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This chapter is dedicated with love and respect to the memory of Eric Wang (1984-2002), and to his loving family.


In this chapter the term Chinese refers to people of Chinese ancestry, regardless of whether they are from the Republic of China (Taiwan), the People's Republic of China (mainland China), or are "overseas" Chinese from any of the world's other countries. Chinese culture and social structures are very old - dating to as long ago as around 2500 B.C. or about the same time as the beginning of the Pharonic Dynasties of Egypt (Char, Tom, Young, Murakami, & Ames, 1996; Grun, 1982). For millennia the Chinese have followed precepts laid out the earliest teachers and written out by the Sages, especially Lao Tsu and Confucius around 500 B.C. (Hummel, 1962).

History of Immigration

The Chinese have a long history of out-migration from China; and as a result, there are few places in the world where there are not Chinese people living. It is not widely recognized (except by Chinese) that there is a long history of discrimination against the Chinese, such as the United States Chinese Exclusion act of 1882, exclusion of Chinese serving in the military in several Southeast Asian countries today, and institutionalized violence against Chinese in, for example, Indonesia (Braun & Nichols, 1997; Landler, 1998). Chinese immigration (especially from Taiwan) to the west increased in the 1940s and further increased after 1965 and again increased from 1980-1990. Prior to 1965, most Chinese immigrants were working class; and after 1965, most have been professionals (Chang, 1999). Currently there are significant numbers of Chinese entering western countries legally and illegally (Braun & Nichols, 1997; U.S. Department of State, 2000 & 1991). In the year 2000 there were 2.3 million people in the U.S. who claimed Chinese ancestry exclusively and another 0.4 million who claimed Chinese and other ancestry (U.S. Census Bureau, 2002).

Culture and Social Relations

The continuous primary theme or value in social structure among Chinese throughout history is the centrality of the family (Chin, 1996; Kim, Yang, Atkinson, Wolfe, & Hong, 2001; Tong & Spicer, 1994). From the centrality of the family (Kim et al, 2001) arise:

Although extended families are the ideal and relatively common in China, nuclear families are also common - especially in the West.

Family structure is traditionally hierarchal and patriarchal, with the oldest adult male the primary decision-maker in health and other matters. Older children have precedence over younger children and male children over female (Chang, 1999). In family matters there also is significant influence from elders - including women. Families tend to be very private, and few are willing to discuss family issues or conflict with non-family members.

The family is often the first and sometimes only source of health care. Health decisions may be made by the family based as much or more on what is best for the family as on what is best for the patient (Tong & Spicer, 1994). In most Chinese immigrant homes, both Chinese and English are spoken. Many youth go to "Chinese school" where they learn etiquette, calligraphy, and other cultural matters important in maintaining the culture in a foreign land.


China is an enormous country with at least 58 indigenous ethnic groups, a number of which speak different languages or dialects (Yusuf & Byrnes, 1994). There are seven major Chinese language groups, with numerous dialects within each. The seven groups are Mandarin (spoken by the largest number of people), Cantonese, Hakka, Xiang, Min, Gan, and Wu. Mandarin, Wu, and Gan are mutually intelligible, while the others are not - except that written characters are the same throughout. Mandarin (also called Guoyu) is the official language of the People's Republic of China and Taiwan (Chinalanguage, undated).

Communications are complex and based on context, social status, intuition, and other matters not readily discernible to Westerners. (Chang, 1999; Chin, 1996; Kagawa-Singer & Blackhall, 2001). For example, if a young patient is asked by an older health provider if she or he would like a glass of cold water, the answer would likely be yes, even though cold drinks traditionally are undesirable to ill persons. In general, yes-no questions should be avoided when possible, as the polite response is nearly always, "yes."


Religion, as commonly practiced among many Chinese, blends religious beliefs and practices with philosophical systems. Religion (Buddhism) and philosophical systems (Taoism and Confucianism) are integrated with cultural identity to the extent that it is difficult to understand or examine one without the other (Kagawa-Singer & Blackhall, 2001).

The primary religion is Buddhism. Virtually all Chinese Buddhists practice one of many branches of Mahayana Buddhism. In Mahayana Buddhism, there is belief in a vast array of saints and Buddhas stretching over time incomprehensible or ages (kalpas) of the universe. Buddhism is discussed more fully in the chapter on religions.

The primary philosophical influences on Chinese culture are Confucianism and Taoism (the latter pronounced, and sometimes spelled Daoism). Confucianism teaches the proper relationship of people to one another, i.e., child to parent, student to teacher, and so on. Confucianism, then, is the basis for veneration of ancestors and respect for elders. Taoism teaches the proper relationship of people to nature, yet also addresses in a deep way, the relationship of people to one another. Thus Buddhism, Confucianism, and Taoism all affect the health/illness experience and health decision-making.

Knowing others is wisdom;
Knowing the self is enlightenment.
Mastering others requires force;
Mastering the self needs strength.

He who knows he has enough is rich.
Perseverance is a sign of will power.
He who stays where he is endures.
To die but not perish is to be eternally present.
Chapter 33 of the Tao Te Ching (Translation by Gia-Fu & English, 1972)

Health Beliefs and Practices
A first concept to understand in Chinese approaches to health and illness is that of balance, as expressed by the yin-yang symbol ([ ). The Chinese yin-yang symbol is well known and mightily misunderstood in the West. Misunderstood, yin and yang are presented as opposites, with yin representing female, cold, or negative force; and yang representing male, hot, or positive force. A more complete understanding is that these are dynamic and complementary forces. One cannot exist without the other. Within yin there is yang and within yang there is yin; and when either reaches its extreme, it becomes the other. There is no completeness without yin and yang in harmony (Ji, Nisbett, & Su, 2001). In terms of health and illness, a lack of harmony or balance leads to trouble and illness.

Medicines and foods are often considered as either "hot" or "cold." Western medicines are more often hot than cold; while traditional Chinese medicines may be either. Food properties are sometimes subject to debate with respect to which are hot and which are cold. Hot foods are generally high in protein, fat, and calories. Examples of hot foods include chicken, pork, organ meats, eggs, brown sugar, ginger, and alcohol beverages. Cold foods include cold drinks, fruits, most vegetables, and soy products (Chan et al, 2000; Cheung, 1997; Liu & Moore, 2000).

A second important (and related) concept is that of traditional Chinese medicine (TCM). The origins of TCM reach back more than 3000 years and the best-known (old) text was first published in 300 B.C. TCM is based philosophically on Taoism (Kagawa-Singer & Blackhall, 2001) and operationally on a channel (meridian) system, in which various body channels carry vital or life energy called qi or ch'i, blood, and other body fluids (Nestler, 2002). There are numerous channels, with internal organs connected to these channels, and acupuncture points determined by the channels. Imbalance or disruption in the channels leads to illness; and the treatment goal of TCM is to restore balance. The two primary means of TCM treatment are acupuncture and the use of compounds (Nestler, 2002). While some of the latter are herbal in nature, heavy metals are also used, and may, in some cases lead to toxicity - most commonly lead and mercury poisoning (Ernst & Coon, 2001). In the West, the practice of medicinal TCM is not as open as in Asia, but there are TCM practitioners and medications available in most large metropolitan areas.

A third concept important in understanding Chinese approaches to health and illness is a belief in western allopathic medicine. In China, TCM and western medicine may be practiced side by side, with patients utilizing one or the other - or both - according to illness or patient inclination (Nestler, 2002). Indeed, in much of Southeast Asia, a typical pharmacy has one (physical) side of the business devoted to Western medicine and the other side devoted to compounding and dispensing TCMs.

Pregnancy and Childbirth

Prenatal care is highly valued among Chinese women, as evidenced by the third highest rate among women in 17 ethnic groups in the United States in seeking prenatal care in the first trimester of pregnancy (Leigh & Lindquist, undated). TMC remedies may be used for nausea, fatigue, edema, and other conditions of pregnancy.

Postpartum, many women practice Zuo yuezi (sitting in for the first month) for 30 days. Zuo yuezi includes staying in the house; avoiding cold foods, drinks, wind, water, and any other cold substance or contact; diet based on balance (of yin-yang) as discussed earlier; abstinence for physical work; and abstinence from excessive pleasurable activities (e.g., sex, parties, etc.). Bathing (and especially washing the hair) is limited and may include a warm bath with ginger wine or other "hot" alcoholic beverage (Cheung, 1997).

Dying and Death

End-of-life care for Chinese patients and families centers around family and communications (Tang, 2001). Symptom management may be complicated by patient and family reluctance to complain and respect for others - especially those in positions of authority. Barriers to pain and other symptom management by family caregivers may also be related to other issues, including a lack of knowledge about pain and pain management, fatalism, fear of addiction, desire to be a good patient, and fear of distracting the physician from treating the disease (Lin, 2000; Lin, Wang, Lai, Lin, Tsai, & Chen, 2000; Tang, 2001).

Communications related to end of life issues are often complicated by reluctance to discuss prognosis and in some instances, diagnosis (Kagawa-Singer & Blackhall, 2001; Tong & Spicer, 1994). To a greater extent than in other cultures, it remains a norm among Chinese patients and families for (1) the family to withhold information or even lie to the patient and (2) for the patient to pretend that she or he does not know what is really happening (Kleinman, 1988; Lapine, Wang-Cheng, Goldstein, Nooney, Lamb, & Derse, 2001). The family is expected to help prepare the body for burial. Traditionally, there is always an older relative or person from the temple to instruct the oldest son or daughter on what to do regarding washing and dressing the body.

Burial is preferred by most, but not all Buddhists. In the homeland, the body may be disinterred at five years or longer after burial, and the remains placed in a large urn, which is kept at home, in a temple, or is reburied.

"My disciples, my end is approaching, our parting is near, but do not lament. Life is ever changing; none can escape the dissolution of the body. This I am now to manifest by my own death, my body falling apart like a decaying cart." (From the Last Teaching of The Buddha, Bukkyo Dendo Kyokai, p. 24, [translation] 1981)

Health Problems and Health Screening

China is is a vast country and conditions and health problems vary widely. Overall, the healthy life expectancy (HALE) is 63.2 years; and the life expectancy at birth is 71 years (Population Reference Bureau, 2002; World Health Organization [WHO], 2002a). Infectious diseases have been greatly reduced over the past several decades, e.g., reported cases of measles dropped from 1.2 million in 1980 to less than 90,000 in 2000. However, China is one of 22 countries worldwide designated by WHO as "high burden" for tuberculosis. The number of TB cases in China is the highest in Asia, but the rate (per 100,000) of new cases in China is 18th among 41 Asian countries (WHO, 2002). With declining rates of infectious diseases, the rates of chronic non-infectious diseases (e.g., cancer and cardiovascular disease) are increasing. Infectious disease risks for new immigrants from China (Hawn & Jung, 2003; Kemp, 2002; WHO, 2002b) include:

For screening guidelines, see General Health, as well as the above.

Authors: Bi-Jue Chang, RN, MS, CCRC & Charles Kemp, FNP, FAAN


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