The Indian Health Belief System

To care for people of Asian Indian backgrounds effectively, it is important for providers to be familiar with their traditional health beliefs that may have influenced their attitudes toward health care. (Sonal Bhungalia, Tara Kelly, Stephanie Van De Keift, Margaret Young 2010)

Modesty is highly valued among Indians and patients are decidedly more comfortable and secure with same-sex care providers. An Indian child is likely to mature earlier than some others because of responsibilities beginning at an early age. In many cases, when a family has recently come from India, a child is responsible for many of the adult tasks, such as finance, legal forms, and translation. The healthcare provider should take note when scheduling appointments during school time if the child is needed for translation. The healthcare provider can also assess the effects on the child of having adult responsibilities. (Sonal Bhungalia, Tara Kelly, Stephanie Van De Keift, Margaret Young 2010)

Teaching nutrition should be focused first on assessing the cultural diet. Many Asian Indians have chosen to be vegetarians, which, depending on the type of vegetarian they are, limits the choices of foods that are available to them. The foods should then be evaluated to identify which vitamins, minerals and other nutrients each provides. Information on making healthy food choices should be made available. This is especially important for the pregnant or lactating woman and for those with illnesses or conditions such as diabetes.

Finally, allowing the patient to continue eating their cultural or religious foods while teaching them how to make nutritious food choices will be a major key to facilitating health and wellness in Indian families. (Sonal Bhungalia, Tara Kelly, Stephanie Van De Keift, Margaret Young 2010)

Lifestyle intervention accrues major benefits in preventing diabetes. However, Asian Indians identify a number of barriers to prevention of diabetes, including certain health beliefs and practices relating to diet, attitudes to physical activity, religious beliefs, levels of underlying knowledge about diabetes, and attitudes to the concept of self-management.

In order to understand the impact of culture on diabetes, it is necessary to examine at a number of factors, including migration, diet, physical activity, tobacco use, socio-economic status, language barriers, access to health services and attitudes to medical treatment, according to Dr Amritha Sobrun-Maharaj is Director of the Centre for Asian Health Research and Evaluation at the Tamaki Campus of the University of Auckland's School of Population Health. (2010)

Traditional Beliefs

Many believe in the traditional Indian system of medicine called Ayurvedic Medicine as the means of preventing and curing illness. Ayurveda is an intricate system of healing that originated in India, thousands of years ago.

Ayurveda is made up of two Sanskrit words, 'Ayu' meaning life and 'veda' meaning the knowledge of. Ayurveda is not merely a medical system dealing with physical disorders. It is a science that relates to the complete human being (body, mind, senses and soul). It explains how balance can be attained physically, mentally and spiritually. Indian medicine mixes religion with secular medicine, and involves observation of the patient as well as the patient's natural environment.

Traditionally more than eighty-percent of people in India rely on herbal remedies as the principal means of preventing and curing illnesses. (Sonal Bhungalia, Tara Kelly, Stephanie Van De Keift, Margaret Young 2010)

Limited studies are available on the use of traditional health practices by Asian migrants. The scant literature suggests that simultaneous use of both Western and traditional health practices is very common among Asian immigrants. (Ho, Au, Bedford and Cooper, 2003)

Hindu is the largest religion and aspects of this commonly affect health care decisions. Hinduism is a social system as well as a religion; therefore customs and practices are closely interwoven. "Karma" is a law of behaviour and consequences in which actions of past life affects the circumstances in which one is born and lives in this life. Despite complete understanding of biological causes of illness, it is often believed that the illness is caused by "Karma ( Alagiakrishnan and Chopra 2010)

Older Asian Indian immigrants may not speak English and may need a health care interpreter or translator. The patient may expect the doctors to have all the answers and make all the decisions. As a result, the patient takes a passive role, answering but not asking questions, and waiting for physicians to impart their diagnosis and recommendations. Most of the time medical advice is accepted without question.

Culturally Appropriate Care

Fasting frequently is a common practice among elderly women. It is done because of religious belief that it improves the welfare of the family. Health providers should respect these practices if the patient's medical condition can tolerate it. It should be made clear to the patient and family that this maybe dangerous, especially for insulin dependant diabetics. Nutrition should be taught based on the cultural diet of the patient.

Many elderly do not prefer counselling as an option for problem resolution. (Alagiakrishnan and Chopra 2010)

Inpatient Care

Hospital food can present a problem for Asian Indians, particularly those who strictly observe religious dietary restrictions. Hospital meals may also be too bland for most Asian Indians. Many will prefer to know whether the food served to them contains beef, as beef is forbidden for Asian Hindus. Foods containing pork are prohibited for Muslims who follow a religiously prescribed diet. Some patients hesitate to wear clothing that others have worn before them, even though it has been washed and sterilized.

Barriers to Learning

Language Difficulties

The inability to communicate well with the host population has been identified as an important factor influencing the health and psychological well-being of new immigrants, refugees and student sojourners. A lack of English proficiency affects all aspects of a newcomer's life and exacerbates virtually every problem he/she faces.

Learning a new language is particularly difficult for women, older immigrants and refugees. Research has shown that many Asian women and older migrants who have limited English language ability tend to rely on their children or grandchildren for interpretation and translation. However, when these children leave home, they may suffer from intense isolation as a result of their inability to speak adequate English and their dependence on their family members to provide transport for them. (Ho, Au, Bedford and Cooper (2003)

Health providers need to be considerate when making appointments for these patients as they often need to take children out of school to interpret for them.

Acculturation Attitudes

Acculturation refers to changes in behaviour, attitudes, values and identity that happen when individuals from one cultural group are in constant contact with people from another cultural group. Research on acculturation attitudes among immigrants has suggested that as immigrants become more acculturated to their host society and adopt the host society's behaviours and attitudes, they may increasingly identify with the new culture. (Ho et al, 2003)

Health Professionals

In order for Nurses to be able to learn new information and skills, to enable them to confidently support their patients, the following points have been identified:

1. A positive learning environment will enhance quality of care.

2. It is imperative that training programmes reflect the learning styles and preferences of individuals in order for them to be effective.

3.Organisational leaders must be aware of factors that can impede effective learning, and be proactive in creating positive learning environments.

4. Nurses must seek opportunities to practise new skills in a safe and supportive environment, with structured supervision and mentorship. (Frankel, 2009)

Four stages of learning have been identified:

1. Activist - Active experimentation (simulations, case study, homework)

2. Reflector - reflective observations (logs, journals, brainstorming)

3. Theorist - abstract conceptualisation (lectures)

4. Pragmatist - concrete experience (observations, application to practice) (Frankel, A. 2009, Source: Kolb 1984)

Most adult learners develop a preference for learning that is based on childhood learning patterns (Edmunds, Lowe, Murray, & Seymour, 1999). Several approaches to learning styles have been proposed, one being based on the senses that are involved in processing information. An assessment of the persons learning style is a fundamental step prior to beginning any educational activity. Determining the learning style will help identify the preferred conditions under which instruction is likely to be most effective (Richardson, 2005).

The most frequently used method of delineating learning styles is in describing visual, auditory, and kinesthetic learners.

1. Visual learners prefer seeing what they are learning. Pictures and images help them understand ideas and information better than explanations (Jezierski, 2003). A phrase you may hear these learners use is "The way I see it is." The teacher needs to create a mental image for the visual learner as this will assist in the ease of holding onto the information. If a visual learner is to master a skill, written instructions must be provided. Visual learners will read and follow the directions as they work and will appreciate it even more when diagrams are included.

2. Auditory learners prefer to hear the message or instruction being given. These adults prefer to have someone talk them through a process, rather than reading about it first. A phrase they may use is "I hear what you are saying." Some of these learners may even talk themselves through a task, and should be given the freedom to do so when possible. Adults with this learning style remember verbal instructions well and prefer someone else read the directions to them while they do the physical work or task.

3. Kinesthetic learners want to sense the position and movement of the skill or task. These learners generally do not like lecture or discussion classes, but prefer those that allow them to "do something." The phrase this group of people will often use is "I feel like " These adults do well learning a physical skill when there are materials available for hands-on practice. (Russell 2005)

A 2003 study published in "Diabetes Care" on the effect of nurse-directed diabetes care in a minority population, shows specially trained nurses who follow detailed protocols and algorithms under the supervision of a diabetologist can markedly improve diabetes outcomes in a minority population. This approach could help moderate the increased morbidity and mortality seen in minority populations. (Davidson 2003)

Staff members' ability to learn and then apply learning to practice has a significant impact on delivering effective clinical care. A skilled and competent workforce ensures patient safety, and they will be able to recognise and respond to clinical need more appropriately. It is believed that the knowledge and application of a range of learning theories, concepts and approaches is the foundation for building and managing effective learning environments.

An eclectic model is therefore suggested, which combines the individual's learning needs with the organisation's practice requirements. Consideration for individual learning styles is fundamental in designing effective training programmes. Study results highlight that most health professionals prefer a visual learning style (Frankel, 2009).

A podcast by Teresa Doran, Diabetes Nursing Lecturer, E.I.T. Taradale, as reviewed in course Learning Resources highlights learning styles for adult learners, as Andragogy. (as opposed to children's learning styles; Paedagogy)

1. Need to know the reason for learning

2. Learners Self concept

3. Role of the learners experience, these can be barriers and preconceived ideas

4. Readiness to learn

5. Orientation to learning, its relevance to career and health etc

The Peter Principle outlines stages of learning concepts:

1. Not aware they don't know

2. Become conscious of a deficit in knowledge

3. Aware of need to do something about it, and capable of doing this.

4. Become an expert: auto action

As Nurses, we must recognise that our current practice does not always reflect best practice. We need to integrate best research evidence with clinical expertise. (Di Censo, A., Guyatt, G., and Ciliska, D., 2005) With the evidence-based information before us on the consequences of modern diets consisting of an excess starch, refined sugars and flours, we can no longer tolerate complacency, we firstly owe it to ourselves to become competent nutritionists.

We need to enlighten the whole nation to the dangers of a highly refined diet and discourage its consumption, we need to promote a wholesome diet around the principals of the Mediterranean Diet and lobby the government to review health promotional literature.

Nurses are recognised as change agents (Wright 1989) as they are ideally positioned to implement new ideas and engage others. Be it a one-on-one consultation with a patient, a discussion with a peer or colleague, as leader taking a group study session, a keynote speaker at a conference, or writing for publication.
New Zealand has an aging population and our health system is already over burdened with escalating costs, so it is imperative that we try to mitigate the effects of the five major inflammatory ailments which are diabetes, cardiovascular disease, obesity, arthritis and cancer. They are all associated with poor dietary practices that make our bodies into a pro-inflammatory mode, thereby accelerating the disease process. (Karl 2010)

As nurses we are in a pivotal position to roll out revised and innovative nutritional information, especially to our ethnic minority groups such as the Asian Indians.

Changing Patient Behaviours

Many patients with a chronic illness have to endure physically debilitating and psychologically challenging treatments and most chronic illnesses require self-management that entails ongoing motivation. Motivation is a state of readiness or eagerness to change. Motivational interviewing (MI) is a relatively new cognitive-behavioural technique that aims to help patients identify and change behaviours that may be placing them at risk of developing health problems or may be preventing optimal management of a chronic condition.

It is a relatively simple, transparent and supportive talk therapy based on the principles of cognitive-behaviour therapy.

These principles are to help the patient:

1. To understand their thought processes related to the problem

2. To identify and measure the emotional responses to the problem

3. To identify how thoughts and feelings interact to produce patterns in behaviour

4. To challenge his or her thought patterns and implement alternative behaviours. (Bundy 1997)

Motivational Interviewing has developed from the theoretical aspect of the Transtheoretical Model (TTM) which is based on the premise that people are at different stages of motivational readiness for engaging in health behaviours and that intervention approaches are most useful when they are matched to a person's current stage of change. (Ruggiero 2000)

The stages of change most commonly used:

Precontemplation-not intending to change to the goal level of a behaviour in the near future;

Contemplation-intending to change to the goal level in the foreseeable future (next 6 months), but not the immediate future (next 30 days);

Preparation-intending to change to the goal behaviour in the immediate future and taking behavioural steps in the direction of the change required;

Action-has made a change to the goal level of the behaviour in the recent past (6 months);

Maintenance-has been at the goal level of the behaviour for 6 months or longer. (Ruggiero 2000)

Much of the evidence base for MI comes from literature around addictions, but is beginning to be applied to the fields of chronic illness management, when it has been shown to help people with heart disease quit smoking and people with diabetes to achieve better control of blood glucose. (Bundy 1997)

Patients need to be aware that their current situation has consequences. Goals should be generated by the patient and not imposed on them. The exercise of getting the patient to outline their goals gives the therapist valuable insight into how realistic these goals are and what the priority for change is. (Bundy 1997)


The research herein confirms my own findings, that there is a need to view the Asian Indian community separately from other New Zealanders as they have their own specific health risks and requirements.

I have created a health tool and resources to help inform health professionals working with people of Asian Indian descent to improve their nutrition and wellness generally and specifically to aid control of obesity and diabetes. I believe these resources have potential to fill a deficit in our National Health toolkit.

Nurses in advanced roles demonstrate a high level of communication and integration skills. These are ideally utilised in patient-centred group dynamics, peer support, multidisciplinary teams and motivational interviewing techniques. The focus is on information exchange rather than provision, and collaborative development of care plans (Watts et al 2007).

Nurses are becoming more advanced as leaders and developing expert communication skills, showing commitment by giving of themselves personally and professionally, planning ahead and reflecting on own practice. As a leader the nurse engages in lifelong learning and develops their own style while maintaining boundaries and a good sense of humour. Being a leader often means taking risks, being self confident and assertive, but also mindful that one can fail and needs to begin again. A willingness to collaborate is an essential quality while maintaining cultural sensitivity, shared power and a willingness to mentor others.(Hamric et al 2009).

(Hyppocrates, Ancient Greek philosopher, 460-370 BC)

© 2010 De La Haye