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Cultural Approaches to Pediatric Palliative Care in Central Massachusetts: Indian

This subject guide is a collaborative project with the Children's Medical Center Pediatric Palliative Care Team, the Lamar Soutter Library, and Interpreter Services.

Indian

India

Geography:

India constitutes the largest part of the South Asian Subcontinent, an area it shares with six other countries, including Nepal, Bhutan, Pakistan, Sri Lanka and Bangladesh.  

Population:1,065,070,607 (July 2004 est.). US Indian Population: From 1,700 people in 1900, the Hindu population in America grew to 2 million (1.8 million Indian and 200,000 Indo-Caribbean) today. Roughly 83 percent of Indian immigrants are Hindu.

General Culture Information:

Ethnic groups: India is home to several thousand ethnic groups, tribes, castes, and religions. Indo-Aryan 72%, Dravidian 25%, Mongoloid and other 3%.  The Caste divides society into four social classes. The highest class is called the priest class, or the Brahmans. The lowest class is referred to as the laborer class, or Sudras. One inherits class at birth, based on one's karma, or tally of good and bad deeds from previous lives. Castes and sub-castes in each region relate to each other through a permanent hierarchical structure, with each caste having its own name, traditional occupation, rank, and distinctive subculture. The caste system is part of Hinduism.

Language:There are two main categories of languages in India: Indo-Aryans in the north and the Dravidians in the south. Indo-Aryans predominantly speak Hindi, but have numerous dialect variations. It is the national language and is spoken by more than one-third of the people; English is taught as a second language and is the dominant business language. There are 14 other official languages: Bengali, Telugu, Marathi, Tamil, Urdu, Gujarati, Malayalam, Kannada, Oriya, Punjabi, Assamese, Kashmiri, Sindhi, and Sanskrit. All together, there are more than three hundred spoken languages; In America today, Indians are commonly well-educated, English speaking individuals. Older, first generation Indian immigrants, though well educated, may not speak English and need a translator for health care transactions.

Religion: 
Hindu 81.3%, Muslim 12%, Christian 2.3%, Sikh 1.9%, other groups including Buddhist, Jain, Parsi 2.5% (2000)

-Hinduism has many variations, ranging from philosophical beliefs to worship of a variety of gods and goddesses. Aspects of Hinduism that commonly affect health decisions and communications between patient, family, and provider include:

Karma is a law of behavior and consequences in which actions in past live(s) affects the circumstances in which one is born and lives in this life. Thus a patient may feel that his or her illness is caused by karma (even though there may be complete understanding of biological causes of illness).

The Bindi is a sign worn by many women of the Hindu faith as a red dot on the forehead. Traditionally a symbol of honor and intelligence, today it is common for women to wear it as decoration.

Many Hindus use meditation and prayer. Some meditate silently, while others chant "Om" and other prayers aloud.

Devout Hindus are vegetarian. Vegetarianism among Hindus is based on belief in reincarnation, the idea that the soul of a person enters back into creation as a living being.

Family Structure:

People typically define themselves by the groups to which they belong rather than by their status as individuals. In India, families adhere to a patriarchal ideology (father as head of the family), follow the patrilineal rule of descent (from fatherfs lineage), are patrilocal (wife and family moves to fatherfs domicile) and endorse traditional gender role preferences. Historically, the family in India is the joint family which includes three to four living generations, including uncles, aunts, nieces, nephews, and grandparents living together in the same household.  

Among Indians in US, extended families are still prevalent. Often, the husbandfs parents move in with the family after they have retired, for grandchildren or if there is an illness and help is needed. Many times brothers live together for both financial and familial reasons. Because of the value placed on independence and privacy in Indian culture and the desire to save face, family issues, including healthcare decisions, are frequently discussed within the immediate family before seeking outside help. Because of the close-knit family structure, a family can expect many visitors when a family member is in the hospital. 

Gender roles: are very distinct. Women manage the home by keeping all finances, family, and social issues in order. Men typically are the breadwinners and managers of issues requiring interaction with individuals in the community, e.g., health care.  However these roles are changing among educated Indians. Modesty is highly valued among Indians and patients are decidedly more comfortable and secure with same-sex care providers. Respect for elders is highly valued. 

Parenting: India is an extremely pronatalistic society (encourages having children), and the desire to have a male child is greatly stressed. Male children are raised to be assertive, less tolerant, independent, self-reliant, demanding, and domineering. Females, in contrast, are socialized from an early age to be self-sacrificing, docile, accommodating, nurturing, altruistic, adaptive, tolerant, and religious, and to value family above all. Children are not encouraged to be independent and self-sufficient. In the Indian culture, the whole family is involved in the care of the children. Grandparents play an important role in rearing the children, and if the grandparents do not live with the couple, they will come before the birth and stay to help out for first few months to several years. The children often sleep with the parents from the time of birth to early childhood. If the grandparents are part of care taking, the children may be as attached to the grandparents as to the parents. During an invasive procedure, the healthcare worker may want to give the child a choice for support: grandparent or parent – or better, both. 

Children are expected to listen, respect, and obey their parents. Generally, adolescents do not share their personal concerns with their parents. Arranged marriages are still the norm, and dating generally is not allowed. Furthermore, sex and sexuality issues are not openly discussed, interrelationships with the opposite sex are discouraged, and premarital sex is frowned upon. The elderly in India are generally obeyed, revered, considered to be fountains of knowledge and wisdom, and treated with respect and dignity by family and community members.  (India--Family Life and Family Values)

Food:

There are major geographic differences in diet with about half the people eating rice as their staple, while the remainder subsists on wheat, barley, maize, and millet. Common spice choices include, garlic, ginger, turmeric, cumin, and mustard seed.  Tea is India's favorite drink. The perception of Hindus is the belief that some foods are "hot" and some are "cold", and therefore, should only be eaten during certain seasons and not in combination; foods are thought to affect body functions. Indian food is eaten with the right hand, using fingers or utensils; tablespoon and a fork.

Hindu Dietary Practice: In keeping with their belief in non-violence towards all living things, Many Hindus are vegetarian. Hindus may be offended by any form of meat from cows, since cows are considered sacred animals. Various Hindus may fast on different days depending upon the God they worship.

Muslim Dietary Practice:  Muslims do not eat Pork or any pork products, such as lard, ham and pepperoni. They cannot take alcoholic beverages such as wine and liquor, as well as any food items that contain alcohol. Muslims do fasting during the month of Ramadan.

Christian Dietary Practice: Roman Catholics do fasting during Lent and on Good Friday in which they avoid all meats and eat one full meal.

Sikhs Dietary Practice:Some of Sikhs are vegetarian, other eat chicken but no beef.

Buddhist Dietary Practice:  Buddhist are vegans or vegetarians.

Communication:

The influences of Hinduism and the tradition of the caste system have created a culture that emphasizes established hierarchical relationships.

1.     Just Can't Say No: Indians do not like to express 'no,' be it verbally or non- verbally. Rather than disappoint you, they will offer you the response that they think you want to hear. This behavior should not be considered dishonest. They may give an affirmative answer but be deliberately vague about any specific details. This will require you to look for non-verbal cues, such as a reluctance to commit to an actual time for a meeting or an enthusiastic response.

2.     Indians revere titles such as Professor, Doctor etc as status is determined by age, university degree, caste and profession. If someone does not have a professional title, use of honorific title "Sir" or "Madam" are used. Someone's first name without the title should be used only after invitation.

3.     Greeting the eldest or most senior person first is preferred. Each person must be bid farewell individually. Men may shake hands with other men and women may shake hands with other women.

Health Proxy / End of Life:

The cultural and religious background of Asian Indian elders often influence end of life care decisions. Older patients are more likely to subscribe to family centered decision making rather than being autonomous. Sometimes family members may ask the physician not to tell patients their diagnosis or other important information. Many patients prefer to die at home, and there are specific rituals and practices in each religious community.

Death Practices:

Hindu: Many believe suffering is due to karma, which is inevitable; resulting in difficulty with symptom control. When close to death, family members are likely to be present in large numbers. Chanting and prayer, incense, and various rituals are part of the process. A dying person may wish to be moved to the floor, with an idea of being close to the mother earth. After death, healthcare staff should touch the body as little as possible and ideally, the family should be the only ones touching the body. A same sex family member should clean the body. The body is wrapped in a red cloth. The mourning Hindu family may prefer to have a Hindu priest perform a prayer and blessing. It is very important to provide privacy to the family after the death of a family member to allow for the religious rites to be performed. It is an accepted practice for family members and others to have an open expression of grief. The preference is for cremation and ideally, the ashes are spread over the holy river, The Ganges (or Ganga Ma).  After cremation there is a mourning period of from 10 to 40 days. The men and boys of the family may shave their hair as a symbol of mourning for the dead. The mourning family may wear all white and wish to have a Brahman at the funeral to perform a prayer and blessing. 

Hindus death rituals:

http://www.mailerindia.com/hindu/veda/index.php?death

Muslim death rituals:

http://www.bmj.com/cgi/content/full/bmj;309/6953/521

Christian death rituals:

http://www.indianmirror.com/culture/cul2.html#chris

Sikhs death rituals:

http://www.indianmirror.com/culture/cul2.html#sikh

Buddhist death rituals:

http://www.webhealing.com/articles/lama.html  

Traditional Beliefs and Alternative Medicine: India has a tradition of medical healing, teaching, and research that goes back more than two thousand years. Today there are four major systems as well as dozens of localized and tribal ones that depend on herbal treatments. All of these systems attribute disease to an imbalance between underlying constituents. More than eighty-percent of people in India rely on herbal remedies as the principal means of preventing and curing illnesses.Some Indians believes in Homeopathy as alternative medicine. 

Ayurveda: It is the oldest system of traditional medicine. In the Ayurveda system, the body is comprised of three primary forces, termed dosha. The state of equilibrium between the dosha is perceived as a state of health; the state of imbalance is disease. Each dosha represents characteristics derived from the five elements of space, air, fire, water, and earth. Space represents the ears and is responsible for hearing, speech, and sound. Air represents skin, which is responsible for touch, pressure, and the feeling of cold to dry sensation. Fire represents the eyes, which are responsible for sight, heat, and light. Water represents the tongue, which is responsible for taste, liquids, and hot or cold. Earth represents the nose, hence is responsible for smelling and odor.The herbs used in Ayurvedic remedies have few side effects on the body.

Ayruveda Medicine and Common Health Problems:

Fever: Common remedies for fever include fasting to remove excess toxins, and mild sweating to digest the toxins. Lying down on a bed covered with a warm blanket for 15-20 min causes sweating. A drink made of raisins and crushed, boiled fresh ginger is believed to help reduce the symptoms of fever.  

Headaches: Common symptomatic remedies for headache include applying a paste of clove powder, cinnamon, and almond in equal quantities to the forehead of the patient. Several drops of ghee (clarified butter) mixed with 3 or 4 pieces of saffron are rubbed together for two minutes. The saffron is taken out and two drops are put in the each nostril of the patient. Wrapping a wet cloth around the neck helps to relieve headaches. Oil massage on the head, Meditation and relaxing the mind also helps in treating headaches. 

The common cold: Common remedies for the common cold and cough include keeping the body warm, especially the feet, chest, throat, and head; fasting; and fresh ginger mixed with honey taken in water three times a day. In case of dry cough, fresh peeled ginger is cut into small pieces with salt applied and then chewed by the patient. Cold foods aren't consumed.

Stomachaches: Remedies for stomachache include one to three ajwain seeds with warm water, two teaspoons of lemon juice with water at least three times a day, one teaspoon of ginger and vegetable oil mixed with warm water, and water in which anise seeds have been soaked. Another remedy is mixing equal weights of dry ginger, black pepper, roasted cumin seeds, and dry mint leaves together with water and drinking the mixture.

Diarrhea: Remedies for diarrhea include fasting; herbs such as nutmeg, oak bark, raspberry, and marshmallow; sugar and salt solution; pieces of skin from the pomegranate; and if excessive thirst is evident, a drink made from coriander seeds.  

Constipation: Remedies for constipation include massaging the whole body with oil once or two a week; applying oil or ghee on the navel every day; taking lemon juice mixed with warm water; or one or two teaspoons of a specific type of gel. Triphala Churna, a powder made of fruits and herbs can be taken with warm water or milk and helps in having a clean bowel movement the next morning.   

Arthritis: Remedies for arthritis include fasting; camphor, wintergreen and cinnamon oils; guggul, an herb, taken three or four times a day; a paste of red chilies and fresh ginger mixed together and applied to the painful area; two cloves of garlic fried in ghee or oil; and alternate hot and cold baths with camphor powder in kerosene oil which was placed in the sunlight.

Religious Ceremonies Related to Birth

In many Hindu families, a ritual called "The Sixth" is performed on the sixth day after delivery. It involves placing a religious blanket under the newborn, applying holy red powder that has been mixed with water on to the palms and soles of the infant, and reciting prayers over the child. Afterwards, the baby is to be untouched for a period of time in which it is believed that a Holy Spirit descends onto the child and blesses his or her life. The baby is officially named on the eleventh day after delivery during the "cradle ceremony," and further rituals are performed to protect the baby from evil spirits.

In Muslim families, it is common for the father or the grandfather of the child to recite the Azan in the childfs right ear and the Iqama in the childfs left ear just after birth to confirm that the child is Muslim. Muslim ceremonies involves the shaving of the newbornfs head, the sacrifice of one or two goats and the distribution of alms to the poor.

Christian families may wish to pray over the infant for blessings and health. In addition, they may choose to apply holy water or anointing oil to the child's head, hands and/or feet as a symbolic dedication of the child's life to Christ.

 Local community information:

http://aapkatv.bizland.com/beta/worship.php

http://boston.localfiles.com/indian/boston/yellow_pages/religious_worship_place/list_1.htm  

References:

end of life decision making:  a cross-national study

meeting jewish and muslim patients' dietary needs

https://www.cia.gov/library/publications/the-world-factbook/geos/in.html

http://www.everyculture.com/ge-it/india.html

http://www.indianchild.com/culture%20_1.htm

http://www.indianmirror.com/culture/cul8.html

dickson, n. (1998). world: south asia indianfs battle with population

growth. BBC Online Network. Available online: http://news.bbc.co.uk/hi/english/health/default.html

India. In The Encyclopedia Americana: International Edition (Vol. 14, pp. 865-881). Danbury, CT: Grolier Incorporated.

Knipe, D. M., (1991). Hinduism. New York, N.Y.: Harper Collins.

Lipson, J.G., Dibble, S.L., & Minarik, P.A. (Eds.). (1996). Culture & Nursing Care: A Pocket Guide. San Francisco: UCSF Nursing Press.

Paulanka, B.J., & Purnell, L.D. (Eds.). (1998). Transcultural Healthcare: A Culturally Competent Approach. (CD-ROM). F. A. Davis Company.

World Health Organization (2000). Healthy life expectancy rankings. Accessed on the World Wide Web on October 14, 2000 athttp://www-nt.who.int/whosis/statistics/dale/dale.cfm?path=statistics,dale&language=english

http://falcon.jmu.edu/~ramseyil/asialit.html

http://india.coolantlanta.com/GreatPages/sudheer/medicine.html

http://www.ayruvedic.org/html

http://www.bbc.co.uk/education/medicine/nonint/prehist/dt/prdtcs4.shtml

http://www.chronicpainsolutions.com/articles/sogalspr.98.html

http://www.censusindia.net

http://www.censusindia.net/cendat/datatable12.html

http://www.encycolpedia.com

http://www.indiagov.org/culture/cuisine.html

http://www.indianherbs.com/herbalist.html

http://www.personal.si.umich.edu/~lija/design/ayurevda.html

http://www.qqq.com/india/cuisine.html

http://www.sikhs.org

http://www.sikhs.org/religion.html

http://www.spindlepub.com/India/profile/htm