Cultural aspects of adjustment to coronary heart disease in Chinese-Australians: a review of the...
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INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES
Cultural aspects of adjustment to coronary heart disease in Chinese-
Australians: a review of the literature
John Daly PhD RN FINE FCN FRCNA
Professor of Nursing and Head, School of Nursing, Family and Community Health, College of Social and Health Sciences,
University of Western Sydney, Sydney, Australia
Patricia Davidson ICNC BA MEd RN MRCNA
Adjunct Associate Professor of Nursing, School of Nursing, Family and Community Health, College of Social and Health
Sciences, University of Western Sydney and Clinical Nurse Consultant, Department of Cardiology, St George Hospital, Sydney,
Australia
Esther Chang BAppSc MEdAdmin PhD RN CM
Professor of Nursing and Director, International Programs and Business, School of Nursing, Family and Community Health,
College of Social and Health Sciences, University of Western Sydney, Sydney, Australia
Karen Hancock BSc PhD
Research Consultant and Director, Compugenics, Sydney, Australia
David Rees MBBS PhD FRACP
Consultant Cardiologist, Department of Cardiology, St George Hospital, South-Eastern Sydney Area Health Service, New
South Wales, Australia
and David R. Thompson PhD RN FRCN
Professor of Nursing, School of Health, University of York, York, UK
Submitted for publication 12 October 2001
Accepted for publication 30 April 2002
� 2002 Blackwell Science Ltd 391
Correspondence:
John Daly,
School of Nursing,
Family and Community Health,
College of Social and Health Sciences,
University of Western Sydney,
Locked Bag 1797,
Penrith DC 1797,
NSW,
Australia.
E-mail: [email protected]
DALY J DAVIDSON P CHANG E HANCOCK K REES D . & THOMPSON D RDALY J., DAVIDSON P., CHANG E., HANCOCK K., REES D . & THOMPSON D.R.
(2002)(2002) Journal of Advanced Nursing 39(4), 391–399
Cultural aspects of adjustment to coronary heart disease in Chinese-Australians:
a review of the literature
Background. The burden of illness associated with Coronary Heart Disease
(CHD) has determined this as a key focus for research at a basic science, indi-
vidual and population level. Although considerable research has been conducted
on specific aspects of the experience of CHD, such as anxiety or depression, there
is a lack of research investigating the global aspects of the illness experience from
the individual’s perspective. Furthermore, there is a paucity of research examining
the cross-cultural experiences of patients from Non-English Speaking Back-
grounds (NESB). Given the multicultural nature of Australian society, and that
health and illness are culturally constructed experiences (Manderson 1990), it is
important to include the perspectives of people from minority cultures in health
related research in order to provide culturally sensitive and appropriate health
care and information during an illness. Further, the potential to prevent and
modulate the course of CHD, by strategies such as smoking cessation and lipid
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Introduction
Local context
Australia has a culturally diverse population of 18Æ5 million,
with 24% born overseas, and a further 27% with one or both
parents born overseas (Australian Bureau of Statistics [ABS]
1999). The most common ethnic groups are people from
England, New Zealand, Italy, former Yugoslav Republics,
Vietnam, China, Greece and Germany, with China propor-
tionally the fastest growing of these groups (ABS 1999). From
a multicultural perspective, there are a large number of
Australian people whose needs and expectations may be
different from what would be expected within a unicultual,
Anglo-Celtic society. In terms of health care, these needs
should be recognized, acknowledged and met �in accordance
with the principles of social justice, including fairness, equity
and access� (Cameron-Traub 2000, p. 239).
Australia has a relatively well public-funded universal
health insurance system (called Medicare) compared with
other developed countries such as the United States of
America (USA). Although such public funding means that
people who do not have private health insurance have access
to quality health care service, the Australian government has
recently taken steps to encourage Australians to undertake
private insurance to lower the ever-increasing burden on its
health system.
Cardiovascular disease in Australia
Cardiovascular disease is Australia’s greatest health problem
in terms of mortality and its health and economic burden
(Australian Institute of Health and Welfare 2000). The
Australian Government has set national goals and targets for
all major causes of morbidity and mortality, specifically in the
areas of cardiovascular disease, mental health, injury and
cancer. One of the ongoing priority areas for cardiovascular
health identified in the National Health Priority Areas report
on cardiovascular health (Commonwealth Department of
Health and Aged Care and Australian Institute of Health &
Welfare) is to develop, review and implement better practice
guidelines.
In the establishment of evidence based best practice and
evaluation of health outcomes, it is necessary to investigate
all aspects of health care, including nursing practice.
Coronary Heart Disease (CHD) is one area of heart disease
that is increasingly recognized as an area needing research in
terms of best-practice, to the extent that the National Health
and Medical Research Council (NHMRC) (1996) of Aus-
tralia established a working party which developed guidelines
to the management of acute coronary syndromes (ACSs). The
term ACS describes variable presentations related to vulner-
able coronary artery lesions including: unstable angina
pectoris; ST segment elevation myocardial infarction (MI);
and non-ST segment elevation MI. (Veghiazarians et al.
management, mandate a health promotion agenda based on equity and access for
all members of society.
Aims. This article discusses cultural aspects of CHD in relation to nursing and
allied health care during the recovery phase of an acute cardiac event. It reviews
the research that has been conducted in this area, focusing on the Chinese-Aus-
tralian population.
Literature search. The CINAHL, MEDLINE, FAMILY (Australian Family and
Society Abstracts Database), PsychINFO, and Multicultural Australian and im-
migration Studies (MAIS) databases were searched, identifying literature pub-
lished from 1982. Keywords used were Chin* (Chinese, China), Asia* (Asia,
Asian), experience, adjustment, psychological, heart, coronary, cardiac, health
and services. Reports not written in English were excluded. Australian Govern-
ment reports were also searched, as well as hand searching of nursing and
medical textbooks. These searches resulted in over 1000 articles. However, only
around 50 were relevant for this review.
Implications. Chinese-Australians are one of the fastest growing populations in
Australia, and are at increased risk of CHD upon settling to Australia. Recom-
mendations for future research and for the practice of nursing are provided.
Keywords: cross-cultural, coronary heart disease, nursing, adjustment, Chinese-
Australians
J. Daly et al.
392 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(4), 391–399
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2000). Although the death rate from CHD has been falling
since the mid-1960s, unstable angina has increased in
prevalence as an admission diagnosis (NHMRC Media
release 1996).
Adjustment following a diagnosis of ACS
This period of time is reported to be a stressful, vulnerable
one for survivors (Thompson et al. 1994, 1995, Davies
2000). Vulnerability may be composed of factors of anxiety,
inferiority, insecurity, lack of intimacy and disconfirmation
(Lidell et al. 1998). Examples of stressors experienced by
people with cardiac conditions include interpersonal, family
and financial problems; therapy and self-care obstacles; and
work or physical difficulties (Stewart et al. 2000). Anxiety
and depression are frequently experienced following CHD
(Conn et al. 1991a, Crowe et al. 1996, Shapiro et al. 1999),
with approximately one-third of patients experiencing con-
tinuing anxiety and depression following MI (Conn et al.
1991b). Spouses have also been found to experience anxiety
and depression (Thompson & Cordle 1988, Coyne & Smith
1991). Beach et al. (1992) found that these reactions can
interfere with the adjustment of MI survivors.
These responses have significant implications for adjustment
of patients and their spouses to life following an ACS
admission, with potential influences on morbidity, mortality
and appropriate modification of lifestyle risk factors
(Thompson et al. 1994, 1995, Shapiro et al. 1999). For
instance, Levine et al. (1996) found that depression was an
important predictor of rehospitalization among persons
admitted with CHD. Depression is associated with increased
mortality following a MI (Frasure-Smith et al. 1999, Shapiro
et al. 1999). Ongoing anxiety is associated with a reduced
likelihood of returning to work, greater hospital readmissions
and higher mortality rates (Webster & Christman 1988).
Return to work appears to be important in adjusting to MI, as
evidenced by research by Tooth et al. (1999), who found that
poor psychological status was greater in those not working.
Social support is another factor that has been found to
influence adjustment to CHD. Lin et al. (2000) found that
patients with CHD who had low social support and higher
uncertainty were more likely to have worse psychological
well-being. Drory et al. (1999) found that depression, sense
of coherence and social support at discharge predicted
psychosocial adjustment in most life domains 3–6 months
after MI, and that medical variables were partly mediated by
psychological variables. It is considered that reversion to
previous risk factors, e.g. smoking and lack of exercise is
potentially related to anxiety and depression. It is also
possible that reversion to previous behaviours may be due to
lack of support and reinforcement of health promotion
strategies (Rodeman et al. 1995).
Uncertainty is another factor that may influence adjust-
ment to CHD. Carroll et al. (1999) found that an increased
perception of uncertainty was related to decreased perception
of health status and quality of life up to 6 months later.
Christman et al. (1988) found that patients reporting more
uncertainty also reported greater distress. Lin et al. (2000)
also found a significant negative relationship between uncer-
tainty and psychological well-being. Related to uncertainty is
perceptions of control. Moser and Dracup (1995) found that
patients with high perceptions of control were less likely to
experience anxiety and depression.
Adjusting to CHD may be also hampered by an inad-
equately resourced health care service that is characterized by
shortened periods of hospitalization allied with lack of
continuity of care when the patient is discharged (New South
Wales Health Council 2000).
Although considerable research has been conducted on
specific aspects of the experience of MI, such as anxiety or
depression, there is a lack of research investigating the global
aspects of the illness experience from the survivor’s perspec-
tive (Johnson & Morse 1990, Thompson et al. 1995).
Furthermore, the postexperiences have commonly been
examined using questionnaires that do not allow a more
detailed, fuller exploration of the psychological experiences
or issues influencing their recovery (Stewart et al. 2000).
Further research is necessary that investigates this area using
both quantitative and qualitative research methods.
Cultural aspects of health seeking behaviourin Australia
Culture may be described as �the sum total ways of living
built up by a group of human beings, which is transmitted
from one generation to another� (Macquarie Dictionary
2002). Australia is characterized by its cultural diversity,
with preliminary estimates for 1999 identifying 24% born
overseas, and almost 14% from non-English speaking back-
grounds (NESB) (ABS 1999). Migrants from different socio-
cultural and linguistic backgrounds have been found to
possess varying perceptions of illness and health (D’Cruz &
Tham 1993). Given the multicultural nature of Australian
society, and that health and illness are culturally constructed
experiences (Manderson 1990), it is important to include the
perspectives of people from minority cultures in health
related research in order to provide culturally sensitive health
care during an illness. Furthermore, as one’s experience of
health and illness is likely to be influenced by their culture,
culture may affect and have implications on the patient’s
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recovery process. Thus it is also important to research the
experiences of such individuals during recovery from illness
in order to better understand and meet their needs following
discharge from hospital.
Although the manner in which people from NESB com-
munities seek health services in Australia is not well under-
stood, it is well documented that people of NESB are less
likely to make use of health services when in need (Rissel &
Rowling 1991, Cass 1995, Grypma 1997, Ziguras et al.
1998). Not only do they lack knowledge of services they can
access, but they often have difficulties gaining access to health
and welfare services (Duong 1993, Lau 1995, Ziguras et al.
1998). Accessibility to health services is not the only issue,
with inequity in the quality of care of services provided being
reported (Lopez & Fazzalori 1995, Macintyre & Dennerstein
1995). The quality of nursing care delivery is one area that
has been criticized, with evidence to suggest that the nursing
profession has failed to provide nursing services to preserve
the cultural backgrounds and meet the needs of NESB
patients that nurses serve (Kanitsaki 1993, Gorman 1995).
Research has also demonstrated that other health profes-
sionals have failed to provide culturally appropriate health
care to NESB people (Lopez & Fazzalori 1995, Macintyre &
Dennerstein 1995, Pardy 1995), with some health profes-
sionals defending their position by arguing that migrants
should not receive �special� treatment (Mitchell 1989, Lopez
& Fazzalori 1995).
It is of concern that an inequitable service is being provided
in the health system in terms of meeting cultural needs,
especially when one considers the growing multicultural
nature of Australia’s population. It is important that recom-
mendations for the nursing care of cardiac patients are based
on the heterogeneous nature of the Australian culture,
especially as the mandate of the Australian governments is
to strive for equity, access, justice, inclusiveness and colla-
boration in all aspects of health service delivery (New South
Wales Health Council 2000). The NSW Government has
increased its focus on consumer participation in health care
(New South Wales Health 1999) by involving consumers
collaboratively with health professionals in health service
planning, delivery, monitoring and evaluation. Consumer
participation enhances the acceptability of services because
consumers can express their health service needs. Thus, it is
important to gain the perspectives of individuals from NESB
concerning their health-seeking behaviours and experiences.
Although access and equity in health services remains a
significant problem for NESB populations in Australia, there
is a growing focus on meeting their specific health needs in a
culturally sensitive manner (Thompson & Retasas 1998).
Thompson and Retasas (1998) argue that one of the reasons
for this is that the demographic profile of Australia has
changed due to immigration policies which encouraged
migrants, and because of increased life expectance, better
nutrition and health of people from NESB. Rather than
expecting migrants to adopt the Anglo-Australian way of life,
the Australian Government has adopted a policy of multi-
culturalism and acceptance of different values and traditions
(Blackford & Street 2000). While in theory health care
institutions are expected to ensure equity and access to health
care services for all Australians, in practice the necessary
structures have not been put in place to facilitate this
(Henenberg & Pardy 1995, Multicultural Affairs Unit 1997).
Culturally specific research investigating psychosocial
responses to CHD
The cardiac rehabilitation literature lacks information on
social, psychological and particularly cultural implications of
heart disease. Exploration of individuals’ experiences during
this period may increase knowledge and understanding of
health problems and needs of survivors of CHD which may
assist in the planning of nursing support services during
convalescence. Although there is abundant literature on the
recovery process for survivors of MI (Johnson & Morse
1990, Thompson et al. 1994, 1995) there is a paucity of
research investigating a specific cultural group’s experiences
during the recovery process following an CHD. Studies have
been conducted on the spouses of Taiwanese (Yeh et al.
1994) Finnish (Hentinen 1983) and Lebanese-Australian
(Daly et al. 2000) survivors of MI, but not on the experiences
of survivors of MI of specific cultural groups.
Chinese/Asian cultural influences on the experience
of cardiovascular conditions
Australia has a significant Asian population as part of its
cultural diversity representing 26% of all settler arrivals in
1998–1999. The Chinese population is one of the fastest
growing in Australia, with Chinese (Cantonese and Manda-
rin) the third most common languages spoken at home,
behind Italian and Greek (ABS 1999). Although the Asian
population has traditionally represented a low-risk group in
terms of CHD, the increased Westernization of this group has
led to a concomitant increase in CHD (Webster 1997, Lien
et al. 1998). In Australia, while Asian mortality from
cardiovascular disease is significantly less than the Austra-
lian-born population, rates tend to increase after their first
10 years of residence in Australia (National Heart Founda-
tion 1996). In the United Kingdom (UK) the incidence of
CHD in Asians is high, with mortality from CHD in the four
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main groups of Asians (Gujarati Hindus, Punjabi Sikhs and
Muslims from Pakistan and Bangladesh) living in England
and Wales 36% higher in men and 46% higher in women
compared with non-Asians, with the percentage growing
each year (Webster 1997). The apparent growing of Asian
susceptibility to CHD, fuelled by factors such as changing
dietary behaviours and high incidence of smoking behav-
iours, reinforces the importance of identifying Asian
migrants’ knowledge, beliefs and health seeking behaviours
about CHD in order to plan culturally sensitive future
services.
Most studies of Chinese survivors of CHD have examined
specific responses such as anxiety, depression and coping
methods rather than their experiences (Yeh et al. 1994,
Chiou et al. 1997, Shih et al. 1998, Taylor-Piliae &
Molassiotis 2001). Little is known about the needs of
Chinese CHD survivors. An important reason for studying
the needs of Chinese survivors of CHD is that some aspects of
their cultural tradition may hamper their equity of access to
health services. For example, Lui and MacKenzie (1999)
studied the rehabilitation needs of Chinese stroke patients,
and suggested that the priorities, interpretations and expres-
sions of need are affected by Chinese upbringing and family
values, particularly among the elderly population. In contrast
to Western populations, who focus on individual need,
Chinese people have a strong emphasis on collectivism (Bond
1995). Hence, Chinese people traditionally are less inclined
to express individual need unless encouraged to do so. Lui
and Mackenzie (1999) found that most Chinese elderly
people tend to take a passive role in expressing their needs,
which is particularly related to their educational, social and
cultural background. Webster (1997) also found that nurses
perceived that Asian MI patients were more passive than
other patients, often preferring to stay in bed rather than
being involved actively in their rehabilitation. They tended to
receive the support they needed from their extended family
rather than cardiac rehabilitation programs. Taylor-Piliae
and Molassiotis (2001) suggested that traditional Chinese
philosophies of Confucianism, Taoism and Buddhism pro-
vide perspectives on health and share an approach to the
management of life stresses among Chinese. The Chinese
view is that these stresses are determined by fate and any
associated suffering is valued because it develops character
and repays the debts of previous lives. Confucian values also
emphasize the centrality of the family in the management of
life problems. Thus one possible explanation of Webster’s
(1997) findings is that it may be possible that the Chinese
patients tend to be more passive and stay in bed because they
believe adoption of a �do nothing� approach allows fate to
take its course. Further, they may not seek help from
nurses so much because of their heavy reliance on their
family.
Webster’s (1997) study found that nurses also felt that the
care they offered to Asian MI patients was inferior to that
offered to other patients. The most common reason reported
was a perceived lack of knowledge of the needs and
expectations of Asian patients and their families. Thus the
implication of these studies is that many Chinese patients
may have unmet needs because nurses do not know these
patients’ requirements. This research highlights the need for
more information on the experiences of Asian patients so that
nurses can provide more culturally sensitive care.
Use of health services by Chinese-Australians
There is a paucity of Australian research investigating the
health needs of Chinese patients and of those in the
community. There is also a lack of research investigating
access and use of health services by Chinese-Australians.
However, Chan and Quine (1997) conducted a qualitative
study using focus group to explore experiences of 27 Chinese
migrants in utilizing Australian health care services (main-
stream and ethno-specific). They found that Chinese migrants
preferred to use Chinese-speaking general practitioners, there
were insufficient interpreter services and a lack of knowledge
about the existence and role of ethnic health workers. They
also found that Hong Kong migrants tended to use available
health care services more than migrants from China. Almost
all participants reported that if western treatment failed,
alternative methods such as herbalism, acupuncture and
cupping were used. The National Health Survey conducted
by the ABS in 1992 found that the use of doctors by ethnic
Chinese was low; there were problems with access, and some
had chosen other sources of health service (Young & Coles
1992). These studies suggest a need for improving the quality
and quantity of interpreter services; promotion of the
availability of ethnic health workers; and the importance of
producing Chinese-written pamphlets.
Research in cardiovascular nursing
Knowledge of patients’ perceptions and interpretations of
their illness can have a significant impact on how they adjust
and behaviour during their recovery (Thompson et al. 1995).
There is limited Australian literature describing the personal
experiences of survivors of CHD in the initial discharge
period. Daly et al. (1998, 2000) have conducted a series of
studies in this area. In the first study, Daly et al. (1998)
undertook a qualitative, exploratory-descriptive study of
the experiences of seven Lebanese-born female spouses of
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survivors of MI in the initial discharge period. Qualitative
data analysis uncovered three themes: struggle to resolve
distress, intensive monitoring of the survivor and searching
for avenues of support. The research participants experienced
the first 4 weeks following the discharge of their spouse as a
period involving considerable distress comprised of a number
of emotions, oversolicitousness toward the survivor, psycho-
somatic symptoms, fear of recurrence of the acute myocardial
infarction (AMI) or loss of the spouse, searching for support,
and anticipating the future. These findings parallel those
uncovered in previous studies of female spouses of AMI
survivors (Thompson & Cordle 1988, Marsden & Dracup
1991, Moser et al. 1993, Thompson et al. 1995). However,
cultural issues impacted on gender and family roles. The
women experienced a lack of support during a stressful
family crisis, a sense of isolation and they suborned their
needs to that of the survivor (even when this resulted in a
deterioration in personal health and quality of life). However,
the participants were able to maintain a sense of hope that
their circumstances would return to normal in the future.
While the study findings were not generalizable, they provide
useful information on how to improve nursing support to the
target group in the community.
In the second study, Daly et al. (2000) sought to explore
health status, perceptions of coping, and social support
among survivors of a recent AMI in the 3 weeks after
discharge from hospital in South-western Sydney. In this
study a descriptive, exploratory approach with a triangulated
methodology was used to assess the experiences of 38
survivors (26 males and 12 females), detect patterns in these
experiences, explore the health-support needs of the survi-
vors, and determine changes in health status in the first
3 weeks after discharge. Analysis of qualitative data from the
12 female survivors revealed both similarities to and differ-
ences from the data of male survivors. Similarities included
anticipating resumption of valued tasks and activities and
emotional flux. As in the male survivors, this emotional flux
was manifested as anxiety, depression, ambiguity and uncer-
tainty, fear of recurrence of the AMI, and fear of further
deterioration in health. Female survivors also reported a
struggle to integrate changes in their lifestyle. The women
tended to seek external support as well as from family,
including church groups and the National Heart Foundation.
These findings support those of Riegel and Gocka (1995),
who compared 32 women and 32 men with a first AMI and
found that women reported wanting, receiving and giving
more support than men did at 4 months. That is, the women
appeared to activate their social support system more
effectively than the men after AMI.
In the third study, Jackson et al. (2000) undertook serial
interviews with women survivors of first-time MI. These
interviews were conducted at 7, 14 and 21 days posthospital
discharge, and aimed to explore the recovery experiences and
needs of women survivors of first-time MI in the initial
postdischarge period. Findings revealed the 3 weeks following
hospital discharge was a period of intense introspection,
which involved examination and contemplation of many
previously taken-for-granted aspects of their lives. The
women described feelings of exhaustion, fear and marked
emotional lability. Their major unmet need was for informa-
tion about the MI and implications for lifestyle arising from it.
Svedlund and Axelsson (2000) examined the meaning of
lived experiences after and AMI in nine women and their
partners. The experience of AMI contained two themes:
�rehabilitation needed� and �loss of freedom�. The women
reported that they felt distressed and vulnerable but struggled
against the fear the illness means. The partner’s role was one
of trying to adapt to the women’s experiences of the illness.
Although the generalizability of these studies is limited by
their small sample size and predominant use of qualitative
research methods, together they suggest that the postdis-
charge period is a stressful, uncertain one in which informa-
tion about their illness is an important need. The results
support the role that nurses have in discharge planning and
providing ongoing information and support for survivors of
AMI in the recovery period. However, evidence-based
cardiac research needs to focus more on specific cultural
groups in order to identify their postdischarge nursing needs.
Unless nurses appreciate individual’s needs in relation to
information, services and care they risk delivering interven-
tions and care plans on assumptions that are not meaningful,
appropriate or based on evidence. The authors plan a study to
evaluate systematically the health seeking behaviours and
belief models of Chinese-Australians.
This study will use a triangulated methodology that allows
both generalizability and depth of insight into the postdis-
charge experiences of Chinese CHD patients. This study
seeks to partly replicate the Daly et al. (2000) study in a
Chinese-Australian population. It will investigate the health
patterns, information and adjustment of experiences of
Chinese individuals who have been recently hospitalized
with ACS in Southern and Western Sydney. It will also
conduct a community study of Chinese migrants to determine
whether their health seeking behaviour regarding cardiac
conditions is conventional, and their awareness of the
services they can access. This will be a collaborative study
with Hong Kong, UK and the USA to explore the similarities
and differences of needs, beliefs, health seeking practices and
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experiences of Chinese cardiac patients in Australia as
compared with those in Hong Kong, UK and USA.
Conclusion and suggestions for future research
Aspects of the illness experience and recovery phase of CHD
in Chinese-Australians remain unexplored and poorly under-
stood because of the lack of research in this area. However,
the research that does exist indicates that cultural aspects do
influence the experience of Chinese patients, in terms of their
passive health-seeking behaviours and reliance on family
members rather than nursing services. Future research should
focus on comparing the needs of Chinese patients vs. patients
from Western backgrounds rather than limiting its focus to
one sample. Furthermore, research in this area would be
more generalizable by using larger sample sizes, and the use
of both valid quantitative and qualitative research methods.
Such research will provide insights into the initial recovery
period and increase the knowledge and understanding of
Chinese patients’ recovery and their discharge needs after
CHD in comparison with Anglo-Celtic patients.
Given the multicultural nature of Australian society and
the growing awareness of inequity in use of and access to
health services by people of NESB, it is imperative to include
the perspectives of people from minority cultures in health-
related research. Barriers to inclusion often centre around the
expense of interpreters and translations together with the lack
of availability of validated and reliable measures. Cultural
aspects related to perceptions of confidentiality and research
can also hamper recruitment of specific cultural and ethnic
groups. Despite the challenges, these obstacles are not
insurmountable and mandate attention by policy makers,
clinicians and researchers. This may serve to reduce the
obstacles to cross-cultural care within nursing practice and
inform a research agenda and planning for service delivery.
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