(e.g., Mexican American, Latino, Hispanic). Most
Mexicans consider a handshake to be a polite greet-
ing but do not appreciate other touch by strangers,
although touching and embracing warmly are com-
mon among family and friends. To convey respect,
Mexican clients may avoid direct eye contact with
authority figures. They usually prefer polite social
interaction to help establish rapport before answering
health-related questions. Generally one or two ques-
tions will produce a wealth of information, so listen-
ing is important. Silence is often a sign of disagree-
ment, which these clients may use in place of words.
Orientation to time is flexible; the client may be 15 or
20 minutes late for an appointment but will not con-
sider that as being late (Miller & Davidhizar, 2001).
There is no clear separation of mental and phys-
ical illness. Many have a naturalistic or personal-
istic view of illness and believe disease is based on
the imbalance of the person and the environment
including emotional, spiritual, social, and physical
factors (Mendelson, 2002). Mexican Americans may
seek medical care for severe symptoms while still
using folk medicine to deal with spiritual or psychic
influences. Eighty percent to 90% of Mexican Ameri-
cans are Catholic and observe the rites and sacra-
ments of this religion (de Paula et al., 1996).PUERTO RICANS
Preferences for personal space vary among Puerto
Ricans, so it is important to assess each individual.
Typically, older and more traditional people prefer
greater distance and less direct eye contact, while
younger people prefer direct eye contact and less dis-
tance with others. Puerto Ricans desire warm and
smooth interpersonal relationships and may express
gratitude to health care providers with homemade
traditional cooking; these clients might interpret the
refusal of such an offer as an insult. There may be
some difficulty being on time for appointments or
limiting the length of an appointment (Juarbe, 1996).
Physical illness is seen as hereditary, punish-
ment for sin, or lack of attention to personal health.
Mental illness is believed to be hereditary or a result
of sufriamientos(suffering). Mental illness carries
great stigma, and past or present history of mental
illness may not be acknowledged. Religious and spiri-
tual practices are very important, and these clients
may use spiritual healers or healing practices (Juarbe,
1996).
RUSSIANS
A formal greeting or a handshake with direct eye
contact is acceptable. These clients reserve touching
or embracing and kissing on the cheeks for close
friends and family. Tone of voice can be loud even in
pleasant conversations. Most clients are on time or
early for appointments (Evanikoff, 1996).
Russians believe the cause of mental illness to be
stress and moving into a new environment. Some
Russian Christians believe illness is God’s will or a
test of faith. Sick people often put themselves on bed
rest. Many Russians do not like to take any medica-
tions and will try home remedies first. Some older
Russians believe that excessive drug use can be
harmful and that many medicines can be more dam-
aging than natural remedies. Primary religious affil-
iations are Eastern Orthodox with a minority being
Jewish or Protestant (Evanikoff, 1996).SOUTH ASIANS
South Asians living in the United States include peo-
ple from India, Pakistan, Bangladesh, Sri Lanka,
Nepal, Fiji, and East Africa. Preferred terms of
identification may be related to geography, such as
South Asians, East Indians, Asian Indians, or Indo-
Americans, or by religious affiliation such as Sikhs,
Hindus, or Muslims. Greetings are expressed orally
as well as in gestures. Hindus and Sikhs press their
palms together while saying namaste(Hindus) or
sasariyakal(Sikhs). Muslims take the palm of the
right hand to their forehead and bow slightly while
saying AsSalamOAlaikuum.Shaking hands is com-
mon among men but not women. Touching is not com-
mon among South Asians; rather, they express feel-
ings through eyes and facial expressions. They may
consider direct eye contact, especially with elders,
rude or disrespectful. Silence usually indicates accep-
tance, approval, or tolerance. Most South Asians have
a soft tone of voice and consider loudness to be dis-
respectful. Although not time-conscious about social
activities, most South Asians are punctual for sched-
uled appointments for health care (Lee et al., 2001).
South Asians believe mental illness to result
from spells cast by an enemy or possession by evil
spirits. Those who believe in Ayurvedic philosophy
may think a person is susceptible to mental problems
related to physical imbalances in the body. Sick peo-
ple usually assume a passive role and want to rest
and be relieved of daily responsibilities. Hindus wor-
ship many gods and goddesses and believe in a social
caste system. Hindus believe that reciting charms
and performing rituals will eliminate diseases, ene-
mies, sins, and demons. Many believe that yoga will
eliminate certain mental illnesses. Muslims believe
in one God and pray five times daily after washing
their hands. They believe that reciting verses from
the holy Koran will eliminate diseases and ease suf-
fering. Sikhs also believe in one god and the equality
of all people. Spiritual healing practices and prayer
are common, but South Asians living in the United7 CLIENT’SRESPONSE TOILLNESS 149