Cultural competency | Working with interpreters | Important note

The Chinese are guardians of a magnificent tapestry of legacies resulting in an extensively diverse and dynamic culture. They are one of the most heterogeneous groups of people and describing their culture is complex and a challenging task necessarily full of generalizations. Their extensive origins, varying countries of residence (even within Southeast Asia), numerous dialects (more than a dozen in mainland China) and variety of traditions and beliefs make categorization very difficult. People with the same dialects may have different practices and beliefs depending on where they reside, and upon the local influences; some ethnicities classified as Chinese do not consider themselves Chinese (e.g. some Tibetans). Many Chinese whose families migrated some generations before may not have beliefs or practices much different to the host nations of their resettlement countries.

The Chinese are guardians of a magnificent tapestry of legacies resulting in an extensively diverse and dynamic culture. They are one of the most heterogeneous groups of people and describing their culture is complex and a challenging task necessarily full of generalizations. Their extensive origins, varying countries of residence (even within Southeast Asia), numerous dialects (more than a dozen in mainland China) and variety of traditions and beliefs make categorization very difficult. People with the same dialects may have different practices and beliefs depending on where they reside, and upon the local influences; some ethnicities classified as Chinese do not consider themselves Chinese (e.g. some Tibetans). Many Chinese whose families migrated some generations before may not have beliefs or practices much different to the host nations of their resettlement countries. 

The Han Chinese constitute 95% of China’s population (and are also the largest ethnic group in the world). They are in themselves a diversely heterogeneous group. The remaining 5% of China's population are made up of 55 other ethnic groups. 

Chinese settlement has taken place in Australia and New Zealand from the mid 19th century, with most people coming from southeast China (Guandong). Wars, floods, famine and poverty were initial reasons for migrating, with more recent immigrants fleeing for political freedom after incidents such as the Tiananmen Square event. Others, including those with high levels of tertiary education are seeking business, lifestyle and educational opportunities. Over the past 20 years, Cantonese speaking Chinese have arrived from Malaysia, Singapore, Hong Kong, Vietnam and elsewhere in Indochina. More recent arrivals originating from the People’s Republic of China (PRC) have often spent time in other countries before coming to New Zealand and bring with them their own culture, a new culture, and have to merge with yet a third culture.

The following information is to be regarded as extremely general.

Mandarin greetings

Speech bubble

Welcome

Speech buble

Huān yíng

Speech bubble

Hello

Speech buble

Nĭ hăo

Cantonese greetings

Speech bubble

Welcome

Speech buble

Foon Ying

Speech bubble

Hello

Speech buble

Néi hóu

  • Mandarin
  • Cantonese

The two main languages are Mandarin (Kwoh Yue/Poo Toon Hwa) and Cantonese (Kongtongwah). Most people from the PRC (People’s Republic of China) and Taiwan would speak or understand Mandarin while most Chinese people from South East Asia and Hong Kong, and also older migrants from Grungdong are likely to speak Cantonese. There are 7 major groups of dialects with Mandarin the largest. The nonMandarin is also referred to as the Southern dialects. Other major dialects include the Hakka, Hokkien, or Techeow, Shanghainese.

  • Use a title and surname
  • Shaking hands with men is acceptable
  • Greet women with a ‘hello’ or traditional greeting
  • A nod or slight bow is also customary
  • Avoiding eye contact, shyness and passivity are cultural norms
  • Many Chinese will avoid saying ‘no’ as it is considered impolite
  • Silence (listening) is a sign of politeness; interrupting is considered rude
  • To summon someone using your fingers is considered extremely rude (hands palm facing downwards and moving fingers together in a scratching motion is acceptable)
  • ‘Yes’ can be an ambiguous response, sometimes used to indicate paying attention, not necessarily indicating agreement (ask open-ended questions)
  • Show respect, especially for elders, (e.g. greet the elders first, be on time for appointments, greet in their traditional way)
  • Show an interest in the culture and practices
  • Invite the client and family to ask questions as they may be reticent out of respect for authority
  • Use a title and surname
  • Shaking hands with men is acceptable
  • Greet women with a ‘hello’ or traditional greeting
  • A nod or slight bow is also customary
  • Avoiding eye contact, shyness and passivity are cultural norms
  • Many Chinese will avoid saying ‘no’ as it is considered impolite
  • Silence (listening) is a sign of politeness; interrupting is considered rude
  • To summon someone using your fingers is considered extremely rude (hands palm facing downwards and moving fingers together in a scratching motion is acceptable)
  • ‘Yes’ can be an ambiguous response, sometimes used to indicate paying attention, not necessarily indicating agreement (ask open-ended questions)
  • Show respect, especially for elders, (e.g. greet the elders first, be on time for appointments, greet in their traditional way)
  • Show an interest in the culture and practices
  • Invite the client and family to ask questions as they may be reticent out of respect for authority

‘Saving Face’ is a strong principle and will be used over confrontation or questioning of those in authority

‘Saving Face’ is a strong principle and will be used over confrontation or questioning of those in authority

  • Traditional families are extended with more recent trends tending towards nuclear and ‘astronaut’ families (where the father of the migrant family spends periods of time in the country of origin for business and returns to the family when time permits)
  • Eldest sons inherit family leadership and wealth and are expected to look after the parents when they are older
  • Younger sons are expected to leave the home and live close to the parents
  • Extended family structure – more recent move towards nuclear and ‘astronaut’ families
  • Sons valued over daughters (traditionally)
  • Filial duty
  • Fathers and sons heads of household
  • Eldest sons inherit family leadership
  • Younger sons are expected to leave home and live close to the parents
  • Women raise the family (changing value)
  • Life Force (Chi) - Maintaining the balance of the Life Force or Chi is essential for good health.
    • Yin gives way to “cold” illnesses, e.g. depression, hypo activity, hypothermia, abdominal cramps and indigestion
    • Yang guided health includes hyperactivity, hyperthermia, stroke and seizures
    • Treatment of hot/cold illnesses is through the use of the opposite force
  • Spiritual forces
  • Cosmic disharmony or astrological factors
  • Supernatural forces where there is interference from evil entities
  • Poor Feng Shui (the impact of the natural and built environment on the fortune and wellbeing of inhabitants)
  • Superstitions
  • Western concept of disease causation
  • Life Force (Chi) and Body balance
    It is believed that health is based on keeping the body elements in ‘balance’ and that certain kinds of diet, lifestyle, treatments and external factors can influence this balance. Maintaining the balance of the Life Force or Chi is essential for good health
  • Yin-Yang is a complex and dynamic principle, and although a relatively wellknown term in the west, it is often oversimplified and misunderstood. It consists of 2 complementary forces inherently oriented towards the maintainance of harmony within any dualistic system. Each opposite force contains an element of the other and when the one reaches its extreme it evolves into the other
    • Yin in excess gives way to "cold" illnesses, e.g. depression, hypo activity, hypothermia, abdominal cramps and indigestion
    • Yang in excess would underlie conditions such as hyperactivity, hyperthermia, stroke and seizures
    • Treatment of hot/cold illnesses is through the use of the opposite force to achieve balance. This can be done by regulating body temperature, or through food and other means. (e.g. the common cold is treated with hot soup made from bean sprouts
    • Spiritual factors where moral retribution by ancestors, or deities for misdeeds and negligence, is experienced (including fate or karma)
    • Cosmic disharmony or astrological factors such as a person’s combination of year, month, day and time of birth, and whether these may clash with those of a family member
    • Supernatural forces where there is an interference from evil entities such as malevolent ghosts and spirits or impersonal evil forces
    • Poor Feng Shui (the impact of the natural and built environment on the fortune and wellbeing of inhabitants)
    • Superstitions – many things can bring bad luck, (e.g. number 4 has similar connotations as number 13 for western cultures because it sounds like death in Chinese, Korean & Japanese languages)
    • The Western concept of disease causation is accepted by most and may coexist with any of the other attributions of illness
  • Patent medicines
  • Acupuncture
  • Acupressure or Massage
  • Coining or Scraping
  • Cupping
  • Moxibustion
  • Herbal remedies and dietary therapy
  • Feng Shui
  • Qi Gong, Tai Chi
  • Traditional Chinese Medicine (TCM) and practices
    • Patent medicines
    • Acupuncture
    • Acupressure or Massage
    • Coining or Scraping
    • Cupping
    • Moxibustion
    • Herbal remedies and dietary therapy
    • Use of shamans
    • Feng Shui
    • Qi Qong, and various martial art forms such as Tai Chi
  • Western medicine

This is commonly practised alongside TCM in China (and reportedly in New Zealand)

Important factors for Health Practitioners to know when treating Chinese clients:
  1. The client’s understanding of the cause and meaning of their illness is an important factor and their perception of the practitioner’s interest in this is likely to influence trust and compliance
  2. Clients may integrate traditional medicine practice with western treatment, this needs investigation by the practitioner
  3. Same gender practitioners are preferred (especially by women)
  4. Open discussion about sexuality is often considered taboo
  5. Many people expect a tangible form of treatment, e.g. a prescription
  6. It is expected that family members will be involved in consultations about treatment
  7. The ‘sick role’ is conventionally adopted by a family member who is ill and health practitioners may be seen as uncaring if they push for independent behaviours from the client. The benefits of rehabilitation programmes may need to be explained
  8. There is a strong tendency to somatise social and psychological problems
  9. Some traditional techniques (e.g. coining, cupping, moxibustion) may leave marks on the body and providers need to investigate these before assuming abuse)
  10. It is necessary to identify the dialect in order to find an appropriate interpreter
  11. When doing HOME VISITS:
  • Give a clear introduction of roles and purpose of visit
  • Check whether it is appropriate to remove shoes before entering the home (notice whether there is a collection of shoes at the front door)
  • If food or drink is offered, it is acceptable to decline politely even though the offer may be made a few times
Important factors for Health Practitioners to know when treating Chinese clients:
  1. The client’s understanding of the cause and meaning of their illness is an important factor and their perception of the practitioner’s interest in this is likely to influence trust and compliance
  2. Clients may integrate traditional medicine practice with western treatment, this needs investigation for drug interactions and conflictual goals by the practitioner
  3. Same gender practitioners are preferred (especially by women)
  4. Open discussion about sexuality is often considered taboo
  5. Many people expect a tangible form of treatment, e.g. a prescription. If one is not given, an explanation will be needed
  6. It is expected that family members will be involved in consultations about treatment
  7. The ‘sick role’ is conventionally adopted by a family member who is ill and health practitioners may be seen as uncaring if they push for independent behaviours from the client too soon. The benefits of rehabilitation programmes may need to be explained
  8. There is a strong tendency to somatise social and psychological problems
  9. Some traditional techniques (e.g. coining, cupping, moxibustion) may leave marks on the body and providers need to investigate these before assuming abuse)
  10. It is necessary to identify the dialect in order to find an appropriate interpreter
  11. When doing HOME VISITS:
  • Give a clear introduction of roles and purpose of visit
  • Check whether it is appropriate to remove shoes before entering the home (notice whether there is a collection of shoes at the front door)
  • If food or drink is offered, it is acceptable to decline politely even though the offer may be made a few times

Sue to add

  • Foods are considered to have the qualities of either ‘hot’ or ‘cold’ and for many clients diet is balanced according to needs around these elements (health needs, climatic conditions, taste etc.)
  • Daily meals generally consist of four food groups: grains, vegetables, fruit, and meat
  • Because of a general lactose intolerance, traditionally Chinese do not consume large amounts of dairy products; soymilk and tofu are the normal substitute
  • Rice and noodles are a staple. Too much bread and pasta in hospitals can cause distress to clients
  • A common food, and much loved comfort food for most Chinese, is the rice porridge congee/conjee which can be eaten at almost any meal. For clients who find difficulty with western hospital food, families are usually happy to supplement foods and could be requested to provide this porridge. They can also advise re cultural dietary needs and preferences
  • Herbs and special ingredient soups are used to replenish energy levels when a person is feeling unwell, and to maintain health (called “gin bou," in the North and "bo sheng" in the South). These may need to be prepared by skilled home cooks
  • When in hospital, meals may remain untouched if dietary needs cannot be met

Sue to add

Mental illness and disabilities are regarded as stigmas

Sue to add

  • Traditional Chinese bereavement customs are based on the blend of four primary religions/practices (Buddhism, Taoism, Shamanism and Confucianism). Funeral rites and burial customs are taken very seriously as improper arrangements are believed to have dire consequences for the family of the deceased
  • Traditionally a younger person cannot be shown respect by an older person so young children and babies have no funeral rites and are buried in silence, a young man may not be taken home but left in a funeral parlour before the burial
  • The third day following the funeral and burial is ceremonially significant, and ceremonies are also held on the 21st, 35th, 49th and 60th days following the death
  • Great respect is shown to Chinese dead throughout the lifetimes of surviving relatives, both in memory and in ceremony over the years
  • After migration Asian people may have an increased risk for cardiovascular disease and diabetes due to lifestyle changes, physical activity and changes in diet
  • Asian immigrants have higher than average rates of communicable infectious diseases, in particular TB
  • Asian people have statistically higher rates of traffic injuries
  • The top 6 potentially avoidable deaths in the Auckland region are heart disease, motor vehicle crashes, stroke, lung cancer, diabetes and suicide
  • The 6 leading causes of preventable hospitalisations are angina, respiratory infections, cellulitis, gastroenteritis, road injuries and asthma

According to Metha’s (2012) report on health needs for Asian people living in the Auckland region:

  • Diabetes prevalence among older men and middle-aged and older women
  • Diabetes in pregnancy
  • Child oral health
  • Low cervical screening coverage
  • Cataract extractions
  • Terminations of pregnancy (highest amongst all ethnic groups studied)
  • After migration, an increased risk for cardiovascular disease due to lifestyle changes, physical activity and changes in diet (reported for Asian migrants)

In addition, Unexmundi, August 2014 lists the following as major infectious diseases for China:

  • Hepatitis A and E
  • Typhoid fever
  • Malaria
  • Dengue Fever
  • Yellow Fever
  • Japanese Encephalitis
  • African Trypanosomiasis
  • Cutaneous Leishmaniasis
  • Plague
  • Crimean-Congo hemorrhagic fever
  • Rift Valley fever
  • Chikungunya
  • Leptospirosis
  • Schistosomiasis
  • Lassa fever
  • Meningococcal meningitis
  • Rabies

Sue to add

According to Metha’s (2012) report on health needs for Asian people living in the Auckland region:

  • Chinese women have the lowest total fertility rate (TFR) in Auckland amongst Asian and European/other ethnicities
  • Chinese women have the lowest rate of live births in each of the Auckland DHBs
  • Asian women have more complications in live deliveries because of diabetes compared with European/other ethnicities
  • Chinese (and other Asian) women had lower rates of hospitalizations due to sexually transmitted diseases than European/other ethnicities

Sue to add

  • Superstition often plays an important part of practices
  • ‘Cold’ foods are avoided during the different phases of pregnancy for fear of miscarriages
  • Chinese women usually want to eat before labour to enhance their energy levels for the process. The western practice of avoiding food for fear of vomiting before labour has been a difficulty for Chinese women, including the fact that they are often offered cold water or ice to suck on when preferring warm water to drink
  • Traditionally men do not play a role in the delivery process although this is changing with modern younger men
  • Self-care immediately after childbirth is seen as crucial in restoring health. The period (termed the “sitting period”) may last from one to three months
  • During the ‘sitting period’ certain practices are observed such as no bathing, hair washing or exposure to cold temperatures, food etc. This often presents a difficulty as many cold foods are offered during hospital stays
  • More western conventional pre- and post-natal care is increasingly accepted as families become acculturated

Sue to add

  • According to Metha’s (2012) report on health needs for Asian (youth) living in the Auckland region:
    • Alcohol consumption is less prevalent amongst Asian students with only 35% of Chinese students as current drinkers as compared to 66% of NZ European students
    • Marijuana use has declined amongst Chinese youth since the 2001 health needs assessment
    • Most Asian youth reported positive relationships and friendships
    • Most Asian youth reported positive family, home and school environments (more Chinese students reported positive feelings about school than their NZ European counterparts)
    • 40% of Asian students identified spiritual beliefs as important in their lives
    • 75% of Asian students do not meet current national guidelines on fruit and vegetable intake
    • 91% do not meet current national guidelines on having one or more hours of physical activity daily
    • Mental health is of concern amongst Chinese students with 18% of females and 7-8% of males reporting significant depressive symptoms
  • In addition, adolescents who migrate without family may encounter the following difficulties:
    • loneliness
    • homesickness
    • communication challenges
    • prejudice from others
    • finance challenges
    • academic performance pressures from family back home
    • cultural shock
  • Others who live with migrated family can face:
    • status challenges in the family with role-reversals
    • family conflict over values as the younger ones acculturate
    • health risks due to changes in diet and lifestyle
    • engaging in unsafe sex
    • some young Chinese New Zealanders report not feeling safe at school, and for some this leads to absenteeism
    • barriers to healthcare because of lack of knowledge of the NZ health system, as well as associated costs and transport difficulties

Sue to add

According to Metha’s (2012) report on health needs for Asian (youth) living in the Auckland region:

  • There are no significant differences in mortality rates compared to European/other children
  • Chinese boys (0-14) have a significantly lower rate of potentially avoidable hospitalizations (PAH) as compared to European/other children (but no difference as compared with other Asian children)
  • Chinese girls (0-14) have a significantly lower rate of potentially avoidable hospitalizations (PAH) as compared to European/other and Indian children
  • The main 3 causes of PAH were ENT infections, dental conditions or asthma
  • Low birth weights are similar to European/other babies
  • Chinese children had the highest proportion of full immunization by two years and five years of age than all other ethnic groups studied
  • Chinese five-year olds had the worst oral health of the ethnic groups studied

Chinese New Year is a special occasion, and in particular being with family on the Lunar New Year’s Eve. The dates are determined by the Chinese Lunar Calendar and it usually falls around January to February. There is a reluctance to spend this time in hospital or to have diagnostic tests during the celebrations and so these are often postponed to the 15th day of the Lunar New Year (when the period ends).

Amongst traditional superstitions surrounding this time there are a number of subjects which are considered inauspicious to talk about and death is included in the list.

Chinese New Year is a special occasion, and in particular being with family on the Lunar New Year’s Eve. The dates are determined by the Chinese Lunar Calendar and it usually falls around January to February. There is a reluctance to spend this time in hospital or to have diagnostic tests during the celebrations and so these are often postponed to the 15th day of the Lunar New Year (when the period ends).

Amongst traditional superstitions surrounding this time there are a number of subjects which are considered inauspicious to talk about and death is included in the list.

The major religious practices in China are:

  • Buddhism
  • Christianity
  • Confucianism
  • Taoism
  • Islam

Many people may practice a blend of any of the above, or have their world view at least influenced by a number of systems or faiths.

  • Buddhism is the primary religion
  • Christianity has increasing numbers in China
  • The major philosophical systems that have great influence on the culture and are blended with religion are:
    • Confucianism
    • Taoism
  • Shamanism is also still practiced by some 

Many people may practice a blend of any of the above, or have their world view at least influenced by a number of systems or faiths.

View references and resources in the Comprehensive Guide section.

  1. Allotey, P., Manderson, L., Nikles, J., Reidpath,D., Sauvarin, J. C: A Health Guide for Professionals. Australian Centre for International and Tropical Health and Nutrition, University of Queensland. Updated February 2015 from: http://www.health.qld.gov.au/multicultural/health_workers/chinese.pdf
  2. Asian Public Health Project Report (NZ) February, 2003. Available at:  http://www.asianhealth.govt.nz/Publications/AsianPublicHealthProjectReport.pdf
  3. Confessore, N. (Retrieved 4 June 2006). A Spoonful of Foreign Culture Helps Western Medicine Go Down. The New York Times. Updated February 2015 from: http://www.nytimes.com/2006/06/04/nyregion/04clinic.html
  4. Hoai Do. Retrieved July 2006. Harborview Medical Center/University of Washington Seattle, WA. Updated February 2015 from: https://ethnomed.org/culture/chinese
  5. Kemp, C., Rasbridge, L. (2004). Refugee and Immigrant Health. A handbook for Health Professionals. Cambridge: University Press.
  6. Lim, S. (2005). Cultural Perspectives in Asian Patient Care (handout). Asian Support services. Waitemata District Health Board.
  7. Lim, S., Tsang,B. (2005). Asian Children’s Health. Available at: http://www.asianhealthservices.co.nz 
  8. Lin, Kathy (November 2000, downloaded July 2006) . Harborview Medical Center/University of Washington Nadine Chan, Editor, Fred Hutchinson Cancer Research Center, Seattle, WA. Available at: https://ethnomed.org/culture/chinese
  9. Mehta S. Health needs assessment of Asian people living in the Auckland region. Auckland: Northern DHB Support Agency, 2012.
  10. No author. (2014). China Major Infections Diseases. Retrieved February 2015 from: http://www.indexmundi.com/china/major_infectious_diseases.html
  11. No author. Chinese New Year. Retrieved November 2006. Available at: http://en.wikipedia.org/wiki/Chinese_New_Year
  12. Rasanathan, K. et al (2006). A health profile of Asian New Zealanders who attend secondary school: findings from Youth2000. Auckland: The University of Auckland.  Available at: http://www.youth2000.ac.nz, http://www.asianhealth.govt.nz, http://www.arphs.govt.nz 

Resources

  1. The http://spiral.tufts.edu website has Patient Information by language with many resources in Chinese
  2. The http://www.ecald.com website has patient information by language and information about Asian health and social services.
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