Cultural Sensitivity and Global Pharmacy Engagement in Asia: India, Indonesia, Malaysia, Philippines, and Vietnam

India.

India is a federal union comprised of 29 states and seven union territories.^3,4 According to the 2017 census, India’s estimated population is 1.3 billion.^3,4 Its ethnic groups are Indo-Aryan, Dravidian, Mongoloid, and others.^3,4 Religions include Hindu (80%), Islam (14%), Christianity (2%), Sikh (2%), and others (2%).⁴ Official languages include Hindi (the most commonly spoken language; 41%), Bengali (8%), Telugu (7%), Marathi (7%), Tamil (5%), Urdu (5%), Gujarati (5%), Kannada (4%), Malayalam (3%), Oriya (3%), Punjabi (3%), Assamese (1%), and others.⁴ Every state also has its own native language.^3,4 English is taught, starting in elementary school, and it has the status of being the subsidiary official language for political and commercial communication.⁴ English is also commonly used as a primary language in higher education.

India has a diverse open-market economy emerging as one of the fastest growing in the world. Monetary advancement measures began in the early 1990s, the goals of which were to stimulate economic growth, attract overseas manufacturing, provide relief to the middle class, curb black market money, digitalize the economy, enhance transparency in political funding, and simplify tax administration.⁵ Gross domestic product (GDP) grew to nearly 7% per year from 1997 to 2017.⁵ Many pharmaceutical companies have their research-and-development and manufacturing units in India, and the country is also known as one of the largest distributors of generic drugs, supplying to domestic and international buyers.

Indonesia.

Indonesia consists of 13,466 islands formed primarily from volcanos, many of which continue to be active.⁶ Seismic activity in the region often leads to substantial earthquakes and subsequent tsunamis. Its five largest and most populous islands are Borneo, Java, New Guinea, Sulawesi, and Sumatra. The December 2004 tsunami was the result of a devastating quake off the coast of Sumatra. Jakarta, the capital of Indonesia, is located on the island of Java. This also is where the primary airport for international flights is situated. People can also fly into Bandar Lampung, Sumatra, Yogyakarta, and Bali.

Indonesia’s total population is the fourth largest in the world, estimated at 260 million.⁶ Nearly 90% of Indonesians are Muslim and approximately 9% are Catholic or Protestant Christians.⁶ Indonesia is the home of a myriad of traditions and cultures, with at least 300 major ethnic groups and 400 languages.⁷ People from Indonesia are referred to as “Indonesians.” The country’s population includes immigrants from other Asian countries such as the Philippines, Malaysia, China, and Papua New Guinea. The official language of Indonesia is Bahasa Indonesia, but there are hundreds of local dialects and languages spoken throughout the country.⁶ English is a second language for many health care professionals.

Malaysia.

Malaysia, established in 1963, consists of two noncontiguous areas, peninsular Malaysia (formerly known as West Malaysia) and East Malaysia.^8,9 The capital of Malaysia is Kuala Lumpur.⁸ Malaysia has a population of roughly 31 million people, of which over 80% live on the Malay Peninsula.⁸

Malaysians are made up of multiple ethnic groups: Bumiputeras (69%), Chinese (23%), and Indians andSikhs (7%).¹⁰ Languages spoken include Bahasa Malaysia (the official language), English, Chinese, Tamil, Telugu, Malayalam, Panjabi, and Thai.⁸ Of its 134 living languages, 112 are indigenous. Malaysia was under British colonization, and Malaysians are known to have relatively high proficiency in English.¹¹ Islam is the official religion of the country, practiced by 61% of the population; other religions include Buddhism, Christianity, and Hinduism.⁸

Philippines.

Officially called the Republic of the Philippines, this archipelago is composed of 7,641 islands.¹² Only about one-third of the islands are inhabited. Luzon is the largest island. It covers 47% of the country’s total land area.^12,13 Luzon is home to Manila, the capital city of the Philippines. The estimated population of the Philippines is 104 million.¹² The people of the Philippines are called Filipinos. They reflect the cultural and racial blend of the country’s ancestors and colonizers who were Malays, Chinese, Spaniards, Americans, and others.^12,14-16 The Philippines was under Spanish rule for more than 300 years (16th-18th centuries), under American rule for nearly 40 years following the Spanish-American War, and gained its full independence in 1946 as the Republic of the Philippines.^14-16

The Spanish friar missionaries brought Christianity to the Philippines.¹⁷ Over 80% of the population is Christian, 80.9% of whom are Roman Catholics.¹² Islam was already established in the southern islands of the Philippines prior to the arrival of the Europeans. Today, Muslims comprise 5% of the population.^12,18 Of the nearly 100 culturally and linguistically distinct ethnic groups in the country, the three largest groups are the Tagalog, Cebuano, and Ilocano; which constitute half of the country’s total population.^12,15,18 The country’s official languages are Filipino (also called Pilipino, based on Tagalog) and English. It is common to hear Filipinos speak “Taglish,” a mixture of English and Tagalog words or phrases in their everyday conversations.¹⁹ English is widely used in government, education, business, and the media, and is the language of instruction in health professions programs.

Reflecting the country’s English-speaking proficiency, people also visit the Philippines for medical care. In 2015, the Philippines ranked eighth in the world as a medical tourism destination.²⁰ One of the contributing factors to this ranking was the ability to provide health care in internationally accredited hospitals by English-speaking health care professionals.²⁰

Vietnam.

Vietnam is a multiethnic (54 ethnic groups) and multilingual country.²¹ The Kinh people account for 87% of the population and live in the Red River delta, the central coastal delta, the Mekong delta, and major cities.²¹ The other 53 ethnic minority groups are scattered over mountainous areas spreading from the north to the south of Vietnam. The country’s population is approximately 93 million, and the proportion of people 65 years old or above has been increasing rapidly, from 4.7% in 1989 to 8.0% in 2016.²² According to the 2015 report of the Government Committee for Religious Affairs, there were approximately 12 million Buddhists, 7 million Catholics, 2 million Caodaists, 1.5 million Hòa Hảo Buddhists, 1.5 million Protestants, 80,000 Muslims, and 500,000 followers of other religions.²³

Vietnamese is the national and official language. In recent years, English has become more popular and is favored as a second language. Students in elementary schools can choose to learn English as an optional course, and it is a required course for sixth to twelfth graders in the secondary school. Health care professionals, including physicians, nurses, and pharmacists, often communicate in English if they work in urban hospitals where care is provided to international visitors. However, the use of English is likely limited in other health care settings, and interpreter services are not typically available.

India.

In India, the health care system is regulated at the federal government level, while the states are responsible for organizing and providing health services to their populace. The responsibilities of the federal government include negotiating international health treaties, overseeing medical and health sciences education, ensuring food adulteration prevention, conducting quality control over drug manufacturing, ensuring national disease control, and administering family planning programs.²⁴ The life expectancy in India is 67 years for men and 70 years for women.²⁵ Total health expenditures for 2013-2014 were 4.02% of the GDP.²⁴ Citizens can purchase their own health insurance from private companies; however, the majority of the population pay medical bills out of pocket. Patients can receive care either at hospitals supported by the federal or state government or at private hospitals. Primary care is available in both urban and rural areas, but disparities exist in the quality of health care among rural and urban regions and also among public and private practice settings.^24,26 The public health care system focuses on providing primary care in rural areas whereas the private sector provides the majority of secondary, tertiary, and quaternary care in densely populated areas.^24,26

In the Indian education system, students who pass state-level entrance examinations after completing secondary education enter professional programs such as medicine and pharmacy, depending on their ranking on the examination and individual’s interest (Figure 1). The role of pharmacists, also referred to as chemists or druggists, varies according to their level of study and experience in a particular field.²⁷ Those interested in practicing within a retail pharmacy or opening their own business can pursue a two-year diploma in pharmacy (DPharm) degree. Another educational path is the traditional four-year bachelor of pharmacy (BPharm) program. The BPharm degree is required for a pharmacy license. BPharm graduates can work for pharmaceutical companies or government agencies, open their own pharmacy business, or work in research (Table 1). They can also pursue advanced degrees such as the master of pharmacy (MPharm) or doctor of philosophy in pharmacy (PhD). In 2008, the Doctor of Pharmacy (PharmD) degree program was initiated by some colleges and universities and included training in monitoring patient health and progress, and optimizing response to medication therapies by working alongside physicians and experts.^28-30 The US National Association of Boards of Pharmacy (NABP) does not recognize this PharmD degree as equivalent to its US counterpart; thus, PharmD graduates from India may need to complete additional education or testing to practice in the United States.

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Figure 1.

System of Pharmacy Education in India, Indonesia, Malaysia, Philippines, and Vietnam

• Vietnamese figure was adapted from Vo TH, Bedouch P, Nguyen TH, et al. Pharmacy education in Vietnam. Am J Pharm Educ. 2013;77(6):114.⁵¹

Pharmacies in India are often referred to as “medical stores” and are found in communities and hospitals. Pharmacists oversee the dispensing process; however, there are typically no electronic databases or records of patients’ medications and/or medical histories in these medical stores.³¹ The Pharmacy Council of India continues to work with the various disciplines of pharmacy to establish the role of pharmacists as medication experts who can promote patient’s health and contribute to disease prevention.^28-30

Indonesia.

There are two sectors of the health care system in Indonesia: public (or state) and private. The government funds public hospitals and primary health care clinics (Puskesmas) across Indonesia, while individual organizations or private companies run private clinics and hospitals.³² Despite significant government investment in public health and the implementation of decentralized health care since 2001, the quality of both public and private health facilities has not significantly improved.³³ Many health care facilities reported health workforce deficiencies and poor infrastructure particularly in remote areas.³⁴ Life expectancy is shorter in Indonesia than in the United States: 67 years for men and 71 years for women.³⁵ Most physicians and midwives work in urban areas, and limited numbers are in remote areas.³⁴ Health care professionals (particularly physicians) are highly respected and commonly come from higher socioeconomic classes.³²

Indonesia initiated universal health care, the Badan Penyelenggara Jaminan Sosial (BPJS), in 2014.³⁶ The BPJS aims to consolidate existing insurance services that provide comprehensive care to 180 million people. It is expected to cover all citizens by 2019, including civil servants, formal sector workers, and low-income individuals.³⁶ The BPJS is designed to cover catastrophic expenses. Leading causes of death in Indonesia are stroke, ischemic heart disease, and diabetes, with increasing prevalence of these diseases projected through 2021.³⁵

Indonesia has a range of pharmacy education programs: three year diploma, undergraduate bachelor of science (BSc), pharmacist professional (Apoteker), masters, and PhD (Figure 1).^34,37 Currently, more than 200 universities offer undergraduate pharmacy programs; only 42 offer pharmacist professional programs (Table 1).^37,38 To become an Apoteker, students study for five years, consisting of four years in an undergraduate pharmacy program and one year in a pharmacist professional program.³⁴ The Ministry of Education, in accordance with the Association of Colleges of Pharmacy Indonesia and the Indonesian Pharmacist Association (Ikatan Apoteker Indonesia or IAI), has set the standard minimum of credits for undergraduate and professional pharmacy programs to generate pharmacists competent in carrying out the work and delivery of pharmacy services.³⁴ The majority of pharmacists practice in the community, while others practice in pharmaceutical industry and hospitals (Table 1). Hospital pharmacists provide and manage medical supplies, nonclinical pharmaceutical care, and clinical pharmacy services.³⁴ The Ministry of Health and IAI have set regulations and standards to improve the quality of pharmacist services in both hospital and the community settings. Regulations for pharmacy employment services have also been standardized by the Indonesian government.³⁴ Many private and state institutions are establishing new educational programs and facilities. Pharmacists are working to gain more authority within the health care system to address public health needs. For example, some pharmacists are beginning to check blood pressure readings in the outpatient setting.

Malaysia.

Malaysia has a two-tiered health care system, consisting of a public and a private sector.³⁹ Although government expenditures on health care is a small portion of the country’s GDP, Malaysia has nonetheless made advancements in health care, particularly in rural areas.³⁹ Rural health care is one of the largest sectors supported almost entirely by the government, which deploys physicians, nurses, pharmacists, dentists, and other allied health care workers to rural clinics, district hospitals, or tertiary institutions in more remote areas.³⁹ The private sector provides care on a nonsubsidized, fee-for-service basis.⁴⁰ The country has been successful in establishing a health care facility within every five-kilometer radius, allowing access to basic health care to all who need it.³⁹ Overall, the Malaysian health care system has developed effective integration over the past five decades, with primary health care linked to larger hospitals and the provision of a government-managed fleet of ambulances and airlift for remote areas.

Large referral/teaching hospitals began development and growth in the 1980s, and in the past decade tertiary care specialist facilities have been built in most major cities within the country.³⁹ As of 2012, Malaysia had 140 public hospitals, 1025 health clinics, and 1831 community clinics.⁴⁰ This advancement in health care services has resulted in life expectancies of 73 and 78 years for men and women, respectively.⁴¹

Pharmacy services began in 1951 with the enactment of the Registration of Pharmacist Act, the Poison Act, and the Dangerous Drug Act.⁴⁰ The establishment of the Drug Control Authority and the Pharmaceutical Control Bureau in 1984 developed a more systematic pharmaceutical regulatory system.⁴⁰ Pharmacy practice began as the supplier of pharmaceuticals but has expanded to include services of regulating and ensuring quality, safety, and efficacy of medications.⁴⁰ By the 1990s, there was a shortage of pharmacists in the public sector.⁴⁰ The Ministry of Health enacted measures to attain a pharmacist to population ratio of 1:2000 by 2020.³⁹ Included in these measures were requiring pharmacists to provide four years of government service after registering as a pharmacist and increasing the number of institutions offering the four-year undergraduate pharmacy program.⁴⁰

Pharmacy education is offered by both public and private universities and consists of a four-year bachelor’s degree (Table 1, Figure 1). Universities offer both undergraduate and postgraduate pharmacy programs. Upon graduation from the four-year degree, all graduates must complete a one-year internship as provisional registered pharmacists and pass the pharmacy jurisprudence examination before becoming fully registered. The master’s degree in pharmacy is available in six focus areas: clinical pharmacy, pharmaceutical chemistry, pharmaceutical technology, pharmacology, physiology, and social and administrative pharmacy.⁴⁰ Upon graduation from the four-year degree program, all graduates must complete a one-year internship as provisional registered pharmacists and pass the pharmacy jurisprudence examination before becoming fully registered.

Philippines.

In the past 30 years, the Philippines has launched several major reform efforts to address inefficiencies and inequities in health care access and outcomes between socioeconomic groups.^18,42 Health care financing is a public-private mixed system.^18,42 Since 1995, the Philippines has had a national health insurance agency, PhilHealth, but high household out-of-pocket payments persists.^18,42 Because of lack of access and the high cost of health care, some Filipinos rely on alternative medicine and faith healers.⁴³

The 2017 estimated life expectancy at birth was 66 years for men and 73 years for women.¹² The Philippines has a decentralized health care system.^18,42,44 The system has three levels: national, provincial, and local. The national, provincial, and larger city governments are responsible for providing tertiary and secondary care. Smaller city, municipal, and local government units called barangay are responsible for providing primary care. Although the majority of trained health professionals remain in the country, many immigrate to other countries.⁴⁴

The Philippine Pharmacy Act was enacted in 2016 with the following objectives: standardization and regulation of pharmacy education; administration of licensure examination, registration, and licensing of pharmacists; supervision, control, and regulation of the practice of pharmacy; development and enhancement of professional competence of pharmacists through continuing professional development, research, and other related activities; and integration of the pharmacy profession.⁴⁵ The Act included a provision that required registered pharmacists to maintain active membership in an accredited professional organization (that is, the Philippine Pharmacists Association, PPhA) and to obtain their Professional Identification Card and renew it every three years.

The Pharmacist Licensure Examination (PLE) is administered twice a year. By law, a complete list of successful examinees as well as the performance of schools is published in a newspaper with national circulation and is available online.⁴⁶ Attempts to standardize and regulate pharmacy education have been ongoing since the 1980s. A 2006 law defined pharmacy education as “a four-year bachelor’s degree which provides a broad spectrum of scientific training and can lead to employment in a wider range of scientific fields” (Table 1, Figure 1).⁴⁷ It also encompasses education in pharmaceuticals, cosmetics, household hazardous substances, drug delivery devices, and veterinary medicines.⁴⁷ The four-year BS Pharmacy curriculum consists of general education courses, core courses, professional courses with thesis/research project requirement, and 600 hours of practicum/internship (200 hours each for community pharmacy, hospital pharmacy, and manufacturing pharmacy).⁴⁷ In addition, pharmacy graduates are required to complete 360 hours of internship prior to taking the PLE.

The 2016 Philippine Pharmacy Act (PPA) opened more opportunities for pharmacists. For example, the PPA created a demand for pharmacists in the government sector to procure medicines for primary care facilities.⁴⁵ The current demand has raised the salaries of community pharmacists. This has reduced the outmigration of pharmacists. It is not yet commonplace in the Philippines to see pharmacists working directly with physicians and other health care professionals. A 2015 survey showed that of 1,812 hospitals, only 20 private and six government hospitals provided clinical pharmacy services.⁴⁸

Vietnam.

The health care system in Vietnam is organized in a four-level (primary, secondary, tertiary, and quaternary) system. The quaternary level is the Ministry of Health (MoH), the national authority that formulates and executes health policy and programs. The tertiary level is at the provincial level; 63 provincial health bureaus follow MoH policies but are in fact organic parts of the local governments. The primary and secondary levels are at basic health networks, including district health centers, community health stations, and village health workers.⁴⁹ The reported life expectancy in Vietnam is 72 years for men and 81 years for women.⁵⁰

The education system for pharmacists in Vietnam is quite complex. After graduating from high school, those wishing to become pharmacists can choose courses leading to one of the four qualifications: elementary diploma in pharmacy (EDPharm, one year), secondary diploma in pharmacy (SDPharm, two years), college diploma in pharmacy (CDPharm, three years), or bachelor of pharmacy (BPharm, five years) (Figure 1).⁵¹ Pharmacy programs vary in length depending on the preexisting pharmacy training of the candidate and levels of the study. For instance, after graduating from high school, students can be enrolled directly in the five-year BPharm program or complete a two-year SDPharm program before continuing to the four-year BPharm program. If students hold a bachelor’s degree in science, they can also apply for the three-year BPharm program. Pursuant to pharmaceutical laws, after obtaining a degree from pharmacy school, graduates can be employed immediately in most public or private settings. However, only those who have completed the BPharm program are considered fully qualified pharmacists. Additionally, a BPharm degree and a minimum of five years of practical experience are typically required to become a chief at a private pharmacy in an urban area; two years of practical experience are general requirements in rural areas. Similarly, a BPharm degree with a minimum of three to five years of practical experience is needed to become supervising personnel for a pharmaceutical manufacturing company, a wholesale drug distributor, or a company providing pharmaceutical storage services. Those holding the one-year EDPharm degree with at least two years of experience can work as the person in charge of a community health center or as a distributor-owned wholesaler.⁵²

The regulation of pharmacy practice in Vietnam is also quite different from that in the United States. For example, a larger number of medications can be dispensed by pharmacies in Vietnam without prescriptions. Reflecting this practice, high rates of antibiotic use have been followed by a high incidence of antibiotic resistance. In a study among Asian countries in 2001, Vietnam had the highest prevalence of penicillin-resistance with an estimated 71.4% rate of streptococcus pneumoniae resistance.⁵³ Inexpensive out-of-pocket health care expenditures, ability to purchase antibiotics without prescriptions, and lack of knowledge about appropriate antibiotic use have contributed to the problem. Many Vietnamese find it cheaper and faster to buy drugs directly from pharmacies than to seek help first from medical practitioners.⁵⁴

India.

Although Hindi is the most common language spoken in India, not everyone speaks Hindi. Many foreigners believe most Indians speak English with a thick accent, but this is not true. Also, British English is taught in most Indian schools. In terms of skin color, the common view that all Indians are dark-skinned is inaccurate as some Indians have lighter skin tones.

Another misconception is that all Indians are vegetarians. While it is true that a large population of Indians are vegetarians, Northeast India is famous for its cuisine using water buffalo, goat meat, chicken, and fish. Poultry dishes are consumed throughout the country. A small number of Indians also eat beef and pork.

India is still considered a male-dominated society, where the head of the home is a man and is respected by younger family members. Arranged marriages, where parents choose the future spouse of their sons or daughters with some minor consent from their children, are common. However, socializing between young men and young women is quite common in metropolitan cities as well as towns, and self-selected marriage is equally accepted in India. Many women and young girls wear a red dot called a bindi in the center of their forehead. Traditionally, the red bindi had a spiritual role in the Hindu religion and signified married status, while a black bindi implied loss and was worn by widows. In modern times, its symbolic meaning has lessened. Women can now wear various colors of bindi irrespective of their marital status or religion.⁵⁵

Indonesia.

Geographically, many visitors think that Indonesia is in Bali or that Bali is a stand-alone country. Bali is Indonesia’s largest tourist destination and is one of the most famous cities in the world. However, Bali is a relatively small island in Indonesia.

Some people also believe that Indonesia is an Islamic country. While it is true that around 90% of Indonesians are Muslims, the country itself is not constitutionally a Muslim country.⁵⁶ The Indonesian Constitution guarantees freedom of religion, and a number of different religions are practiced in Indonesia. Non-Muslims are given the same rights as Muslim citizens, and all citizens are free to practice their religion.

While poverty is still an issue in Indonesia, the general perception that Indonesians are poor is not accurate. In fact, as a country, Indonesia is experiencing strong economic growth. Many parts of the country are now very well developed in terms of infrastructure and technologies. While some ethnic groups choose to live traditionally with little to no modern technology, there are several big cities in Indonesia that are dense with shopping malls, hotels, and other modern facilities. The thought of Indonesians as being un- or under-educated is incorrect. In reality, government regulations require all children to attend at least nine years of schooling.

Malaysia.

Because the people of Malaysia are predominantly Muslim, there is a misconception among Westerners that the country is uninteresting and/or dangerous, which is untrue. Visitors will find that Malaysians are warm, friendly, and quite laid back. Although the Islamic religion prohibits alcohol intake in addition to other social customs that may seem conservative to foreigners, select cities in Malaysia do have night life and restaurants. Additionally, Islamic culture brings unique aspects to the country and visitors might enjoy taking part in mosque trails and halal hubs.

Although in some Asian countries the population is relatively homogenous in ethnicity, it would be wrong to assume the same of Malaysia. In fact, Malaysia is very multi-cultural. While the population is predominantly Malaysian, there are many different ethnic groups within the country. Terminology referencing ethnic groups varies. For example, Malay refers to a distinct population within Malaysia, and is different from the term Malaysian, which refers to the broad population of the country. In fact, similarly to the viewpoints that some Americans hold about people from certain areas of the United States, different ethnic groups within Malaysia likely hold their own stereotypes about people of other ethnicities within Malaysia.⁵⁷

Philippines.

The people of other countries in Southeast Asia perceive the Philippines to be a non-English-speaking country.⁵⁸ However, English is an official language of the Philippines. Most Filipinos understand and speak English.

One misunderstood practice of Filipinos is their view of time as flexible. For medical or work-related appointments, punctuality is expected. However, for a party or social function, Filipinos run on “Filipino time,” that is, it is acceptable to show up 15 to 30 minutes late. It is actually considered impolite to be on time for these types of events.^58,59

Occasionally, the Philippines has been portrayed in the news as a dangerous country.⁵⁸ Terrorist attacks and kidnappings of foreign nationals by terrorist groups and criminal gangs have been reported. However, these are isolated incidents are not the norm. The majority of the populated islands in the Philippines are generally safe. Filipinos are genuinely warm, friendly, generous, and hospitable. Filipino hospitality is best exemplified in regard to foreign guests, who are treated with utmost respect. Filipinos enjoy the company of foreign visitors, and most who have visited the country can testify to the warmth and friendliness of the locals.²⁰

Vietnam.

Vietnam’s value system is influenced by multiple cultural and religious layers, including traditional values, Confucian and Taoist values, Buddhist values, western values, and socialist values.⁶⁰ Traditional values can be described as having patriotism, self-strengthening spirit of the nation, compassion, diligence, and optimism.⁶⁰ Confucianism and Taoism teach having a studious spirit, allegiance to family, and a desire for reputation, respect, and harmony.⁶⁰ Values affected by Buddhism are the causes and effects of rules, sympathy, tolerance, benevolence, and heartedness.⁶⁰ The Western values contribute the ideas of individualism, liberty, equality, and democracy.⁶⁰ Vietnamese socialism also adds independence, freedom, happiness, justice, and civilization to the values system.⁶⁰

Vietnamese students have mostly a passive learning style, and they may be perceived as “shy.” Vietnamese high school students rarely have a chance to challenge and discuss concepts. Instead, the usual learning style is to memorize information provided by their teachers. In addition, high schools often lack courses to help students develop personal and soft skills.⁶¹ Student’s shyness might be a simple reflection of their learning styles, and this should not be taken as individual’s personality.

India.

As in the United States, many Indians migrate from their hometowns to other cities and states in search of higher education or work. Every state in India is unique and has its own culture, traditions, staple foods, and language. Therefore, US visitors should realize that the Indians they encounter may come from different cultural backgrounds. Language is probably one of the most fundamental facets shaping a person’s cultural background. Although Hindi is primarily spoken in India, a person speaking Hindi in New Delhi will have a different dialect than a person from Mumbai. English is commonly used in business, but it may take some time for visitors to get adjusted to the different dialects.⁶² Learning a few Hindi words and phrases would be helpful for prospective visitors. The traditional Indian greeting is to say, “Namaste” while pressing the palms together with fingers pointing upwards and giving a slight bow of the head.⁶² It is standard practice for visitors to shake hands with men. Shaking hands with women is not as common, and it would be better to wait for a woman to offer a handshake. Alternatively, simply saying, “Namaste” will suffice.⁶² A man holding hands with a woman is rare in India, especially in smaller towns. In terms of gestures, travelers are often astounded when Indians make a basic nonverbal movement, shaking their head from side to side, which may send a mixed message, ie, indicating yes and/or no, to the person speaking. However, this motion is actually a nonverbal method of showing comprehension and agreement with the conversation (Table 2).⁶²

In India, religion is a key part of life. In fact, productive business associations in India require keeping each other’s religion and customs in high reguard.⁶² Casteist (social stratification) thinking still remains in some societies within India, and parts of business norms might still be impacted by it.⁶² Visitors should prepare themselves for heavy traffic as India is a highly populated country. Also, environmental pollution is often noticed by visitors to urban areas. Because of sanitary concerns, visitors should avoid eating food or beverages from street vendors.

Indonesia.

Indonesia is a diverse country with hundreds of distinct native ethnic groups, each having their own unique culture and customs. Among these, Javanese is the largest ethnic group and makes up about 40% of the total population.⁵⁶ For Javanese people in particular, pointing with the thumb is considered more polite than using the index finger, although some US visitors may find this unclear especially when they are asking for directions. While punctuality is not usually a primary concern to Indonesians, many Indonesians, particularly health care professionals, are much more sensitive about punctuality. Visiting Americans should always be on time for professional activities and adapt to norms after gaining trust and knowledge of person- and site-specific expectations regarding time. Although Bahasa Indonesia is the lingua franca and the formal language used in towns and cities, it is also frequently used by many people in rural areas of the country.⁷ English also is commonly spoken, particularly among the young. When communicating with patients, however, avoiding complex medical terminology, slang, or jargon is still recommended. Also, visiting Americans should ask if it is okay to speak English at the outset of the conversation. While many Indonesians will humbly state that their English is not very good, most Americans will find it to be quite adequate for basic communication. Independence Day, August 17, is a national holiday and festivity, and various social gatherings take place in most Indonesian neighborhoods and communities in urban and rural areas.⁷ It is a very important day for social gatherings where Indonesians form strong personal bonds and friendships among participants. If possible, visitors to Indonesia should avoid arriving in or departing from Indonesia on this day so as not to disrupt the festivities for their host.

Neighbors providing mutual help to each other to achieve a shared goal is called gotong royong and is an ancient tradition.⁷ American visitors should recognize that an Indonesian host and sponsoring organization have a shared goal of providing their visitors with a satisfying experience and will go to great lengths to do so. Thus, Americans should adapt to the local culture as much as possible and avoid making excessive or unnecessary requests. Expressing gratitude to their hosts is recommended to recognize the hosts’ efforts.

Malaysia.

Culturally, Malaysians may be perceived to be more conservative with regards to social life. While allowances are often made for visitors, it is best to become familiar with local customs to avoid being rude. Local customs regarding traditions and laws should be respected, particularly if visiting during the month of Ramadan.⁶³ Dressing modestly (eg, covered arms and legs, covered hair for women) when visiting places of worship is a must. Within the education sector, adhering to a formal dress code is expected in most situations, and pharmacy students visiting for rotations should consult their host regarding required attire. Business meetings require the standard western-style suit and jacket for men. Women should avoid any clothing that displays skin around the back, chest, stomach, and feet.

Many cultural customs are similar to those of other Asian countries. Family is often considered the center of the social structure, emphasis is placed on respecting the elderly, and all strive to maintain “face” and avoid shame both publicly and privately.⁶³ Visitors should remember that open criticism and disagreement with someone will not be taken kindly. Remaining calm and courteous, discussing errors or problems in private, and speaking about problems without assigning blame is the best way to resolve tense situations.⁶³ Pharmacy students visiting Malaysia should remember to approach interactions with their preceptors or other figures of authority in a similar manner.

Because of the multicultural nature of the country, the correct greeting often depends on the ethnicity of the hosts.⁶⁴ Malay women do not shake hands with men, but will shake hands with other women.⁶³ Generally, men will bow rather than shake hands with a woman. Chinese Malaysians will shake hands with either gender, and many older Chinese lower their eyes as a sign of respect.⁶³ Indian Malaysians will shake hands with those of the same gender, while a simple smile and nod is sufficient when greeting someone of the opposite gender.⁶³ Most Malaysians are not accustomed to hugs and kisses. Similar to other Asian countries are the importance of respecting rank and title in Malaysia.⁶³ Those visiting for pharmacy conferences, meetings, or rotations should remember to greet locals in rank order, with the most senior person first, and to address all by their formal titles unless directed otherwise. Business cards should be prepared by both professionals and students and should be given and received with both hands, paying attention to look carefully at the card, as respecting someone’s business card is indicative of the respect one will show in business.⁶³ Whether business or social, Malaysians rely on nonverbal communication that is subtle and indirect.⁶⁴ If someone is unsure about the response he received, he should continue the discussion and rephrase his question in multiple ways.

Philippines.

Philippine society has certain affinities with Western culture, influenced mostly by centuries of Spanish and American rule. Filipinos have strong religious faith, respect for authority, and high regard for amor propio (“love of self” or self-esteem) and amiable interpersonal relationships.^14,65 Many of the religious and liturgical practices introduced by the Catholic Spaniards are still practiced today, such as devotion to and veneration of the saints, praying of the rosary, attending misa de aguinaldo or misa de gallo (Christmas dawn masses), and the building of little altars or family shrines in one’s home.¹⁷ Strong religious faith enables Filipinos to deal with tough situations or life-changing moments. One of the most widely used phrases in the Philippines, including in patient-care settings, is “bahala na,” short for “bahala na ang Diyos”; it means “God will take care of it.”⁶⁶ Filipinos are taught to respect their elders, parents, and older siblings at a very young age. By extension, respect for authority is afforded to anyone in a position of power.^14,65 Filipinos in subordinate positions generally accept the hierarchy in companies as described above in the Malaysia section.⁴³ It is important for visitors to address people directly using their academic, professional, or honorific titles. In the college classroom setting, students are addressed as “Mr” or “Ms” followed by their last name.

Maintaining one’s self-esteem is highly regarded by Filipinos in almost all social situations and Filipinos are sensitive to attacks on their self-esteem.^14,65 It is closely tied to the concept of hiya, a sense of shame or losing face. Filipinos may hesitate to ask a question for fear of looking foolish. If Filipinos fail to conform to accepted standards of behavior or live up to expectations, they lose self-esteem and bring shame to their family.⁶⁷ Anything that might hurt another’s self-esteem is also to be avoided as discussed in an above section for Malaysia. An example of hurting another’s self-esteem can be the simple act of refusing outright any offer of food or drink. Filipinos pride themselves on their hospitality. They also value harmony and smooth personal relationships. They may sacrifice their self-interest to avoid embarrassment or confrontation. They have difficulty saying “no” and will often avoid answering a question with “no.” Instead, they may say “yes” but mean “I’m not sure,” “perhaps,” or “if you say so.”⁵⁹

There are some unwritten rules in professional and business settings.^59,67 For medical or work-related appointments, it is best to be punctual. When it comes to attire, it is mostly formal and conservative. It is best to dress well because appearances and first impressions matter to Filipinos. Handshakes are the most common form of greeting. One must avoid using the casual greeting, “How are you?” as Filipinos may interpret the greeting literally and provide an answer to the question. When conversing, Filipinos favor direct eye contact but staring is considered rude. Furthermore, there is considerable demonstrative touching between men and men, and women and women, but limited contact between men and women. For nonverbal cues, one must avoid standing with hands on one’s hips as this indicates anger or displeasure. The same goes with pointing or wagging a finger at people.

Vietnam.

Because of historical Chinese influence on Vietnam, Confucian philosophical beliefs have permeated Vietnamese culture. A patriarchal family is the traditional structure.⁶⁸ Extended families from three or even four generations are also common.⁶⁹ Compared to the United States, individualism is less prominent, and Vietnamese people consider themselves more strongly as part of their family, which includes a long line of ancestors, living family members, and future descendants.⁶⁸ People seek help from family members first in times of personal crisis and highly value their family’s opinions and interests when making personal or household decisions. Vietnamese people typically give deep respect to their ancestors as many traditionally believe that the dead can influence the living.⁶⁸ As also seen in other Asian countries, people are expected to show respect to those who are senior to them in age, status, or position. At home, individuals respect their parents, older siblings, and older relatives.⁷⁰ Although constitutionally women are equal to men, visitors may observe that Vietnam is still a male-dominated society.⁷¹

In terms of personal space, Vietnamese people prefer standing at least two to three feet from one another. While they may touch their friends and acquaintances during conversations, there is almost no touching between men and women. Vietnamese people tend to favor indirect eye contact; direct eye contact may be overtly viewed as suspicious or threatening.⁷² Harmony is important to the Vietnamese, and as described for Filipinos, Vietnamese people often avoid saying “no.” For these reasons, it is important for the visitor to catch nonverbal cues (Table 2); thus, meeting in person rather than speaking over the phone is most likely preferable.

In Vietnam, working hours may differ from what Americans might expect. Offices usually open at 7:30 or 8:00 am and close around 4:30 or 5:00 pm. In local governmental organizations, employees tend to have 1- to 1.5-hour lunch breaks and usually take a nap after lunch for 30 minutes or one hour, which can extend their midday break. In addition, in local organizations, deadlines and work schedules are not strictly followed. It is not surprising to find people arrive late and leave early. Also, meetings and events can be scheduled and cancelled at the last minute. These time orientations may not necessarily apply to health care settings and international organizations, so visitors should clarify meeting times explicitly.

India.

The United States has been well known among Indian students for their quality of higher education. When Indian students visit the United States, they may need some time to adjust to American culture. Because the majority of higher education in India is delivered in English, most Indian students can speak English fluently. However, their pace of speech may vary, some faster than others, and preceptors may need to understand this aspect of speech. Generally speaking, Indians are shy about sharing personal issues, such as roommate or family issues, with others, hence, routinely checking with them about their well-being can help them feel more comfortable.

The Indian education system is very strenuous. Course syllabi are vast, and examinations are in essay formats rather than in multiple-choice questions commonly used in the United States. The grading system is also very different. For example, achieving 60% on an Indian examination may be considered equivalent to the US grade of A. Hosts should be aware of this difference in performance scales when reviewing the transcripts or curriculum vitae of Indian students.

Prior to the arrival of Indian visitors, the hosts should clarify any dietary restrictions their guests may have as many Indians follow vegetarian diets or have restrictions on the types of meats they can consume. For example, visitors following the Hindu religion will likely be vegetarians and consume no meat, while guests following the teachings of Islam would eat halal meats except for pork. Halal meats are those prepared in accordance with Islamic law. Hence, when hosting social gatherings, it is important for hosts to consider serving appropriate food for Indian guests.

India is a multi-cultural country where people follow various rituals based on where they are from and their religion. Religion is an important element of Indian life. Conversations on religion might be sensitive and awkward for some; hence, it may be best for hosts to avoid the topic.

Indonesia.

The United States has been one of the most popular destinations for Indonesian students to study abroad. Because of the differences between the respective cultures and climates, it may take a while for Indonesian students to adjust to their new environment. Prior to the students’ arrival in the United States, their hosts should provide them with information on such things as accommodations, transportation, and accessibility to Asian grocery markets, prayer areas or local religious centers, halal butchers, and halal restaurants. Serving halal and/or vegetarian foods at social gatherings is thoughtful. With regards to meals, most Indonesians eat rice two or three times daily. Many Indonesians tolerate or love spicy food. In terms of language proficiency, many Indonesians speak English, especially younger generations. Thus, US hosts can anticipate that pharmacy students from Indonesia will have at least workable English proficiency.

Malaysia.

Hosts to Malaysian visitors should keep their guests customs and traditions in mind while teaching them about American culture. In many ways, American customs may be perceived as rude or offensive because of the propensity for individual expression without regard to the larger group. Thus, the host should educate Malaysian visitors about what to expect. In general, Malaysians pause before answering questions to indicate that thought has been put into a response, whereas Americans tend to provide answers immediately. The hosts should explain to visitors that this is normal in the United States and they should not be offended by this practice. For visitors who practice Islam, the hosts should learn about their dietary restrictions, such as whether they drink alcohol.

Pharmacy students coming from Malaysia may experience some culture shock in both social and professional etiquette. Socially, Malaysians tend to arrive a little later than the agreed meeting times, and this is both accepted and expected at times. In the United States, this may not be appropriate, so students should be informed in advance that they are expected to arrive on time or even five minutes early. Also, US hosts should realize that Malaysian students are accustomed to addressing their preceptors formally and may not change this habit even if told otherwise.

Philippines.

Filipinos are exposed to the US way of life through televisions, movies, or social media. Therefore, Filipinos may have a romanticized perception of Americans or stereotypes about them. It may take some time and guidance from their hosts for Filipinos to adjust to the disparities and unique characteristics among Americans in different regions of the country and among diverse racial and ethnic groups.

In the pharmacy setting, Filipinos may lack confidence in their knowledge and skills, especially if they do not hold a PharmD degree or do not have clinical practice experience. Because of hiya and amor propio, they may hesitate to ask for guidance and assistance. Filipino guests may have to be shown around their work environment and provided with detailed information on what they are expected to do and can do rather than being left on their own to find their way.

Filipinos maintain a strong sense of family ties and obligations. Filipino guests may suffer from homesickness and often be connected via social media. Commitment to family may be seen through the care packages of assorted goods or remittances they send home. Food holds a special place among Filipinos. Plain steamed rice is a mainstay of Filipino meals. In addition to three main meals, Filipinos partake of meriendas or substantial snacks in between meals.^59,67

Vietnam.

Vietnamese students might experience various challenges in the United States, but one of the most common is language barriers. They may hesitate to communicate with others as they might be afraid of pronouncing English words incorrectly. Hosts should encourage their Vietnamese students to speak up and assure them that they understand what the student is trying to communicate.

Another challenge Vietnamese students might face is differences in teaching styles and learning environments. Professors are highly respected in Vietnamese medical education.⁷³ As Vietnamese are raised to respect their elders, Vietnamese students may hesitate to interact directly with their professors or interrupt them while teaching even when they have questions. Hosts should reinforce that questions are welcome and that students can share their thoughts with teachers and preceptors. Vietnamese students usually passively listen to lectures and are not used to the concept of active learning. They also may not be familiar or comfortable with self-directed learning. Providing counseling early for these adjustments, setting time to hear from them, and regularly offering feedback are recommended.

The Vietnamese view time in a more relaxed sense for the most part. They put more emphasis on people and relationships than on time.⁷⁴ It may be wise for hosts to acknowledge differences in the perception of time to their guests and to communicate the importance of schedules and deadlines.