia and her husband, Nestor, an American-born Filipino who works as a machinist. Nestor has accused Felicia of giving excessive attention to her mother and father. Felicia is worried that her parents’ health has made Nestor very resentful. He increased his already daily outings with “the boys.” Felicia maintains a full- time position in acute care and a part-time night-shift position in a nursing home. Mr. Bisigan’s discharge is pending and a decision must be made before Medicare coverage runs out. Felicia has to consider the possible choices available to her father and the family circumstances and expectations. Mrs. Bisigan, who is being treated for hypertension, has always deferred decisions to her husband and is looking to Felicia to make the decisions. Because of her work schedule, the absence of a responsible person at home, her mother’s health problems, and intergenerational friction, Felicia considers nursing-home placement. She is, however, reluctant to broach the subject with her father, who expects to be cared for at home. Mrs. Bisigan disagrees with putting her husband in a nursing home and is adamant that she will care for her husband at home. Felicia delayed talking to her father until the rehabilitation team requested a meeting. At the meeting, Felicia indicated that she could not bring herself to present her plan to put her father in a nursing home because of her mother’s objection and her own fear that her father will feel rejected. Feeling very much alone in resolving the issue about nursing-home placement, she requested the team to act as intermediary for her and her family. Study Questions 1. Identify cultural family values contributing to the conflicts experienced by each family member. 2. Identify a culturally competent approach the team can use when discussing nursing-home placement with the Bisigans. 3. How might the rehabilitation program be presented to Mrs. Bisigan and still allow her to maintain her spousal role? 4. Discuss at least three communication issues in the family that are culture- bound and suggest possible interventions. 5. Identify psychocultural assessments that should be done by the rehabilitation team to have a greater understanding of the dynamics specific to this family. 6. Identify and explain at least two health-promotion issues for each family member that are complicated by cultural beliefs and practices. 7. How might the family and the rehabilitation team benefit from consultations with a geriatric nurse practitioner or a transcultural clinical nurse specialist? 8. What food preferences in the traditional Filipino diet might be detrimental to Mr. and Mrs. Bisigan’s health? 9. Identify health-promotion counseling that might be discussed with the Bisigan’s grandchildren. 10. List at least five culturally sensitive communication guidelines for talking with Mr. and Mrs. Bisigan. 11. Identify and explain major sources of stress for each member of this household. 12. What cultural belief system complicates the family members’ responses and may contribute to the discharge plan for a subacute rehabilitation program? FILIPINO CASE STUDY #2 Sixty-eight-year-old Ramona Mag-pantay from the Philippines is visiting her daughter in New Jersey. She has been alternating with her husband in coming to the United States for 6 weeks at a time to keep their immigrant status in good standing. Although neither she nor her husband plans to reside in the United States permanently, they applied for immigration through the sponsorship of their daughter so they can facilitate immigration of their youngest child. Ramona and her husband are both retired and live comfortably in the Philippines. She was an elementary school teacher and her husband maintains an accounting office with one of his sons, who is also an accountant. They have six children, three of whom reside in North America (two in New Jersey and one in Toronto). In the United States, they stay with their married daughter, Virginia, who lives with her husband and three children. Ramona’s son Roberto lives with his wife and two children: a 3-year-old boy and a 1-year-old girl. Because her daughter, Virginia, is a full-time homemaker, Ramona stays with her son on the weekdays to help look after her grandchildren while the couple are working. She goes home to Virginia’s family on weekends. One Friday evening, Virginia phoned her friend Rowena, a Filipino nurse residing in the same neighborhood. She asked Rowena to come and check her mother, who was not feeling well. Rowena sensed the urgency in Virginia’s tone of voice and quickly drove to her home. She found Ramona in bed, fully covered with a comforter, with visible chest heaves and lifts. After examining Ramona and taking her vital signs, Rowena spoke with Virginia alone in the kitchen so Ramona would not hear their conversation. Rowena told Virginia that her mother should be taken to the hospital. Virginia explained that her mother does not have medical insurance because she stays for only 6 weeks at a time and has a medical examination before her trips. She also told Rowena that her mother has diabetes, hypertension, and an irregular heartbeat. When Ramona’s heart medications (Digoxin and Inderal) ran out, she did not inform Virginia. She did not want her to purchase her medications because she is not “working and earning.” She also thought that, because she would be going home in 2 weeks, she could wait until then. Before calling Rowena, Virginia already consulted her cousin Leticia, a physician who lives in Long Island, New York. Rowena called her cousin’s husband, who is a cardiologist, to get his recommendation. Upon hearing Ramona’s symptoms, the cardiologist insisted that she be taken to the emergency room (ER) at once. When she heard his recommendation, Virginia agreed to call for an ambulance and accompanied her mother in the ambulance to the local hospital. The ER physician determined that Ramona should be admitted to the cardiac- care unit (CCU). Virginia requested that her cousin Leticia speak to the doctor before any decision was made. Leticia explained to the doctor the financial ramifications of Ramona’s admission and explored the possibility of her discharge on medications. The ER physician vehemently disagreed with Leticia and explained the seriousness of Ramona’s condition as well as her need for close medical supervision. Leticia then spoke with Virginia and apologized for her inability to convince the ER physician. She warned her to anticipate the high cost of CCU care. Virginia’s husband was called to sign the promissory note of payment for Ramona’s hospitalization. He was resigned to the idea that Ramona’s life was in danger and money should not be a barrier to her well-being. He was also confident that Virginia’s two brothers in North America would share the cost. Ramona was never made aware of all these discussions. In her presence, Virginia and her husband did their best to present a calm, reassuring presence. She was told that she would be given a thorough examination, which is advantageous because it is done in a U.S. facility, far superior than health care in the Philippines. Ramona spent 3 days in CCU, followed by 4 days in a medical unit. When visited by her daughter’s friend Rowena, she verbalized her concern for her daughter’s family paying the cost of her hospitalization. What she tried hard to accomplish (not to burden her daughter) turned out to be a very expensive mistake. She had always wanted her daughter to go back to work as a medical technologist to help her husband. She said that with two incomes, her three grandchildren would be ensured a better future. Virginia admitted to Rowena that her mother had tried many times to convince her to return to work, but her previous experience with babysitters was traumatic and she decided to stay home and live economically to compensate for the loss of income. She said that she would consider returning to work when the children were much older. Two weeks after her discharge, Ramona returned to the Philippines. She decided not to return to the United States, but assured her family that her husband would travel every year to maintain their immigration status. Her children make every effort to visit her regularly in the Philippines and speak with her frequently by phone. Study Questions 1. Describe how these Filipino cultural values are manifested in this family: • Utang na loob: reciprocal obligation to kin. • Pakkipagkawa: shared identity. • Pakiramdam: shared perception with others. • Bahala na: fatalism. 2. Discuss how these values may have contributed to the crisis in the family. 3. Identify potential problems that can arise from these values in a different cultural context, such as in the United States. 4. Explore culture-specific assessments and communication approaches for the patient and the family. 5. Identify culturally competent care strategies for health promotion. FRENCH CANADIAN CASE STUDY #1 Julie is a 28-year-old gravida 0 and para 0 who presents herself to a nurse at the family- planning clinic. Julie has just learned that she is 6 weeks pregnant. She has been living with Jean-Michel for the last year. Julie has been working as a contractual teacher in an elementary private school for the last 2 years. Jean-Michel, of Haitian origin, has lived in Canada for 5 years. His whole family lives in Haiti except for a brother who lives in Montréal. Jean-Michel works for the Canadian International Development Agency. He enjoys his work, but the position offers little job security. Julie’s parents live in the area and are very devout Catholics. They never really approved of Julie’s living with Jean-Michel without being married. At first, Julie’s father didn’t like the fact that Jean-Michel was black, but now that he knows more about Jean- Michel, he is more accepting of the relationship. Julie’s pregnancy is not planned. Julie and her partner have been using condoms for contraception. Thus, Julie is very surprised and does not understand how she became pregnant. Julie is anxious and worried; she has not said anything yet about the pregnancy to Jean-Michel. Julie is not sure if she is ready to become a mother. She doesn’t know if she wants the baby and is really confused. The couple has never discussed having a family since they have been living together. She doesn’t know what to do or what to say to Jean-Michel, or even whether she should tell Jean-Michel that she is pregnant. She walks into the clinic in an agitated state of mind. Study Questions 1. What are the major obstacles to health and well-being for this young couple? 2. Which of the transcultural domains are the most in jeopardy? 3. What are the major obstacles to independence/health? How do these differ from those that interfere with health and well-being? 4. How do the meanings people attach to health and well-being, the control they assume or wish to assume over their health, and the objective features of health reflect cultural differences in life? 5. Discuss the role of the nurse and the implications for culturally competent care with this couple. 6. What types of assistance and relationships between generations are most important in maintaining this family unit? 7. How important are kinship ties in minority settings with regard to the adjustment and morale? 8. Are cultural factors more important for young adults than for other age groups? Explain your answer. FRENCH CANADIAN CASE STUDY #2 Mr. Tremblay, a retired 63-year-old car dealer, lives with his wife, Aline, aged 58, in a nice suburban bungalow. The couple has five children, each of whom has their own family now, and no one is living close to them. Mrs. Tremblay has been a housewife since she married 40 years ago; she is not self-confident and is very dependent on her husband. Mr. Tremblay has always been the decision maker, but now he is not healthy and is tired of taking all the responsibilities. Mrs. Tremblay comes into the emergency room complaining of chest pain for 2 weeks. She describes the pain as burning and squeezing; it is steady and ends gradually. The pain started while she was raking the lawn. She didn’t say anything to her husband because he is an anxious man and she didn’t want to worry him. When her daughter, a nurse, came to visit them a week ago, she talked about her symptoms. Her daughter said she should see her family doctor as soon as possible because her maternal grandfather died of an acute myocardial infarction at the age of 59. Although Mr. Tremblay is completely bilingual, Mrs. Tremblay never mastered the English language further than necessary for the everyday needs of shopping. Mrs. Tremblay is hesitant to consult her family physician because he does not speak much French. She prefers to wait and see . . . until a stronger pain forces her to seek help. Study Questions 1. What are the major obstacles to health and well-being for this elderly couple? 2. Which of the transcultural domains are in the most jeopardy? 3. What are the major obstacles to the Tremblays’s independence and health? How do these differ from those that interfere with health and well-being? 4. How do the meanings people attach to health and well-being, the control they assume or wish to assume over their health, and the objective features of health reflect cultural differences in later life? 5. Discuss the role of the nurse and the implications for culturally competent care for this couple. 6. What types of assistance and relationships between generations are important in maintaining this family unit? 7. How important are kinship ties in minority settings with regard to the adjustment and morale of older adults? 8. Do cultural factors have a stronger impact on older adults than on those in other age groups? GERMAN CASE STUDY Margaret Schmidt, a terminally ill 60-year-old American of German descent, was recently admitted to a hospice service and is receiving care at home. Diagnosed with metastatic breast cancer, Margaret’s prognosis is less than 6 months. Margaret’s cancer has metastasized to her ribs and liver and often causes intense pain. Although Margaret speaks freely of her impending death, her family has expressed their discomfort at her decision to secure hospice care. Over the last 10 years, Margaret, a nurse, has practiced homeopathy (for herself and others) and consults frequently with a medical intuitionist. She follows the medical intuitionist’s recommendations to attenuate her symptoms but avoids, when she can, the traditional cancer pain–management therapies. Medical staff and her family have entered into continuous discussions with her about her lack of acceptance of traditional medical approaches. Margaret remains unconvinced of their value within her scheme of care. Margaret maintains a strong belief in an afterlife, believing that she will be reunited with her husband. Margaret meditates daily, calling upon her spiritual guides and angels for strength and peace in the dying process. She often asks those around her to join her during this time. Study Questions 1. What experiences have you had with patients of German descent? 2. How does Margaret’s German ancestry mold her beliefs about medical treatment? 3. What Western medicine concepts complicate the staff and family’s understanding of Margaret’s self-prescribed medical regimen? 4. How do you, as a health-care professional, feel about the use of homeopathic remedies? 5. What is your view of the use of medical intuitionists and other non- Western health practices? 6. How do Margaret’s health-care choices differ or match your own? 7. How do you deal with cultural health practices unlike your own? 8. Discuss Margaret’s desire to control her life even through terminal illness. 9. Relate Margaret’s strong spiritual beliefs in an afterlife to her ability to cope with her impending death. 10. Describe a plan of care that is culturally sensitive to the patient and her family. 11. How can your knowledge of the German American culture positively influence health outcomes for Margaret? 12. Discuss the cultural filters you may use as you assist Margaret in her health-care decisions. 13. Describe the enculturation you, as a health-care professional, have experienced and how this influences your own health-care decisions. GREEK CASE STUDY Mr. Glinatsis is a 76-year-old immigrant from Athens, Greece. In 1940, at the request of his father, Mr. Glinatsis migrated to Chicago, Illinois. Greece had just entered World War II, and the father wanted Mr. Glinatsis to “earn some money for the family.” In fact, Mr. Glinatsis believes that his father sent him away so he would not have to enter the war as a soldier. Avoiding conscription in the Greek military was somewhat of an embarrassment. So Mr. Glinatsis moved to Chicago to the home of his mother’s sister and, then, after a short time, to the Quad Cities between Iowa and Illinois to be near two of his father’s brothers. For a number of years, Mr. Glinatsis worked as a waiter and later as a manager of his uncle’s business. On three occasions, he took second jobs to send extra money home. When possible, Mr. Glinatsis traveled to Greece to see his family. After he became a U.S. citizen, he married a woman from Athens and she joined him in Davenport, Iowa. There they raised a family of four, and shortly after the second child was born, Mr. Glinatsis went into the wholesale pharmaceutical distribution business and became very successful. Shortly after the death of his wife, Mr. Glinatsis retired. At the age of 75, he sold his business to a nephew, because all his children went to college and received graduate professional degrees unrelated to his business. Although financially able to live alone, he lives with his eldest son’s family in Moline, Illinois. His son is an engineer and owns his own firm. Both Mr. Glinatsis and his son are financially able to manage Mr. Glinatsis’s health-care needs. The rest of Mr. Glinatsis’s children also live in the area. He has a rich social life, centered around the Greek Orthodox Church. Mr. Glinatsis visited the Family Health Medical Clinic in October complaining of headaches and lightheadedness. His son said that he had been irritable. Some days ago, he had a dark urine stream. A health history further uncovered that he was sure it was not what he called matiasma. Unusual in his history is that he reported never going to a physician until this time. He began to feel ill only recently, diagnosing his condition as arthritis and taking “several pills a day” for the last few weeks. Nothing else in the history was remarkable. A urine culture was negative. However, a preliminary diagnosis of urinary tract infection was made, and Mr. Glinatsis was sent home with sulfisoxazole (500 mg four times a day). Mr. Glinatsis appeared in the emergency room complaining of severe abdominal and back pain and weakness several days after the clinic visit. He appeared in distress. Additional health data obtained in the emergency room indicated that Mr. Glinatsis consumes approximately two glasses of wine and an after-dinner drink each evening, has a 50-pack-per-year history of smoking, and has been relatively compliant on the antibiotic medication prescribed during his clinic visit. Clinical laboratory results indicate severe anemia. A subsequent laboratory analysis for glucose-6-phosphate dehydrogenase (G-6-PD) deficiency indicates that Mr. Glinatsis has this deficiency. He is treated for anemia, and the sulfa drugs and aspirin are removed from his therapy. He remains in the hospital for only 2 days. The illness and hospitalization are hard on Mr. Glinatsis, and one social worker recommends that he be discharged to an intermediate-nursing facility for recovery. On the evening before his discharge, he had an argument with his son and his daughter-in- law over whether Mr. Glinatsis should continue to reside in their home. Mr. Glinatsis is discharged to home with an instruction to no longer treat his self-diagnosed and unconfirmed arthritis. Study Questions 1. List some social values presented in the case that are common to members of the Greek community. 2. The migration of Mr. Glinatsis to the United States served as both an obligation and a source of shame. How might this be explained? 3. In what ways was Mr. Glinatsis’s immigration pattern similar to that of other people of Greek heritage? 4. U.S. immigration laws in the early half of the 20th century instituted quotas for Greek immigrants. Examining the basic values of Greek immigrants, how might you explain the shift to U.S. citizenship by Greek residents? 5. From a clinical perspective, the influence of the two drugs aspirin and sulfisoxazole uncovered a hereditary medical problem, G-6-PD. Discuss that problem. 6. What reasons might account for the fact that the disease did not occur until late in life? 7. How does Mr. Glinatsis’s pattern of family life demonstrate core cultural values of Greeks in America? 8. What is the folk illness in this case? Why did Mr. Glinatsis think it might be important? 9. How does Mr. Glinatsis’s health-seeking pattern fit with Greek values? 10. One issue in this case is where Mr. Glinatsis will reside. Discuss this issue in the context of family and residential preferences of older Greek Americans based on their heritage. HAITIAN CASE STUDY #1 Marie-Jose Paul is a 76-year-old Haitian woman who lives alone in a two-bedroom apartment in an enclave in East Hollywood, Florida. She has five children: one girl and four boys. According to Mrs. Paul, her youngest son died at the age of 23 in New York, from a policeman’s bullet. Her daughter, Marie-Nicole Joseph, lives with her family in an apartment next door to her mother. Mrs. Paul, born in Haiti, has been in the United States for 22 years, living first in New York and then in Florida. She is a legal resident, and because she had worked for 11 years as a hotel maid, she receives a monthly Social Security check for $450.00. She also receives Medicaid and food stamps. Mrs. Paul completed a sixth grade education in Haiti. She is functional linguistically and is able to sign her name. She primarily communicates in Creole. Although she understands English, since her retirement, she sees no need to communicate in English. Her children take care of her and are able to function within the American bureaucracy. Her apartment costs $455.00 per month. Her children help with the apartment rental and provide her meals and other basic necessities. She looks after her grandchildren when their parents are at work, a task that is becoming more difficult since she lost her vision. During the past year, Mrs. Paul has been in the hospital three times. She has been a diabetic for the last 25 years and is very unstable. She is also hypertensive with periods of instability and has peripheral neuropathy, a kidney disorder, severe progressive vision loss, anemia, and difficulty with her bowels, which she claims she has always had. She has a bowel movement every 5 to 7 days, for which she takes herbal tea two times per week and lavman weekly. Upon hospital discharge, she has a home health nurse. She is on a 2-g sodium, 80- g protein, and 1800-calorie American Diabetic Association diet. She likes only Haitian foods and has refused Meals on Wheels. She is currently on Procardia XL, Nitro-Bid, Epogen, and DiaBeta. She tells the nurse that she takes tea and other herbal products for her diabetes and hypertension. She experiences periods of depression, especially around her deceased son’s birthday or the date of his death. She says he was her most supportive son and her soulmate. Mrs. Paul subscribes to the hot and cold theory of disease. Study Questions 1. Identify three socioeconomic factors that influence Mrs. Paul’s health status. 2. Identify strategies the health-care practitioner might use to instruct Mrs. Paul’s daughter about her diet. 3. Discuss strategies that might be used to explain these recurring hospitalizations to Mrs. Paul without blaming her for them. 4. Identify strategies the health-care practitioner might use to determine Mrs. Paul’s understanding of her illness. 5. Explain the role of elders within the Haitian family concept. Relate this to Mrs. Paul and her family. 6. What inferences can you make about Mrs. Paul’s temporal beliefs? 7. Identify strategies to encourage compliance with diet and medication prescriptions. 8. Relate the hot and cold theory of disease management to Mrs. Paul’s ways of managing her illness. 9. What are some of the prescriptive activities Mrs. Paul uses? 10. Give two examples of popular foods within the Haitian culture that might be contradictory to Mrs. Paul’s dietary regimen. 11. Identify three instructional strategies that might be used to improve communication with Mrs. Paul. 12. If Mrs. Paul were on her deathbed at home, what strategies might be used to assist the family in meeting their needs? 13. Identify common health problems of Haitian immigrants. 14. Identify three factors that affect Haitian assimilation and acculturation. 15. Identify two concepts that have shaped Haitian societal identity. 16. Discuss two significant periods in Haitian migration to the United States. 17. Identify the two cities in the United States with the largest groups of Haitian immigrants. HAITIAN CASE STUDY #2 Marie-Carmel Theodore is a 36-year-old Haitian woman who lives with her three children: two daughters, aged 10 and 13, and one son, aged 17. They live in a two- bedroom, subsidized-housing project in an enclave in Lauderhill, Florida. Mrs. Theodore, born in Haiti, has been in the United States for 15 years. She is a legal resident and has a minimum-wage job. She also receives Medicaid and food stamps. Her 17-year-old son holds a part-time job after school. She has no support system in the United States. Her mother lives in Haiti. She does not speak of the children’s father. Mrs. Theodore completed sixth grade in Haiti, is functionally literate, and is able to sign her name. She primarily communicates in Creole, although she understands and speaks English. Her children are well versed in English and Creole. Mrs. Theodore states that she has been ill for the last year but could not afford to miss work, so as a result, she has not seen a doctor. She has been vomiting and experiencing abdominal cramps, diarrhea, generalized weakness, fatigability, and jaundice. Most recently, she has developed abdominal distention. She was treating herself at home with herbal tea, plain bread soup, and lavman for the abdominal distention, although she was having diarrhea. She thought that she had not fully evacuated, and therefore, the lavman would help. When the abdominal pains became unbearable, she had to be admitted to the hospital. She was diagnosed with metastatic hepatocellular carcinoma. She was discharged to hospice care at home with a prescription for MS Contin, which she could not afford to purchase. Upon arrival at the patient’s home, the hospice nurse found the patient to be extremely weak and emaciated, having lost 40 pounds in the last 2 months. Her children were caring for her. The 13-year-old had been giving her mother Ensure, tea, and soup. Mrs. Theodore was too weak to get out of bed. The 10-year-old stayed in the bathroom throughout the nurse’s visit. The 17-year-old was sleeping, having worked the night before. The apartment was extremely hot, over 90°F. With the patient’s permission, the air conditioner was turned on. Mrs. Theodore was in excruciating pain and had no medication in the home. The nurse went to the pharmacy and picked up the medication. Study Questions 1. Identify three socioeconomic factors that influenced Mrs. Theodore’s health status. 2. Identify strategies the health-care practitioner might use to instruct Mrs. Theodore’s daughter about her diet. 3. Discuss strategies that might be used to explain her terminal condition without placing blame. 4. Identify strategies the health-care practitioner might use to determine Mrs. Theodore’s understanding of her illness. 5. Explain the role of the family support system in the Haitian family concept. Relate this to Mrs. Theodore and her family. 6. What inferences can you make about Mrs. Theodore’s temporal beliefs? 7. Identify strategies you can suggest to support Mrs. Theodore and her children in pain management. 8. What are some of the prescriptive activities that Mrs. Theodore uses? 9. Give two examples of popular foods within the Haitian culture that might conflict with Mrs. Theodore’s dietary regimen. 10. Identify three instructional strategies that might be used to improve communication with Mrs. Theodore. 11. Mrs. Theodore is terminally ill with three underage children and no support system. What strategies might be used to assist the family in meeting their needs? 12. What Creole term would Mrs. Theodore use to indicate to you that she believes she is in the final phase of life? 13. Identify three factors that affect Haitian assimilation and acculturation. 14. Identify two concepts that have shaped Haitian societal identity. 15. Discuss two significant periods in Haitian migration to the United States. 16. Identify the two cities in the United States with the largest groups of Haitian immigrants. IRANIAN CASE STUDY #1 Mustafa E., aged 46, brought his wife, Mina, aged 39, and his three children to the United States in 1983. Their son Hamid was 12 years old; their daughter, Maryam, was 11 years old; and their son Ali was 7 years old. In addition to economic difficulties imposed by the Iran-Iraq war, they feared that Hamid would be drafted and sent to the front. Mustafa preferred not to leave Iran; he spoke no English and was afraid he would feel isolated in the United States. Mina, conversely, was somewhat eager to leave the social constraints that were becoming permanent; she had always hoped that their children, especially their daughter, would have the opportunity for more than her own ninth grade education and for a successful professional life. Mustafa graduated from high school and worked in Iran’s Ministry of Education. He held a bookkeeping job on the side, which allowed him to save money for the journey. Mina’s brother, who immigrated to the United States in the early 1970s, encouraged the family to go to Turkey, and he arranged for an attorney to obtain a visa for the family. They were granted a tourist visa and flew to Dallas. Mustafa quickly repaid his brother- in-law $5000 for legal fees. Mina’s brother and his wife, an American, welcomed the family into their house, but language and cultural differences made Mustafa and Mina uncomfortable. After 2 months, they rented an apartment nearby. With the help of her brother’s acquaintances, Mina enrolled the children in school and registered herself in an adult-learning center. Because they had a tourist visa, neither parent could get a work permit. With no knowledge of English or the local economy, Mustafa relied on the advice of everyone around him, such as an Iranian businessman who helped him look into purchasing a business. Within a few months, he had bought a gas station. Mina began sewing and doing alterations for their small circle of Iranian acquaintances. Whereas the children were adjusting well, Mina and Mustafa were beginning to feel the strains of social and cultural alienation. The news of war and family affairs in Iran was getting more intense. Mustafa still showed no desire to learn more English than he needed to do the bookkeeping for the gas station and deal with customers. Deep inside, he believed that he would return home as soon as the children started college. By 1990, Mustafa’s business had gone bankrupt and the family’s savings had dwindled. Their only sources of income were Mina’s earnings and Hamid’s part-time job while attending the local junior college. Relations at home were extremely tense, with emotions always on the edge. Mustafa had increased his smoking to three packs of cigarettes daily, and he had frequent bouts of bronchitis. Mina had lost nearly 20 pounds since their arrival in the United States, and her migraine headaches had increased, occurring almost daily, particularly since she lost her mother without having been able to visit her in Iran. Mustafa found a bookkeeping job in an accounting firm owned by an Iranian, but his excessive smoking and occasional shortness of breath and heartburn continued. Mina made several visits to the local hospital emergency room with complaints of fatigue and sleeplessness. Mustafa and Mina had treated some of their symptoms with herbal remedies, but their problems persisted to the point at which Mustafa was admitted to the hospital with chest pain to rule out myocardial infarction. The two older children were attending school and working, leaving the youngest son to act as cultural and language interpreter for their parents during this hospitalization. Study Questions 1. Identify three major emotional and physiological problems commonly seen among Iranian immigrants. 2. Identify significant socioeconomic factors that limit access to health care for Iranian immigrants. 3. Identify the family spokesperson and discuss salient issues in establishing effective communication with this family. 4. How should prevention be taught to this family? What would be appropriate goals? 5. Name three major risk factors that this family experienced. 6. What mechanisms for coping with stress were predominantly used in this household? 7. Identify the family’s social support system. 8. What hospital policies and constraints might negatively or positively affect this family’s dynamics? 9. Compare and contrast the three waves of Iranian immigration in terms of educational status, reasons for migration, and occupations in the United States. 10. Explore assertiveness tactics for female Iranians in the American workforce. 11. What are the most common health problems of Iranian immigrants? What are some implications for health-care providers? 12. Identify characteristics of a healthy Iranian diet. IRANIAN CASE STUDY #2 Hamid moved his family to the United States within 5 years of the 1984 revolution.The restrictions of the Islamic government were increasingly affecting everyone’s social, economic, and private lives. With two young daughters and a third child on the way, he “didn’t want to take any chances by remaining in Iran.” He thought that leaving while he was “fairly young” would allow him and his family to adjust better and more easily. The family fled Iran with great hardship and settled in Pakistan until they could obtain their visas to enter the United States. A friend from high school was helping him. The friend had left Iran many years ago and had a successful accounting firm in a southeastern state. Hamid was promised a job and a company to sponsor him so he could get a green card. The year the family spent in Pakistan was filled with frustration, anger, and illness. Eventually, they managed to obtain tourist visas and entered the United States in 1985. By now, the two daughters were 10 and 11 years old and the baby was 9 months old. Jaleh, Hamid’s wife, was exhausted and weak. The pregnancy was problematic, and without the support of her sisters and mother, her recovery had been slow and rocky. Hamid and Jaleh began a constant stream of arguments because of her mental and physical state. She felt that their situation in the United States was no better than they had had in Pakistan. They could not afford housing in a good neighborhood; the girls and Jaleh were scared at night because Hamid had to work long hours at the accounting firm. Leaving Iran was a desire but never a priority for Jaleh, especially while she was pregnant. Hamid’s hours became longer, and the work became more involved. He had to improve his English and increase his technical skills and knowledge of U.S. tax rules and regulations. His friend told him that, to succeed in the United States, he was expected to perform. “No time to feel sorry for yourself. What better place to be than here?” Jaleh had a probable genetic predisposition to mental illness. She had always heard rumors about different aunts, uncles, and cousins who had suffered from different forms of anxiety and depressive disorders. She was always told that they had a “nervous problem.” But Jaleh had always thought that she was strong willed and would not succumb to the pressures. Unfortunately, as Hamid worked harder and longer, Jaleh became more and more depressed and nonattentive to the children. Three years passed. The only easy task was changing from their tourist visa to permanent residency. Hamid’s desire to excel had also been financially rewarding. They moved to a better house. Jaleh remained at home, didn’t try to improve her English, and felt she should keep the baby at home. Neither she nor Hamid trusted leaving the baby in day care. The two girls were adjusting a little differently; the older was active and outgoing. She was befriended by classmates and neighbors and was enjoying her teenage years. The second daughter was now 13, reclusive, and slightly overweight. Hamid constantly commented on her looks, and Jaleh attempted to protect her against his words. Jaleh thought of her as her soulmate. As the sisters drifted apart, the bond between Jaleh and her second daughter became stronger. The baby was often sick, but Jaleh was increasingly too tired to care. One night, as the baby’s fever spiked, he began to have difficulties breathing. Hamid rushed him and the family to the hospital. By this time, Jaleh’s weight had dropped to 98 pounds. Even though she was small statured, the weight loss made her appear weak and unhealthy. In the emergency department (ED), the family was assessed and evaluated by the triage nurse. She was attentive and noticed the strained family dynamics. In reporting the case to the ED physician, she stressed that the physician should consider the family’s circumstances. Study Questions 1. If you were the nurse or physician, what areas would you focus on first? 2. What initial interventions would you suggest? 3. How would you develop a relationship that would allow you to ask private and personal questions? 4. Would you talk to the family as a unit or separately? Why? 5. As a health-care provider, what might you do to help the two girls adjust in the United States? 6. Describe how Jaleh might perceive her changing behaviors and mood. Describe her perception of any effects the change might have on family dynamics. 7. How would you approach this family for mental-health counseling? 8. Describe culturally congruent dietary counseling for Jaleh. 9. Why do Hamid and Jaleh not trust leaving the baby in day care? 10. Why did the entire family accompany the baby to the ED? 11. Describe traditional Iranian health beliefs and practices. IRISH CASE STUDY The O’Rourke family lives on a small farm in Iowa and comprises David, aged 30; his wife, Mary, aged 29; and two children: Bridget, aged 7, and Michael, aged 6. Both David and Mary are second-generation Irish. Before purchasing their farm 5 years ago, David sold farm equipment in Ohio. The O’Rourkes are Catholic; Mary converted to Catholicism when they married. David, who works long hours outdoors, is concerned about profitability from his corn crop because of the unpredictable size of the harvest, and thus, his income varies depending on the weather. Mary did not work outside the home because she wanted to be with their children until they started school. However, because both children are now school age, Mary has discussed with David the possibility of working part time to supplement the family income. He would prefer that she stay at home, but Mary is anxious to return to the workforce and believes the timing is right. Both David and Mary are happy with just two children and do not desire more. They use the rhythm method for family planning. Eating a healthy breakfast is important to the O’Rourkes. Because eggs are readily available on the farm, they have fried eggs with potato bread and juice at least four times a week. Their main meal in the evening usually includes meat, potatoes, and a vegetable. David enjoys a glass of beer with dinner. David has been a little edgy lately because of his concerns about the corn crop. He admits to having some minor chest pain, which he attributes to indigestion. His last visit to a physician was before their marriage. Mary knows David is concerned about finances and believes it would help if she had a job. Bridget and Michael spend a lot of time outside playing and doing some minor chores for their parents. Both children enjoy school and are looking forward to returning in the fall. Bridget is starting to show concern over her appearance. She does not like her red hair and all the freckles on her face. Her teacher has noted that Bridget has trouble reading and may need glasses. Michael wants to be a farmer like his Dad but worries about his Dad being tired at night. The O’Rourkes have not taken a vacation since they were married. They go to the state fair in the summer, which is the extent of their trips away from home. They are active in the church and attend services every Sunday. Study Questions 1. Describe the O’Rourke family structure in terms of individual roles. 2. Identify two potential health problems related to the O’Rourke’s dietary practices. 3. Identify potential health-risk factors for the O’Rourkes as a family unit and for each family member. 4. Explain the relationship between risk factors and ethnicity specific to the O’Rourke family and their Irish heritage. 5. Describe culturally competent health-promotion strategies for the identified risk factors for the O’Rourke family. 6. Describe the O’Rourke family’s fertility practices. Are they congruent with their Irish background and religious beliefs? 7. Describe the O’Rourke family’s communication patterns. 8. What are the predominant health conditions among Irish immigrants? 9. Explain the significance of the Great Potato Famine for Irish Americans. 10. Name two genetic diseases common among Irish Americans. 11. Identify accepted fertility practices for Irish American Catholics. 12. Identify three sources of strength for the Irish American in times of illness. 13. Identify traditional home remedies commonly used by Irish Americans. ITALIAN CASE STUDY #1 Rosa and Mario Gianquito live on the ground floor of a three-family house in Brooklyn, New York. Although they completed only grammar school in Italy, they speak English and have little difficulty understanding most verbal communication. They have a daughter, Lucia, aged 25, and a son, Anthony, aged 28, who were born in this neighborhood but now live in Manhattan. Both children speak fluent Italian. Anthony is an attorney and does not visit with his sister very often. Lucia is a grammar school teacher, married to an Italian man, Guido Venetto, who recently immigrated from southern Italy and is 10 years older than Lucia. Guido speaks mostly Italian at home but does speak broken English. In addition to smoking two packs of cigarettes a day, Guido is emotionally abusive to Lucia. He is very jealous and does not want Lucia to go out after work with her friends or to spend much time visiting with her parents. Lucia has allergies, and the last time she visited the doctor, he told her that her blood pressure was elevated. She has noticed lately that, after standing all day at work, she often has swollen ankles and leg pain. Lucia’s husband works 12 hours a day as a construction worker and expects her to cook Old-Country–style Italian food, which requires that she use a great deal of salt. She is often depressed and feels isolated and powerless. She has been trying to have a baby for 3 years. Rosa comes to visit her daughter when she can. She often brings homemade manicotti or tortellini when she comes. She is very concerned about Guido’s behavior toward her daughter but does not feel that she can challenge Guido because he is the capo di famiglia. Rosa is concerned about Lucia’s swollen feet and suggests that she drink red wine and eat more garlic and dandelions. She tells Lucia to pray to the Virgin Mary to ask for help in conceiving a child and to make Guido treat her better. Lucia and Guido attend the neighborhood Catholic Church on Sunday. Lucia always wears the cornicelli around her neck that her mother gave her to protect her from il mal occhio. Lucia says her faith and her family help her cope with life challenges with pazienza. Study Questions 1. Identify three problems and a related plan of care for Lucia. 2. Identify two health-teaching goals for this family that are congruent with family order and rituals. 3. Identify three socioeconomic factors that influence the health of the Venetto family. 4. How might the health-care provider involve Lucia in a mutual-planning process for her holistic health-care needs, including mind, body, and spirit? 5. Knowing that many first-generation Italians generally mistrust health-care providers, how would you encourage Lucia to engage in health-promotion behaviors? 6. Discuss at least two preventive health maintenance–teaching activities that respect the folk practices used to treat illness in this family. 7. Define the Italian’s unique relationship with food and discuss implications this could have on the health of the Venetto family, particularly Lucia. 8. Discuss the status and role of elderly Italians in the extended family. 9. Identify two practices common among Italian women that might affect conception and pregnancy. 10. Name two dietary health-care risks and two dietary health-care assets for Italians. 11. What are some of the primary religious practices and use of prayer for Italian people? 12. Define the terms capo di famiglia, il mal occhio, and pazienza. ITALIAN CASE STUDY #2 Ezio Ciarlelli, aged 33, and his wife, Maria, aged 31, live in a six-family tenement house in a small town in Connecticut. They immigrat ed to the United States in 1990 from the small hill town of Amarosa in southern Italy and have their U.S. citizenship. They have four children: Giovanni, aged 9; Marguerita, aged 8; Francesca, aged 7; and Ada, aged 2. Maria’s sister, Flora, is pre gnant with her second child a nd lives in the same tenement house. Ezio and Maria completed grammar school in Italy. Because Ezio had a childhood leg injury that never healed properly, he learned the shoemaking trade instead of working on his father’s farm. Maria raised silkwo rms and learned crocheting. Both Maria and Ezio speak limited English and have difficulty understanding most verbal communication. Although the older children atte nd school in which English is spoken, only Italian is spoken at home. Ada is due for her immunizations; however, Maria is reluctant to take her to the clinic. Frances ca is frail and often suffers from colds and fevers. Maria usually gives her tea made from the mallow plant and sometimes wraps potato slices around her wrists. Ezio has his own variety stor e where he sells magazines, candy, and cigarettes and repairs shoes. Maria cares for the children at home. Ezio’s 20- year-old brother, who is in poor health from thalassemia, has come from Italy to visit and rest in his brother’s house. He does not comp lain about his illness because “it is God’s will.” He expresses interest in working in Ezio’s shop. Maria’s father recently died, and her 80-y ear-old mother still lives in southern Italy. Maria is thinking about brin ging her mother to the United States to live with her, but her mother is reluctant to come because she does not want to be a burden to her daughter. Study Questions 1. Identify culturally congruent prenatal teaching appropriate for Flora. 2. Identify two health-teaching goals for the Ciarlelli family that are congruent with family order and rituals. 3. Identify three socioeconomic factors that influence the health of the Ciarlelli family. 4. Identify the Italian work ethic in the Ciarlelli family. 5. Knowing that many first-generation Italians generally mistrust health-care providers, how would you encourage Maria to bring her young children to the clinic for their immunizations and other illnesses? 6. Discuss at least two preventive maintenance–teaching activities that respect the folk practices used to treat illness in the Ciarlelli family. 7. Define the Italian’s unique relationship with food and discuss implications this could have on the health of the Ciarlelli family. 8. Discuss the status and role of the Italian elderly in the extended family, and explain the reluctance of Maria’s mother to come to live with her. 9. Identify two health conditions common among Italian Americans that affect drug metabolism. 10. Name two dietary health-care risks and two dietary health-care assets for Italian Americans. 11. Define the terms capo di famiglia, padrone, and pazienza. 12. Identify two locations in the United States where the greatest numbers of Italian Americans have settled. JAPANESE CASE STUDY #1 This case study is a composite of actual situations. Marianne, who is American, and Ken Shimizu, who is Japanese, have worked in Tokyo for over 30 years as Methodist missionaries. They have annual furloughs and occasional sabbaticals, during which they visit relatives and sponsoring organizations and engage in continuing education in the United States. They met as college students in the United States, and their three grown children have established their own careers in the United States. Ken’s 98-year-old mother resides with Marianne and Ken. She is not Christian but has always been extremely supportive of Ken and Marianne’s work. Ken teaches at a large Christian university, whereas Marianne has served in various church-related positions over the years. As missionaries, they live in subsidized post–World War II housing near Ken’s university. Marianne has been a frugal housewife, preparing local foods in the Japanese style for her family. Ken, who is nearly 60, recently learned that he has glaucoma. By the time it was discovered, he had lost a significant amount of peripheral vision. Although Marianne delivered all three children at a Christian hospital in Tokyo, she gets her annual physical examination when visiting relatives in the United States. She has never believed that the Japanese health system is as proactive as that in the United States. On her most recent visit to the United States, Marianne learned that she has hypertension. Her physician prescribed a medication that is readily available in Japan, but the physician was concerned about the level of stress in Marianne’s life. Mother Shimizu is quite confused and requires considerable care, but it is unthinkable for Ken, the only child, to put his mother in a long-term-care facility. Even if he would, the quality of facilities in Japan leaves much to be desired. Most of the responsibility for Mother Shimizu falls on Marianne, in addition to her work. Marianne’s relatives are urging her to consider placing Mother Shimizu in a church-related life-care community near Marianne’s family in the United States, where Marianne and Ken would like to retire. Marianne’s own parents lived in this facility at the end of their lives. She is considering these issues as she returns to Tokyo. Study Questions 1. Identify some of the cultural issues that may lead to conflict in this international family. 2. What are the family resources for this international family? 3. What factors within the Japanese health system may account for the late diagnosis of Ken’s glaucoma? 4. What practical issues might arise for the Shimizus if Mother Shimizu were placed in a long-term-care facility in the United States? 5. What dietary factors may contribute to Marianne’s hypertension? 6. In what ways might you consider Ken to be countercultural as a Japanese man? 7. What social pressures might Marianne have faced, given some of her choices, as a housewife in Japan? 8. What pressures will Ken likely experience as he considers how to meet the needs of both his mother and his wife? 9. Compare and contrast the fertility and mortality rates of Japan and the United States. 10. Do the traditional Japanese maintain sustained eye contact with strangers? Why or why not? 11. To which drugs might Japanese people have greater sensitivity than that of white ethnic populations? 12. How do most Japanese people meet their need for calcium? JAPANESE CASE STUDY #2 Noriko Hayashi and her husband, Aki, recently came to the United States to advance their careers. Noriko earned her master’s degree in linguistics and plans to continue for a doctorate, whereas Aki, a graduate of the Tokyo University School of Medicine, completed a residency program at a prestigious academic medical center. When Noriko became pregnant, the Hayashis decided that the time was not right for them to begin a family. But they could not find a clinic or physician willing to provide abortion services to a healthy, middle-class, married couple in their 20s. After much consultation with their families in Japan, who were unable to come take care of Noriko during her pregnancy or postpartum, they decided that she would stay in the United States and have the baby. Noriko experienced vaginal bleeding in the 21st week of pregnancy. She fully expected the pregnancy to be terminated because of its poor prognosis; however, she was placed on a regimen of bedrest and tocolytic therapy. At 24 weeks, their baby boy, Ken, was born precipitously and placed in the neonatal intensive-care unit. Aki did not attend the birth. Bewildered, Noriko and Aki tried to indicate to the neonatal team that they strongly felt that this baby should be allowed to die, but the team assured them that the infant was doing quite well for his gestational age. Noriko was urged to take care of herself from the moment she arrived on the postpartum unit in the morning. She was discharged that evening at 9 p.m. Though she was in severe discomfort, the nurses could not get her to accept the analgesics available to her. They were dismayed that her husband would not encourage her to seek pain relief, and they questioned his supportiveness of her. The neonatal nurses were concerned that Noriko did not maintain eye contact when they interacted with her, and they could not get her to express her questions and concerns. After a long, complicated course, the baby was discharged to his parents’ care at the age of 7 months. Developmental follow-up was scheduled at the medical center where Aki worked. Noriko and Aki repeatedly expressed concerns to the social workers involved in Ken’s care that they could not cope with all his needs, and they wondered whether or not they could ever return to Japan with a child such as this. The social workers believed that Noriko suffered from postpartum depression, and they found her passive and somewhat noncompliant. Study Questions 1. Identify two social risk factors related to Noriko and Aki’s coping with the pregnancy. 2. Discuss the significance of their families’ inability to come to the United States. 3. Discuss the decision to seek an abortion from Noriko and Aki’s perspective and the competing values of the clinic that refused them. 4. Explain the differences between Noriko’s and the health-care provider’s views on maintaining her high-risk pregnancy. 5. Describe beliefs that may have contributed to Noriko and Aki’s desire that Ken’s life not be prolonged. 6. Identify factors in Noriko’s refusal of analgesia and Aki’s acceptance of that. 7. Explore the way that Noriko and Aki might perceive the self-care philosophy of the postpartum unit. 8. Identify other potential stressors related to Noriko’s early discharge from the postpartum unit. 9. Identify cultural behaviors exhibited by Noriko and Aki that may have contributed to adverse evaluations by the health-care team. 10. Identify long-term social concerns for Ken and for his family that Noriko and Aki would be likely to share. 11. Explain behavioral factors that might make Noriko appear to be passive and noncompliant. JEWISH CASE STUDY #1 Selecting a “typical” Jewish client is difficult. An ultra-Orthodox Jew has a particular set of special needs. Yet, it is more common to see a Jew who is a middle-of-the-road Conservative. Sarah is an 80-year-old woman who is a first-generation American. She was raised in a traditional Conservative home. Her husband died after 50 years of a strong marriage. She has three children. Although her home is not kosher, she practices a variation of kosher-style eating, avoiding pork and not making dishes that combine meat and milk. Two months ago, she was diagnosed with pancreatic cancer. Surgery was attempted, but the cancer was already in an advanced stage. Chemotherapy was started, but the cancer has progressed and is not responding to the medications. She is having difficulty eating because of the pressure of the tumor on the gastrointestinal tract. Discussions are being held to determine whether or not treatments should be stopped and whether hospice care should be initiated. Her hospital room is always filled with visitors. Study Questions 1. What must you anticipate in discussing with Sarah her wishes regarding the continuation of medical care? 2. How would you respond to her initial decision to have surgery and initiate chemotherapy? 3. What questions do you need to ask in the initial patient interview to assess her degree of religious practice? How will you determine her spirituality needs? 4. What is your understanding of the reason she has so many visitors in her room? 5. Is hospice care appropriate for this patient? 6. Sarah dies with her family at her bedside. What interventions can you take at the time of death to demonstrate religious sensitivity to the family? What questions do you need to ask the family? 7. Describe three genetic or hereditary diseases common with Ashkenazi Jews. 8. Describe Jewish burial rituals and grieving process. 9. Discuss the laws of Kashrut in regard to food practices for observant Jewish clients. 10. What should the health-care provider keep in mind when entering a Jewish home to provide care? 11. Distinguish between the terms Sephardic and Ashkenazi. 12. How might a non-Jewish and a Jewish coworker share holidays in the workforce? 13. What is the official language the Jewish people use for prayer? JEWISH CASE STUDY #2 Selecting a “typical” Jewish client is difficult. An ultra-Orthodox Jew has a particular set of special needs. Yet, it is more common to see a Jew who is a middle-of-the-road Conservative. Sonia is an 80-year-old woman who was born near Kiev, Russia. Most of her family was killed in the pogroms, and she escaped to the United States at the age of 10. She married and raised a family in a Conservative traditional home. As she aged, she became less committed to keeping kosher outside her home, although her home is kosher. At age 62, she was diagnosed with type 1 diabetes. She initially expressed some concern about her use of pork-based insulin. Currently, she is admitted for amputation of her right leg owing to the complications of diabetes. Her hospital room is always filled with visitors. Study Questions 1. What questions will you specifically ask Sonia about her dietary preferences? 2. How would you have responded to her initial concern about using insulin made from pork? 3. What questions do you need to ask in the initial patient interview to assess her degree of religious practice? How will you determine her spirituality needs? 4. What must you anticipate discussing with her about her surgery as it relates to the disposition of her leg? 5. What is your understanding of the reason she has so many visitors in her room? 6. How might your care be altered if the client in this case study were a Hasidic man? (Your answers will vary depending on whether you are a male or a female health-care provider.) 7. Describe three genetic or hereditary diseases common among Ashkenazi Jews. 8. Describe the Jewish ritual of circumcision. 9. Discuss the laws of Kashrut in regard to food practices for observant Jewish clients. 10. What should the health-care provider keep in mind when entering a Jewish home to provide care? 11. Distinguish between the terms Sephardic and Ashkenazi. 12. How might a non-Jewish and a Jewish coworker share holidays in the workforce? 13. What is the official language the Jewish people use for prayer? 14. Identify fertility practices for Jewish Americans from all three denominations. KOREAN CASE STUDY Joon Kim, aged 31, and Yung-Hee Kim, aged 30, immigrated from Korea 5 years ago. They came to the United States as newlyweds and moved in with family members in Los Angeles. When they had saved enough money, they were able to find a small, one- bedroom apartment, where they have lived for 4 years. Yung-Hee finished secondary school in Korea, and Joon graduated from a university with a degree in business. They have two children: Soony, their 4-year-old daughter, and Suk-Choo, their 2-year-old son. Both children were born in the United Stat es and are cared for by an elderly family member while the other family members work. When they arrived in the United States , Joon was unable to find a job using his business skills because of his poor profic iency in English. Although Joon is able to speak minimal English, he is not confident in his abilities in this new culture. Joon eventually obtained a job working at a dr y cleaner for family friends. Yung-Hee found a job working for a Korean grocer. She a ssists in restocking shelves and managing inventory. Yung-Hee became pregnant shortly after ar riving in the United States. This had not been planned, and finances were of great concern. Halfway through her first pregnancy, Joon hit Yung-Hee after an ar gument about finances. Yung-Hee had a black eye, which was concealed with makeup and not discussed with anyone. Battering occurred sporadically throughout the next several years and seemed to heighten with financial woes and pregnancy. Yung-Hee gave Joon several warnings about leaving with the children, but she felt she had nowhere to turn for support. Soony will begin kindergarten in the fall, yet her English-language skills are lacking. Korean is spoken at home, and the children have been brought up in a Korean community in which minimal English is spoken. Soony has never been to a dentist, and two of her teeth are decaying. Suk-Choo was born with a mild form of mental retardation. Public-health nurses repeatedly suggested early-intervention programs, but the family was embarrassed about their child’s “problem.” They blamed themselves, and Joon felt especially guilt-ridden for having hit his wife during her pregnancies. He enjoys drinking beer while watching television and frequently gets intoxicated on the weekends. The Kims are a religious family and attend their community’s Protestant church regularly. They are involved in many church activities. Study Questions 1. Discuss some approaches a public-health case manager might take in relation to the health of the Kim family. 2. Identify three areas of health teaching needed by this Korean American family. 3. Discuss two implications for Soony’s poor understanding of the English language. 4. Identify how traditional role relations in Korean American families might affect Yung-Hee’s alternatives in an abusive situation. 5. Name three health problems a health-care professional should be aware of when assessing the Kim family. 6. Discuss how the role of the church can be used in terms of health education. 7. Discuss the role of alcohol in Korean American society. 8. How might a health-care professional approach the topic of alcoholism with the Kim family? 9. Where do Koreans primarily live in the United States? 10. Discuss social support issues for Korean families not living in highly populated Korean areas of the United States. 11. How might the model-minority theory affect the Kim family in terms of health resources? Identify health problems common among Korean immigrants. 12. As a home-health caregiver, how might you handle the Korean American offer of food on your arrival? 13. Discuss contraceptive practices in the Korean American childbearing family. MEXICAN CASE STUDY #1 Mr. Sanchez is a 61-year-old Mexican American who was recently diagnosed with osteomyelitis, requiring 6 to 8 weeks of intravenous antibiotic treatment in the home. Mr. Sanchez is married and has three adult children—two daughters, aged 35 and 27, and a son, aged 33—and four grandchildren, aged 14, 12, 9, and 5. The youngest daughter lives with Mr. and Mrs. Sanchez. The two older children are married and live within 1 mile of the Sanchez family. Mr. Sanchez’s 85-year-old mother, Doña Reyna Sanchez (called Mama Reyna), lives with them. All members of the family were born in the United States, with the exception of Mama Reyna, who was born in San Juan Obispo, Mexico. Mr. Sanchez has worked in a steel mill for the last 40 years. All members of the family speak Spanish and English, except Doña Sanchez who speaks mainly Spanish. The Sanchezes are practicing Catholics, as is evidenced by the religious items hanging on the walls. A small shrine is dedicated to Our Lady of Guadalupe with a candle nearby. Mrs. Sanchez and Mama Reyna recently returned from a manda to pray for the safe recovery of Mr. Sanchez and for the health of the family. The family attends Mass every Sunday, and then they have breakfast as a family. Mr. Sanchez believes that his health is in the hands of God. The Sanchez family lives in a modest three-bedroom home, which they bought about 35 years ago. The home is located in a predominantly Mexican American community. Mr. and Mrs. Sanchez are active in the church community, and other family members and friends live in the neighborhood. The Sanchez home is usually occupied by many people and has always been known as the gathering place in the community. Mr. Sanchez is the sole provider of the family, except for a small Social Security check from Doña Reyna. Mrs. Sanchez worked for short periods as a secretary for the church, but she is not working at the present time. Doña Sanchez has been the caretaker of the family and has always known the ways of folk practices and home remedies. Members of the family and community seek Doña Reyna’s skills of healing. Even though she has the gift of healing and knowledge of herbs, the family practices both folk and Western health care. Mrs. Sanchez, the wife, has always taken care of the family, looking out for their emotional, spiritual, and physical well-being. In caring for family and friends, she shows concern, love, and attention to the needs of the ill person. Mrs. Sanchez will be caring for Mr. Sanchez during his treatment for osteomyelitis. Study Questions 1. What type of health-care provider is Doña Reyna? 2. When the home-health nurse comes to administer the intravenous medication to Mr. Sanchez and teach about the care of the line, who should be included in the teaching? 3. Explain the significance of family and kinship for the Sanchez family. 4. Identify two stereotypes about Mexican Americans that were dispelled in this case with the Sanchez family. 5. Describe the importance of religion for the Sanchez family. 6. Name three things that need to be assessed that would allow the nurse to promote culturally congruent care. 7. Identify strategies for assessment and treatment for the Sanchez family. 8. If the family believes in the hot and cold theory of illness, is Mr. Sanchez’s illness hot or cold? How would it be treated? 9. Identify four major health problems of Mexican Americans in the United States. 10. Explain the importance of familism in the Mexican American culture. 11. Using the hot and cold theory, what folk treatments might be prescribed for osteomyelitis? MEXICAN CASE STUDY #2 Pablo Gaborra, aged 32, and his wife, Olga, aged 24, live in a migrant-worker camp on the eastern shore of Maryland. They have two children: Roberto, aged 7, and Linda, aged 18 months. Olga’s two younger sisters, Florencia, aged 16, and Rosa, aged 12, live with them. Another distant relative, Rodolpho, aged 28, comes and goes several times each year and seems to have no fixed address. Pablo and Olga, born in Mexico, have lived in the United States for 13 years, first in Texas for 6 years and then in Delaware for 1 year, before moving to the eastern shore of Maryland 5 years ago. Neither of them have U.S. citizenship, but both children were born in the United States. Pablo completed the sixth grade and Olga the third grade in Mexico. Pablo can read and write enough English to function at a satisfactory level. Olga knows a few English words but sees no reason for learning English, even though free classes are available in the community. Olga’s sisters have attended school in the United States and can speak English with varying degrees of fluency. Roberto attends school in the local community but is having great difficulty with his educational endeavors. The family speaks only Spanish at home. Not much is known about the distant relative, Rodolpho, except that he is from Mexico, speaks minimal English, drinks beer heavily, and occasionally works picking vegetables. The Gaborra family lives in a trailer on a large vegetable farm. The house has cold running water but no hot water, has an indoor bathroom without a shower or bathtub, and is heated with a wood-burning stove. The trailer park has an outside shower, which the family uses in the summer. The entire family picks asparagus, squash, peppers, cabbage, and spinach at various times during the year. Olga takes the infant, Linda, with her to the field, where her sisters take turns watching the baby and picking vegetables. When the vegetable- picking season is over, Pablo helps the farmer to maintain machinery and make repairs on the property. Their income last year was $30,000. From the middle of April until the end of May, the children attend school sporadically because they are needed to help pick vegetables. During December and January, the entire Gaborra family travels to Texas to visit relatives and friends, taking them many presents. They return home in early February with numerous pills and herbal medicines. Olga was diagnosed with anemia when she had an obscure health problem with her last pregnancy. Because she frequently complains of feeling tired and weak, the farmer gave her the job of handing out “chits” to the vegetable pickers so that she did not have to do the more-strenuous work of picking vegetables. Pablo has had tuberculosis for years and sporadically takes medication from a local clinic. When he is not traveling or is too busy picking vegetables to make the trip to the clinic for refills, he generally takes his medicine. Twice last year, the family had to take Linda to the local emergency room because she had diarrhea and was listless and unable to take liquids. The Gaborra family subscribes to the hot and cold theory of disease and health-prevention maintenance. Study Questions 1. Identify three socioeconomic factors that influence the health of the Gaborra family. 2. Name three health-teaching interventions the health-care provider might use to encourage Olga to seek treatment for her anemia. 3. Identify strategies to help improve communications in English for the Gaborra family. 4. Identify three health-teaching goals for the Gaborra family. 5. Name three interventions Olga must learn regarding fluid balance for the infant, Linda. 6. Discuss three preventive maintenance–teaching activities that respect the Gaborra family’s belief in the hot and cold theory of disease management. 7. Identify strategies for obtaining health data for the Gaborra family. 8. Identify four major health problems of Mexican Americans that affect the Gaborra family. 9. If Olga were to see a folk practitioner, which one(s) would she seek? 10. Explain the concept of familism as exhibited in this family. 11. Distinguish between the two culture-bound syndromes el ataque and susto. 12. Discuss culturally conscious health-care advice consistent with the health- belief practices of the pregnant Mexican American woman. 13. Discuss two interventions to encourage Mexican American clients with tuberculosis to keep clinic appointments and to comply with the prescribed medication regimen. 14. Identify where the majority of Mexican Americans have settled in the United States. NAVAJO CASE STUDY Mr. Begay, aged 78, lives with his wife in a traditional Navajo hogan. He has lived in the same area all his life and worked as a uranium miner until the government closed the mines. His hogan has neither electricity nor running water. Heat is provided by a fire, which is also used for cooking. Lighting is obtained from propane lanterns. Water is hauled from a windmill site 20 miles away and stored in 50-gallon steel drums. Because the windmill freezes and the roads are often too muddy to travel in the winter, sometimes he must travel an additional 10 miles to the trading post to obtain water. Because Mr. Begay does not own a car, he must depend on transportation from extended family members who live in the same vicinity. Mr. Begay has continually experienced shortness of breath, and it is getting worse. He has been hospitalized with pneumonia several times as a result of the uranium poisoning. He had a cholecystectomy at age 62. His diet is traditional and is supplemented by canned foods, which are obtained at the trading post. All health care is obtained at the Public Health Service Hospital in Shiprock. Neither Mr. Begay nor his wife obtain routine preventive-health care. He was admitted from the clinic to the hospital with a diagnosis of pneumonia. Mr. Begay shows clinical improvement after initial intravenous antibiotic therapy. However, his mental status continues to decline. His family feels that he should see a traditional medicine man and discusses this with his physician. The physician agrees and allows Mr. Begay to go to see the medicine man. Several members of the nursing staff disagree with the physician’s decision and have requested a patient-care conference with the physician. The physician agrees to the conference. Study Questions 1. Identify three physical barriers Mr. Begay must overcome to obtain health care. 2. Discuss the benefits of Mr. Begay’s seeing the traditional medicine man. 3. Identify some potential negative outcomes of Mr. Begay’s seeing the traditional medicine man. 4. Identify culturally relevant interventions to reduce the potential for the recurrence of pneumonia. 5. Identify at least two major health risks that the Begays face, based on their current lifestyle. 6. Discuss potential outcomes for negotiation during the conference. 7. Mr. Begay’s diet is described as traditional Navajo. What foods are included in this diet? 8. Because of his continued need for oxygen, what services do you anticipate for Mr. Begay when he returns home? 9. What might the nurse do to encourage preventive-health measures for the Begay family? 10. Identify at least three types of traditional Navajo healers. 11. Identify contextual speech patterns of the Navajo Indians. 12. Distinguish differences in gender roles among Navajo Indians. 13. Identify two culturally congruent teaching methods for the Navajo client. 14. Discuss the meaning of the First Laugh Ceremony for the Navajo. 15. Identify two culturally congruent approaches for discussing a fatal illness with a Navajo client. POLISH CASE STUDY Thomas Wyzinski came to America as a young boy in the 1930s and has lived in the same Polish neighborhood his entire life. He married his neighborhood girlfriend, Zosia, and has two children. He is proud of his ethnic heritage and the fact that his wife is a “healthy-looking woman and a good Polish cook.” He openly boasts about how proud he is of his wife and children, but he does not like the idea that his children moved to the suburbs 15 years ago. He states, “They act so stuck up sometimes.” Mr. Wyzinski has always prided himself on working hard and earning his seniority at the electronics factory. When Thomas was younger, he was a heavy drinker, and he smoked one pack of cigarettes daily for 30 years. He gave up smoking 10 years ago and drinking about 5 years ago. He stopped smoking because he felt “winded” and stopped drinking because “I just couldn’t hold it like I used to. I guess I’m just getting old.” Mr. Wyzinski has been feeling sick for the past month. Finally, his wife told him he had to go to the doctor because he was drinking so much water and was going to the bathroom all the time. Mr. Wyzinski was concerned that he could not hold his urine getting to the bathroom. At the physician’s office, his blood glucose level was 450 mg/dL. Thomas was told he had to go to the hospital. Protesting loudly, he called his wife and went to the hospital. A complete physical examination revealed that his legs were swollen and that he was having trouble breathing. Thomas was prescribed furosemide (Lasix) 20 mg daily and Novolin 70/30 insulin 25 units in the morning and 10 units in the evening. He was a model patient and was discharged 3 days later. The visiting nurse came every day for a week to teach Mr. Wyzinski diabetic care and assist him with giving himself insulin. Mr. Wyzinski was a quick learner, but he did not like the food restrictions and thought the cost of needles and insulin was too expensive. The nurse said she would call in 1 week to see how he was doing. Mr. Wyzinski took sick days from his job for the first time in 10 years. He still felt tired but insisted on returning to work. Mrs. Wyzinski is a full-time secretary. When the nurse called a week later, Mrs. Wyzinski told the nurse that, when her husband picks her up from work, she has noticed chocolate on his shirt. He denies having any desserts. She is also concerned that he may have started drinking again, and he reuses needles three times because he feels it’s a waste of money to use them once and throw them out. After 3 weeks, the swelling in his legs is still present, and Mr. Wyzinski tells his wife there is nothing to worry about. Mr. Wyzinski gets angry when his wife tells him he should call the nurse. Study Questions 1. For health-teaching strategies and interventions to be successful, what is the overriding theme in working with Mr. Wyzinski? 2. What must the health-care provider keep in mind when providing nutritional counseling to the Wyzinski family? 3. How can meals be modified to meet the family’s nutritional needs? 4. State two short-term goals for the Wyzinski family. 5. For the health-care provider “to be present” for this family, what personal qualities must be considered? 6. What role might the extended family play in this situation? 7. Prepare a flexible medication and meal schedule that would allow Mr. Wyzinski to manage his illness at work. 8. Will Mr. Wyzinski wear a Medical Alert bracelet? 9. What care plan might be better for the Wyzinski family than the one developed by the visiting nurse? 10. What health-promotion activities should the nurse encourage for this family? 11. What might the health-care provider do to assist the new Polish American immigrant in obtaining access to health-care services? 12. Describe the living conditions of newer Polish American immigrants in America. 13. Identify health risks that Polish immigrants may bring with them to the United States. 14. Describe postpartum practices for Polish American clients. 15. Identify rituals related to terminal care for Polish Americans. 16. Identify the primary religious practice and the use of prayer for Polish Americans. PUERTO RICAN CASE STUDY #1 Mr. López, aged 62, lives with his second wife, Mirna, aged 51, his parents-in-law, his 4- year-old grandson, and his three children: Carmen, aged 21; Daniel, aged 17; and Consuelo, aged 16. He owns a small car shop in Denver, Colorado. They came from Puerto Rico after experiencing financial hardships. Mirna used to work as a teacher, but since they had children, she has devoted her time to being a housewife and, more recently, to being a caregiver for her parents and grandchild, Paquito. They are both devout Catholics and active members of the local Spanish-speaking parish. The López family has health insurance, and both of Mirna’s parents are covered through Medicare. Mirna is the administrator for her parent’s finances (Social Security pension) and her own home. They live in a four-bedroom home in the back of Mr. Lopez’s car shop. Carmen is a single mom who works full-time in a shoe store. She takes care of her financial needs and those of her 4-year-old son. She sleeps in the same room with her sister and her son and contributes to the financial needs of the family. Mirna’s mother, aged 66, has been in the hospital three times during the last year for the management of diabetes. Her father, aged 67, had a myocardial infarction 6 months ago and is in cardiac rehabilitation. Paquito has asthma and was in the emergency room twice during the last 3 months. Mrs. López has been feeling tired, with headaches, irregular menses, bleeding, and abdominal pain. She experienced a fainting episode during her father’s hospitalization, and she was found to have anemia. She was given instructions for follow-up care, but she cancelled her appointment twice to accommodate her parents’ and Paquito’s medical-care appointments. Both Mr. López and Mirna’s parents believe that, as a result of all of these problems, Mirna is having ataques de nervios. During the last 7 months, there have been several family arguments about home rules, family values, and responsibilities. The last discussion took place 3 weeks ago. The discussion emerged when Consuelo got home at 11 p.m. and her parents confronted her. She has been skipping classes and dating an older man. When her brother became part of the discussion, she told the family of his gay “friends,” and he angrily disclosed and responded, “Yes, I am gay and so what.” Carmen has decided to move out with her son and is advising her mother to place her grandparents in a senior- housing facility. Mr. López came with his wife to her first primary-health-care appointment in 5 years. His last visit to a primary-care provider was 12 years ago, before he got the family life insurance. Both look tired and overwhelmed. Mr. López is quietly listening to the health-care encounter, and Mrs. López has been crying through most of the appointment. Study Questions 1. List the two most significant primary-care needs for Mrs. López. 2. Identify primary-care interventions for Mrs. López. 3. Discuss a culturally relevant approach to schedule Mr. López for a primary-care appointment. 4. Identify potential barriers and their solutions for the continuation of care for Mrs. López. 5. What are the high-risk physical, mental, and spiritual behaviors exhibited by this family? 6. Identify health-care utilization barriers for all family members. 7. List potential medical- and mental-health diagnoses for each member of this family. 8. Discuss gender and family roles in the context of the traditional Puerto Rican culture. 9. Identify potential factors that may affect the physical- and mental-health well-being of Consuelo, Daniel, and Paquito. 10. Identify Puerto Rican spiritual practices appropriate for this family. 11. If the family decides to make changes in their living arrangements, what would be the most appropriate approach? Why? 12. What interpersonal processes of care may enhance or hinder the health-care encounter with the members of this family? 13. Identify culturally congruent interventions to facilitate the health care of Mr. and Mrs. López. 14. Discuss the importance of respeto and familism in the López family. 15. Identify culturally congruent interventions for the management of adolescent-related health such as sexuality, family roles, delinquency, and substance abuse. 16. Identify health-promotion and disease-prevention strategies for each member of this family. Consider issues related to aging, pediatric needs and childcare, and women’s health. 17. What interactions may lead to foster simpatía and personalismo in the health-care encounter? PUERTO RICAN CASE STUDY #2 Carmen Medina, aged 39, lives with her husband, Raúl, aged 43, who works as a mechanic in a small auto shop. Mr. Medina has worked in the same place since he and his wife came to the United States from Puerto Rico 15 years ago. The Medinas have a 4- year-old son, José; a 16-year-old daughter, Rosa; and an 18-year-old son, Miguel. The Medinas both attended vocational school after completing high school. Mrs. Medina is employed 4 hours a day at a garden shop. She stopped working her full-time job to care for her ill mother and aged father, who do not speak English and depend on government assistance. The family income last year was $28,500. The family has health insurance through Mr. Medina’s job. They live in a three- bedroom apartment in a low-income Illinois community. Miguel works in a fast-food store a few hours a week. Because Rosa has responsibilities at home, the Medina’s do not allow her to work outside the home. She is very close to her grandmother but avoids talking with her parents. Both Rosa and Miguel are having difficulties in school. Rosa is pregnant and the family does not know. She is planning to drop out of school, get a job in a beauty shop, and leave home without telling the family. Miguel frequently comes home late and, on occasion, sleeps out of the home. He is beginning college next semester and has plans to move out of the house during the summer. The family is having difficulty dealing with Rosa’s and Miguel’s developmental and behavioral challenges. Although Mrs. Medina is outspoken about these concerns, Mr. Medina is quiet and not actively involved in the discussion. He is more preoccupied with the family’s financial situation. Mrs. Medina’s parents are encouraging them to return to Puerto Rico. Mr. Medina was diagnosed with hypertension 2 months ago, when he went to the emergency room for a respiratory infection. He smokes cigarettes and drinks two to three beers every evening after work. He has not followed up on his blood pressure treatment. Miguel is beginning to smoke, but not at home. José has had frequent colds and sinus allergies. He has been to the emergency room three times during the past year for respiratory infections. Mrs. Medina’s last physical examination was after she had José. She is experiencing insomnia, tiredness, headaches, and gastrointestinal problems. She is very concerned about Rosa and Miguel, her parents, and the family’s finances. Mrs. Medina is Catholic and recently has been visiting her church more often. Study Questions 1. Explain Mrs. Medina’s attitude in her relationship with her adolescent daughter. 2. Identify strategies to ensure that Rosa seeks prenatal care. 3. Identify barriers to accessing health care for the Medina family. 4. What are the high-risk behaviors exhibited by this family? 5. What communication barriers exist in this family that affect care delivery? 6. Discuss gender and family roles in the context of traditional Puerto Rican culture. 7. Identify sociodemographic factors affecting the physical- and mental- health well-being for this family. 8. Identify Puerto Rican folk practices appropriate for this family. 9. If the Medina family chose to visit a folk healer, which one(s) do you think they might visit? Why? 10. If Mrs. Medina’s parents visit a health-care provider, what might they expect? 11. Identify culturally congruent interventions to ensure compliance with Western health prescriptions for Mr. Medina. 12. Discuss the importance of respeto and familism in the Medina family. 13. Identify culturally congruent interventions for Rosa’s pregnancy. 14. Identify health-promotion and disease-prevention interventions needed for José. TURKISH CASE STUDY Ilhan and Zeynep Özoglu, their son, Hasan, aged 5, and their daughter, Bilge, aged 3 months, have lived in California for 3 years. Ilhan, aged 33, holds a master’s degree in electrical engineering. He returned with his new family to California when he was offered a midlevel position with a software company in Silicon Valley. Ilhan and Zeynep met when they were both studying electrical engineering in Türkiye, where most instruction was delivered in English. Therefore, both Ilhan and Zeynep understand English well, although Zeynep still struggles to express herself fluently. After working as an engineer in Türkiye for about 5 years, Zeynep, aged 30, left her position to marry Ilhan and become a full-time wife and mother. A few months before the baby’s birth, Zeynep and her son visited her parents in southern Türkiye. When they returned to California, Ilhan’s parents accompanied them for a visit of indefinite length. Ilhan’s father, Kemal, is 76, and his mother, Güzide, is 59. Kemal and Güzide are more traditional in their customs than are Ilhan and Zeynep. Kemal does little in terms of running a household, but he does play with the children each morning after he has finished his breakfast. One morning, the family finds Kemal on the couch sweating profusely and complaining that something has given him very bad indigestion. Güzide warms a cup of milk and gives it to Kemal immediately. After an hour, he complains of continued pain. Zeynep telephones Ilhan, who is on a business trip in Seattle, and he directs them to take his father to the doctor immediately. The family takes him to the emergency department of a private hospital, where they know he will get “the best care.” Kemal has had a heart attack; the physicians want to perform an immediate angioplasty and ask for informed consent from Kemal. After a brief discussion, Zeynep and Güzide decide they cannot tell Kemal about his condition, and Güzide signs the form. Unfortunately, no Turkish interpreter is available, so they must rely on Zeynep’s understanding of the procedure to gain informed consent. The angioplasty is performed and results in a minor stroke. Over the next few weeks, Kemal is observed and treated on a rehabilitation unit. However, the family begins to feel that he is not receiving the proper attention. Not only do the young nurses call him by his first name, but also the food is almost inedible. The nurses, conversely, dread the days they are assigned to care for Kemal Özoglu, feeling the family is constantly hovering, looking over their shoulders, and always asking questions. Meanwhile, Zeynep is beginning to feel the effects of the situation. Because Ilhan must work, she must stay with her father-in-law during the day while her mother-in-law cares for the children at home. Ilhan and his mother spend evenings with Kemal, while Zeynep cares for the children. Zeynep is trying to continue to breastfeed, but she feels exhausted, and the baby is beginning to refuse her breast when she arrives home and attempts to nurse him. By the time Kemal is discharged 3½ weeks later, he has only mild hemiparesis. The family is so thankful that they present the neurologist with a beautiful leather wallet and a hand-painted plate for his wife. Kemal is sent home on warfarin (Coumadin), with detailed instructions about its use and the necessity of blood tests. However, Kemal’s International Normalized Ratio (INR) remains quite low, and 2 months later, he suffers a massive myocardial infarction. The prognosis is grave, and doctors want to discuss treatment options with the client and his family, but the family refuses to translate and give such information to Kemal. The clinical-nurse specialist for organ donation wants to approach the family, but they refuse to meet with her. Study Questions 1. What are some of the risk factors associated with Kemal’s medical condition? 2. Why did the family not call 911 immediately when Kemal began complaining about chest pains? 3. Why did the family not take him to the county hospital? 4. Discuss some of the complications of using Zeynep as a translator. What are some of the legal ramifications? 5. Why did the family refuse to obtain an informed consent from Kemal? 6. Discuss the problems between the nursing staff and the family and how they might be resolved. 7. What advice might you give Zeynep about her and her baby’s health? 8. How should the neurologist respond to the gifts from the family? 9. What are some possible reasons for the continued low INR levels for Kemal? 10. Why did the family refuse to translate for the doctors who wanted to discuss treatment options after the second myocardial infarction? 11. Why did the family refuse to see the organ donation clinical-nurse specialist? 12. Describe touch practices common to traditional Turkish Americans. 13. Identify death rituals common to Turkish American Muslims. 14. Describe nutritional concerns that can arise for Turkish American clients during the celebration of Ramazan. VIETNAMESE CASE STUDY Cao Thi Xuan, aged 48, arrived in Arlington, Virginia, about 5 years ago, directly from Vietnam under the Orderly Departure Program. Her husband, Nguyen Van Minh, now a cook at a restaurant owned by his brother, had come several years earlier with their son, Danh, now aged 19, and daughter, Tuyet, aged 23. Xuan’s departure had been delayed several times through a combination of clearance problems and a commitment to remaining to care for an elderly father, who has since died. Although she had a high school education in Vietnam and studied some English, she is not fluent and finds paperwork and communication with Americans difficult, if not impossible. She is now usually at home or visiting Vietnamese friends but also works part time at the restaurant. Although pleased with some aspects of life in the United States, Xuan is somewhat upset by the radical differences from the traditional Vietnamese lifestyle, notably the role of young people. Her daughter, Tilly, as she is known to American friends, has adapted well to the United States, speaks English fluently, has completed college, and holds a good job as a computer programmer, but spends a great deal of time away from the family. Her son, often called Danny, drifts back and forth, has dropped out of school, has no steady employment, and often accompanies members of a local Vietnamese gang. When he does return home, he is subjected to criticism from other family members, especially his father, though Xuan tends to be somewhat protective. Xuan considers herself in good health and is not aware of any problems, other than worry and tiredness. She had not been to any Western doctor or clinic since her examination before immigration. However, after persuasion by Tilly and a number of female acquaintances, she agreed to go to a clinic for a general examination, including a mammogram and Pap smear. The results were mostly favorable, but the Pap smear showed some abnormalities and she was asked to return for follow-up testing. Confused and troubled, Xuan has not complied with the clinic’s instructions. She told Tilly and others that she feels fine and has noticed no pain or symptoms. Moreover, she already had been seeing an elderly local Vietnamese woman reputed to be a traditional healer and has been given various herbal concoctions. That has been comforting to her, and she feels it is sufficient. She was upset by her experience at the clinic, especially the invasive tests by a male doctor, and by her inability to communicate effectively. Study Questions 1. What are the preferred forms of address for Xuan, Minh, and Tilly? How should their names be recorded? 2. Identify the most-critical cultural factors affecting Vietnamese people after immigration. How might they apply in the case of Xuan’s family, especially Tilly and Danny? 3. What information can be provided to Xuan and her family to help improve compliance with clinical instructions and other aspects of physical health? 4. What should Xuan know about the dangers and treatment of cervical cancer, especially with respect to Vietnamese women? 5. How might Xuan’s clinical experience be improved, particularly with respect to communication, presence of others, and designation of the examiner? 6. What questions should be asked regarding Xuan’s traditional treatments? 7. Explain some of the major religious factors influencing the Vietnamese outlook toward health care. 8. Distinguish ethnic Vietnamese from other Southeast Asian groups. 9. What are generally considered the most serious health problems for Vietnamese refugees? 10. What is the role of the family in Vietnamese health care? 11. Explain the connotations of “hot” and “cold” in traditional Vietnamese health care. 12. Discuss some of the customary practices in a Western hospital that might be upsetting to a pregnant or postpartum Vietnamese woman. 13. Name three traditional Vietnamese treatments and their connotations to Western professionals.