South Asians living in North American are heterogeneous in language and culture, and include those from India, Pakistan, Bangladesh, Sri Lanka, Nepal, as well as those from Fiji and East Africa whose origins are Indian Subcontinent. This chapter highlights three culture groups: Hindus, Muslims, and Sikhs. Variations among South Asians due to country of origin, level of education, social class, religious affiliation, background (rural or urban), and number of years lived in North America.
Major language and dialects. Common languages spoken by South Asians include Hindi, Urdu, Gujrati, Punjabi, Pushto, Bengali, Oriya, Marathi, Telugu, Tamil, Kannada, and Malayalam. More than 400 dialects common among South Asians.
Nonverbal communication. Touching not common among South Asians. Love and caring expressed through eyes and facial expressions rather than kissing or hugging. Direct eye contact may be considered sign of rudeness or disrespect, especially with elderly. Silence usually indicates acceptance, approval, and/or tolerance. At difficult times, people usually pray in silence. Personal space constricted among family members. Modesty, humility, shyness (sharm), tolerance, and silence admired and emphasized from childhood. These patterns of nonverbal communication shared by most Hindus, Sikhs, and Muslims.
Use of interpreters. If possible, South Asians prefer close family members of same gender and older in age to interpret in health care setting and to offer advice. For discussing sensitive issues such as sex, may prefer to consult with family members of same sex and age group.
Greeting. Greetings expressed orally as well as in gestures. Hindus and Sikhs: press palms of hands together in front of chest. While greeting, they utter phrase Namaste (Hindus), or Sasariyakal (Sikhs). Muslims: take the palm of right hand to forehead and bow down slightly. While greeting, they utter phrase AsSalamOAlaikuum. Shaking hands common among men but not among women in most South Asian cultures. Individuals of same age group or younger addressed by first names. Older preferably called by titles, e.g., Baji/Didi used for women of an older sister's age, Bhayya for other brother, Chachi (female)/ Chacha (male) for individuals of parents' age and Amman (female)/Baba (male) for individuals of grandparents; age. Hindus, Sikhs, and Muslims use similar titles for addressing individuals.
Tone of voice. Most South Asian languages have soft tone of voice. Loudness may be interpreted as disrespect, command, emotional outburst, and/or violence. Considered okay to give commands, boos around, and be demanding of younger individuals; however, older individuals expect to be treated respectfully and politely.
Orientation toward time. May not be extremely time conscious, especially in social gatherings. May not like to monitor every minute of daily life. Tardiness accepted in social gatherings. However, South Asians quite aware of importance of keeping doctors' appointments and being on time for physical examinations.
Activities of Daily Living
Modesty. Men comfortable with pajama top and bottoms; however, women prefer not to wear hospital clothes as body parts likely to show through. Hindu women may prefer to wear sari. Most Sikh and Muslim women prefer to wear shalwar (loose pants) and kamiz (top that is below knee in length). Many would prefer to cover head and chest with rectangular cloth (chader, approximately 6' x 3').
Skin care. Most South Asians like to take daily morning shower. Person with respiratory tract infection or prior surgery would prefer bed bath. They use a lot of running water when bathing as water consider symbol of purity.
Hair care. Among many South Asians women, long hair considered sign of feminine beauty. Hair washed once or twice weekly. Women massage scalp with coconut or mustard oil weekly, and comb and braid hair daily. Usually wear head covering. Traditional Sikh males are not supposed to cut their hair or shave their beard. Their hair is usually secured in turban. No restrictions on cutting or shaving body hair among Hindus and Muslims.
Nail care. Nails cut short and kept clean. No cutting of nails at night and once clipped, nail paring must be thrown in sink with running water.
Toileting. South Asians prefer private toilets for elimination; however, also accept bedpans, urinals, or bedside commodes. Would like thorough peri-wash with water after elimination. Provide pint sized plastic water pitcher near commode for peri-care. Must use left hand to wash and wipe their perineal area. Muslims do not eliminate at certain times of day [e.g., at time of Azan (prayer) in mosque]. Strict Muslims must purify themselves by washing before prayer. No special rituals for elimination among Hindus and Sikhs.
Special clothing/amulets. High caste Hindu men have a sacred thread tied around the body. Thread must never be removed without permission of patient or family member. Baptized Sikh men and women wear kirpan ( a piece of cloth around chest), kanga ( a wooden comb), Kara ( an iron bracelet). Kirpan, kara, and kanga must never be removed. Muslims sometimes wear Taawiz (Koranic verses folded in small cloth) for protection, usually provided by high level spiritual person.
Self-care. Sick individuals assume dependent sick role and expect caregiver or a family member to assist with personal hygiene and meals. Other family members relieve patient from family responsibilities to ensure physical and emotional rest.
Usual meal pattern. South Asians usually eat two to three meals per day. Prefer big meal at lunch and small meal at supper. May prefer supper in late evening. During acute illness, may like bland, easily digested foods.
Special utensils. Hindus may prefer to use metal utensils such as copper, brass, or iron for cooking and for eating as these considered sacred. Sikhs and Muslims have no such preferences in utensils.
Food beliefs and rituals. Food given much respect in most South Asian religions. Advised that one must eat food with love and compassion and be thankful to God for giving food that alleviated hunger and nourishes body and mind. One must also avoid any form of distraction such as watching television, reading, or excessive talking while eating. Many South Asians use fingers of right hand to eat food and most prefer to wash their hands before touching food. Overeating discouraged equally in Hindu, Sikh, and Islam religions; believed that overeating decreases one's life span.
Usual diet. Most common stable foods among Hindus, Sikhs, and Muslims are rice or chapatti (flat baked bread made with whole wheat flour) with meat, vegetable, or lentil curry. Sweet dishes not part of regular meal.
Fluids. Instead of fruit juices or sodas, water or buttermilk (lasi) are beverages of choice; believed to help digestive processes. Tea is common hot beverage instead of coffee.
Food prohibitions. Hindus: refrain from eating any kind of meat and fish. Some may not even eat eggs. Alcohol permitted only in moderation. Foods may not be eaten during observance of fast. May fast one day each week for each month; may be total abstinence of food and fluid or eating foods that are pure (for example, fruit, yogurt, and nuts).
Muslims: observe fast during month of Ramazan ( a Muslim calendar month). No food and fluids allowed from sunrise to sunset each day until month is completed. Young children, persons who are ill or traveling, and women who are menstruating, pregnant, or breastfeeding exempted from fasting. Pork and alcoholic beverages strictly prohibited. Only fish with fins and scales are allowed. Meat products allowed if halal ( a special method to kill an animal) used.
Sikhs: No dietary restrictions; however, some may fast or refrain from eating meat products. Smoking and alcohol consumption generally discouraged.
Food prescriptions. Those who believe in Ayurvedic medicine (mainly Hindus, Sikhs and some Muslims) classify foods as "hot" or "cold," Concept of hot and cold not related to actual temperature but to food content. Hot foods prescribed in winter climate for such "cold" diseases as arthritis, respiratory tract infection, gastrointestinal problems, and circulatory problems. Fever and surgery considered a cold state. Examples of "hot" foods: all kinds of meat and fish, eggs, yogurt, honey, most oils, nuts and seeds, most herbs, and spices. "Cold" foods must be eaten during hot weather (e.g., milk, butter, cheese, most vegetables and fruits, some grains and legumes such as wheat, rice, barley, and lentils). Also believe certain foods are incompatible when eaten together such as fish and milk, meat and milk, sour fruits and milk. Believe that eating incompatible foods leads to production of toxins in body. Fasting recommended for fever, cold, constipation, or arthritic pain. For normal health individual, warm water fast one day a week advised to rest digestive system.
Pain. Darad is term used to express pain many South Asian languages. Would understand numerical scale to quantify pain. Hindu and Sikh patients will accept narcotics for pain. Muslim patients may refuse narcotics for mild to moderate pain, as narcotics forbidden in their religion; however, usually accepted for severe pain. Some South Asians may prefer taking analgesics via IM route. Many South Asians prefer home remedies to manage certain acute pain such as muscle pain and joint inflammation secondary to physical trauma. For pain secondary to surgical incision or other chronic illnesses such as cancer, arthritis, etc., analgesics prescribed by Western physician usually taken. Common home remedies include; mustard paste poultice applied to painful muscle and tumeric paste warmed and applied on piece of gauze to painful joint and wrapped with bandage overnight.
Dyspnea. Sans Ukhrna describes breathlessness. May get very anxious and hyperventilate as dyspnea also considered sign of death. Will accept oxygen with some explanation. Need to be approached in calm manner. Some may use home remedies such as licorice and ginger tea.
Nausea/vomiting. Ulti (nausea) and vomiting indicates toxins in stomach which body must eliminate. Vomiting sometimes induced for therapeutic reasons in disorders such as chest congestion, asthma, indigestion, and edema. No medical treatment sought for nausea/vomiting initially, except person is encouraged to refrain from eating to rest gastrointestinal tract, and my be offered herbs and spices such as black pepper and/or dill seeds.
Constipation/diarrhea. Kabz (constipation); Julab (diarrhea). Believed that constipation causes abdominal distention and discomfort, headache, and bad breath. To relieve constipation, one teaspoon of ghee (clarified butter) mixed with hot milk and taken at bedtime. Enemas generally accepted. For diarrhea, paste of fresh ginger mixed with buttermilk taken orally. Black coffee, cumin, or nutmeg also thought to cure diarrhea.
Fatigue. Individuals who complain of thakan lagna (fatigue) advised to get enough rest and eat proper diet. Taking hot bath or shower and drinking warm glass of milk with some sugar just before bedtime believed to promote sleep and alleviate fatigue.
Depression. Dil uddas hona in Hindi, Urdu, Punjabi, and Gujrati languages. May be considered sign of spiritual unhappiness. Some may resort to many prayers and meditation. Those who believe in Ayurvedic therapy may learn to perform Yoga exercises. In extreme or psychotic depression, help of psychiatrist or spiritual healer may be sought.
Self-care for symptom management. Usually prompt in responding to symptoms causing discomfort. Tend to rely on home remedies rather than Western medications to alleviate symptoms. Medical advice sought as last resort.
Preparation. Concept of death well accepted among South Asians. Hindus, Muslims, and Sikhs believe that body dies, but soul remains alive and is immortal. Hindus and Sikhs also believe in reincarnation. Unusual to inform dying person of impending death. Family members told first about imminent death; up to them to decide whether to tell dying person. Discuss death openly with family, and offer advice to surviving younger members.
Home vs. hospital. Strongly favored that death occur at home in presence of all family members. Family may wish to perform some religious rituals at time of death.
Special needs. If death is imminent, family members and relatives must be called and be allowed to stay at bedside. Muslim families may offer special prayers for dying person to ease suffering. Some families may wish to call spiritual leader who prays for dying person and gives holy water to drink to purify body internally just before death. Surviving family members express their grief openly by mourning and crying. Hindu family of deceased mourns for 40 days. Muslims mourn for three days, but hold periodic memorials gatherings (e.g., one week later, one month later, etc.).
Care of the body. Muslims: As person dies. The body, arms, and legs are straightened, eyes closed, toes fastened together with bandage, and body covered with a sheet. The body then washed ritually just before burial. Body buried as soon as possible after death. Hindus and Sikhs: the body is washed by close family members, dressed in new clothes, and prepared for cremation. Hindus save ashes of cremated body until they can be thrown in Ganges (sacred river in India). * Attitudes toward organ donation. Hindus, Muslims, and Sikhs do not allow organ donation. * Attitudes toward autopsy. Most South Asians would not agree to autopsy unless absolutely necessary. Muslims would request that, if autopsy performed, organs must be returned to body afterward.
Primary religious/spiritual affiliation. Most South Asians follow Hinduism, Islam, or Sikhism. Some follow practice of Zoroastrianism, Judaism, Jainism, Buddhism, or Christianity.
Usual religious/spiritual practices. Hindus: worship many gods and goddesses. Believe in caste system, in which society is divided into hierarchy of four social classes; Brahmins (priest class), Kshatriyas (warrior class), Vaishyas (merchant class), and Sudras (laborer class). Untouchable class has been legally abolished but still influences social relations. An individual inherits a class at birth from parents. Birth in a particular caste believed to be predetermined, based on one's Karma in previous lives. It is one's religious duty (dharma) to adopt occupation and behavior that fit one's social class. Hindus worship in temple (Mandir) or at home. Part of their religious practice consists of reading from holy scripture, Vedas.
Muslims: Believe in one God. Religious practices include: Prayers after ritual ablution five times daily at home or in congregation at mosque; fasting during month of Ramazan; giving alms (Zakaat); and reciting verses from holy book, the Koran.
Sikhs: Believe in one God and equality of all people. Guru Granth is holy scripture of Sikhs, They sing hymns from Guru Granth in congregation at Sikh temple and offer prayers daily.
Use of spiritual healing/healers. In homeland, South Asians may prefer a Hakim (homeopathic physician) or an Ayurvedic doctor. In Western countries, physicians generally well accepted and contacted for curing illness. However, many South Asians believe in spiritual healing. For example, Hindus believe that recitation of charms and performance of certain ritual acts will eliminate diseases, enemies, sins, and demons. Many believe that Yoga eliminates certain physical and mental illnesses. Muslims believe that recitation of certain verses from Koran eliminates illness or eases suffering. Muslims sometimes visit shrine of spiritually elevated person and give alms. May also go to a pir (spiritual leader) who prays for sick person and may offer a Taawiz to wear (Koranic verses). These practices believed to get rid of diseases.
Causes of physical illness. Hindus: Diseases believed due to Karma (actions) in past lives, which determines person's body constitution in this life and determines susceptibility to illnesses.
Muslims: believe that illness can result from bad actions, not necessarily in past life, and the illness washes away person's sins. This believed that one should never complain to God about illness; rather, prayers recited to alleviated suffering.
Sikhs: Believe in concept of reincarnation and disease thought to be result of past Karma.
South Asians who believe in Ayurvedic philosophy may think that illnesses result from imbalance in bodily humors, which creates circulating toxins that accumulate in weaker areas of body. For example, if joints are weak, toxins would accumulate in joints, causing problems such as arthritis.
Causes of mental illness. Psychosis often believed either due to spells cast by enemy or body falling prey to evil spirit. Those who believe in Ayurvedia explain that person's constitution influences susceptibility to mental problems.
Causes of genetic defects. South Asians who believe in Karma believe that those who suffer hereditary or congenital problems must have inflicted pain on helpless animals or people in their past lives.
Concept of health. Because many South Asians believe in Ayurvedic medicine, body is thought to be in state of good health when; digestive fire (agni) in balanced condition; bodily humors in equilibrium; waste products (urine, feces, and sweat) produced at normal levels and are in balance; senses are functioning normally; and body, mind, and consciousness harmoniously working as one (Lad, 1994).
Health promotion and prevention. Health considered precious gift which a person must enjoy. Emphasized that one must adopt practices that preserve, maintain, and protect health. To stay healthy, suggested that person get adequate rest and sleep; rise before sunrise and sleep early at night; bathe and shower daily; eat in moderation; exercise and pray regularly. To much sex is unhealthy, and negative emotion such as hate, anger, greed, jealous, fear, and worry bad for health.
Screening. South Asians will give consent for all screening procedures except unmarried women (virgins) may not allow vaginal examinations.
Source: Lipson, Juliene G., Dibble, Suzanne L., Minarik, Pamela A. Culture & Nursing Care: A Pocket Guide. The Regents. 1996