Increasing longevity has become a reality regardless of race. The older population of the United States has grown constantly through the past century. Between 1900 and 1980, persons aged older than 65 years increased in number from 3 million to 25 million. This eightfold growth in 80 years was far greater than that of the general population, which itself more than tripled over the same period.
Particularly, Asian older adults are a cultural minority growing more rapidly than any other nationality. Between 1970 and 1980, within the old population, whites and blacks increased respectively by 27% and 35%, whereas Asian/Pacific and Native Americans grew by about 90%. 1,2 There are about 100 identifiable ethnic groups in the United States.3 Yet sometimes, maybe too often, healthcare providers view and treat these groups as homogenous. We fail to recognize that the subcultures within each ethnic group differ and reflect a unique set of socio-historical forces.4
As a result, experiences in healthcare settings can be traumatic for the older Asian who neither understands the system nor the language, and negligence from healthcare providers can have devastating effects on this individual's well-being, as well as health status. This article describes the traditions of the Asian culture, especially the impact of Confucianism. Such information should prevent nurses from misinterpreting the behavior of older Asians and should help them to make accurate assessment of health and cultural needs.
Impact of Confucianism
To understand older Asians, we must consider the impact of Confucianism, which is deeply ingrained in their way of life. Although this Confucian heritage is mixed with earlier Shaman concepts, as well as later Western philosophical ideas, it is reflected in the many different components of their society.
Such components include social hierarchy in respect given to the older adult, the desire for education, ceremonies to commemorate the deceased, and the continuing influence of the extended family even though the nuclear family is increasingly the most common living unit.
The family is a unit of clan as well as a component of society, and social life is based on human relations within the family. As a result, group ties are strong, and it is expected that the individual will work hard to contribute toward the success of the group (or family). The most important aspect of traditional family consciousness is the father-son relationship.
Confucianism teaches that "filial piety" is the basis of all conduct, and followers are educated along this principle. Duty to parents demands strict obethence, and it is a son's moral obligation to serve them with all sincerity.
Based on this tenet, rule of seniority is applied: a child obeys the parents, a wife obeys her husband, and a younger brother obeys an older brother. Age indicates dominance within families, and older adults expect to be respected and supported by their children.5,6
Immigration and Its Effects
The Western principle of family life has come to exert many influences which tend to destroy the extended family and the advantageous positions of the older people. The traditional sense of family has undergone a change even though traditional thought still plays an important role under the surface. Thus, older people experience even greater hardship because they feel unwanted, they are often treated as guests, and they have no significant role in matters of consequences in their family.
Even when the matter is something about them, frequently they are the last persons to be informed of their family's decisions. Furthermore, a majority of older Asians are first generation immigrants who still value Confucian norms and ideals.7 Illese values conflict with values of American society which emphasizes individual-centered orientation, self-reliance and independence.8 I0
These differences often cause intergenerational frictions. The older generation intends to keep its traditional privileges while the younger generation has different opinions about something, like the extent of the child's filial responsibility, and they view filial piety as an ethical issue rather than a realistic one.
Immigration, particularly from a non- Western culture, can be itself a stressful life event, even under the best circumstances." Older Asians are dealing with tremendous major changes over which they have little control, in addition to the burden of the aging process. Immigration often has psychological effects for some years after the event itself.12 The most important factor influencing an immigrant's stress level is the length of residence in the United States. Usually successful adaptation to the new country takes at least three to five years.13
In addition, the adjustment is positively related to education and household structure; in other words, older immigrants who have little education, immigrated recently, and live alone are at risk for maladaptation in a new setting.12 The loss of familiarity, the language barrier, shifting traditions, and changing cultural roles have the potential for creating social isolation, disorganization, and functional illiteracy, as well as health problems in general.
There are two myths about older Asians as viewed by me dominant society. Many people believe that Asian- American communities are highly stable and have full control of their social and mental health concerns.8,14,15 Moreover, it is believed that Asian-Americans are a successful "model minority" and do not need any outside help, which directs their systematic exclusion from social opportunities and resources.14,16
In reality, however, numerous older Asians suffer from poverty and illness and are ignored and neglected by their own families. Long hour and low wage work require all family members' hands and force older family members and children to be left alone without appropriate care or supervision. According to Nee and Nee,17 San Francisco's Chinatown has the highest suicide and tuberculosis rates in the nation, and many of the older adults suffer from general malnutrition.
The study of older Asians by Fujii18 pointed out much the same result. He stated that like other ethnic groups, older Asians are in multiple jeopardy in that they suffer poverty, poor health and housing, racism, and loneliness. There are also more significant health hazards and a poorer sense of individual wellbeing among older Asians compared with the dominant population. Nevertheless, many needy older and new immigrants avoid seeking out social services which they are entitled to, mainly because of the language and cultural barriers, and unfamiliarity with the institutional arrangement in the community.14
A second myth about Asian older adults is that they are viewed as an oppressed group. Many people believe that all ethnic groups are dealing with lack of education, underemployment and low skill jobs, little income, poor quality housing, and short life-expectancy with multiple illnesses.1,2 Osako's19 study on aging and family among Japanese families showed a positive relationship between younger and older generations who shared some components of cultural heritage, as well as their hardships like racial discrimination. He concluded that the cultural inheritance of the Japanese contributed to reduced intergenerational conflict and enhanced the older Japanese in their adjustment of aging process.
One of the cultural contributions is the emphasis on "group achievement orientation" which reflects the Confucian ideal of priority in education. The Confucian tradition places a concern for education at the very top of what people believe to be the most important things in their life. Education is valued both for its own sake and as a key to social and economic advancement.
Even poor parents encourage their children to pursue education, and parents' sacrifice is rewarded by children's success, whether or not parents receive benefits from these accomplishments. As a result, the second generation and younger first immigrants of Asians are a highly educated group and have largely attained middle class status in comparison with any other ethnic group 14,19,20
In general, older Asians may face multiple disadvantages and difficulties in accordance with assimilation. Indeed, just like other ethnic groups, older Asians can be wealthy and highly educated as well as poor, powerless, and less educated. Further, advanced age can be a successful life event for older Asians who live in communities where their values and traditions have been maintained and transmitted to their children. Yet, the aging process can be a lonely and devastating battle for those who have no children or family and are isolated from their ethnic communities.9
Since 86% of all those over age 65 suffer from at least one chronic condition,21 it is expected that large numbers of older Asians are affected by illness-related changes. Due to the rapid growth of the older Asian population, nurses' contact with this ethnic group is also increasing. To understand older Asians' behaviors and attitudes, nurses must be sensitive to the nature of their cultural influences, beliefs, values, and health perceptions in addition to their support systems and special needs (such as food and religion).
Unfortunately, healthcare providers tend to pay superficial attention to cultural differences which frequently results in misinterpretation of older Asians' behavior and attitude. Here are two cases that can be easily seen as examples for such misinterpretations.
A healthcare team labeled an 85year-old Chinese man as "stubborn and noncompliant" and concluded that he was not willing to take care of himself and was not interested in his health because he refused to have prostate removal and further treatment for its cancer.
Before accusing him of being an "old stubborn Chinese man," they should have attempted to understand what this surgical procedure meant to him. Careful assessment should have been made according to his cultural background in addition to his health conditions.
In contrast to the Western concept, the Confucian followers view the body as property of their parents and ancestors rather than their own. The Confucian philosophy teaches that the body must be cared for and well maintained until death. Confucian teaching states, "Only those shall be truly revered who at the end of their lives will return their physical bodies whole and sound."22
Another illustration can be made of a 72-year-old Japanese woman who was admitted to a nursing home six months ago, due to her severe physical disability. Accompanied by her only son, she had had multiple episodes of stroke and hip fractures, and the son claimed that he and his wife were no longer able to take care of her in his home without professional assistance. Since admission to the nursing home, she had isolated herself in her room and refused any personal contact including her own family members.
Soon, she was diagnosed as psychotic and most healthcare providers treated her like one. This misinterpretation or mistreatment could have been prevented simply by understanding the dimensions of her culture and what institutionalization meant to her. Older Asians expect to be taken care of by their young until death, regardless of physical disability.
Yamaguchi23 emphasizes that the trauma of institutionalization for the older Japanese is not only unfamiliarity with institutional living, but rather it is perceived as a personal, as well as a family, disgrace.9 For the family members to be unable to care for their own old family members is a "loss of face" and brings shame on the children and their parents.24 Older Asians, in general, want to say and believe only good things about their relatives, particularly their children, because of family cohesion.25
These kinds of mislabeling and misdiagnoses can be seen as discrimination because cultural values and beliefs are not recognized, perhaps due to lack of knowledge. Thus, nurses as the core of the healthcare team, must be made aware of cultural differences in order to provide appropriate care. Since a majority of older immigrants have a major language barrier, it is also imperative that nurses use simple and explicit words based on their client's intelligence and life experience to sustain effective communication. Accordingly, it is important to maintain the information about clients' level of education, occupation (both native and new countries) and formal social status with the native country.
However, nurses who deal with personal information must be careful about emotional involvement, especially with ethical matters. Asians expose themselves much less than Americans do, and tend to keep their problems or sufferings within me family. Particularly, they are generally more concerned with what the other views or feels about ethical decisions than with their own opinions.5,26
In as much as the United States is a multicultural society, nurses should be sensitive not only to the health needs of a diverse clientele, but also to their unique cultural backgrounds in order to provide effective care that meets cultural needs. Since the older Asian population is growing more rapidly than any other ethnic group, nurses should become knowledgeable about the impact of Confucian philosophy on the Asian culture.
Even when traditional norms and values are essentially stable, nurses should not conclude that older Asians are incapable of modifying their behavior. As the older Asians live in a constantly changing environment, behavior can be modified in an effort to maintain a state of well-being. With appropriate approaches that do not defy cultural tradition, nurses provide necessary interventions making healthcare experience less traumatic for the older Asians, thereby enhancing the quality of their late life in a new country.
- 1. Manuel RC, Berk ML: A look at similarities and differences in older minority population . Aging 1983; 21-29.
- 2. Manuel RC, Reid J: A comparative demographic profile of die minority and minority aged, in Manuel RC (ed): Minority Aging: Sociological and Social Psychological Issues. Connecticut, Greenwood, 1982.
- 3. Themstron S: The Harvard Encyclopedia of American Ethnic Groups. Cambridge, Mass, Harvard University Press, 1981.
- 4. Aday L: Economic and noneconomic barriers to the use of needed medical services. Med Care 1975; 13:477.
- 5. Ko HC: Korean Culture. Seoul, Korea, Dong ah Publishing Co. 1982.
- 6. Modell J: The Japanese American family: A perspective for future investigations. Pacific Historical Review 1968.
- 7. Holzberg CS: Ethnicity and aging: Anthropologica] perspectives on more than just the minority elderly. Gerontologist 1982; 22:249-257.
- 8. Kalish RA, Moriwaki S: The world of the elderly Asian American. Journal of Social Issues 1973; 29:187-209.
- 9. Moriwaki S: Ethnicity and aging, in Burnside IM (ed): Nursing and the Aged. New York, McGraw Hill, 1976.
- 10. Yee BW: The golden years: Myth or reality for the Asian/Pacific elderly. Paper presented at meeting of Asian Human Services, Denver, Colorado, May 1981.
- 11. Lipson JG, Meléis AM: Culturally appropriate care: The case of immigrants. Topics in Clinical Nursing 1985; 7:48-56.
- 12. Kiefer CW, Kim S, Choi K, et al: Adjustment problems of Korean American elderly. Gerontologist 1985; 25:477-482.
- 13. Nann RC: Uprooting and surviving: Adaptation and resettlement of migrant families and children, in Nann RC (ed): Unrooting and Surviving: An Overview. Dordrecht, Holland, D Reidel Publishing Co, 1982.
- 14. Kim BL: Asian-Americans: No model minority. Social Work 1973; 18:44-53.
- 15. Wong L: The Chinese experience. Civil Rights Digest 1976; 8.33-35.
- 16. Pujii S: Elderly Asian Americans and use of public services. Social Casework 1976b; 57:202-207.
- 17. Nee VE, Nee BB: Longtime Californ". A Documentary Study of an American Chinatown. New York, Pantheon Books, 1972.
- 18. Fujii S: Old Asian Americans: Victims of multiple jeopardy. Civil Rights Digest 1976a; 22:22-99.
- 19. Osako MM: Aging and family among Japanese Americans: The role of ethnic tradition in the adjustment to old age. Gerontologist 1979; 19:448-455.
- 20. Sue S, Sue DW: Asian Americans as a minority group. Am Psychol 1975; 30:906-910.
- 21. Johnson CL: The impact of illness on late-life marriages. Journal of Marriage and the Family 1985; 47:165-172.
- 22. Spector R: Cultural Diversity in Health and Illness. New York, Appleton-CenturyCrofts, 1979.
- 23. Yamaguchi Y: 7Ae elderly Japanese and his Institutionalization. Paper presented at Ethnicity and Aging Seminar, University of Southern California, Los Angeles, July 1973.
- 24. Kim SS: Ethnic elders and Americans health care: A physician's perspective. West J Med 1983; 139:885-891.
- 25. Carp FM: Health care problems of the elderly of San Francisco's Chinatown. Gerontologist 1976; 16:30-38.
- 26. Minami H: East meets West: Some ethical considerations. Int J Nur s Stud 1985; 22:311-318.