Author(s): Hoai Do, MPH, Harborview Medical Center/University of Washington
Date Authored: June 01, 2000
Date Last Reviewed: 2014
China
An attempt to describe the Chinese people can be a very complicated and challenging task. Chinese people are very diverse in their country of origins. In China, the Han Chinese constitutes 95% of the nation’s population and is also the largest ethnic group in the world. The remaining 5% of China’s population are made up of 55 other ethnic groups. Although many of these minorities live in China, they do not consider themselves as Chinese. The minority population is spread in the western part of China, the border regions around India, Afghanistan, Russia, Central Asia, and Vietnam. The three largest minority groups including the Tibetans, the Uighurs who live in Xinjiang province in northwestern China and the Mongolians who live on the northern grasslands of Inner Mongolia.
Within the Han ethnic group, there are many subtleties in their beliefs and practices that make it difficult to categorize this group as one hom*ogeneous group. For the general public, the Chinese are assumed to behave like other Chinese and speak mutually understandable language. In reality, depending on where the Chinese come from, their spoken language, religions, cultural practice can be different from each other. For instance, within Mainland China, there are more than a dozen Chinese dialects and people who speak these dialects do not necessary understand each other.
Outside of Mainland China, the Chinese from Hong Kong may share a dialect with the Chinese from Southeast Asia. Although they may speak the same dialect and mutually understand each other, their religions, beliefs, daily practices or the food they eat can be different due to local influences. Because the Chinese people are very heterogeneous and their differences can be quite subtle to a non-Chinese person, it is important to first understand where the Chinese are from and the dialects/language they speak.
The Chinese can be generally divided into four categories:
- Chinese who live permanently in Mainland China. Numbers of these may be temporarily resident abroad, as diplomats, representatives of China-based companies or visiting scholars,
- Mainland Chinese who live or study abroad or who live in Taiwan and Hong Kong. Many are migrants who may or may not return to China, or may choose to become naturalized in their host countries,
- Overseas Chinese (known as Hua Qiao) are people born and raised in countries other China. Examples of these are the “hyphenated Chinese”, such as Chinese-American, Sino-Thais, etc.,
- Assimilated Chinese ancestry who have, through intermarriage or other means of assimilation, melted into another people and cease to call themselves Chinese.
Geography
China is the largest of all Asian countries and it occupies nearly the entire East Asian landmass. The country is bordered by Mongolia to the north, Russia and North Korea to the northeast, the Yellow Sea and the East China Sea to the east, the South China Sea to the southeast, Vietnam, Laos, and Myanmar (Burma) to the south and Afghanistan to the west. There are three major rivers — the Huang He (Yellow River) in the north, the Yangtze (Chiang Jiang) in central China, and the Zhu Jiang (Pearl River) in the south.
The terrain of China varies from thick mountainous to vast coastal lowlands. The climate ranges from extremely dry, desert- like conditions in the northwest to tropical monsoon in the southeast. China is noted to have the greatest contrast in temperature between the northern and southern borders than any nation in the world. Beijing (Peking) is the Capital, also the cultural, economic and communications center of China. Shanghai is the main industrial city and Hong Kong (which was recently returned to China) continues to be the leading commercial center and port.
History and Politics
The first evidence of a dynasty ever existed in China’s ancient history took place during the Shang Dynasty (1766-1123 B.C.) where daily life and literature have been found carved on bones and bronze. The Zhous (1122-770 B.C.) later conquered the Shangs and ruled by a feudal system where leaders of the different states were required to pay tributes and taxes to the emperor. The Zhou Dynasty eventually disintegrated into many rival states that were constantly at war with each other. The Qin Dynasty under the leadership of Qin Shihuang took over the Zhous (221-206 B.C.). Qin Shihuang was known to be the first ruler to unify China and link up all parts of the walls into today’s Great Wall. He was also the first to abolish the feudal system, standardize the written language and establish a system of weights and measures. The discovery of the legendary underground terracotta warrior in Xian was one of Qin Shihuang’s well known artifacts.
The two most important dynasties to rule China after the Qin were the Han and the Tang. The Han Dynasty (206 B.C. – A.D. 220) created such an impression on China that even today the Chinese refer themselves as “Men of Han”. The Han Empire stretched from the Pamir mountains (Afghanistan) in the west to Korea in the east, and from Mongolia in the north to Vietnam in the south. Major achievements during this dynasty included the expansion of the Silk Road, Buddhism and Confucianism became the state doctrine, painting and arts flourished, historical and philosophical works were written, a new scholar writing style developed, the first Chinese dictionary was compiled, paper was invented and seismograph was developed.
Following the Han Dynasty was a period of The Three Kingdoms. Afterwards came the Western and Eastern Jin, Northern and Southern dynasties and the Sui. The Tang Dynasty, which led China into the Golden Age of Chinese history was A.D. 618-907. During the Tang Dynasty, food production increased as the result of the development of agriculture and farming tools. Chinese arts and literature flourished and the art of the printing was developed.
As the Tang Dynasty deteriorated and was overthrown, many less known dynasties took over the ruling of China. The Yuan Dynasty under the Mongolian ruled from A.D. 1271-1368 and the Ming from A.D. 1368-1644. The Qing Dynasty, the Manchurians from the north, succeeded the Ming and ruled for the next 200 years (A.D. 1644-1911). Internal power struggles and corruption court officials eventually led to the demise of the Qing Dynasty.
During the Qing Dynasty, Britain introduced opium to China as a means to reverse the trade deficit. Many Chinese became addicted to opium subsequently. The Qing government attempted to ban the sale but corrupted officials and merchants did nothing to stop it. As tensions mounted, wars led by the Chinese against the British, known as the Opium Wars, broke out. Plagued with opium addiction and internal corruption, China was defeated badly by Britain and forced to sign the Treaty of Nanking. The Qing government had to make many concessions to Britain. This included giving away land to the British and allowing them to open several ports for trade. Hong Kong became a British colony. Seeing that China was at its most vulnerable state, other Europeans seized the opportunity and forced China to sign similar treaties. The Qing dynasty collapsed in 1911.
In 1911, Sun Yat-sen, leader of the Kuomingtang (National People’s Party) and also known as the father of the modern China became the president of China. He ruled only briefly and once again China was back in the hand of the warlords.
In 1925, Sun Yat-sen died and his colleague, Chiang Kai-shek defeated the warlords and took over the ruling of China. During this time, the Communists were busy recruiting and forming a party. Chiang Kai-shek and the Communists were constantly at war with each other. As the Communists gained power and popularity, Chiang’s army weakened. In 1950, Chiang withdrew his forces and fled to Taiwan to re-establish his ruling.
On October 1, 1949, Mao Zedong, leader of the Communist party, declared the founding the People’s Republic of China.
Language
There are seven major groups of Chinese dialects that are differentiated on the basis of phonological features, vocabularies and grammar. The major dialects groups are: Baifanghua (known as Mandarin), Wu, Yue (known as Cantonese), Min, Kejia (known ass Hakka), Xiang, and Gan. Mandarin is the largest dialect group that many native Chinese speak. The non- Mandarin groups are also called the Southern dialects.
Phrases of Courtesy in Nine Languages: A Tool for Medical Providers
This language learning tool features videos of native speakers saying phrases of courtesy in nine languages, including Chinese (Mandarin). Phrases of greeting, introduction, acknowledgment, departure and for emergency situations in a clinical setting can be played at a normal speed and at a learning speed. The goal of this tool is to provide a jumping-off point for developing rapport in the interpreted health encounter. View Chinese videos.
Reproduction
Pregnancy
Pregnancy is considered a normal but also an expected stage for married women. During the early phase of pregnancy, Chinese women are encouraged to take it easy, rest, avoid heavy work, and eat well in order to ensure a healthy pregnancy and subsequently a healthy baby. Even though the Chinese are diverse in their background and country of origin, one traditional belief that has not changed much was the value of a son over a daughter. In Mainland China, the “One Child Only” policy combined with today modern technology have led numbers of expectant mothers to terminate their pregnancy when the fetus is a female.
During pregnancy, women are advised to avoid various activities and follow certain food regiments and practices. For example, pregnant women are strongly discouraged from carrying heavy load or engaging in strenuous work during the first trimester for fear of miscarriages. Superstition plays a role in some pockets of Chinese population. It was believed that expectant mothers should avoid using sharp objects, knives or scissors on their bed. Failing to heed this advice can result in cleft lip babies. Women are also not to tape or post any things on the wall of their bed. This could cause unwanted birthmarks on babies’ faces.
Sexual intercourse is acceptable during the course of pregnancy. However, most couple would abstain during the first trimester for fear of miscarriages.
As for food regiments, women are advised not to eat “cold food” such as mung beans, bean sprout, banana or watermelon during the first trimester to reduce a risk of miscarriage. Some Chinese also believe that in order to prevent babies from developing rashes, women were to avoid eating shell seafood such as crabs, shrimps or clams. Some women also supplement herbal drink during the first trimester to safeguard the pregnancy and a different type of herb toward the end of third trimester as a means to get rid of the toxins in the womb, and expectantly, to ensure themselves a healthy baby.
As Chinese women living in North America become more acculturated with Western culture, conventional prenatal care with intake of prenatal vitamins are increasingly accepted as a norm. Women will seek OB care, undergo blood draw and comply with routine OB visits. Illegitimate pregnancy (pregnancy outside of marriage) is considered shameful and dishonorable to the families especially to the woman’s side. Women do not discuss abortion openly but will seek this medical service when in need.
Child Birth
Women want to eat to get the energy before going through the labor. Western culture, however, discourages eating for fear a full stomach will induce nausea/vomit especially during active labor phase. This has been a common complaint for Chinese women. Many did not understand why they were not allowed to eat and thought the hospital policy is too strict. When asked for a drink of water, women were offered ice chips instead of warm water that they prefer. Most Chinese women will endure the thirst for fear the cold water from ice chip will upset their internal hot/cold balance and subsequently increase their risk of developing arthritis in old age.
Traditionally, men do not play a major role during deliveries. Husband/expectant fathers usually remain outside of labor room till the baby is born. Female family members/relatives such as mother, mother-in-law, aunts or sisters provide much of needed support during this time. This tradition is slowly evolving as extended family members/relatives are not readily available and nuclear families are becoming more prevalent. Younger and more western acculturated couples will want to attend childbirth classes. Expectant fathers are more willing/wanting to stay in labor room with their wives to provide support and serve as labor coaches.
Postpartum Practices
Chinese women believe strongly in postpartum practices. Caring for oneself immediately after childbirth is very crucial in restoring women’s health to pre-pregnant condition. There are wide regimens of self-care and special food intake during postpartum period. A period of care right after the delivery ranging from one to three months is known as the “sitting month”. Depending on regional differences, there are variances in regiments and practices associated with sitting month. During the sitting month, women are to abstain from taking a bath, washing their hair, exposing themselves to cold water, cold temperature environment and wind, drinking ice water or eating “cold” food (i.e. uncooked vegetables, salads or fruits). The reasons for these restrictions are based on the beliefs that women are undergoing a cold stage right after the delivery due to loss of blood. In order to restore the energy, women need to consume food that are considered “hot” (i.e. hot water, soups, ginger, wine and food that are high in protein) and avoid exposing themselves to cold air, cold water or wind.
Western providers and health care members who are unfamiliar with sitting month have a difficulty time in understanding the Chinese women who just gave birth. In Western culture, cold drinks such as milk, orange juices, ice water and cold food such as salad, cold sandwiches, tomato based sauce dishes and deserts such as Jell-O, fruits and ice cream are routinely offered to women during their inpatient stay. In contrast, for Chinese women these are the types of food that their mothers, women friends and relatives have advised avoiding as much as possible.
Women who had Cesarean section would want to avoid not only “cold” food but also beef or seafood. Beef and seafood are believed to prolong the healing process. It is not unusual for hospital staff to find the food served left untouched. Inpatient women preferred to have their food brought in from home.
For women who have an episiotomy, nurses will advise women to use ice packs to reduce swelling and inflammation. Young Chinese women who have been exposed to Western culture will heed the advice and adopt the practice. For the majority of Chinese women, however, the practice is considered contradictory to their Chinese health belief. Traditionally, women should avoid using anything cold for fear that cold compress will increase their risk of incontinence, headache, backache and/or arthritis in old age.
Adulthood and Old Age
For information on geriatrics and older Chinese Americans, see Stanford’s Ethnogeriatrics Health and Health Care of Chinese American Older Adults. This is an on-line learning module, but you can download the module as a PDF and print the cultural profile by filling out a short survey. Additional cultures and geriatric information also available on their site.
Nutrition and Food
See related article: Chinese Food Cultural Profile
Experience with Western Medicine
This section was written by Christopher Green, September 2015, reviewed by Hoai Do, Yufeng Liu and Rui Lin.
Experience with Western Medicine in Country of Origin
Western medicine has been integrated into the traditional Chinese medicine (TCM) and widely applied in hospitals and clinics in China since the 1950’s. In Chinese, this integrated medicine is referred as Zhong Xiyijiehe (中西医结合), utilizing modern Western drugs alongside traditional elements like acupuncture and herbs. (Muse, 2007) Patients have the option of going to a doctor that will solely practice Western or Chinese medicine or one that integrates both. Often, patients can find different approaches in the same clinic or hospital. Many Chinese may visit a fully Westernized hospital for surgery or to treat serious issues but go to a more traditional practitioner for milder illnesses.
There has also been a health insurance (Jiankang Baoxian, 健康保险) system in China, beginning in the 1950’s, which was run by the government and government-owned companies. This kept out of pocket expenses very minimal and provided near universal coverage for China. After various changes, China’s health insurance now operates under a nationwide multi-plan approach, with one plan for rural residents, one for those working in urban areas, and one for unemployed urban residents. As of 2008, the current system covered 93% of rural residents and 72% of urban residents. (Barber, 2010)
Experience with Western Medicine in the United States
Many Chinese immigrants in the area will be seen at Harborview Medical Center or at the International Community Health Services Clinic, which is in the International District.
A major barrier for patients seeking care is limited English language skills, with an estimated 51% of Chinese immigrants lacking proficiency. Given the range of dialects spoken in China, it is important to get an interpreter for the correct one, with the three most common being Mandarin, Cantonese, and Toisanese.
Another barrier is the Chinese view of respect and “face saving” (mianzi, 面子), where patients may go through significant effort to avoid looking foolish or weak. This is a very strong concept in Chinese culture and, along with a deep sense of respect for elders, teachers, or care providers, may prevent patients from being vocal or disagreeing with a healthcare provider even if they have questions or concerns. Providers may consider using the teach-back method to address this barrier. For this method, ask the patient to describe what they just learned to assess how much they understood.
Many Chinese also believe in a holistic approach to illness and healing involving many aspects of complementary and alternative medicine. This can include acupuncture, herbs, and massage, which can be expensive in the United States and is often not covered by insurance. With herbal approaches, it is also important for providers to be aware, and help their patients be aware, of potential herb/drug interactions (see “Chinese and Western Herbal Medicine” for more information).
Be sure to ask patients about any herbs they may be taking at home. One common belief is that medicines of a certain color are “hot” or “cold” and can have different effects on a particular illness. Western medicine is generally considered “hot” because they are synthetic rather than derived naturally. Having too much “hot” medicine can be considered disruptive to one’s equilibrium and may result in patients with lower treatment adherence (see the “Yin Yang Foods” section of the Chinese Food Cultural Profile and the “Strong Medicine” section of Medication Non-Adherence Issues for more information). Providers can help patients understand that Western medicine does not consider “hot” or “cold” the same way and that generally, different color options are not available for tablets.
How open patients are to Western versus traditional Chinese medicine also depends greatly on their level of education and acculturation to Western culture. (Muse, 2007) Wealthier and more educated immigrants from cities are more likely to use Western medicine in the United States than those who are less financially secure and from more rural areas due in part to the former having greater access to Western medicine. To encourage comfort with Western medicine among patients who are less familiar with the practice, providers may consider spending extra time explaining the specifics of care and procedures and what benefits are likely to result for the patient. An approach of gentle persistence may be useful in asking for more information from patients, as some people may be slower to open up about medical problems.
References
Barber, SL; Yao L. Health Insurance Systems in China: A Briefing Note. World Health Report. 2010 (37).
Muse E.A. Cultural Competency and Chinese Medicine: Immigrant Chinese Beliefs of Utilization and Plurality in Health Seeking Behaviors and Health Care Coverage. International Journal of Transdisciplinary Research. 2007;2(1):1-16.
