In China they have about 1. 3 billion people, making up a little more than 20% of the world’s population. It’s no surprise that with that many people in one country that the culture there would hold many different beliefs and traditions. Chinese are known for many things and their health care practices are one of them. They use different medicines to treat the ill, have different techniques to insure that women have a good pregnancy and a healthy baby as well as old family traditions from how a family is ran to what they do when someone passes away.
A lot of these traditions can compare to other cultures where many are also so different it takes some understanding to get used to them. Family plays a huge role in the Chinese culture. As in a lot of cultures, the Chinese family is run by the father and husband of the household. He makes most of the family decisions and plays a huge role in the decisions his children make. Traditionally the father would arrange marriages for his children, guide them in the career to go and make sure that he raised strong kids who would help contribute to the family when older.
Today the father figure still plays a dominant role but no longer arranges marriages for their children. He does however still influence them on their decisions but does not make them for his children. In most cases children will live with their parents until married. It is not uncommon however for a newly married couple to stay living with the husbands parents for a short time after marriage. Even though fathers in the family play a huge role, mothers play a greater role in the daily lives of their children. The Chinese preferred to have son’s who would be able to take care of them when they were older.
Daughter in-laws were considered the low man on the totem pole and in the old days were actually considered slaves to their in-laws, doing whatever was needed to make their mother-in-law happy. Mothers of sons felt they had every right to treat their daughter-in-laws like that since they themselves had to go through the same thing working their way up from just wife, to mother, to mother-in-law and hopefully grandmother. This mother-in-law/daughter-in-law relationship seems harsh, especially with how things have changed over the years.
In many cultures the mother-in-law is there to help support her son’s new wife and guide her into her role as a wife. In the United States, mother-in-laws look to the daughter-in-laws to help give their son a happy life as well as provide them with grandchildren. The Chinese mother-in-laws are also there to help raise the children and much more. They usually are there to make sure the pregnancy and labor go as smoothly as possible and that all traditions are upheld. Pregnancy and child bearing play a huge role in Chinese culture.
They have many beliefs that need to be followed to insure that the mother to be is carrying a perfectly healthy baby and will have an easy and successful delivery. “The Chinese traditions for pregnancy start as soon as a husband and wife get married. The first thing that is done is the husband will carry his bride over a pan of burning coals when entering his home for the first time to ensure his wife will pass through labor successfully. ” After that first step the rest of the traditions begin once the mother finds out she is pregnant.
They carry many traditions starting from what the mother to be should and shouldn’t eat, what things can and cannot be done during the pregnancy, traditions to keep evil spirits away as well as traditions to make sure nothing is done that might cause bad luck for the baby. Pregnant women must be careful of everything they do in the Chinese culture. It is believed that they must be careful and guarded with their thoughts to make sure that they thoughts they are having do not affect the baby. They believe negative or bad thoughts will affect the mother’s heart which connects to the baby transferring any bad emotions and feelings.
She must be careful on what she eats because certain foods will influence the baby’s skin color or cause them to have odd shaped birth marks. Chinese women will take many precautions to protect their unborn and newborn babies from evil spirits. They will never attend a funeral and they will hang certain embellishments to ward of the spirits. A paper cut out of scissors is hung over the bed curtains of a pregnant woman and when a baby is born a special pendant is placed near the baby’s crib in hopes that any evil spirits would be more attracted to the pendant then the baby.
Another example of keeping the spirits away is the parents of the child would make “arrows from wood of a peach tree and place near the cradle. ” It is considered unlucky to name your child before they are born as well as to celebrate before the baby is born with a baby shower. This is normal for many cultures including some Native American cultures here is America. Though now it is more taboo and people are naming their babies as soon as they know the gender and having showers months before the baby is born to make sure that they are prepared when the baby arrives.
When a baby is being born in China it is customary that the mother and mother-in-law of the mother to be, to be present during the delivery but not the father. It is considered terrible luck to be scared of labor as it is considered the woman’s job. After the baby is born the mother is in a “sitting period” for a month. This insures that the mother is completely healed and only has to focus on herself and the health of her child. She is excused from all house work and cooking during this time. Women will drink a special herbal tea to help ease the pain of pregnancy and the after pain of child birth.
This is just one example of herbal medicine that the Chinese use to cure aliments. The Chinese practice both Western medicine as well as traditional folk medicine. Many of the older Chinese will choose to try naturopathic remedies before they will go to a traditional doctor. These remedies usually consist of some sort of herbal treatment, possibly combined with meditation and praying. The younger generations will usually try the more modern route of a doctor first with Western medicines and then try the treatment of the traditional ways if that does not work.
I used to work for an Insurance agent who was Chinese and had many Chinese customers. One of his main customers was a guy named Daniel; Daniel was an herbalist who made the traditional Chinese medicines used. Most of his herb he made into teas for patients who were suffering an ailment. My agent used him many times for small problems rather than going to a normal M. D. He specialized in herbs for things ranging from headaches, to lack of sleep, to allergies and even more serious conditions such as diseases.
Even though he was a strong believer in natural cures, he knew that they could not cure everything at least not quickly enough and that traditional western medicine was sometimes needed. Traditional Chinese medicines are made to help benefit your “energy, blood, essence, spirit and body fluids. These are the 5 main faucets for this type of medicine. ” Even though many might not think this is something they would have to really deal with on a daily basis, Chinese traditional medicine is practiced here in the United States as much as it is in China and health care professionals need to have an understanding of these practices when caring for patients who use these techniques.
China uses two kinds of health-care systems because of their traditions. One that for Western Medicine and the other for traditional Chinese medicine. This leaves the options open for its patients to find the best route of care that works for them. Another major part in traditional Chinese medicine is spirituality. Having a healthy and strong spiritual belief is key in the Chinese culture.
Most Chinese do not practice praying in a traditional church in front of many people on specific days. The most popular religions practiced in China are “Buddhism, Catholicism, Protestantism, Taoism and Islam. ” However, as more Chinese immigrate to the United States those who practice Christianity are on the rise. The main fundamental of Chinese spirituality is that they believe that “life is viewed in terms of cycles and interrelationships, believing that life gets meaning from the context in which it’s lived. ” You also see spirituality in the death rituals Chinese practice.
When a person dies in the Chinese culture there is what they call “A Monks Vigil”. This is where a monk from the chosen religion keeps vigil over the deceased during the night to help ease them into the afterlife by chanting and reading versus to the deceased throughout the night. Funerals for elders are the most elaborate as they are the most respected in a Chinese family. A lot of money is spent to plan their funerals and make them as amazing as possible. Some of the traditions that go into a death ritual are preparing the body before it is put in the casket and making sure it is dressed in the finest clothes from his or her own wardrobe.
The rest of the clothes are then burned. “The body is never dressed in red as it is believed that it will turn the deceased into a ghost. ” The wake for the deceased is held at the deceased person’s home. If they died at home their coffin is placed inside the home, if they died away from home then the coffin is set up outside. Mirrors are covered in the home so that no one sees the coffin in a mirror. It is believed that if you do see the coffin in a mirror then you will have a death in your family very soon. Once the wake is over the deceased is buried usually in a mountain top as the Chinese believe that the higher a dead person is buried the easier it is for them to reach the afterlife.
This differs from many traditions held her in the United States. When a person dies here they are usually immediately transferred to a funeral home where others prepare the body for viewing and a funeral. The funeral and wake are either held in a funeral home or church and then family and friends follow the body to a cemetery to be buried and prayed over. This is something that even health-care providers need to know so that when someone dies whom they are caring for, they can make sure that they are not encroaching on any family traditions that might be followed.
The Chinese culture has so many fascinating traditions and beliefs to be learned about. It would be impossible to learn and understand them all in such a short period of time. All of these traditions can be compared and sometimes matched to traditions that we are used to here in the United States. Some are even carried over by the many Chinese who have immigrated here. We could benefit from their traditional herbs and many other cultures use them as you find them sold in specialty shops all over.
It’s good to have an idea and knowledge of these traditions when working in the health-care as you will no doubted be faced with dealing with them at one point or another. • Transcultural Health Care, A Culturally Competent Approach, Third Edition • Website: Love to Know, Chinese Death Rituals, C:\Documents and Settings\sqr7\Local Settings\Temporary Internet Files\Content. Outlook\BAB22PZ5\Chinese Death Rituals – LoveToKnow Dying. htm • Babyzone. Com, Tradition Chinese, C:\Documents and Settings\sqr7\Local Settings\Temporary Internet Files\Content. Outlook\BAB22PZ5\Chinese Baby Traditions (2). htm
• About. com: Geography, China’s One Child Policy, C:\Documents and Settings\sqr7\Local Settings\Temporary Internet Files\Content. Outlook\BAB22PZ5\China One Child Policy – Overview of the One Child Policy in China. htm • Chinese Cultural Beliefs Related to Pregnancy, Birth and Post Partum Care, C:\Documents and Settings\sqr7\Local Settings\Temporary Internet Files\Content. Outlook\BAB22PZ5\Traditional Health Beliefs Chinese Pregnancy Childbirth. htm • Interview with Douglas Cheung, Chinese American •Article: Speaking of China, “The troubling Chinese Mother-In-Law Relationships” Jocelyn C. 09/16/2009
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Cultural aspects of primary healthcare in india: A case- based analysis
1School of Medicine, Keele University, City General Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
2School of Medicine, Vardhman Mahavir Medical College, Safdarjang Hospital, New Delhi - 110 029, India
Roger P Worthington: email@example.com; Anupriya Gogne: moc.liamg@engogayirpuna
Author information ►Article notes ►Copyright and License information ►
Received 2011 Feb 7; Accepted 2011 Jun 16.
Copyright ©2011 Worthington and Gogne; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Delivering quality primary care to large populations is always challenging, and that is certainly the case in India. While the sheer magnitude of patients can create difficulties, not all challenges are about logistics. Sometimes patient health-seeking behaviour leads to delays in obtaining medical help for reasons that have more to do with culture, social practice and religious belief. When primary care is accessed via busy state-run outpatient departments there is often little time for the physician to investigate causes behind a patient's condition, and these factors can adversely affect patient outcomes. We consider the case of a woman with somatic symptoms seemingly triggered by psychological stresses associated with social norms and familial cultural expectations. These expectations conflict with her personal and professional aspirations, and although she eventually receives psychiatric help and her problems are addressed, initially, psycho-social factors underlying her condition posed a hurdle in terms of accessing appropriate medical care. While for many people culture, belief and social norms exert a stabilising, positive influence, in situations where someone's personal expectations differ significantly from accepted social norms, individual autonomy can be directly challenged, and in which case, something has to give. The result of such challenges can negatively impact on health and well-being, and for patients with immature defence mechanisms for dealing with inner conflict, such an experience can be damaging and ensuing somatic disturbances are often difficult to treat. Patients with culture-bound symptoms are not uncommon within primary care in India or in other Asian countries and communities. We argue that such cases need to be properly understood if satisfactory patient outcomes are to be achieved. While some causes are structural, having to do with how healthcare is accessed and delivered, others are about cultural values, social practices and beliefs. We note how some young adult women are adversely affected and discuss some of the ethical issues that arise.
India is a country with a diverse range of cultures, ethnicities, religions and languages. While in many ways this is a source of richness and strength, cultural influences sometimes give rise to challenges in the context of managing commonly presenting illnesses. Physicians caring for patients expect to take account of psychological, social and environmental factors that underlie some of the problems with which patients present in general practice, particularly where there are concerns about mental health. But in cases where physical manifestations seem to stem from deep-seated influences relating to socio-cultural norms and expectations, some conditions can prove difficult to treat. In our view, interconnections between socio-cultural factors and health need to be better acknowledged and warrant exploration in the hope of making it easier to achieve best practice and improve patient outcomes. Against this background we consider a case from India involving a young woman who presents late with an underlying psychiatric disorder, paying particular attention to ethical, cultural and social aspects of her care.
As a nation India faces a number of challenges in trying to meet population needs for quality healthcare. For instance, in primary health clinics and state-run community hospitals the length of an average consultation is just a few minutes, which makes it hard to take account of underlying socio-economic and psycho-social factors. The short consultation means that it is difficult to investigate adverse factors impacting on patients' physical and psychological well-being. However, on the positive side, primary healthcare offered by city and district hospitals and by rural primary health centres generally succeed in offering basic treatment with no cost to the patient. The focus in primary care clinics is usually on immunization, treatment of common illnesses, prevention of malnutrition, and providing pregnancy, childbirth and postnatal care; patients needing specialised care (and/or having more complicated illnesses) are referred to secondary and tertiary care centres, which may have district, state or national teaching hospital status.
GPs tend to have well-established connections with such centres enabling them to make suitable referrals, especially in urban areas; patients in turn have long-standing connections with GPs, sometimes extending over generations. Broadly speaking, healthcare in India is divided between private and state-funded and between rural and urban centres, and these divergent limbs form part of a complex system that tries to cater for the needs of a vast population. On the one hand it succeeds in catering for large numbers of patients providing basic care for uncomplicated ailments; on the other hand compromises have to be made regarding quality of care, especially when treating illnesses that demand resource-intensive standards of care.
Some people have the chance to access quality, private insurance-based healthcare, but others are excluded due to lack of affordability. Imbalances arise between the private and state-funded health sectors, and these are both significant and growing . While the Indian system relies on a mix of primary health village centres and government hospitals to provide free medical care for the general population, private hospitals cater more for urban, higher socio-economic strata in society. The public system seeks to make healthcare accessible to all sectors of the population and it was structured with this in mind. However, the system does not always function in the way that was originally intended due to problems such as poor standards of literacy, overt political and religious influences, an ever-expanding population, and poor doctor to patient ratios.
These factors can combine to form a vicious circle, and the healthcare system often lacks the necessary resources to enable proper provision of inpatient facilities, including basic essential medical equipment or help with transport for patients coming from more remote geographical locations. Patients from these areas experience additional barriers in terms of accessing quality, affordable, local care. Hindrances have to do with politics as well as geography, and on account of relatively low standards of education there is often a general lack of awareness about family planning.
Culture, Belief and Health
Against this background we consider the role played by culture and belief and how they can impact on patient outcomes. Belief systems and moral values are intrinsic to human life, and for many people cultural and religious considerations exert strong, positive influences on their lives. But norms bound by culture and belief can also negatively impact on people in terms of mental and physical well-being. Culture-bound syndromes are not uncommon within primary care in India and Asian communities more generally, with cases arising that display psychiatric and associated somatic symptoms . Recognising that there is an element of controversy surrounding the diagnosis,  an example we wish to consider is that of dissociative trance or possession-like state, most commonly encountered amongst young adult women. Dissociative trance or possession states capture the essence of the problems we are addressing, and we offer the following case as a way of exploring them further.
'S' is a 23 year-old female who presents with episodes of anxiety, accompanied by feelings of impending doom, shortness of breath, palpitations, and loss of sensation in her limbs lasting for 15-20 minutes. Symptoms are accompanied by a shift in consciousness whereby 'ancestral spirits' appear to take control over her body and personal identity. This experience is accompanied by violent behaviour, a change in voice and irrelevant speech content, as well as general weaknesses, body aches and decreased appetite. Anxieties appear to result in somatic symptoms with autonomic instability. However, S is reluctant to seek psychiatric help, partly because of the stigma attached to this kind of therapy.
Family levels of education range from illiteracy to having full secondary education; the family is closely-knit and conforms to conventional societal norms. S is well-educated and a graduate with ambitious plans for further study; however, these are interrupted when she becomes engaged as part of an arranged marriage. She experiences a number of problems and has no recollection of episodes involving 'possession and dissociative trance'; eventually a decision is made to consult the local religious healer, whom the family has been seeing for generations. S is taken to a temple where rituals are carried out to 'drive out spirits from her body'. Her symptoms improve but only for a matter of days. The family eventually seeks help and advice from the GP for S's abnormal behaviour, and the GP makes a referral to a local psychiatrist. S and her family are open to psychotherapy, although it requires motivation and persuasion in order to try and break the cycle of events; in total, the delay in seeking qualified help amounts to six to eight months, largely by reason of family beliefs and S's lack of insight into her illness.
Eventually she is treated and her psychological stressors are identified, namely that S was unwilling to get married and felt unable to convey this to her parents or express her desire to do further studies; S felt it would be disrespectful towards her parents to talk openly about such matters. At the consultation it was thought that subconsciously she was using denial and dissociation to cope with stresses arising from her internal conflict. She is eventually admitted to a local hospital for psychiatric observation and 'distraction therapy'.
Gradually, psycho-educative sessions involving both patient and the family are undertaken to clear away apparent misconceptions about healing rituals, while at the same time stressing the importance of seeking out and complying with professional treatment and advice. Without being disrespectful to values and sentiments of the parents, the focus gradually shifts towards S's long-term professional ambition. The advice given is for her not to marry until she feels that she is ready.
Upon further psychiatric evaluation S is found to have 'histrionic personality traits and immature maladaptive defence mechanisms' for coping with family rules based on strict societal norms and expectations. After a week of observation as an inpatient no further episodes of abnormal behaviour are seen. Subsequently S receives regular psychotherapy as an outpatient and makes a steady improvement.
Culture and religion played a significant role in the course of her illness from original diagnosis through to treatment and eventual prognosis. To understand the aetiology of her condition and navigate some of the roadblocks to accessing timely medical care it is important to note the effect of culture and religious belief, particularly regarding 'ancestral spirits' (however that term is understood). Such manifestations are not uncommon,  and presenting symptoms are often caused by maladaptive responses, especially in younger women.
Such family pressures need not be negative in their effect, and family values and ideals inculcated over generations can exert positive influences by providing crucial support. The role of family should not be undervalued, and the concept of joint, extended families is central to everyday living, providing economic as well as psycho-social stability. Family support is often vital to the recovery of patients, especially for those with advanced illnesses. Whole families sometimes make long trips to hospital with the patient in order to seek the necessary help, and outside the setting of public hospitals it can fall to the extended family to pay for treatment from their own private resources, which in the case of a young mother, could be with help from a grandparent.
It must be borne in mind that people with different cultural, religious and demographic profiles will not always react in the same way, and to ensure optimal care for patients such as S it is important to try and consider all determinants of physical and mental wellbeing. Delays in seeking professional help as well as issues of non-compliance once therapy is eventually started are commonly found in cases such as this, stemming from deeply held faith in religious healing and the associated rituals . The trend towards finding healers first and then doctors covers all fields of medicine in India and beyond. It cannot be wrong to show respect for cultural traditions and belief, but if pursued without heed to possible harms that arise from not seeking timely professional help the situation could change. Blind adherence to conventional patterns of behaviour may not be ethically defensible if the consequences are harmful to the patient; therefore, judgment needs to be exercised in order to properly assess a situation such as the one we describe.
Key to S's case are social tensions between respecting rights to live in accordance with established cultural tradition and social norms, and respecting individual autonomy to make free, independent personal choices. Mutual incompatibility between these positions lies at the root of problems seen in this and similar cases. The pressure felt by S to conform to social and family values led her to abandon her career aspirations without having adequate coping mechanisms for dealing with the resultant inner conflict. S's family explain her condition by making reference to 'ancestral spirits', reflecting patterns of traditional belief and health seeking behaviours commonly associated with Indian cultural beliefs.
Old and new forms of belief in health and healing can comfortably co-exist, although in this case belief in cultural tradition means that spiritual healers are consulted before consideration is given to seeking out Western forms of medicine. While the delay did not help the patient, traditional forms of medicine and healing are nonetheless part of the web of everyday life. Just as it is naïve to suggest that modern allopathic medicine has an answer to every problem, so it is wrong to suppose that allopathic medicine always has to be a first line of defence. We suggest that having an open mind is the best and most appropriate response.
The issue here is not about lack of education, because articulate, well-educated people can still express preferences for traditional over modern forms of medicine; nor is it about prioritising one system of medicine over another. It is about finding an accommodation for a workable co-existence between different forms of medicine and dealing with conflicting attitudes, values and preferences. Furthermore, the situation we describe is not unlike that which is commonly found in China, where the two different types of medicine (traditional and allopathic) generally work in parallel, and have done for many years .
The role played by culture and religion in Indian culture is undeniable, but it must be remembered that cultural tradition and religious beliefs are not necessarily the same thing. For instance, people can describe themselves as belonging to a dominant culture but without subscribing to the tenets of the main associated religion. The converse can also be true, and someone can be religious without having any particular interest in local culture; furthermore, someone can be interested in spirituality but not organised religion. In short, culture, religion, spirituality and belief may or may not be coterminous, and these distinctions are worth bearing in mind. Here the issue is about respecting the role played by cultural values in people's lives and navigating a path between old and new modes of living in order to try and optimise patient outcomes.
The social aspiration of women is an important part of this discussion, and the case study highlights questions surrounding family values, arranged marriages, and rights to education. None of these issues should be viewed in isolation, and while the first two points are more symbolic of 'old' culture, the third is more about 21st century social and political aspirations. Clearly, not all women experience mental health problems if they express preferences to uphold rights to individual autonomy over family values or enrol in higher education; that does not follow. However, in our case internalised social, familial pressure acted as a trigger for the onset of mental illness, causing the patient to present with a range of seemingly disconnected symptoms. Family belief, coupled with stigma leading to apprehension, commonly found in relation to people's attitude towards psychiatry, created obstacles in the path of our patient[7,8].
In terms of the underlying ethics, patient autonomy in Indian culture may not play the same role that it does in the West;  sometimes the moral imperative is to be seen and treated more than presented with choices that may not exist (especially in publicly funded healthcare). This leads to an awkward if inescapable conclusion that in practical terms autonomy may mean different things in different cultural and geographic settings, or at least it can have different applications. There is limited scope within this paper to discuss these ethical tensions fully, and our case is not about patient autonomy in the customary sense of reaching joint decisions about clinical care. Rather, it is about broader relationships between personal autonomy, family and society. Indian society is multi-faceted, and the same applies to other Asian cultures, and while we do not merely seek to draw generalisable conclusions, we do want to highlight a set of phenomena that are not uncommon and that are not always well understood.
In the primary care setting, even though time may be a scarce resource, it is important to be mindful of social and cultural factors that can negatively impact on patient well-being. The problems encountered in relation to patient S are not uncommon in India or in Asian culture more generally. The root cause of the difficulties we describe and the potential social remedies probably lie beyond the power of the family physician to solve because they are so deep-seated. However, they can and do affect day-to-day clinical practice, and we argue that such issues have a moral and a practical relevance that merits wider discussion and recognition.
We end with these key summary points:
1. If there is limited time for discussion about patient values and beliefs, this may present a real challenge, especially where socio-economic and cultural factors play a role.
2. Keep an open mind as to the cause of symptoms presented by patients within family medicine (especially in the case of young adult women).
3. Recognise that it may be beyond the power of the clinician to address underlying factors affecting patient well-being.
4. Different systems of medicine can work in parallel, and while spiritual healing has a long tradition, sole reliance on it sometimes leads patients to avoid seeking other forms of care.
5. Cultural values, spirituality, and religious belief do not necessarily concern one and the same thing; it is possible to be influenced by one but not others.
6. While patient autonomy is important it can lead to tension with cultural and social norms and satisfactory outcomes may have to be negotiated.
The authors declare that they have no competing interests.
RW planned the article and acted as first author; AG provided the case study and background information; both authors contributed to the final draft and have read and approved the final manuscript. RW and AG would like to thank Sinthuja Visahan (Keele University, UK) for help in researching references.
RW lectures at Keele University School of Medicine (UK), where he leads on ethics and law. He is an Assistant (Adjunct) Professor of Medicine at Yale University (USA) and an Associate (Adjunct) Professor of Medical Ethics and Law at Bond University (Australia). Roger has a lifelong interest in Indian philosophy and culture.
AG graduated from Vardhman Mahavir Medical College in New Delhi (India), and she is starting psychiatric residency training at the State University of New York, Brooklyn (USA).
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