Despite the publicity about the progress of the United States in becoming a multicultural, multiethnic society, little preparation has been initiated by local governments, social service organizations, and health care providers regarding the actual provision of services to immigrants or to their organizations and communities. Most Americans assume that past and future generations of immigrants voluntarily will learn the English language, demonstrate expected social behaviors, and integrate themselves into the America's "melting pot" society. The assumption of voluntary social assimilation is based on the belief that immigrants arrive in the United States with the purpose of becoming "Americanized." This belief presumes their willingness to rapidly change their historical social orientation, national loyalties, language, cultural beliefs, family roles and structure, and lifestyle patterns. The assumption of voluntary Americanization continues to exist despite the behaviors of past generations of immigrants who resisted the assimilation process and have, in fact, reestablished their pre-immigration cultural practices in multiple voluntarily segregated ethnic enclaves and communities. The immigrant groups' geographic, social, and cultural isolation eventually will cause social, legal, and health care problems for the enclaves' residents when they interact with representatives of the dominant society. For example, culturally based conflicts will become magnified when home-based or community-based health care must be provided for elderly individuals who live in the enclaves. The purpose of this Guest Editorial is to provide information about:
* The usual pattern of establishment of immigrant, ethnic neighborhoods.
* The influence cultural expectations have on an immigrant's health care decisions.
* Suggestions for establishing an ongoing cultural database that may form the basis of providing appropriate, acceptable health care to the group.
The history of the immigrant experience during the past century demonstrates that most significant decisions about the establishment of an ethnic neighborhood are based on pragmatic, economic, and cultural considerations. The immigrants' decisions are made or significantly influenced by the elders in the community who, by tradition, are the groups' respected leaders and cultural caretakers. The leaders' multiple roles may help explain the reason many immigrant groups, regardless of their country of origin, have demonstrated a predictable pattern of initial settlement behaviors. On arrival, most immigrants overtly sought to settle in neighborhoods or communities established by earlier immigrant groups. The choice of where to settle usually was dictated by the immigrants' sponsor, who was an established member of the cultural community. These ethnically segregated communities, or enclaves, were established to resemble, as much as possible, and function in a fashion similar to their former towns, villages, and communities, and included the same religious establishments, social expectations, organizations, and foods available in their homeland. Historically, many of these enclaves were given unofficial descriptors by the dominant society that identified a geographical area with a particular ethnie or cultural group (e.g., Chinatown). Living in these ethnic enclaves has both positive and negative implications for its residents.
Settling in these ethnically dominated immigrant communities provides immigrants with a sense of belonging because of the prevalent use of their native language, availability of ethnic foods, and dominant display of their religious and cultural symbols. This same feeling of belonging may, and often does, contribute to the immigrants' isolation from the social support and political and health care systems of the dominant community and, consequently, delays their integration into American society. In many situations, older immigrants have chosen to isolate themselves in these socially segregated communities. As a result, many older immigrants, who may be long-term residents of the United States, have very limited English language skills, demonstrate behaviors one would expect of a new immigrant, and express a great deal of apprehension when finally entering the health care system. In many cases, the older immigrants' cultural beliefs about health and illness, fear of the unknown, and reluctance based on the perceived mistreatment of others can cause them to delay their entrance into the system and, consequently, increase the seriousness of their health condition. Many older patients enter the system with certain expectations and preconceived cultural beliefs or attitudes about health and illness and memories of experiences with professional and alternative health care providers in their former country. Older immigrants expect health care providers to be somewhat knowledgeable about and demonstrate a respect for their culture, customs, and social status. Demonstrating respect or disrespect to the elders of a community will have a cascading effect on the entire immigrant community and may influence significantly whether other residents seek professional health care. Many elderly patients have strong beliefs in cultural healing practices and in community-based traditional practitioners who are respected as individuals whose basis of care is considered to be spiritually motivated. A nurse's demeanor will influence immigrant patients' future health care decisions greatly. In some cases, although unintended, initial interactions with health care providers may be so culturally insulting that older immigrant patients will be reluctant to make any future visits. For example, the formality, brevity of interactions, and dominant behaviors that are common characteristics of many initial patient-provider interactions are considered insulting behaviors in many cultures.
Health care providers, especially nurses, must recognize the importance of their initial interactions with elderly immigrant patients and also be aware of the possibility that the individuals may be under the simultaneous care of both professional and traditional practitioners. Nurses should remember older immigrant patients perceive benefits from cultural practices, and whenever possible, these should be incorporated into the prescribed care regimen. For example, a patient's family may expect to play a significant role in their care. AU reasonable accommodations should be made to facilitate their wishes.
Many communities have long established immigrant neighborhoods with recognizable cultures and easily identifiable political, economic, and religious leaders. Organizations whose purpose is to serve the social, political, and health care needs of the area's residents would derive multiple benefits from establishing informal liaisons with the leaders of the immigrant community. Cooperative efforts could result in the preparation of a cultural database about the local immigrant population. Community resources such as bilingual individuals, cultural healers, communication channels, local social support organizations, health care resources, and other useful information could be identified. The shared database could be used as a basis for developing an ongoing immigrant cultural education program for health care providers. Programs should incorporate information about local language patterns, cultural courtesies, religious and health and illness beliefs, food preferences, as well as the significance of various colors, numbers, and other symbols. Increasing nurses' knowledge about immigrant communities and their cultures and incorporating what has been learned into action plans would significantly improve the likelihood that immigrants would be less reluctant to enter the health care system. Each community has a health care facility or function that should service the specific needs of an ethnic or immigrant group. Health care providers must recognize that the cultural beliefs and practices of a local immigrant community are relatively constant. Collecting specific usable information about the local immigrant community should result in the formulation of a strategy that improves acceptance and access, and provides culturally sensitive acceptable health care.