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People of Indian Heritage, People of Turkish Heritage, and People of Vietnamese Heritage.

Read content chapter 25, 37 and 38 in Davis Plus Online Website and review the attached PowerPoint presentation. Once done present a 900-word essay without counting the first and last page discussing the cultural health care beliefs of the study heritages and how they influence the delivery of evidence-based health care.

You must cite at least 2 evidence-based references without counting the class textbook. APA Style, Fonts: Arial 12.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition American Indians Alaskan Natives (AI/ANs) Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Amount of Indian blood necessary to be considered a tribal member varies among the tribes—¼ to be a Navajo, which is the largest tribe in United States and live in the Southwest ▪ 556 different tribes in the United States and Canada ▪ Each tribe unique but share similar views regarding cosmology, medicine, and family organization Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Heritage ▪ Forced migration by United States government ▪ Life on MOST reservations is hard with high poverty and high unemployment although a few have significant money due to oil, land leases, gambling casinos, etc. ▪ Children were taken from them and placed in “White Man’s Schools” Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Group, clan, or tribal emphasis Present oriented Time is always with us Age Cooperation Harmony with nature Giving/sharing Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Pragmatic Mythology Patience Mystical Shame Permissiveness Extended family and clan Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Non-aggressiveness Modesty Silence Respect other’s religion Religion is a way of life Land, water, forest belong to all Beneficial, reasonable use of resources Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Low educational levels for most tribes, preferring children to remain at home and learn Indian ways ▪ For the traditional, health care is an undesirable profession because one should not work with the dead or ill ▪ Navajo sometimes have a special cleansing ceremony to allow them to work in a hospital Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Language and dialect vary by tribe, but most speak English and in the southwest many speak Spanish instead of English ▪ Minor variations in pronunciation can change the meaning of the word ▪ Talking loudly or interrupting someone is considered rude Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Navajos generally do not share thoughts and feelings easily outside family and friends, making it difficult to obtain trust in the healthcare setting ▪ Comfortable with long periods of silence ▪ Touch is unacceptable unless you know the person very well Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ No set pattern for willingness to share tribal ceremonies ▪ Pueblo groups usually do not share any tribal ceremonies ▪ Light passing of the hands for a handshake ▪ Considered rude to point with the finger; instead shift your lips in the desired direction Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Direct eye contact is rude and confrontational—deadpan facial expression ▪ Proximity for conversations usually greater than 24 inches ▪ Time sequence is present, past, and future Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ The future is out of one’s control. ▪ Very few are future oriented and for the Navajo there is no future verb tense ▪ Time is not something that can be controlled, nor should time control the person; events start when the people arrive Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Navajo, like most Native Indian tribes, is matrilineal in decision-making and land rights ▪ Relationship between brother and sister is more important than that between husband and wife ▪ Children's names are not revealed at birth Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Older people are addressed as grandmother, grandfather, mother, father, or a nickname. ▪ Algonquin are egalitarian society ▪ Dene and Athabascan are patriarchal ▪ Navajo, Iroquois, Pueblos, and Haida are matriarchial societies Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ AI/AN naming traditions vary greatly from tribe to tribe and are frequently determined by nature, animals, or character. ▪ In the past, AI/AN women practiced breastfeeding exclusively. ▪ Since the early to mid-1980s, the use of formula has become popular. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ A primary social premise is that no person has the right to speak for another. ▪ Parents are permissive in childrearing practices and may allow a child decide whether if not go to school or take medicine. ▪ Ceremony plays a vital, essential role in AI/ANs everyday life. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ When a couple marries in the Pueblo tribes, the man goes to live in the woman’s house. ▪ In Navajo tradition, families have separate dwellings but are grouped by familial relationships. ▪ The Navajo family unit consists of the nuclear family and relatives such as sisters, aunts, and their female descendants. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ In all American Indian and Alaska Natives extended family members play an important role in the infants’ life. ▪ Older adults are looked on with clear deference ▪ Elders play an important role in keeping rituals and in instructing children and grandchildren. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Social status is determined by age and life experiences. ▪ Among the Pueblos governors are chosen from a particular clan; unless one is born in the clan they cannot run for tribal governor. Generally, individuals are discouraged from having more possessions than their peers, and those who display more material wealth are ignored. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Standing out is not encouraged among the different tribal groups. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Many AI/ANs remain traditional in their practice of religious activities. Family matters are more important than work, resulting in high rates of absenteeism. ▪ In addition, tribal ceremonies are seen as necessary and they often must take time from work or school. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Tribal members in the community function informally as cultural brokers and assist by helping non– American Indian staff to understand important cultural issues. ▪ Conflict is addressed indirectly through third parties in some tribes Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Group activities are an important norm in AI/AN cultures. ▪ One individual should not be singled out to answer a question because the student’s mistakes are generally not forgotten by the group. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Issues of superior-subordinate roles exist and are related to age. ▪ IHS is the only organization allowed to discriminate in hiring practices; it is required to hire an AI/AN when possible. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck AI/AN tribes and clans are a. Patriarchal. b. Matriarchal. c. Egalitarian. d. Depends on the tribe and clan. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: D Some tribes and clans are patriarchal, some are matriarchal, and some are more egalitarian. Variations exist within the tribe and clan as well. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Skin color among AI/ANs varies from light to very dark brown, depending on the tribe. ▪ Each of the American Indian tribes vary in terms of facial features and height. ▪ Never assume that an AI/AN patient is from a particular tribe, if wrong, he or she will be offended. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Historically, most diseases affecting AI/ANs were infectious such as tuberculosis, smallpox, and influenza. ▪ Diseases of the heart, malignant neoplasm, unintentional injuries, diabetes mellitus, and cerebrovascular disease are the top five leading causes of AI/AN deaths Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Type 1 diabetes mellitus is almost nonexistent in AI/ANs but type 2 diabetes mellitus is the third most prevalent chronic disease affecting all AI/AN tribes. ▪ The incidence of diabetes varies among tribes has steadily increased and is approaching 30 percent. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Albinism occurs in the Navajo and Pueblo tribes. ▪ Navajos who lived in Rainbow Grand Canyon are genetically prone to blindness that develops in individuals during their late teens and early 20s. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ The Zunis have an incidence of cystic fibrosis seven and one-half times that found for Caucasians. ▪ Methamphetamine (meth) abuse and suicide are two top concerns in Indian country. ▪ Suicide rates among American Indians and Alaska Natives (AI/ANs) are 1.7 times higher than the national average. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Alcohol use is more prevalent than any other form of chemical misuse. ▪ Many accidents are attributed to driving while under the influence of alcohol. ▪ Spousal abuse is common and frequently related to alcohol use. The wife is the usual recipient of the abuse, but occasionally, the husband is abused. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Food has major significance beyond nourishment in AI/AN populations. ▪ Food is offered to family and friends or may be burned to feed higher powers and those who have died. ▪ Life events, dances, healing, and religious ceremonies evolve around food. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Corn is an important staple in the diet of American Indians. ▪ Rituals such as the green corn dance of the Cherokees and harvest-time rituals for the Zuni surround the use of corn. ▪ Corn pollen is used in the Blessingway and many other ceremonies by the Navajo. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Each tribe has its own version of fry bread. ▪ Access to fresh fruits and vegetables is minimal during wintertime. ▪ AI/AN diets may be deficient in vitamin D because many members suffer from lactose intolerance or do not drink milk. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Traditional AI/ANs do not practice birth control and often do not limit family size. ▪ In Apache and Navajo tribes, twins are not looked on favorably and are frequently believed to be the work of a witch. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Some want their blood and urine specimens returned to them upon discharge. ▪ Many use herbs during labor and delivery. ▪ A ceremony may be performed by the medicine man during labor and delivery. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Be flexible with positioning for delivery. ▪ Some may want the umbilical cord, meconium, and afterbirth. ▪ Some may use peyote during labor and delivery. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The most common form of substance abuse among AI/ANs is a. Alcohol. b. Peyote. c. Marijuana. d. Methamphetamine. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer The most common substance abuse among AI/AN tribes is alcohol which is 1.7 times higher than other groups who have been studied. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Most AI/AN tribes believe that the souls of the dead pass into a spirit world and became part of the spiritual forces that influenced every aspect of their lives. ▪ Today some tribes maintain their traditional practices but use a mortuary or use the IHS morgue to prepare their dead. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The Pueblo tribes prepare their own dead and only certain family members are allowed to prepare the body. ▪ Hopis bury their dead before the next setting of the sun and bury them in upright sitting positions with food and goods in the grave with the person. ▪ After the Zuni burial, the members must take off three days from work for a cleansing ceremony. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The body must go into the afterlife as whole as possible. ▪ In some tribes, amputated limbs are given to the family for a separate burial and later the limb is buried with the body. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ In some tribes, family members are reluctant to deal with the body because those who work with the dead must have a ceremony to protect them from the deceased’s spirit. ▪ In the Navajo, if the person dies at home, the body must be taken out of the north side of the hogan and a ceremony conducted to cleanse the Hogan or it must be abandoned. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Older adults are reluctant to discuss advance directives once they discover what it means. ▪ Effective discussions require that the issue be discussed in the third person, as if the illness or disorder is happening to someone else. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ If a provider makes a statement such as “if you don’t get medical care, you will die,” this implies that the provider wishes the client dead. ▪ If the patient does die or is extremely ill, the provider might be considered a witch. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The Navajo are not generally open in their expression of grief; they often will not touch or pick up the body or prepare the body for burial. ▪ Grief among the Pueblo and Plains Tribes are expressed openly and involves much crying among extended family members Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ AI/AN religion predominates in many tribes. ▪ When illnesses are severe, consultations with appropriate religious organizations are sought. ▪ Sometimes, hospital admissions are accompanied by traditional ceremonies and consultation with a pastor. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ AI/AN tribal traditional members start the day with prayer, meditation, and corn pollen. ▪ Prayers ask for harmony with nature and for health and invite blessings to help the person exist in harmony with the earth and sky. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ The meaning of life for AI/ANs is derived from being in harmony with nature. ▪ The individual’s source of strength comes from the inner self and depends on being in harmony with one’s surroundings. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Spirituality cannot be separated from the healing process in ceremonies. ▪ Illnesses, especially mental illnesses, result from not being in harmony with nature, from the spirits of evil persons such as a witch, or through violation of taboos. ▪ Healing ceremonies restore an individual’s balance mentally, physically, and spiritually. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Traditional AI/AN beliefs influence biomedical healthcare decisions. ▪ asking patients questions to make a diagnosis fosters mistrust. ▪ This approach is in conflict with the practice of traditional medicine men, who tell people their problem without their having to say anything. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ IHS has attempted to shift its focus from acute care to health promotion, disease prevention, and chronic health conditions. ▪ Wellness-promotion activities include a return to past traditions such as running for health, avoiding alcohol, and using purification ceremonies. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Medicine men, diagnosticians, crystal gazers, and shamans tell them how to restore harmony. ▪ Many families do not have adequate transportation and must wait for others to transport them to their appointments. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Frequently, pain control is ineffective because the intensity of their pain is not obvious to the health-care provider because patients do not request pain medication. ▪ Herbal medicines may be preferred and used without the knowledge of the health-care provider. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Mental illness is perceived as resulting from witches or witching (placing a curse) on a person. ▪ In these instances, a healer who deals with dreams or a crystal gazer is consulted. Individuals may wear turquoise or other items such as a medicine bag to ward off evil. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ The concept of rehabilitation is relatively new to AI/ANs because, in years past, they did not survive to old age to which chronic diseases became an issue. ▪ Autopsy and organ donation are becoming a little more accepted among traditional AI/ANs. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ AI/AN healers are divided primarily into three categories: those working with the power of good, the power of evil, or both. ▪ Some are endowed with supernatural powers, whereas others have knowledge of herbs and specific manipulations to “suck” out the evil spirits. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ Health-care providers must be careful not to open medicine bags or remove them from the patient. ▪ These objects contribute to patients’ mental well-being, and their removal creates undue stress. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ Treatment regimens prescribed by a medicine man not only cure the body but also restore the mind. ▪ Individuals living off reservations frequently return to participate in this ceremony, which returns them to harmony and restores a sense of well-being. Copyright © 2013 F.A. Davis Company
Transcultural Health Care: A Culturally Competent Approach, 4th Edition Theories, Models, and Approaches Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cultural Theories, Models, and Approaches ▪ Leininger: First nurse cultural theorist from early 1950s. She states it is for nursing only ▪ Campinha-Bacote: basic simple model without complex constructs but applicable to all healthcare providers. Also has a Biblical based model. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cultural Theories, Models, and Approaches ▪ Giger and Davidhizar: Nursing only ▪ Purnell: For all health care providers and is an example of a complexity and holographic conceptual model with an organizing framework. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cultural Theories, Models, and Approaches ▪ Papadopoulous, Tilki, and Taylor Model for Transcultural Nursing and Health ▪ Andrews and Boyle Nursing Assessment Guide ▪ Spector’s Health Traditions Model Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cultural Theories, Models, and Approaches ▪ Ramsden's Cultural Safety Model ▪ Jeffrey’s Teaching Cultural Competence in Nursing and Health Care: Inquiry, Action, and Innovation Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Leininger’s Theory of Cultural Care Diversity and Universality www.madeleine-leininger.com ▪ Leininger described the phenomena of cultural care based on her experiences. ▪ Began in the 1950s with her doctoral dissertation conducted in New Guinea ▪ www.tcns.org and go to theories and then to the Sunrise Enabler and her model is displayed as well as publications. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Transcultural Nursing ▪ "Transcultural nursing has been defined as a formal area of study and practice focused on comparative human-care (caring) differences and similarities of the beliefs, values, and patterned lifeways of cultures to provide culturally congruent, meaningful, and beneficial health care to people.“ Leininger and McFarland text, 3rd ed.,2002, pp5-6. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Leininger: Purpose and Goal ▪ To discover, document, interpret, explain and predict multiple factors influencing care from a cultural holistic perspective. ▪ The goal of the theory was to provide culturally congruent care that would contribute to the health and well being of people, or to help them face disability, dying, or death using the three modes of action. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Leninger: Theoretical Tenets ▪ Leininger’s tenets: Care diversities (differences) and universalities (commonalties) existed among cultures in the world which needed to be discovered, and analyzed for their meaning and uses to establish a body of transcultural nursing knowledge. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Leininger: Assumptions ▪ Care is essence of nursing and a distinct, dominant, central, and unifying focus. Some would say that caring is not unique to nursing. ▪ Care is essential for well being, health, growth, survival, and to face handicaps or death. ▪ Culturally based care is the broadest means to know, explain, interpret, and predict nursing care phenomena to guide nursing care decisions and actions. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Leininger Assumptions ▪ Nursing is a transcultural humanistic and scientific care to serve individuals, groups, communities, and institutions worldwide. ▪ Caring is essential to curing and healing for there can be no curing without caring. ▪ Cultural care concepts meanings and expression patterns of care vary transculturally with diversity and universality. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Leininger Assumptions ▪ Every human culture has generic care knowledge and practices and some professional care knowledge that vary transculturally. ▪ Culture care values, beliefs, and practices are influenced by the (rays of the sun see the Model). ▪ Beneficial, healthy, and satisfying culturally based care influences the health and well-being of individuals, families, groups, and communities within the cultural context. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Leininger Assumptions ▪ Culturally congruent care can only occur when individuals’, groups’, and communities’ patterns are known and used in meaningful ways. ▪ Culture care differences and similarities between professionals and clients exist in all human cultures worldwide. ▪ Culture conflicts, imposition practices, cultural stresses, and pain reflect the lack of professional care to provide culturally congruent care. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Leininger’s Sunrise Enabler to Discover Culture Care To view the model go to: http://leiningertheory.blogspot.com/ Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Leininger Orientational Theory Definitions ▪ Cultural Care Preservation or Maintenance: all is well with the patient so encourage to continue what has been done ▪ Cultural Care Accommodation or Negotiation: Needs some change. What is acceptable weight from the patient’s perspective ▪ Cultural Care Repatterning or Restructuring: Practices are deleterious to overall health and need restructured: sexually promiscuous and has not been practicing safe sex Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cultural Competence in the Delivery of Healthcare Services: A culturally Competent Model of Care ▪ Dr. Josepha Campinha-Bacote but cannot display her model. Go to http://www.transculturalcare.net Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Process of Cultural Competence ▪ Cultural Competence is a process not an event. ▪ The process consist of five inter-related constructs: Cultural desire, cultural awareness, cultural knowledge, cultural skills, and cultural encounter. ▪ The key and pivotal construct is cultural desire. ▪ There is more variation within a cultural group than across cultural groups. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Process of Cultural Competence ▪ There is a direct relationship between healthcare professionals level of cultural competence and their ability to provide culturally responsive health care. ▪ Cultural competence is an essential component in delivering effective and culturally responsive care to culturally diverse clients. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cultural Desire ▪ . . . Cultural desire is defined as the motivation of the healthcare professional to “want to” engage in the process of becoming culturally competent; not the “have to”. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Concepts ▪ Cultural awareness is the self-examination and in-depth exploration of one’s own cultural background. ▪ Cultural knowledge is the process of seeking and obtaining a sound educational base about culturally diverse groups. ▪ Cultural Skills is the ability to collect relevant cultural data regarding the client’s presenting problem as well as accurately perform a culturally based physical assessment. ▪ Cultural encounter is the process which encourages the healthcare professional to directly engage in face-to-face interactions with clients from culturally diverse backgrounds. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition The Giger and Davidhizar Transcultural Assessment Model Dr. Joyce Giger Dr. Ruth Davidhizar (deceased) Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Giger and Davidhizar Assumptions ▪ The Giger and Davidhizar Transcultural Model postulates that each individual is culturally unique and should be assessed according to the six cultural phenomena. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Giger and Davidhizar Communication ▪ Communication embraces the entire world of human interaction and behavior. Communication is the means by which culture is transmitted and preserved. Both verbal and non-verbal communication are learned in one’s culture. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Giger and Davidhizar Space ▪ Space refers to the distance between individuals when they interact. All communication occurs in the context of space. ▪ Zones of personal space: intimate, personal, social, and consultative and public. Rules concerning personal distance vary from culture to culture. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Giger and Davidhizar Social Organization ▪ Social organization refers to the manner in which a cultural group organizes itself around the family group. Family structure and organization, religious values and beliefs, and role assignments may all relate to ethnicity and culture. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Giger and Davidhizar Time ▪ Time is an important aspect of interpersonal communication. ▪ Cultural groups can be past, present, or future oriented. ▪ Preventive health requires some future time orientation because preventative actions are motivated by a future reward. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Giger and Davidhizar Environmental Control ▪ Environmental control refers to the ability of the person to control nature and to plan and direct factors in the environment that affect them. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Giger and Davidhizar Biological Variations ▪ Biological differences, especially genetic variations, exist between individuals in different racial groups. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Boyle and Andrews Culturological Assessment ▪ Biocultural variations and cultural aspects of the incidence of disease ▪ Communication ▪ Cultural affiliations ▪ Cultural sanctions and restrictions ▪ Developmental considerations ▪ Economics ▪ Educational background Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Boyle and Andrews Culturological Assessment ▪ ▪ ▪ ▪ ▪ Health related beliefs and practices Kinship and social networks Nutrition Religion and spirituality Values orientation Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Ramsden Cultural Safety ▪ "the effective nursing practice of a person or a family from another culture, as determined by that person or family", while unsafe cultural practice is "any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual" (Nursing Council of New Zealand (NCNZ). Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Ramsden Cultural Safety http://culturalsafety.massey.ac.nz/RAMSDEN%20THESIS.pdf ▪ Assumes that nurses and the culture of nursing is exotic to people ▪ Gives the power of definition to the person served ▪ Concerned with human diversity ▪ Focus internal on nurse or midwife, exchanges power, negotiated ▪ A key part of Cultural Safety is that it emphasises life chances rather than life styles Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Papadopoulos, Tilki, and Taylor Cultural Awareness Self awareness Cultural identity Heritage adherence Ethnocentricity Stereotyping Ethnohistory Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Papadopoulos, Tilki, and Taylor Cultural Knowledge Health beliefs and behaviours Anthropological, Sociological, Psychological and Biological understanding Similarities and differences Health Inequalities Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Papadopoulos, Tilki, and Taylor Cultural Sensitivity Empathy Interpersonal/communication skills Trust Acceptance Appropriateness Respect Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Papadopoulos, Tilki, and Taylor Cultural Competence Assessment skills Diagnostic skills Clinical Skills Challenging and addressing prejudice, discrimination, and inequalities Copyright © 2013 F.A. Davis Company
Transcultural Health Care: A Culturally Competent Approach, 4th Edition Purnell Model for Cultural Competence Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Purnell Model: Assumptions ▪ All healthcare professions need much of the same information about cultural diversity and share the metaparadigm concepts of global society, community, family, person, and health. ▪ One culture is not better than another culture; they are just different. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Purnell Model: Assumptions ▪ There are core similarities shared by all cultures. ▪ There are differences within, between, and among cultures. ▪ Cultures change over time, but slowly. ▪ Culture has powerful influences on one’s interpretations and responses to health care. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Purnell Model: Assumptions ▪ If clients are co-participants in care and have a choice in health-related goals, plans, and interventions, health outcomes will be improved. ▪ Variant cultural characteristics determine the degree to which people vary from their dominant culture beliefs, values, and practices. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Purnell Model: Assumptions ▪ Individuals and families belong to several cultural groups, usually known as subcultures. ▪ Each individual has the right to be respected for his or her unique differences and cultural heritage. ▪ Caregivers who can assess, plan, and intervene in a culturally competent manner will improve the care of clients for whom they care. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Purnell Model: Assumptions ▪ Caregivers know themselves better by learning about their own cultures. ▪ Professions, organizations, and associations have their own cultures. ▪ Healthcare teams can benefit from a Model and Organizing Framework that is useable by all healthcare disciplines. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Variant Cultural Characteristics ▪ ▪ ▪ ▪ ▪ ▪ Nationality Race Color Gender Age Religious affiliation Copyright © 2013 F.A. Davis Company ▪ ▪ ▪ ▪ ▪ ▪ Educational status Socioeconomic status Occupation Military experience Political beliefs Urban versus rural residence Transcultural Health Care: A Culturally Competent Approach, 4th Edition Variant Cultural Characteristics ▪ ▪ ▪ ▪ ▪ Marital status Parental status Physical characteristics Sexual orientation Gender issues Copyright © 2013 F.A. Davis Company ▪ Length of time away from the home country ▪ Reason for immigration— sojourner, immigrant, undocumented status Transcultural Health Care: A Culturally Competent Approach, 4th Edition Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Metaparadigm Concept: Global Society ▪ Seeing the world as one large community of multicultural people ▪ Evidence of global society ▪ What happens in other parts of the world affects each community Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck What determines a person’s adherence with his/her dominant culture? a. Metaparadigm concepts b. Variant characteristics c. Global society d. Cultural worldview Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: B Variant cultural characteristics determine the degree to which a person adheres to his/her dominant cultural beliefs and practices. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Metaparadigm concept: Community ▪ A group or class of people having a common interest or identity living in a specified locality but can be an online community as well now ▪ What happens in the community has an effect on the family. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Metaparadigm concept: Family ▪ Two or more people who are emotionally involved with each other ▪ They may, but not necessarily, live in close proximity to each other. ▪ What affects the individual, affects the person. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Metaparadigm concept: Person ▪ A human being, one who is constantly adapting to his or her environment biologically, physically, socially, or psychologically ▪ Person is defined differently in other cultures. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Overview/Heritage ▪ ▪ ▪ ▪ ▪ ▪ ▪ Origins Residence Topography Economics Politics Education Occupation Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Communication ▪ ▪ ▪ ▪ ▪ ▪ ▪ Dominant language and dialects Contextual use of the language Paralanguage—volume and tone Temporality—time—and spatial distancing Use of touch Eye contact and facial expressions Greetings and name format Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Family Organization ▪ ▪ ▪ ▪ ▪ ▪ ▪ Head of household Gender roles Goals and priorities Developmental tasks Roles of the aged and extended family Social status Alternative lifestyles Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Workforce Issues ▪ Acculturation ▪ Autonomy ▪ Language barriers Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Biocultural Ecology ▪ ▪ ▪ ▪ ▪ ▪ Biological variations Skin color Heredity Genetics Endemics Drug metabolism Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: High-Risk Behaviors ▪ ▪ ▪ ▪ ▪ ▪ Tobacco Alcohol Recreational drugs Physical activity Safety Sexual behavior Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Nutrition ▪ ▪ ▪ ▪ ▪ ▪ Meaning of food Common foods Rituals Deficiencies Limitations Health promotion Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Pregnancy and Childbearing ▪ ▪ ▪ ▪ ▪ ▪ Fertility practices Views toward pregnancy Pregnancy beliefs Birthing practices Postpartum Prescriptive, restrictive, and taboo practices Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Death and Dying ▪ Death rituals during the dying process ▪ Post mortem practices ▪ Bereavement Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Spirituality ▪ ▪ ▪ ▪ ▪ Religious practices Use of prayer Meaning of life Individual strength Spirituality and health Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Contextual aspect of cultural communication includes a. Dominant language b. Dialects c. Explicit versus implicit communication d. Translation versus interpretation Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C Contextual use of a language is concerned with the number of words used to express a thought. Highcontexted communication uses fewer words to express a thought. Low-contexted communication uses a lot of words to express a thought Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Health-care Practices ▪ ▪ ▪ ▪ ▪ Focus of health care Traditional practices Magicoreligious beliefs Responsibility for health Self-medication practices Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Health-care Practices ▪ ▪ ▪ ▪ ▪ ▪ ▪ Responses to pain Sick role Mental health Rehabilitation Chronicity Blood transfusion Transplantation Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Domain: Health-care Practitioners ▪ ▪ ▪ ▪ Perceptions of practitioners Folk practitioners Gender and health care Status of healthcare providers Copyright © 2013 F.A. Davis Company
Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese American Culture Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Overview/Heritage ▪ In the Japanese language, Japan is called Nihon or Nippon. ▪ The over 500,000 Japanese citizens residing in North America tend to locate in large commercial and educational centers. ▪ Education is highly valued; the illiteracy rate in Japan is nearly zero. About 40 percent of all young people go on to higher education. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Overview/Heritage ▪ Issei (first-generation Japanese immigrants) vary widely in their English-language ability. ▪ Nisei (second-generation immigrants) and sansei (third-generation) were primarily educated under the American educational system. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Japanese is the language of Japan, with the exception of the indigenous Ainu people. ▪ In Japan students complete 6 years of English, even newer Japanese immigrants and sojourners can speak, understand, read, and write English to some extent. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Men tend to speak more coarsely and women with more gentility or refinement. ▪ Light social banter and gentle joking are a mainstay of group relations, serving to foster group cohesiveness. ▪ Polite discussion unrelated to business, often over o-cha (green tea), precedes business negotiations. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Open communication is discouraged making it difficult to learn what people think. In particular, saying “no” is considered extremely impolite; rather, one should let the matter drop. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ A high value is placed on “face” and “saving face.” ▪ Asking someone to do something he or she cannot do induces loss of face or shame. For people to be shown wrong is deeply humiliating. ▪ People feel shame for themselves and their group, but they are respected when they bear shame in stoic silence. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Traditional Japanese exhibit considerable control over body language. Anger or dismay may be quite difficult for Westerners to detect. ▪ Smiling and laughter are common shields for embarrassment or distress. ▪ Prolonged eye contact is not polite even within families. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Social touching occurs among group members but not among people who are less closely acquainted. ▪ In general, body space is respected. ▪ Intimate behavior in the presence of others is taboo. ▪ When people greet one another, whether for the first time or for the first time on a given day, the traditional bow is performed. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ An offer to shake hands by a Westerner is reciprocated graciously. ▪ Overall orientation is toward the future. ▪ Punctuality is highly valued. ▪ Family names are stated first, followed by given names. Seki Noriko would be the name of a woman, Noriko, of the Seki family. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Communication ▪ Women generally assume their husband’s family name upon marriage. ▪ Elders are referred to respectfully. ▪ The designation sensei (master) is a term of respect used with the names of physicians, teachers, bosses, or others in positions of authority. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Family Roles and Organization ▪ The predominant family structure is nuclear. The role of wife and mother is dominant. ▪ Children are socialized to study hard, make their best effort, and be good group members. ▪ They are taught to take care of each other, and girls are taught to take care of boys. Selfexpression is not valued. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Family Roles and Organization ▪ The primary relationship within a family is the mother-child relationship, particularly that of mothers and sons. ▪ It is customary for a mother to sleep with the youngest child until that child is 10 years old or older, and when a new baby is born, the older sibling may sleep with the father or a grandparent. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Family Roles and Organization ▪ Babies are not allowed to cry; they are picked up instantly. Women constantly hold their babies in carriers on their chests and sleep with them. ▪ Corporal punishment is acceptable in Japan. ▪ Traditional teens and college students generally do not date. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Family Roles and Organization ▪ Older people are respected and cared for by the family in the home, if at all possible, with the eldest son being the responsible family member. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Family Roles and Organization ▪ There is less tolerance for marriage of a Japanese person to a foreigner than in the United States. ▪ The existence of a gay and lesbian social network and of cross-dressing clubs is evident, although they are not generally talked about. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Workforce Issues ▪ American practices designed to avoid liability, such as informed consent, are not routinely implemented in Japanese health-care settings. ▪ Japanese workers are sensitive to colleagues and superiors. ▪ Saying “no” or delivering bad news is extremely difficult; they may avoid issues or indicate that everything is fine rather than state the negative. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Workforce Issues ▪ A high value is placed on “face” and “saving face.” ▪ Asking someone to do something he or she cannot do induces loss of face or shame. ▪ For people to be shown wrong is deeply humiliating. ▪ Prolonged eye contact is not polite even within families and among friends. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Biocultural Ecology ▪ Racial features include the epicanthal skin folds that create the distinctive appearance of Asian eyes, a broad and flat nose, and “yellow” skin that varies markedly in tone. ▪ Hair is straight and naturally black with differences in shade. ▪ Negative blood types account for less than 1 percent of the population. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Biocultural Ecology ▪ Commonly occurring health conditions for Japanese include heart disease, tuberculosis, renal disease, asthma, Vogt-Koyanagi-Harada syndrome, Takayasu disease, acatalasemia, cleft lip/palate, Oguchi disease, lactase deficiency, and stomach cancer. ▪ Asthma, related to duct mites in tatami (straw mats) is one of the few endemic diseases. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Biocultural Ecology ▪ Drug dosages may need to be adjusted for the physical stature of Japanese adults. ▪ Many Asians are poor metabolizers of mephenytoin and related medications, potentially leading to increased intensity and duration of the drugs’ effects. ▪ Most individuals require lower doses of some benzodiazepines and neuroleptics. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Biocultural Ecology ▪ Opiates may be less effective analgesics, but gastrointestinal side effects may be greater than among Whites. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese High-Risk Health Behaviors ▪ Smoking rates are high among Japanese and Japanese Americans. ▪ Alcohol (rice wine) is part of many social rituals, such as picnics, to celebrate cherry blossoms, autumn leaves, or moon viewing. ▪ Once alcohol is consumed, one can relax and speak freely; they are forgiven for what they say because of the alcohol. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese High-Risk Health Behaviors ▪ Mothers’ time-honored strategy of rewarding academic diligence with candy and other treats contributes to the issue of the fitness of youth. ▪ Public safety consciousness is high. ▪ The Japanese readily use seatbelts and other safety measures, such as child safety seats and helmets. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Nutrition ▪ Dietary staples include rice, beef, poultry, pork, seafood, root vegetables, cabbage, persimmons, apples, and tangerines. ▪ Rice is the mainstay of the traditional diet and is included in all three meals as well as snacks. ▪ Rice has a symbolic meaning related to the Shinto religion, analogous to the concept of the “bread of life” among Christians. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Nutrition ▪ A staple of schoolchildren’s o-bento (lunch box) is a white bed of rice garnished with a red plum pickle, reminiscent of the Japanese flag. ▪ A popular lunch among working people is a steaming bowl of ramen (noodles) in broth or cold noodles on a hot summer day. ▪ Instant broth, although high in sodium, is another popular quick lunch. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Nutrition ▪ A traditional dinner is a pot of boiled potatoes, carrots, and pork seasoned with sweet sake, garlic, and soy sauce or a stir-fried meat and vegetable dish. ▪ The daily intake of sweets can be high and often includes European-style desserts, sweetbreads and cookies, sweet bean cakes, soft drinks, and heavily sweetened coffee. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Nutrition ▪ Increasingly, Westernized food tastes, resulting in higher fat and carbohydrate intake, have contributed to the rise in obesity and associated increases in diabetes and heart disease. ▪ There is growing public awareness that the sodium content of the traditional soups and sauces contributes to the high rate of cerebrovascular accidents. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Nutrition ▪ Green tea, although high in caffeine, is a good source of vitamin C. ▪ Garlic and various herbs are used widely for their medicinal properties. ▪ Many individuals have difficulty digesting milk products due to lactose intolerance. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Pregnancy and Childbearing Practices ▪ Oral contraceptives became legal in Japan in 1999. ▪ Condoms remain the most common contraceptive method. ▪ Most women have several abortions during their married fertile lives. ▪ Pregnancy is highly valued within traditional culture as a woman’s fulfillment of her destiny. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Pregnancy and Childbearing Practices ▪ Pregnant women may enjoy attention and pampering that they get at no other time. ▪ They may prepare themselves for the possibility of pregnancy when they become engaged and eliminate alcohol, caffeine, soft drinks, and tobacco. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Pregnancy and Childbearing Practices ▪ Loud noises, such as a train or a sewing machine, are thought to be bad for the baby. ▪ Shinto shrines sell amulets for conception and easy delivery. ▪ Husbands do not commonly attend the births of their children. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Pregnancy and Childbearing Practices ▪ Vaginal deliveries are usually performed without medication. ▪ To give in to pain dishonors the husband’s family, and mothers are said to appreciate their babies more if they suffer in childbirth. ▪ Traditionally, postpartum women do not bathe, shower, or wash their hair for the first week. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Pregnancy and Childbearing Practices ▪ Breast-feeding is taken seriously. ▪ Maternal rest and relaxation are deemed essential for success. ▪ If the mother is asleep, the grandmother feeds the baby formula. ▪ Women who give birth in the US may resent the expectation of resuming self-care quickly. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Death Rituals ▪ The taboo against open discussion of serious illness and death is evident. ▪ Hospice patients or those with a terminal illness may not want to be told their diagnosis and prognosis in order to allow a peaceful death and to spare both the patient and the family the difficulty of having to discuss the situation. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Death Rituals ▪ When a person is dying, the family should be notified of impending death so they can be at the dying person’s bedside. ▪ Traditionally, the eldest son has particular responsibility during this time. ▪ The mourning period is 49 days, the end of which is marked by a family prayer service and the serving of special rice dishes. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Death Rituals ▪ When death occurs, an altar is constructed in the home. ▪ Photographs of the deceased are displayed, and floral arrangements are placed within and outside the home. ▪ A bag of money is hung around the neck of the deceased to pay the toll to cross the river to the hereafter. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Death Rituals ▪ Perpetual prayers may be donated through a gift to the temple. In addition, special prayer services can be conducted for the 1st, 3rd, 7th, and 13th annual anniversaries of the death. ▪ Beliefs are common that the dead need to be remembered and that failure to do so can lead the dead to rob the living of rest. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Spirituality ▪ Shinto, the indigenous religion, is the locus of joyful events such as marriage and birth. ▪ Many festivals are marked by offerings, parades, and a carnival on the grounds of the shrine. ▪ Very few people regularly attend services, but most are registered temple members, if only to ensure a family burial plot. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Spirituality ▪ 1% of Japanese people is Catholic or Protestant. ▪ Most do not identify themselves solely with one religion or another, and even a baptized Christian might have a Shinto wedding and a Buddhist funeral. ▪ Buddhist belief in reincarnation and the eternal life of the soul. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Spirituality ▪ Kampo (healers) often set up shop in the vicinity of the temple or shrine, and a person might be seen scooping incense smoke onto an ailing body part. ▪ Prayer boards might bear requests for special healing. ▪ Newborns are taken to a shrine for a blessing. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Because Japanese people are less likely to express feelings verbally, this indulgence may be a way for people to affirm caring for one another nonverbally. ▪ Termination of pregnancy when the health of the fetus is in doubt is common. ▪ Most parents want medically compromised neonates to be treated aggressively when prognoses are not favorable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ The concept of ki, the life force or energy and how it flows through the body, is integral to traditional Chinese healing modalities, including acupuncture. ▪ Good health requires the unobstructed flow of ki throughout the body. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Yin and yang are reflected in the need to balance five energy sources: water, wood, fire, earth, and metal. Strategies that help to restore balance include use of herbal medicines, bed rest, bathing, and having a massage. ▪ One traditional form of massage, shiatsu (acupressure), involves redirection of energy along the Chinese meridians by application of light pressure to acupuncture points. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Whereas Chinese tradition calls for a restoration of balance when one is ill, Shinto calls for purging and purification. ▪ Preoccupation with germs and dirt is not likely to interfere with daily life. ▪ Many pharmacies stock traditional herbal kampo preparations. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Most individuals make liberal use of both modern medical and traditional providers of health care. ▪ Residents in the United States have Internet and mail-order access to traditional medications, if they are not available locally. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices Common Japanese therapies include: ▪ Morita therapy–indigenous strategy for addressing shinkei shitsu, excess sensitivity to the social and natural environment. Introspection is seen as harmful. ▪ Morita therapy–focuses on constructive physical activity to help clients accept reality as it is ▪ Naikan therapy–reflection on how much goodness and love are received from others. ▪ Shinryo Naika– focuses on bodily illnesses that are emotionally induced. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Japanese high regard for the status of physicians decreases the likelihood of their asking questions or making suggestions about their care. ▪ The idea that clients should be given care options may be alien. ▪ Itami (pain) may not be expressed: bearing pain is a virtue and a matter of family honor. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ Addiction is a strong taboo in Japanese society, making clients reluctant to accept pain medication. ▪ Mental illness is taboo. Because emotional problems cannot be discussed freely, somatic manifestations are common and acceptable. ▪ Handicapped people may bring shame to the family, although they are treated kindly.. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practices ▪ The sick role is highly tolerated by families and colleagues, and a long recuperation period is encouraged Organ transplantation and donation issues need to be approached sensitively. ▪ People rely more heavily on the physician’s opinion, and the family may have difficulty negotiating cessation of treatment Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practitioners ▪ Physicians, referred to as sensei, are highly esteemed. ▪ Self-care as a philosophy is not evident among most. Being told what to do by the physician or kampo practitioner is expected, and his (or, occasionally, her) authority is not questioned. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Japanese Health-care Practitioners ▪ Currently in Japan, nurses are well respected, even though women in general are not. ▪ In the past, nurses were not highly respected because “good women” did not touch people with an illness unless they were immediate family members. If she did touch “sick bodies,” the woman would become tainted and less pure.
Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Culture Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Overview/Heritage ▪ The Republic of Cuba is a multiracial society with people of primarily Spanish and African origins. ▪ Other ethnocultural groups include Chinese, Haitians, and Eastern Europeans. ▪ Spain, the United States, and the Soviet Union significantly influence Cuba’s history and culture. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Overview/Heritage ▪ Mistrust of government has reinforced a strong personalistic tradition and sense of national identity evolving from family and interpersonal relationships. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Overview/Heritage ▪ Desire for personal freedom, hope of refuge, political exile, and promise of economic opportunities prompted migration. ▪ Cubans in the United States take great pride in their heritage and tend to be conservative, Republican, and anticommunist. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Overview/Heritage ▪ Many possess a strong ethnic identity, speak Spanish, and adhere to traditional Cuban values and practices.. ▪ The highest concentration of Cubans is in Florida, although significant numbers live in New Jersey, New York, Illinois, and California. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Communication ▪ Many Cubans live and transact business in Spanish-speaking enclaves. ▪ While the second generation speaks Spanish, many converse with friends or peers in “Spanglish,” a mixture of Spanish and English. ▪ The highly educated are more likely to speak English at home. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Communication ▪ Many value simpatía and personalismo in their interactions with others. ▪ Simpatía, the need for smooth interpersonal relationships, is characterized by courtesy, respect, and the absence of criticism or confrontation. ▪ Personalismo, the importance of intimate interpersonal relationships, is valued over impersonal bureaucratic relationships. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Communication ▪ Choteo, a lighthearted attitude with teasing, bantering, and exaggerating is often observed in their communications with others. ▪ Conversations are characterized by animated facial expressions, direct eye contact, hand gestures, and gesticulations. ▪ Voices tend to be loud, and the rate of speech is fast. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Communication ▪ Touching, handshakes, and hugs are acceptable among family, friends, and acquaintances and may be used to express gratitude to the caregiver. ▪ Touch is common between people of the same gender; older men and women rarely touch in public. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Communication ▪ Most tend to emphasize current issues and problems rather than future ones. ▪ Hora cubana (Cuban time) refers to a flexible period that stretches 1 to 2 hours beyond designated clock time. ▪ Most Cubans use two surnames representing the mother and father’s family names. ▪ Married women may also add the husband’s name. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Family Roles and Organization ▪ Traditional family structure is patriarchal, characterized by a dominant and assertive male and a passive, dependent female. ▪ Traditionally, Cuban wives stay at home, manage the household, and care for children, whereas husbands are expected to work, provide financially, and make major decisions for the family. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Family Roles and Organization ▪ Honor is attained by fulfilling family obligations and treating others with respeto (respect). ▪ Vergüenza, a consciousness of public opinion and the judgment of the entire community, is considered more important for women than for men. ▪ Machismo dictates that men display physical strength, bravery, and virility and be the spokesperson, even though they might not make the decisions. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Family Roles and Organization ▪ La familia (the family, nuclear and extended, including godparents) is the most important source of emotional and physical support. ▪ Multigenerational (3 to 4 generations) households are common, including a high proportion of people 65 years and older who live with their relatives. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Family Roles and Organization ▪ According to U.S. standards, Cuban parents tend to pamper and overprotect their children. ▪ Children are expected to study, respect their parents, and follow el buen camino (the straight and narrow). ▪ Boys are expected to learn a trade or prepare for work and to stay away from vices. ▪ Girls are expected “to remain honorable while single,” to prepare for marriage, to avoid the opposite sex, and not to go out without a chaperone. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Family Roles and Organization ▪ When a daughter reaches 15 years, a quinceaneras, or elaborate 15th birthday party, is typically held to celebrate this rite of passage for the daughter. ▪ Adolescents may undergo an identity crisis and reject their heritage causing parents to feel their authority is being challenged. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Family Roles and Organization ▪ Little information is available on homosexuality. ▪ Same-sex behaviors among men may be regarded as a sign of virility and power rather than homosexual behavior. ▪ The gay lifestyle is contradictory to the machismo orientation of this culture. Same-sex couples may be alienated from their families. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck A 22-year-old from Cuba comes to the prenatal clinic for the first time. She introduces herself as Elena Florencia Gonzalez Portillo. The receptionist should ask what a. Is your husband’s surname? b. Is your husband’s last name? c. Name do you wish to be called? d. What is your legal name? ▪ Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: D The legal name is what should be used for recordkeeping. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Workforce Issues ▪ Cuban ethnic enclaves with a familiar language and culture have created numerous employment opportunities for recent Cuban immigrants. ▪ A source of tension is the tendency of Cubans to speak Spanish with other Cuban or Hispanic coworkers. Speaking the same language allows them to form a common bond, relieve anxieties at work, and feel comfortable with one another. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Workforce Issues ▪ Traditional Cubans recognize supervisors as authority figures and treat them with respect and deference. ▪ Cubans value a structure characterized by personalismo, one that is oriented around people rather than around concepts or ideas. ▪ Personal relationships at work are considered an extension of family relationships. ▪ Because of the emphasis on the job or task in the American workplace, many Cubans view this workplace as being too individualistic, businesslike, and detached. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Biocultural Ecology ▪ Most Cubans are white, and only 5 percent are black with physical features similar to those of African Americans. ▪ Cuban Americans tend to have lower incidences of diabetes mellitus, obesity, and hypertension than other Hispanic groups or whites. ▪ Because of their diet, which is high in sugar, many exhibit a high prevalence of tooth loss, filled teeth, gingival inflammations, and periodontitis. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Biocultural Ecology ▪ Commonly occurring health conditions of Cubans are hypertension, coronary artery disease, obesity, diabetes mellitus, and lung cancer. ▪ Specific information related to drug metabolism is limited; however, in general, many require lower doses of antidepressants and experience greater side effects than non-Hispanic white populations. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American High-risk Health Behaviors ▪ Cuban Americans tend to exhibit a higher incidence of smoking than other Hispanic or European groups. ▪ Alcohol use is greater among males than females and among younger versus older groups. ▪ Violent deaths account for high mortality rates among adolescents and young adults. ▪ Suicide rates also exceed those of the white nonHispanic population. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck ▪ The nurse is using an interpreter to interview the parents of a 6-year-old Cuban, Leonardo, who has stomach pain. The nurse should direct questions to ▪ A. The father. ▪ B. The mother. ▪ C. The interpreter. ▪ D. Both parents. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: D The nurse should address the questions to both parents to demonstrate respect to both of them. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Nutrition ▪ Food allows families to reaffirm kinship ties, promotes a sense of community, and perpetuates customs and heritage. ▪ Staple foods include root crops like yams, yuca, malanga, and boniato; plantains; and grains. ▪ Many dishes are prepared with olive oil, garlic, tomato sauce, vinegar, wine, lime juice (sofrito), and spices. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Nutrition ▪ Meat is usually marinated in lemon, lime, sour orange, or grapefruit juice before cooking. ▪ A leisurely noon meal (almuerzo) and a late evening dinner (comida), sometimes as late as 10 or 11 PM, are often customary. ▪ Being overweight is seen as positive, healthy, and sexually attractive. ▪ Food allows families to reaffirm kinship ties, promotes a sense of community, and perpetuates customs and heritage. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Pregnancy and Childbearing Practices ▪ Cuban women’s fertility rate is lower than that of other Hispanic American women. Cuba’s current reproductive rate is among the lowest in the developing world. ▪ Even before the revolution, Cuba had the lowest birthrate in Latin America. ▪ The low fertility rate has been attributed to many women in the workforce. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Pregnancy and Childbearing Practices ▪ Preterm births and neonatal and post-neonatal deaths are lower among Cuban American women than among other Hispanic American groups. ▪ Prenatal care is higher than among other Hispanic and white non-Hispanics. ▪ Mothers tend to use advice about child health given by their spouses, mothers, mothers-in-law, and clerks and pharmacists. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Pregnancy and Childbearing Practices ▪ Childbirth is a time for celebration with family members and friends congregating in the hospital. ▪ Traditionally, men have not attended the births of their children, but younger, more acculturated, fathers are frequently present. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Pregnancy and Childbearing Practices ▪ During the postpartum period, ambulation, exposure to cold, and bare feet place the mother at risk for infection. ▪ Family members and relatives often care for the mother and baby for about 4 weeks postpartum. ▪ Most women consider breast-feeding better than bottle feeding; approximately half choose to breast-feed. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Pregnancy and Childbearing Practices ▪ Cutting the infant’s hair or nails in the first 3 months is believed to cause blindness and deafness. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Death Rituals ▪ In death, as in life, the support of the extended family network is paramount. ▪ Bereavement is expressed openly as loud crying with other physical manifestations of grief. ▪ Death is often seen as a part of life and some, especially men, may approach death stoically. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Death Rituals ▪ The dying person is typically attended by a large gathering of relatives and friends. ▪ In Catholic families, individual and group prayers are held for the dying to provide a peaceful passage to the hereafter. ▪ Religious artifacts such as rosary beads, crucifixes, or estampitas (little statues of saints) are placed in the dying person’s room. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Death Rituals ▪ For adherents of Santería, death rites may include animal sacrifice, chants, and ceremonial gestures. ▪ Candles are lighted after death to illuminate the path of the spirit to the afterlife. ▪ A velorio (wake) lasts 2 to 3 days and is usually held at a funeral parlor or in the home where friends and relatives gather to support the bereaved family. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Death Rituals ▪ Burial in a cemetery is common practice, although some may choose cremation. ▪ The deceased are customarily remembered and honored on their birthdays or death anniversaries by lighting candles, offering prayers or masses, bringing flowers to the grave, or gathering with family members at the grave site. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Spirituality ▪ Approximately 85 percent of Cuban Americans are Roman Catholic; the remaining 15 percent are Protestants, Jews, and believers in African Cuban Santería. ▪ Roman Catholicism is personalistic and characterized by devotion and intimate, confiding relationships with the Virgin Mary, Jesus, and the saints. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Spirituality ▪ Significant religious holidays include Noche Buena (Christmas Eve), Christmas, Los Tres Reyes Magos (Three Kings Day), and the festivals of the La Caridad del Cobre and Santa Barbara. ▪ Santería is a 300-year-old African Cuban religious system that combines Roman Catholic elements with ancient Yoruba tribal beliefs. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Spirituality ▪ Followers of Santería believe in the magical and medicinal properties of flowers, herbs, weeds, twigs, and leaves. ▪ Sweet herbs such as manzanilla, verbena, and mejorana are used for attracting good luck, love, money, and prosperity. ▪ Bitter herbs such as apasote, zarzaparilla, and yerba bruja are used to banish evil and negative energies. Santería is viewed as a link to the past and is used to cope with physical and emotional problems. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Spirituality ▪ Physical complaints may be diagnosed and treated by a physician, whereas the santero may assist in balancing and neutralizing the various aspects of the illness. ▪ Deeply held religious beliefs provide guidance and strength during the long and difficult process of migration and adaptation and continue to play an important role in their day-to-day lives. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Spirituality ▪ Belief in a higher power is evident in practices used to maintain health and well-being or cure illness, such as using magical herbs, special prayers or chants, ritual cleansing, and sacrificial offerings. ▪ Many tend to be fatalistic, believing that they lack control over circumstances influencing their lives. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Health-care Practices ▪ African Cubans may seek biomedical care for organic diseases but consult a santero for spiritual or emotional crises. ▪ Conditions such as decensos (fainting spells) or barrenillos (obsessions) may be treated solely by a santero or simultaneously with a physician. ▪ Many tend to seek help only in response to crisis situations. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Health-care Practices ▪ Many Cuban Americans rely on the family as the primary source of health advice. ▪ Older women provide traditional home remedies such as herbal teas or mixtures to relieve mild or moderate symptoms or cure common ailments. ▪ Older Cuban Americans were socialized into a strong health ideology and successful primary care system while still in Cuba. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Health-care Practices ▪ Use of preventive services in the US is generally determined more by access to care than by acculturation. ▪ Many Cuban Americans use traditional medicinal plants in the form of teas, potions, salves, or poultices. In Cuban communities, stores called botanicas sell herbs, ointments, oils, powders, incenses, and religious figurines to relieve maladies, bring luck, drive away evil spirits, or break curses. ▪ Santería necklaces and animals used for ritual sacrifice are often available at botanicas. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Health-care Practices ▪ Blood transfusions and organ donations are usually acceptable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cuban American Health-care Practitioners ▪ Both traditional and biomedical care are acceptable. ▪ Folk remedies may be used at home, but if the condition persists, folk practitioners such as santeros and biomedical practitioners may be used either simultaneously or successively. ▪ Santeros may prescribe treatment or perform rituals to enable ill people to recover by invoking supernatural deities to intervene to help make them well.
Transcultural Health Care: A Culturally Competent Approach, 4th Edition American Indians Alaskan Natives (AI/ANs) Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Amount of Indian blood necessary to be considered a tribal member varies among the tribes—¼ to be a Navajo, which is the largest tribe in United States and live in the Southwest ▪ 556 different tribes in the United States and Canada ▪ Each tribe unique but share similar views regarding cosmology, medicine, and family organization Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Heritage ▪ Forced migration by United States government ▪ Life on MOST reservations is hard with high poverty and high unemployment although a few have significant money due to oil, land leases, gambling casinos, etc. ▪ Children were taken from them and placed in “White Man’s Schools” Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Group, clan, or tribal emphasis Present oriented Time is always with us Age Cooperation Harmony with nature Giving/sharing Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Pragmatic Mythology Patience Mystical Shame Permissiveness Extended family and clan Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Non-aggressiveness Modesty Silence Respect other’s religion Religion is a way of life Land, water, forest belong to all Beneficial, reasonable use of resources Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Low educational levels for most tribes, preferring children to remain at home and learn Indian ways ▪ For the traditional, health care is an undesirable profession because one should not work with the dead or ill ▪ Navajo sometimes have a special cleansing ceremony to allow them to work in a hospital Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Language and dialect vary by tribe, but most speak English and in the southwest many speak Spanish instead of English ▪ Minor variations in pronunciation can change the meaning of the word ▪ Talking loudly or interrupting someone is considered rude Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Navajos generally do not share thoughts and feelings easily outside family and friends, making it difficult to obtain trust in the healthcare setting ▪ Comfortable with long periods of silence ▪ Touch is unacceptable unless you know the person very well Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ No set pattern for willingness to share tribal ceremonies ▪ Pueblo groups usually do not share any tribal ceremonies ▪ Light passing of the hands for a handshake ▪ Considered rude to point with the finger; instead shift your lips in the desired direction Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Direct eye contact is rude and confrontational—deadpan facial expression ▪ Proximity for conversations usually greater than 24 inches ▪ Time sequence is present, past, and future Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ The future is out of one’s control. ▪ Very few are future oriented and for the Navajo there is no future verb tense ▪ Time is not something that can be controlled, nor should time control the person; events start when the people arrive Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Navajo, like most Native Indian tribes, is matrilineal in decision-making and land rights ▪ Relationship between brother and sister is more important than that between husband and wife ▪ Children's names are not revealed at birth Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Older people are addressed as grandmother, grandfather, mother, father, or a nickname. ▪ Algonquin are egalitarian society ▪ Dene and Athabascan are patriarchal ▪ Navajo, Iroquois, Pueblos, and Haida are matriarchial societies Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ AI/AN naming traditions vary greatly from tribe to tribe and are frequently determined by nature, animals, or character. ▪ In the past, AI/AN women practiced breastfeeding exclusively. ▪ Since the early to mid-1980s, the use of formula has become popular. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ A primary social premise is that no person has the right to speak for another. ▪ Parents are permissive in childrearing practices and may allow a child decide whether if not go to school or take medicine. ▪ Ceremony plays a vital, essential role in AI/ANs everyday life. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ When a couple marries in the Pueblo tribes, the man goes to live in the woman’s house. ▪ In Navajo tradition, families have separate dwellings but are grouped by familial relationships. ▪ The Navajo family unit consists of the nuclear family and relatives such as sisters, aunts, and their female descendants. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ In all American Indian and Alaska Natives extended family members play an important role in the infants’ life. ▪ Older adults are looked on with clear deference ▪ Elders play an important role in keeping rituals and in instructing children and grandchildren. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Social status is determined by age and life experiences. ▪ Among the Pueblos governors are chosen from a particular clan; unless one is born in the clan they cannot run for tribal governor. Generally, individuals are discouraged from having more possessions than their peers, and those who display more material wealth are ignored. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Standing out is not encouraged among the different tribal groups. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Many AI/ANs remain traditional in their practice of religious activities. Family matters are more important than work, resulting in high rates of absenteeism. ▪ In addition, tribal ceremonies are seen as necessary and they often must take time from work or school. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Tribal members in the community function informally as cultural brokers and assist by helping non– American Indian staff to understand important cultural issues. ▪ Conflict is addressed indirectly through third parties in some tribes Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Group activities are an important norm in AI/AN cultures. ▪ One individual should not be singled out to answer a question because the student’s mistakes are generally not forgotten by the group. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Issues of superior-subordinate roles exist and are related to age. ▪ IHS is the only organization allowed to discriminate in hiring practices; it is required to hire an AI/AN when possible. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck AI/AN tribes and clans are a. Patriarchal. b. Matriarchal. c. Egalitarian. d. Depends on the tribe and clan. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: D Some tribes and clans are patriarchal, some are matriarchal, and some are more egalitarian. Variations exist within the tribe and clan as well. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Skin color among AI/ANs varies from light to very dark brown, depending on the tribe. ▪ Each of the American Indian tribes vary in terms of facial features and height. ▪ Never assume that an AI/AN patient is from a particular tribe, if wrong, he or she will be offended. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Historically, most diseases affecting AI/ANs were infectious such as tuberculosis, smallpox, and influenza. ▪ Diseases of the heart, malignant neoplasm, unintentional injuries, diabetes mellitus, and cerebrovascular disease are the top five leading causes of AI/AN deaths Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Type 1 diabetes mellitus is almost nonexistent in AI/ANs but type 2 diabetes mellitus is the third most prevalent chronic disease affecting all AI/AN tribes. ▪ The incidence of diabetes varies among tribes has steadily increased and is approaching 30 percent. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Albinism occurs in the Navajo and Pueblo tribes. ▪ Navajos who lived in Rainbow Grand Canyon are genetically prone to blindness that develops in individuals during their late teens and early 20s. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ The Zunis have an incidence of cystic fibrosis seven and one-half times that found for Caucasians. ▪ Methamphetamine (meth) abuse and suicide are two top concerns in Indian country. ▪ Suicide rates among American Indians and Alaska Natives (AI/ANs) are 1.7 times higher than the national average. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Alcohol use is more prevalent than any other form of chemical misuse. ▪ Many accidents are attributed to driving while under the influence of alcohol. ▪ Spousal abuse is common and frequently related to alcohol use. The wife is the usual recipient of the abuse, but occasionally, the husband is abused. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Food has major significance beyond nourishment in AI/AN populations. ▪ Food is offered to family and friends or may be burned to feed higher powers and those who have died. ▪ Life events, dances, healing, and religious ceremonies evolve around food. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Corn is an important staple in the diet of American Indians. ▪ Rituals such as the green corn dance of the Cherokees and harvest-time rituals for the Zuni surround the use of corn. ▪ Corn pollen is used in the Blessingway and many other ceremonies by the Navajo. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Each tribe has its own version of fry bread. ▪ Access to fresh fruits and vegetables is minimal during wintertime. ▪ AI/AN diets may be deficient in vitamin D because many members suffer from lactose intolerance or do not drink milk. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Traditional AI/ANs do not practice birth control and often do not limit family size. ▪ In Apache and Navajo tribes, twins are not looked on favorably and are frequently believed to be the work of a witch. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Some want their blood and urine specimens returned to them upon discharge. ▪ Many use herbs during labor and delivery. ▪ A ceremony may be performed by the medicine man during labor and delivery. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Be flexible with positioning for delivery. ▪ Some may want the umbilical cord, meconium, and afterbirth. ▪ Some may use peyote during labor and delivery. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The most common form of substance abuse among AI/ANs is a. Alcohol. b. Peyote. c. Marijuana. d. Methamphetamine. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer The most common substance abuse among AI/AN tribes is alcohol which is 1.7 times higher than other groups who have been studied. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Most AI/AN tribes believe that the souls of the dead pass into a spirit world and became part of the spiritual forces that influenced every aspect of their lives. ▪ Today some tribes maintain their traditional practices but use a mortuary or use the IHS morgue to prepare their dead. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The Pueblo tribes prepare their own dead and only certain family members are allowed to prepare the body. ▪ Hopis bury their dead before the next setting of the sun and bury them in upright sitting positions with food and goods in the grave with the person. ▪ After the Zuni burial, the members must take off three days from work for a cleansing ceremony. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The body must go into the afterlife as whole as possible. ▪ In some tribes, amputated limbs are given to the family for a separate burial and later the limb is buried with the body. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ In some tribes, family members are reluctant to deal with the body because those who work with the dead must have a ceremony to protect them from the deceased’s spirit. ▪ In the Navajo, if the person dies at home, the body must be taken out of the north side of the hogan and a ceremony conducted to cleanse the Hogan or it must be abandoned. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Older adults are reluctant to discuss advance directives once they discover what it means. ▪ Effective discussions require that the issue be discussed in the third person, as if the illness or disorder is happening to someone else. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ If a provider makes a statement such as “if you don’t get medical care, you will die,” this implies that the provider wishes the client dead. ▪ If the patient does die or is extremely ill, the provider might be considered a witch. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The Navajo are not generally open in their expression of grief; they often will not touch or pick up the body or prepare the body for burial. ▪ Grief among the Pueblo and Plains Tribes are expressed openly and involves much crying among extended family members Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ AI/AN religion predominates in many tribes. ▪ When illnesses are severe, consultations with appropriate religious organizations are sought. ▪ Sometimes, hospital admissions are accompanied by traditional ceremonies and consultation with a pastor. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ AI/AN tribal traditional members start the day with prayer, meditation, and corn pollen. ▪ Prayers ask for harmony with nature and for health and invite blessings to help the person exist in harmony with the earth and sky. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ The meaning of life for AI/ANs is derived from being in harmony with nature. ▪ The individual’s source of strength comes from the inner self and depends on being in harmony with one’s surroundings. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Spirituality cannot be separated from the healing process in ceremonies. ▪ Illnesses, especially mental illnesses, result from not being in harmony with nature, from the spirits of evil persons such as a witch, or through violation of taboos. ▪ Healing ceremonies restore an individual’s balance mentally, physically, and spiritually. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Traditional AI/AN beliefs influence biomedical healthcare decisions. ▪ asking patients questions to make a diagnosis fosters mistrust. ▪ This approach is in conflict with the practice of traditional medicine men, who tell people their problem without their having to say anything. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ IHS has attempted to shift its focus from acute care to health promotion, disease prevention, and chronic health conditions. ▪ Wellness-promotion activities include a return to past traditions such as running for health, avoiding alcohol, and using purification ceremonies. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Medicine men, diagnosticians, crystal gazers, and shamans tell them how to restore harmony. ▪ Many families do not have adequate transportation and must wait for others to transport them to their appointments. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Frequently, pain control is ineffective because the intensity of their pain is not obvious to the health-care provider because patients do not request pain medication. ▪ Herbal medicines may be preferred and used without the knowledge of the health-care provider. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Mental illness is perceived as resulting from witches or witching (placing a curse) on a person. ▪ In these instances, a healer who deals with dreams or a crystal gazer is consulted. Individuals may wear turquoise or other items such as a medicine bag to ward off evil. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ The concept of rehabilitation is relatively new to AI/ANs because, in years past, they did not survive to old age to which chronic diseases became an issue. ▪ Autopsy and organ donation are becoming a little more accepted among traditional AI/ANs. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ AI/AN healers are divided primarily into three categories: those working with the power of good, the power of evil, or both. ▪ Some are endowed with supernatural powers, whereas others have knowledge of herbs and specific manipulations to “suck” out the evil spirits. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ Health-care providers must be careful not to open medicine bags or remove them from the patient. ▪ These objects contribute to patients’ mental well-being, and their removal creates undue stress. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ Treatment regimens prescribed by a medicine man not only cure the body but also restore the mind. ▪ Individuals living off reservations frequently return to participate in this ceremony, which returns them to harmony and restores a sense of well-being. Copyright © 2013 F.A. Davis Company
Transcultural Health Care: A Culturally Competent Approach, 4th Edition Turkish Culture Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Türkiye, as it is written in Turkish, means “land of Turks.” Referred to as a geographic, religious, and cultural crossroads, the Republic of Türkiye is situated at the geographic intersection of Europe, Asia, the Middle East, and Africa. ▪ While Turks have emigrated throughout the world, many live in Western Europe, largely as a result of “guest worker” programs. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Today, the Republic of Türkiye is politically stable and continues to adapt economically to reforms. ▪ Türkiye remains strategically important to the West and is a strong ally of the United States. ▪ The Turkish immigrant population in the US differs significantly from most of the Turkish population in Europe, both in terms of demographic makeup and socioeconomic status and integration. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Over 202,000 people of Turkish descent live in the United States. ▪ They live in 42 states, with over half living in New York, California, New Jersey, and Florida. ▪ Just over half of the individuals in this group were born outside the United States. ▪ Most arrived in the US before 1980. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ A high proportion of Turks in the United States come from the elite and upper-middle classes, interspersed with smaller groups of middle-class students and skilled laborers who are supported privately or by the government. ▪ Many Turks sought advanced American education in highly technical fields, leading to more abundant employment opportunities in the United States upon completion of their studies. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ A Uralic-Altaic language, Turkish is spoken by 90% of the population and has approximately 20 dialects. ▪ Differences in some of the dialects are so great that they are considered different languages. ▪ The Turkish alphabet is much like the English alphabet, although it does not have a “w” or an “x” and additional sounds are symbolized by an diacritical mark over vowels. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ The Turkish language does not distinguish gender pronouns (ie, “he” from “she” or “her” from “his.”) Therefore, Turks when learning English may inadvertently confuse these pronouns. ▪ Turkish distinguishes a formal from an informal “you,” signifying the importance of status in Turkish society. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Speaking in loud voices is common; this does not always signify anger but rather excitement or deep involvement in a discussion. ▪ More than one person may speak at the same time or interrupt another person; this is not necessarily considered rude. ▪ However, someone of lower status should not interrupt someone of higher status. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Group affiliation is valued over individualism in Turkish society. In fact, identity may be determined by family membership or group, school, and work associations. ▪ Turks generally do not desire much privacy and tend to rely on cooperation between family and friends, although competition between groups can be fierce. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turks value harmony over confrontation. ▪ The outward show of feelings is less restrained. ▪ For women, expressions of anger are usually acceptable only within same-sex friendships and kinship networks or toward those of lower social status. ▪ Generally, women are not free to vent their anger toward their husbands or other powerful men. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Touching, holding hands, and patting one another on the back are acceptable behaviors between same-sex friends and opposite-sex partners. ▪ Same-sex friends, especially among the older generations, are commonly seen holding hands or linking arms while walking. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Very strict Muslims may not shake hands or touch members of the opposite sex, especially if they are not related. ▪ When interacting with someone of higher status, one is expected to maintain occasional eye contact to show attention; however, prolonged eye contact may be considered rude, or may be interpreted as flirting. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turkish people tend to dress formally; men wear suits rather than sports jackets and slacks on social occasions. ▪ Women tend to dress modestly, wearing skirts and dresses rather than slacks. More traditional Muslim women may wear very modest clothing and cover their heads with a scarf, either black or a colorful print. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ However, styles continue to change, and denim jeans and casual dress are becoming common among young people for less formal occasions. ▪ Turks openly display emotions such as happiness, disgust, approval, disapproval, and sadness through facial expressions and gestures. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ No” is indicated by raising the eyebrows or lifting the chin slightly, while making a snapping or “tsk” sound with the mouth. ▪ Appreciation may be expressed by holding the tips of the fingers and thumb together and kissing them and is commonly used to express appreciation for food. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turkish people take pride in keeping their homes immaculately clean, and one is expected to remove one’s shoes inside the home. ▪ Most Turkish hosts in Türkiye and many in the United States offer slippers to their guests. ▪ Whether wearing shoes or not, showing the sole of one’s foot is considered to be offensive in Turkish culture. ▪ Women are expected to sit modestly with knees together and not crossed. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turks tend to have a relaxed attitude about time; social visits can begin late and continue well into the night. ▪ While punctuality in social engagements is not highly important, in business relationships, punctuality among Turkish Americans is gaining in importance. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turks value status and hierarchy. Demonstrating respect for those of higher status is mandatory and determines the quality of interactions with a person. ▪ Strangers are always greeted with their title, such as Bey (Mr.), Hanim (Mrs., Miss, or Ms.), Doktor, or Profesör. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ When friends or family members greet, it is customary for each to shake hands and to kiss one another on each cheek. ▪ Traditionally, when greeting someone of very high status or an elderly person, one might grasp his or her hand and kiss it, and then bring it to touch one’s forehead in a gesture of respect. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ In a very traditional Turkish home, the father is considered the absolute ruler. ▪ The concept of izin (permission or leave to do something specific) captures this significance. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Less traditional families show more equality between spouses, especially in nuclear families in which the wife is well educated. ▪ Yet, remnants of traditional family structure prevail; the husband often acts as the ultimate decision maker, especially in financial matters. ▪ Women may work full time outside the home in addition to assuming full responsibility for running the daily activities inside the home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Legal marriage in Türkiye does not permit polygamy, although some may practice it outside. ▪ A woman’s age, and the number, age, and gender of her children influence her status in the family and the community. A young “gelin” (woman age 15 to 30) has the lowest status. The “middle-aged” woman (30 to 45) has medium status while the “mature” woman (45 to 65) has the highest status. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ In “old age” (65 or older), a woman is highly respected but is not powerful. ▪ However, this status varies according to education, religious practice, socioeconomic level, urbanization, and professional achievement. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Children are held very dear in the Turkish family and they are expected to act as young children, not small adults. ▪ They are accustomed to receiving attention from family, friends, and visitors. ▪ Kissing children and pinching their cheeks is quite common. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Once children enter school, they are expected to study hard, show respect, and obey their elders, including older siblings. ▪ Girls are expected to help care for younger siblings, to help at mealtimes, and to learn to cook. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Traditionally, children are not allowed to act out or talk back to their superiors. ▪ Light corporal punishment is generally acceptable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Male circumcision is a major rite of passage. ▪ This is a time of celebration within the extended family, and newly circumcised boys are honored with gifts. ▪ Traditionally, boys can be circumcised up to the age of about 12, although the modern trend is to perform the circumcision in the hospital shortly after birth. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Urban adolescents are beginning to date in pairs in addition to the more traditionally accepted practice of group outings. ▪ However, sexual interaction is strongly discouraged among youth and the unmarried, especially for young women. ▪ Virginity in unmarried women is a strong cultural value. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ A key objective among Turks is socioeconomic advancement, including education, better professional opportunities, and material success. ▪ Although financial independence is valued in Turkish culture, independence from the family is not encouraged. ▪ Adult children, especially men, remain an integral part of their parents’ lives, and parents expect their children to care for them in their old age. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Because respect is highly valued in Turkish society, maintaining or improving status in the community is of key importance. ▪ Individuals must always consider what impact their actions will have on the family and often they consult parents or other family members before making major decisions. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Young people living in Türkiye generally live in their parents’ home until they are married, unless school or work necessitates other arrangements. ▪ Family-initiated marriages range from rare contractual agreements between parents to the relatively common introduction and gentle encouragement of a newly formed couple. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Elders in Turkish culture are attributed authority and respect until they become weak or retired, at which time their authoritative roles diminish. ▪ Individuals are socialized to take care of elderly parents, regarding it as normal and not as an added burden. ▪ Grandparents play a significant role in raising their grandchildren, especially if they live in the same home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ The extended family is very important in Turkish culture. ▪ Even the apparent increase in nuclear households does not rule out the networks among closely related families. ▪ Whether or not they live under the same roof, a young family may still live under the supervision of the husband’s parents or at least maintain an interdependent relationship. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Divorce is becoming more common in Turkish society, but remains socially undesirable. ▪ Widows, however, are generally taken care of by their late husband’s family and, depending on their age and socioeconomic background, may have the option to remarry. ▪ Premarital cohabitation and unwed motherhood is strongly discouraged. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Homosexuality is only beginning to be received “at a distance.” In fact, one of the most popular entertainers in Türkiye is a homosexual and a transvestite and is accepted as such. ▪ However, most Turks would be hesitant to associate themselves with the gay community. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Because Türkiye is a group-oriented culture, the Turkish workplace may be more team oriented. ▪ Turkish relationship orientation may lead to dependence on personal contacts and networks to accomplish tasks. ▪ Developing these relationships and networks may appear as nepotism or as too much socializing from the American perspective. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Hierarchical structure is highly pervasive throughout Turkish culture, and the workplace is no exception. ▪ Turkish employees expect an authoritative relationship between superior and subordinates. ▪ However, indirect criticism is expected and appreciated to “save face.” Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ A Turk may be highly offended if openly criticized, especially if done in front of other people. ▪ They may be reticent about asking questions for fear of exposing a lack of knowledge. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Turks perceive that aggressive face-to-face confrontation may cause relationships to deteriorate. ▪ The dominant means of conflict resolution is collaboration reinforced by compromise and forcing. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues Many women do not work because it interferes with child care, the order of the home, and it requires them to be together with men from outside the immediate family. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Turkish population is a mosaic in terms of appearance, complexion, and coloration. ▪ Appearances range from light-skinned with blue or green eyes to olive or darker skin tones with brown eyes. ▪ Mongolian spots, usually found at or near the sacrum, are common among Turkish babies and should not be confused with bruising. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Malaria has not been fully eradicated in Türkiye, especially in the southeast. ▪ Endemic goiter associated with iodine deficiency is a major health problem in Türkiye. ▪ Behçet’s disease, a syndrome of unknown etiology, is prevalent in Mediterranean countries, the Middle East, and Japan and primarily affects males between the ages of 20 and 40. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Common health conditions among Turks are lactose intolerance, thalassemia, cardiovascular diseases, cancer, obesity, hypertension, diabetes, tuberculosis, and conditions related to high smoking rates among men and women. ▪ The most prevalent food- and water-borne diseases are infectious hepatitis and sporadic cases of salmonellosis and dysentery. Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-risk Health Behaviors ▪ Cigarette smoking is widespread in Türkiye and tends to start at an early age. Türkiye, a major producer of tobacco in the world, has instituted very limited anti-tobacco activities. ▪ Turks tend to consume less alcohol than Americans or Europeans, perhaps as a result of the Muslim culture that discourages more than moderate alcohol use. Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-risk Health Behaviors ▪ The tendency of Turkish men to view themselves as strong/immune to disease and the traditional cultural view condoning male promiscuity increases the danger for both the man and his wife. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Turkish cuisine is influenced by the many civilizations encountered by nomadic Turks over the centuries, as well as by a mixture of delicacies from different regions of the vast Ottoman Empire. Therefore, food choices are varied and tend to provide a healthy, balanced diet. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck A common genetic/hereditary condition among Turks is a. Hemophilia. b. Thalassemia. c. Anemia. d. Sickle cell anemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: B A common genetic/hereditary condition among Turks is thalassemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Tea and a snack is always on hand for visitors, and dinner guests may have difficulty finishing everything on their plates ▪ Turkish hostesses may relentlessly offer to replace what has been eaten. ▪ Polite guests refuse the first offer, but the hungry need not worry; offers are made again and again. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Turkish cooking is not terribly spicy and is prepared artfully and fastidiously, as Turkish appetites tend to be discriminating. ▪ Breakfast is typically a simple meal of white feta cheese (beyaz peynir), olives, tomatoes, eggs, cucumbers, toast, jam, honey, and Turkish tea. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Hot midday or evening meals may include any of the foods described below: ▪ Çorba (soups) range from light to substantial. ▪ Meze (hors d’oeuvres) include a great variety of small dishes, either hot or cold, such as yaprak dolma (stuffed grape leaves in olive oil), olives, circassian or çerkez tavuğu (chicken with walnut sauce), çiroz (dried mackerel), leblebi (roasted chick peas), or sigara böreği (a savory cheese pastry fried until crispy). Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Salads include lettuce, tomatoes, cucumbers, onions, and other raw vegetables with a dressing of olive oil and lemon juice or vinegar. ▪ Olive oil and lemon are staples in Turkish culinary preparation. ▪ Turks generally prepare meat in small pieces in combination with other vegetables, potatoes, or rice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Famous Turkish cuisine includes köfte, small spicy meatballs, and kebab, skewered beef or lamb and vegetables. ▪ While poultry is less common, fish has a special place in Turkish cuisine. ▪ Türkiye is the birthplace of yogurt, which is an essential part of the Turkish diet and is generally served with hot meals rather than as cold breakfast food. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Vegetables are served cooked or raw, hot or cold, as part of a stew or casserole, or stuffed (dolma) with meat, rice, and currants. ▪ Rice and börek are important parts of Turkish culinary tradition. Börek is made by wrapping yufka (thin sheets of flour-based dough) around meat, cheese, or spinach and then frying or baking until the dough is flaky. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Turkish desserts fall into 4 categories: 1. 2. 3. 4. Rich and sweet pastry, such as baklava Puddings Komposto (cooked fruits) Fresh fruits. In fact, most meals are concluded with fresh fruit and coffee or tea. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Turkish kahve, from which the English word coffee is derived, is famous for its dark, thick, sweet taste. ▪ The Muslim religion requires abstinence from eating pork and drinking alcohol, but not all Muslims abstain, depending on their degree of religious practice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ The Islamic tradition of Ramazan, or Ramadan in Arabic countries, is a month of fasting (oruç tutmak) observed by practicing Muslims throughout the world. ▪ During Ramazan, one is not allowed to eat or drink anything from sunrise to sunset as a test of willpower and as a reminder of the preciousness of the food provided by a gracious Allah (God). Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Generally, pregnant and postpartum women, travelers, and those who are ill are excused from fasting but may be required to make up lost time at a later date. ▪ The evening meal, iftar, is something to which all look forward with great anticipation, and Turkish women, who almost invariably do all the cooking, create veritable feasts each night. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Motherhood is accorded great respect, and pregnant women are usually made comfortable in any way possible, including satisfying their cravings. ▪ Pregnant women may continue their daily activities or work as long as they are comfortable. ▪ In traditional Turkish culture one of the most important desires of a married woman is to have a child. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ A woman who has not had a child is faced with social pressure and accusations and thus may try to use some traditional practices to increase fertility. ▪ Some women damage their bodies by using these traditional practices and sometimes the damage is permanent. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ The pregnant woman is always encouraged to keep up her strength by eating foods that are rich in nutrients. ▪ Many pregnant women take prenatal vitamins, drink a lot of milk, and apply salves such as Vaseline to avoid stretch marks. ▪ Light exercise, such as walking, is encouraged. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ It is acceptable, though not common, for the husband and the birth mother’s father to be present during the birthing process. ▪ Expressions of discomfort and pain are quite acceptable. ▪ However, Laz women from the Black Sea area tend to be stoic. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ The postpartum period can last up to 40 days. ▪ Light exercise is encouraged during this period and bathing, an important part of the Muslim tradition, is strongly encouraged. ▪ A special food called log˘usalik is served to the postpartum woman to increase milk production. ▪ Breastfeeding women drink hot soups and other fluids such as milk. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ At birth, a small blue bead called a nazar boncuk, believed to protect the child from the “evil eye,” is usually placed on the child’s left shoulder. ▪ Other traditional practices include placing iron under the baby’s mattress to protect against anemia, tying a yellow ribbon to the crib to ward against jaundice, and placing a red bow on the crib to distract any envy or negativity. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Practices used to make childbirth easier include unlocking places that are open, untying the woman's hair ribbons, unbuttoning buttons, standing straight and turning so the child will move, drinking water that has been prayed over by religious leaders, enclosing the woman around her waist and rocking her three times, and putting her in a blanket and rocking her three times. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Water is not given to a newborn infant until the call to prayer has been announced three times; otherwise, the infant will have bad breath. ▪ At the end of the 40 days, she returns to normal life. ▪ She is bathed with abundant water and prayers are read. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The home health nurse found an iron under the mattress of a two month old baby. The iron prevents the baby from a. The evil eye. b. Thalassemia. c. Anemia. d. Jaundice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C Placing an iron under the baby’s mattress prevents anemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ When death occurs, the deceased individual's next of kin cry in the most natural manner. ▪ Neighbors who hear about the death gather at the home of the deceased to share in the suffering of the next of kin, to console them, and to help with the initial preparations. ▪ Having prayers said is a common practice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Turkish Muslims do not generally practice cremation because the body must remain whole. ▪ Frequently, the body is displayed in the home for a day or two; it is then placed in a coffin and taken to the cami (mosque) to be visited primarily by men. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Preparations for burial include three important procedures: bathing, wrapping in a shroud, and funeral prayers said outside a mosque. ▪ If someone dies in the morning, they are buried after the mid-afternoon prayers; those who die during the night are buried in the morning. ▪ The funeral may be delayed for distant relatives. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Common rituals after death are closing the eyes of the deceased, tying the chin, turning the head towards Mecca, putting the feet next to each other, putting the hands together on the abdomen, and removing clothing. ▪ In some places the bed is changed; a knife, iron or other metal object is placed on the abdomen of the deceased; the Koran is read at the head of the deceased. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ After the burial, a meal honors the deceased, which signifies moving the deceased into the afterlife. ▪ If these rituals are not completed, the spirit of the deceased will be left behind. ▪ The traditional mourning period is 40 days, during which time traditional women may wear black clothes or a black scarf. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Although Muslim Turks believe in the afterlife, death is always an occasion of great mourning. ▪ An expression of sympathy to one who has just lost someone to death is Basiniz sag˘ olsun (may your head be healthy), hoping that one is not overwhelmed with grief. ▪ Mourning is the most important and careful behavior after a death occurs. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Ninety-eight percent of Turks are Muslim, but freedom of religion is mandated by the Turkish secular state. ▪ Most are Sunni Muslims, with a minority from the Alevi Muslim group. ▪ Other religious minority groups include Jews (mostly Sephardic) and Christians. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Traditional prayer is practiced five times each day and can take place anywhere, as long as one is facing the holy city of Mecca. ▪ A special small rug, called seccade, is used for praying. ▪ When entering the cami, shoes are always removed and women must cover their heads. ▪ Men and women go to separate parts of the cami for prayer. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ One prepares for prayer by ritual cleansing called abdest, which, at minimum, includes washing the face, ears, nostrils, neck, hands to the elbow, and feet and legs to the knee, three times each. ▪ A woman does not enter into a religious activity unless she is ritually pure: women who are menstruating or who have recently given birth are excluded. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Turks rely on their religious beliefs and practices and their family and friends for strength and meaning in life. ▪ Spiritual leaders or healers are sought most often for assistance with relationship or emotional problems and, less frequently, for physical problems. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Most Turks rely on Western medicine and highly trained professionals for health and curative care. However, remnants of traditional beliefs continue to have an impact on health-care practices. ▪ A common explanation for the cause of illness is an imbalance of hot and cold. For example, diarrhea is thought to come from too much cold or heat; pneumonia results from extreme cold. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Terminally ill clients are generally not told the severity of their conditions. ▪ Informing a client of a terminal illness may take away the hope, motivation, and energy that should be directed toward healing, or it may cause the client additional anxiety related to the fear of dying and concern about those being left behind. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ In general, women are responsible for the actual care taking of the ill and the elderly in the home. ▪ In traditional households, the mother-in-law or father-in-law, depending on who controls the finances in the family, makes decisions about going to the physician. ▪ The person who is respected as the most educated has primary input into decisions about health care. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Türkiye has one of the highest rates of consumption of over-the-counter antibiotics and painkillers; aspirin is commonly used as a panacea for a variety of ailments, including gastric upset. ▪ Turks commonly consult a pharmacist before visiting a physician. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Using rubbing alcohol or a wet cloth to bring down a fever and warming the back to treat coughing. ▪ Türkiye encourages health tourism at their 1500 thermal spas, which are frequented for treating conditions, such as rheumatism, respiratory and digestive problems, diabetes, skin conditions, gallstones, female diseases, kidney and heart conditions, nerves, obesity, and hyperlipidemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ The concept of the “evil eye” is prevalent. ▪ Speaking too well of one’s health may incur misfortune through others’ envy or nazar. ▪ Cologne is sprinkled on the hands of guests before and after eating to provide cleanliness and a fresh lemon scent. ▪ Inhaling from a cloth or handkerchief doused with cologne may be used for relief from motion sickness. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Turkish culture allows freedom to express pain, either through emotional outbursts or through verbal complaints. ▪ Although stigma is attached to mental illness, many families seek treatment or care for the client at home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Seriously ill people are expected to conserve their energy to allow their minds and bodies to fight their illnesses; thus, reducing their energy expenditure. ▪ During hospitalization, refakatçí refers to the person who stays overnight with the client, providing emotional and physical support and comfort. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Turkish people usually prefer to receive blood from family members. ▪ Muslims traditionally prefer that the body remain intact after death; thus, organ donation and transplantation remains controversial among some Turks. However, former Prime Minister and President Turgut Ozal and his wife promoted organ donation by publicly signing donor cards to encourage others to do so too. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Mr. Oktay, age 66 years, is alert and oriented and has terminal heart failure. His wife does notwant him to know. The nurse should a. Abide my the wife’s wishes. b. Directly tell Mr. Oktay. c. Consult his children. d. Ask Mr. Oktay what he knows about his condition. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer D The first step is to determine what Mr. Oktay knows about his condition. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ When modern medicine is not available, accessible, or affordable, or when it has not worked, Turks may seek the care of a traditional healer. ▪ Physicians, and to a lesser extent nurses and midwives, have historically been held in very high esteem.
2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 1 Chapter 37 People of Turkish Heritage Marshelle Thobaben And Sema Kuguoglu Overview, Inhabited Localities, and Topography Overview Türkiye (Turkey), as it is written in Turkish, means “land of Turks.” It is located in the Northern Hemisphere, almost equidistant to the North Pole and the equator. The shape of Turkey resembles a rectangle, stretching in the east–west direction for approximately 1565 kilometers (972 miles) and in the north–south direction for nearly 650 kilometers (404 miles). It is bordered by Georgia, Armenia, and Nahcivan (Azerbaijan) to the northeast; the Islamic Republic of Iran to the east; Iraq and Syria to the south; Greece and Bulgaria in the Thrace to the west; and Russia, Ukraine, and Romania to the north and northwest (through the Black Sea). The Anatolian peninsula is the westernmost point of Asia, divided from Europe by the Bosporus and Dardanelles straits. Thrace is in the western part of Turkey on the European continent. Turkey has a diverse geography. It is only slightly larger than Texas with a total area of 783,562 square kilometers (486,882 sq. mi.). Its land area is 769,632 square kilometers (478,227 square miles) and water 13,930 square kilometers (8565 square miles). About 3 percent of Turkey lies in Southeastern Europe (Thrace) and the remainder in Southwestern Asia also called Anatolia or Asia Minor. The sea surrounds Turkey on three sides. The Mediterranean Sea turns into the Aegean Sea along the west coast of Turkey, facing Greece. In the northern part of the Aegean, Çanakkale Bogazi (the Dardanelles) give passage to the Marmara Denizi (Sea of Marmara), which then opens into the Black Sea through the Istanbul Bogazi (the Bosporus) (CIA World Factbook, 2011). A comparable diversity can be seen in the human history of Turkey where over the past ten thousand years various civilizations have risen and fallen due to invasions by newcomers, disease epidemics, and natural disasters such as earthquakes. It continues to be a land of educational, religious, and cultural diversity. The first historical reference to the Turks appears in Chinese records dating back around 200 BC, which refer to tribes called the Hsiung-nu (an early form of the Western term Hun). They lived in an area bounded by the Altai Mountains, Lake Baykal, and the northern edge of the Gobi Desert, and are believed to have been the ancestors of the Turks. In AD 552 many ethnic Turks began to converge under the Gokturks, and later under the Uygurs of Turkistan, followed by the Mongols. In the 10th century, Turkey became fully Muslim and accepted the Arabic script. Under the influence of the Muslim religion, Turkish language and literature were developed, and the building of mosques, schools, and bridges began (CIA World Factbook, 2011). The Seljuk Turks defeated the Christian Byzantine Empire in 1071, resulting in the first of the Christian crusades against Muslims. The Seljuks contributed to medical science and established medical institutions and hospitals in most cities. When the Seljuk Empire collapsed at the end of the 13th century the Ottomans established rule and in 1453 claimed Constantinople as the capital, renaming it Istanbul. The modern Turkish State is a descendent of the Ottoman Empire. Based on a tolerance of differences among its subjects, the Ottoman Empire endured for 600 years and at its height stretched from Poland to Yemen and from Italy to Iran. In 1876 a constitutional monarchy was established under a sovereign sultan, but separatist movements, their subsequent repression, and an emerging Turkish nationalism resulted in the “Young Turk” revolution of 1908 and the erosion of the sultan’s powers. During this time, modest advances in women’s rights began, including the unveiling of nurses in the Balkan Wars and more educational opportunities for women. An armistice at the end of World War I left the Empire stripped of all but present-day Turkey, occupied by Greek, French, British, and Italian armies, and established independence for Armenia and autonomy for Kurds in eastern Anatolia. However, the 1 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 2 2 Aggregate Data for Cultural-Specific Groups Treaty of Lausanne in 1923 officially ended Allied occupation, partitioning Armenia between Russia and Turkey, reinstating the Kurds, and proclaiming an independent Republic of Turkey, with Ankara as its new capital. Although Westernization had begun before independence, Turkey’s president, Mustafa Kemal Atatürk, became synonymous with Westernization and secularism. During his presidency from 1923 to 1938, he initiated many reforms, including banning the fez, outlawing polygamy, instituting marriage as a civil contract, abolishing communal law for ethnic minorities, removing Islam as the state religion, promoting nationalism and pride, instituting educational and cultural reforms, making surnames obligatory, changing the weekly day of rest from Friday to Sunday, and electing 17 female deputies to the National Assembly. Atatürk died on November 10, 1938, but he is still revered as the father of Turkey, and his image can be found in most government and public offices. Turkey remained neutral in World War II, but the postwar economy and Cold War politics prompted U.S. economic and military aid in 1947, forging the political ties that endure today. Despite three bloodless military coups in 1960, 1971, and 1980, Turkey has a multiparty democratic system, a Republican parliamentary democracy. Turkey joined the United Nations (UN) in 1945, became a member of the North Atlantic Treaty Organization (NATO) in 1952, an associate member of the European Community in 1964, and began accession membership talks with the European Union in 2005. Voters approved a referendum in September 2010 that made several constitutional changes including Parliament having increased oversight and diminishing the power of the judiciary and the military; additionally, it provided wider democratic freedoms for Turkey’s citizens (CIA World Factbook, 2011; Information Please, 2011). Turkey remains strategically important to the West and is a strong ally of the United States because of its geopolitical location and its cultural and religious ties. What is presented about the Turkish culture in this chapter is based on studies from Turkey and on observations of and experiences with Turkish immigrants in the United States. remainder in villages (CIA World Factbook, 2011; Turkey’s Statistical Yearbook [TSY], 2010). The capital city of Turkey is Ankara, but the historic capital, Istanbul, remains the financial, economic, and cultural center of the country. Until the 1950s most Turks were peasants living in isolated, self-sufficient villages with their extended family and practical folk-belief system. Depeasantization, migration, and urban settlement have continued, and today squatter housing districts populated by rural “immigrants” in major cities have resulted in permanent low-income neighborhoods juxtaposed against modern urban development. Changes in the social structure and people’s expectations are also shifting. For example, older people’s ability to live in their familiar housing environments, particularly, in large cities and metropolitan areas is forcing the government to change its policy and to strive to provide affordable housing and care centers for them (Turel, 2009). Over the past two decades, Turkey has been hit by several moderate to large earthquakes that resulted in a significant number of casualties and heavily damaged or collapsed buildings. This has been as a result of inadequate seismic performance of multistory reinforced concrete buildings, typically three to seven stories in height. A recent study indicates that a considerable portion of existing building stock may not be safe enough in Turkey (Inel, Ozmen, & Bilgin, 2008). References and further reading may be available for this article. To view references and further reading you must purchase this article. As a result of extensive foreign trade, larger coastal cities are undergoing many changes, which have resulted in an urban environment with a dual character, representing the traditional old way of life and the ensuing new class. Every aspect of life and society is being affected, including changes in values, recreational activities, mass communication and media, and women’s status. Observations suggest that everyday practices of the people, as well as their folk beliefs, are truly changing. However, the Turks still depend on nuclear and extended family and friends for adjustment, job possibilities, and money. Heritage and Residence Reasons for Migration and Associated Economic Factors Turkey is one of the 20 most populated countries in the world and has the second largest population in the Middle East, and in Europe, after Germany. The first national recorded population of the Republic of Turkey was 13.6 million in 1927. The population in 2010 was 73.722.988 with 26 percent of the population age 14 years and younger, and 7 percent age 65 years and older. Roughly, 70 to 75 percent of the population is Turkish, 18 percent Kurdish, and 7 to 12 percent other minorities. Approximately, 75 of the population lives in cities, such as Istanbul, Ankara, Izmir, and the The U.S. Census Bureau (2011) reported 190,000 people of Turkish descent living in the United States. The majority of them lived in the Northeast (39 percent) and the least in the Midwest (13 percent). The Turkish immigrant population in the United States differs significantly from most of the Turkish population that inhabits Europe, in terms of both demographic makeup and socioeconomic status and integration. A high proportion of Turks in the United States come from the elite and upper-middle classes, interspersed 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 3 People of Turkish Heritage with smaller groups of middle-class students and skilled laborers who are supported privately or by the government. Economic reasons, such as unemployment and poor salaries, are the major reasons Turks leave to work in other countries (İcduygu, 2008). Although Turks have emigrated throughout the world, many have lived in Western Europe since the 1960s and in 1970s North Africa and the Middle East, largely as a result of “guest worker” programs. Since the 1990s, Turkish workers have also moved to the neighboring former communists’ countries such as Russian Federation and Ukraine (İcduygu, 2008). A large “Turkic belt” stretches from the Balkans across Turkey, Iran, Central Asia, the former republics of the Soviet Union, and deep into the borders of Mongolia. This belt includes many ethnic Turks who may share cultural, linguistic, religious, and certainly historical links with the people of Turkey. Research studies have indicated that any concern about excessive “brain drain” from the immigration of some of Turkey’s intellectual, academic, and other highly skilled professionals to the United States is unfounded; it has not created a threat to Turkey’s economic, scientific, social, and cultural development. Additionally, Turks living in the United States usually maintain strong bonds with their Turkish families and pass on their Turkish cultural values, traditions. and language to their children born in the United States (Köser-Akçapar, 2006). Turks who have lived or studied in the United States generally have higher status and greater employment opportunities in Turkey. Educational Status and Occupations Education is highly valued in Turkey by all socioeconomic groups. Coeducational primary and secondary education is provided at no cost and is guaranteed under the Constitution. It consists of public and private school at all levels, ranking from preprimary (1 year), primary (8 years), high school (4 years), and universities (4 to 6 years). In 1997, 5 years of compulsory primary school was extended to 8 years including the middle schools. Primary school starts at age of 7 and ends at 13. High schools were extended from 3 to 4 years in 2005. High school includes a number of options, including general, technical, trade, vocational, and theological training. Higher education institutions include universities, faculties, institutes, higher schools, vocational higher schools, conservatories, and research and application centers (TSY, 2009). Students who wish to pursue a university education must take a state examination that determines both their admission to the institution and their subject of study. In a recent study it was reported that only 22 percent of the students who took the nationwide competitive entrance examination were placed in a university program in Turkish universities. Turkey’s university 3 distance education program, one of the largest in the world, annually accepts only about 15 percent of students who apply (Tasçı & Oksuzler, 2010). A high level of education exists among people of Turkish descent living in the United States. Significant numbers hold advanced degrees, and most are employed in professional, managerial, and technical occupations. Turkey’s Statistical Yearbook (2009) reported that of the 48 percent of Turkey’s working age population who participated in the labor force, 70.5 percent were men and 26 percent were women; 45.8 percent worked in urban areas (69.9 percent male and 22.3 percent female) and 52.7 percent in rural areas (72 percent male and 34.6 female). Of those workers employed in the agriculture sector, 46 percent were unpaid family workers; 76.9 percent of the unpaid family workers were female, while 23.1 percent were male. The unemployment rate was estimated to be 14 percent in 2009 (TSY, 2009). Persons not in the labor force composed 52.1 percent of the working-age population. The main subgroups were persons who were busy with household chores (44.9 percent), students, and disabled and retired persons (TSY, 2009). For cultural reasons, many women have continued to maintain their traditional roles and do not work outside the home because it interferes with their household responsibilities, including caring for their children, and it may require them to work with men from outside their immediate family. Communication Dominant Language and Dialects A Uralic-Altaic language, Turkish is spoken by 90 percent of the population. The Turkish language has approximately 20 dialects, including Yakut, Chuvash, Turkoman, Uzbek, Kazakh, and the language of the Gagavuz people. Differences in some of the dialects are so great that they are considered separate languages. Through the centuries, Turks borrowed from Arabic and Persian languages, and bits of “Turkified” French and English can also be found. Until 1928, Turkish was written in Arabic script, but under Atatürk’s direction, a Turkish alphabet was developed based on Latin script. The Turkish alphabet is much like the English alphabet, although it does not have a “w” or an “x,” and additional sounds are symbolized by an “i” without a dot; a “ğ,” an “ö,” and a “ü” with accents; and an “ş” and a “ç” with a cedilla, symbolizing “sh” and “ch,” respectively. The Turkish language does not distinguish gender pronouns such as “he” from “she” or “her” from “his”; therefore, Turks learning English may inadvertently confuse these pronouns. However, Turkish does distinguish a formal from an informal “you,” signifying the importance of status in Turkish society. 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 4 4 Aggregate Data for Cultural-Specific Groups Typical of many Mediterranean cultures, speaking in loud voices is common; this may not signify anger, but rather excitement or deep involvement in a discussion. It can be common for more than one person to speak at the same time or to interrupt another person, which is not necessarily considered rude. However, someone of lower status should not interrupt someone of higher status. Cultural Communication Patterns In the Turkish’s culture group affiliation is valued over individualism. In fact, identity may be determined by family membership, group, school, or work associations. An individual’s behavior is expected to conform to the norms or traditions of the group, and Turks tend to be more people and relationship oriented than Americans. Although Turks may take longer than Americans to form friendships, these relationships last longer, formality is decreased significantly, and interdependence is encouraged as a source of strength. In this group-oriented culture, Turks generally do not desire much privacy and tend to rely on cooperation between family and friends, although competition between groups can be fierce. Turks value harmony over confrontation. However, Turkish communication style is characteristic of Mediterranean cultures in which the outward show of feelings is less restrained. For women, expressions of anger are usually acceptable only within same-sex friendships and kinship networks or toward those of lower social status. Generally, women are not free to vent their anger toward their husbands or other powerful men. Children are very accustomed to being held, hugged, and kissed by family and friends of the family. Touching, holding hands, and patting one another on the back are acceptable behaviors between same-sex friends and opposite sex partners. It is common to see same-sex friends, especially among the older generations, holding hands or linking arms while walking. Likewise, personal space is closer between same-sex friends and opposite-sex partners; physical proximity is valued as a sign of emotional closeness. Very strict Muslims generally do not shake hands or touch members of the opposite sex, especially, if they are not related. Health-care providers are usually looked upon as professionals and touch is allowed and expected when necessary. Eye contact may be used as a way of demonstrating respect. When interacting with someone of higher status, a person is expected to maintain occasional eye contact to show attention; however, prolonged eye contact may be considered rude or interpreted as flirting. Turkish people tend to dress formally; men wear suits rather than sports jackets and slacks on social occasions. Women tend to dress modestly and wear skirts and dresses rather than slacks. Black clothing accented with gold jewelry is quite popular. More traditional Muslim women may wear very modest clothing and cover their heads with a scarf, either black or a colorful print. However, styles continue to change, and denim jeans and casual dress are becoming common among young people for less formal occasions. Turks tend to openly display emotions such as happiness, disgust, approval, disapproval, and sadness through facial expressions and gestures. Two unique gestures in Turkish culture include signals for “no” and signs for approval or appreciation. “No” is indicated by raising the eyebrows or lifting the chin slightly while making a snapping or “tsk” sound with the mouth. Appreciation may be expressed by holding the tips of the fingers and thumb together and kissing them. This signal is commonly used to express appreciation for food. Various phrases are commonly used by Turks. Allahaismarladik (God watch over you) is said to someone leaving and is responded to with gule gule (go with smiles). Ellerine saglik (health to your hands) communicates appreciation for a good meal, and the cook responds with afiyet olsun (good appetite). Cok yasa (live long) is said after someone sneezes with a response of sen de gor (you see a long life, too). Masallah (God protect from the evil eye) is said, for example, when one has a healthy baby or when one has achieved something good, whereas insallah (God willing) is said when something is wished to happen. Turkish people take pride in keeping their homes immaculately clean, and one is expected to remove one’s shoes inside the home. Most hosts in Turkey and many in the United States offer slippers to their guests. Whether wearing shoes or not, showing the sole of one’s foot is considered to be offensive in Turkish culture. Women are expected to sit modestly with knees together and not crossed. Tortumluoğlu, Bedir, and Sevig (2005b) conducted a qualitative study in a village in eastern Turkey by examining individual cultural communication characteristics. Comments from the participants included the following: • According to our religion, men who are not our legal husband are not allowed to listen to our voices. A woman cannot speak out loud and cannot laugh in the community; she would be like bad woman (woman over 65 years old). • We do the duties of the bride (act like a servant) for our husband’s relatives and mother-in-law. We can never speak near them. To speak would be disrespectful (bride, 15 years old). • If the person across from us is a woman, we hug and kiss, but if he is a man outside the family, we don’t touch him. We will not eat at the same table with men outside the family; we won’t be together 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 5 People of Turkish Heritage with them at weddings; we won’t sit next to them on the bus; we wouldn’t go near them without covering our heads and bodies. We don’t look them in the eye (women over 65 years old). • We’re uncomfortable being examined or given a shot by a man because they are strangers. It is very sinful to go to a man even our husband and open what is covered (female, age unknown). • I would not take my wife, daughter, or daughterin-law to a male doctor. I would not show them to unrelated men (man over 65 years old). • Even if I knew my wife would die, I wouldn’t take her to a male obstetrician (boy about 15 years old). Temporal Relationships Turks tend to have a relaxed attitude about time; social visits can begin late and continue well into the night. Whereas punctuality in social engagements is not highly important, in business relationships punctuality among Turkish Americans is gaining in importance. Format for Names Turks value status and hierarchy. Demonstrating respect for those of higher status is mandatory and determines the quality of interactions with a person. A variety of titles are used to show respect and acknowledge status. Strangers are always greeted with their title, such as Bey (Mr.), Hanim (Mrs., Miss, or Ms.), Doktor (Dr.), or Profesör (Professor). Members of the family are also addressed using specific titles that recognize relationships, such as agabey (older brother or older close male friend), amca (uncle or elderly male relative or stranger), abla (older sister or older close female friend), teyze (maternal aunt or older female relative or older female stranger), and yenge (wife of a brother or paternal uncle). When friends or family members greet, it is customary for each to shake hands and to kiss one another on each cheek. Traditionally, when greeting someone of very high status or an elderly person, one might grasp his or her hand and kiss it and then bring it to touch one’s forehead in a gesture of respect. Family Roles and Organization Head of Household and Gender Roles In a very traditional Turkish home the father is considered the absolute ruler. The concept of izin (permission to leave to do something specific) captures this significance. In rural and traditional families, women may require izin from the head of household for doing simple things, such as shopping, traveling, or visiting their nurse midwife, physician, or dentist. The justification is that the one who earns the money may spend the money. The person who bestows izin is responsible for the protection of the izinli (person who requires the izin). Izin exhibits a structure of authority that is 5 both hierarchical and patriarchal; therefore, women typically require izin more often than do men. A young wife (gelin) may require izin from her husband and from her mother-in-law. All are ultimately responsible to the gelin’s father-in-law, who is usually the absolute ruler of the traditional extended family (Tortumluoğlu, Bayat, & Sevig, 2005a; Tortumluoğlu, et al., 2005b). Less-traditional families show more equality between spouses, especially in nuclear families in which the wife is well educated and works outside the home. Yet remnants of traditional family structure prevail and the husband often takes on the role of ultimate decision maker, especially in matters of finance. Women may work full time outside the home in addition to assuming full responsibility for running the daily activities inside the home. Modern Turkish women tend to be more Westernized than some of their Middle Eastern or Muslim counterparts. The first institution for higher learning for women in Turkey was established in 1910. In 1917, women earned the right to divorce and to reject polygamous marriage. Atatürk’s new republic abolished the old legal system based on religion and secularization, giving women equal rights to education and no longer requiring them to wear veils and long overgarments. Legal marriage does not permit polygamy, although some may practice it outside the law. Women have had the right to vote since the early 1930s. In 1966, a charter of the International Labor Organization passed the equivalent of an Equal Rights Amendment, requiring equal wages to both sexes for work of an equal nature. Family Goals and Priorities A woman’s age and the number, age, and gender of her living children can influence her status in the family and the community but varies depending upon such things as education, religious practice, socioeconomic level, urbanization, and professional achievement. Generally, a young gelin (woman aged 15 to 30 years) has the lowest status, middle-aged” woman (30 to 45 years) has intermediate status, a “mature” woman (45 to 65 years) has the highest status, and an “old age” woman (65 years or older) is highly respected but not very powerful. Working outside the home is associated with status positively in the urban context and negatively in the rural context. Professional employment and education raise the status of women. Thus, health-care providers may find significant variations regarding gender roles when working with Turkish American patients. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Children are held very dear in the Turkish family, and they are expected to act as young children, not small 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 6 6 Aggregate Data for Cultural-Specific Groups adults. They are accustomed to receiving attention from family, friends, and visitors. Kissing children and pinching their cheeks is quite common. Once children enter school, they are expected to study hard, show respect, and obey their elders, including older siblings. This concept is referred to as hizmet (duty or service). As children age, they are socialized into more-traditional gender roles. Girls are expected to help care for younger siblings, to help at mealtimes, and to learn to cook. Traditionally, children are not allowed to act out or talk back to their superiors. Light corporal punishment is generally acceptable. Circumcision is a major rite of passage for a male child. This is a time of celebration within the extended family, and newly circumcised boys are honored with gifts. Traditionally, boys can be circumcised up to the age of about 12, although the modern trend is to perform the circumcision in the hospital shortly after birth. Rankina and Aytaç’s (2008) research found that the religiosity of the parents, the vast majority of whom were Muslim, had no effect on the schooling of Turkish children, whether male or female. In contrast, patriarchal family beliefs and practices discouraged the education of children, particularly girls. Their findings also showed a father’s disapproval of daughters going out in public without a headscarf reduced the likelihood of girls finishing or going beyond primary school. Thus, family cultural traits may continue to represent a significant barrier to gender equality in education (Rankina & Aytaç, 2008). As children reach adolescence, they are expected to continue to work hard in school and show respect for superiors. The U.S. and Western culture and lifestyles are exported to Turkey via the various social networks. O’Neil and Güler (2010) explored the meaning high school and university students attached to American popular culture and found no evidence that that American popular culture was in danger of overwhelming Turkish culture. Young adults like to move back and forth between indigenous and foreign products, including American ones, and as a result the researchers felt this continued to embody a multiplicity and hybridity that has characterized Turkish culture for centuries. Young people in the urban areas may talk more about sex and engage more freely in sexual activity than previous generations; however, sexuality largely remains a taboo and is regarded as a forbidden topic for social and cultural reasons. Though not common among rural Turks, urban adolescents are beginning to date in pairs, in addition to the more traditionally accepted practice of group outings. However, sexual interaction is strongly discouraged among youth and the unmarried, especially young women. Virginity in unmarried women is a strong cultural value. According to a study conducted with university students in Turkey, 82.4 percent of female students and 86.5 percent of male students were virgins when they married, because of social rules and religious beliefs. Sixty-two percent of female students practiced sexual abstinence (Tortumluoğlu, Ersay, Pamukçu & Şenyüz, 2006). Parents are expected to provide sexual education within the family but often have insufficient knowledge on the subject. Kukulu, Gursoy, and Gulsen (2009) recommended that structured sex education that incorporated knowledge of specific aspects of the Islamic culture experience would help to promote healthy sexual behavior and decrease sexual myths, such as marrying a virgin increases sexual satisfaction. Successful completion of high school or university education is a first step toward adulthood. Although education earns respect in the family, the concept of hizmet still applies. A further step for men is the completion of required military service (askerlik), the duration of which varies depending on the population and the needs in Turkey. In addition, employment and earning money are symbols of adulthood for both men and women. Marriage is perhaps the most important developmental task for adulthood. Young people generally live in their parents’ home until they are married, unless school or work necessitates other arrangements. This practice may be quite different among assimilated Turks in America. The Turkish word for marriage, evli, translates to “with house.” Family remains an important factor in marriage. Marrying into a “good family,” having a high-status occupation, and achieving wealth are means of attaining higher social status for both the individual and the entire family. Family members’ accomplishments raise the entire family’s status, whereas failures have an equally broad effect. Thus, individuals must always consider what impact their actions will have on the family. Often, they consult parents or other family members before making major decisions. Arranged marriages occurred most often among less-educated, older individuals. Family initiated marriages range from rare contractual agreements between parents to the relatively common introduction and gentle encouragement of a newly formed couple. The more traditional family will “choose” a spouse for a son by considering the individual’s personality, talents, and appearance. For a daughter, it is more important to consider the individual and his family because she marries into the husband’s family. Elders are attributed authority and respect until they become weak or retired, at which time their authoritative roles diminish. However, respect always remains a factor. Although financial independence is valued in Turkish culture, independence from the family is not encouraged. Adult children, especially men, remain an integral 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 7 People of Turkish Heritage 7 part of their parents’ lives and parents expect their children to care for them in their old age which is regarded as normal, not as an added burden. Grandparents play a significant role in raising their grandchildren, especially if they live in the same home. The extended family is very important. Even the apparent increase in nuclear households does not rule out the networks among closely related families. Whether or not they live under the same roof, a young family may still live under the supervision of the husband’s parents or, at least, maintain an interdependent relationship. In many Turkish families, aunts, uncles, cousins, and in-laws form the extended family. Visits with local relatives are assumed and mandatory when traveling. Extended family members have a social relationship and may also play an authoritative role within the network. A cooperative relationship, which includes sharing child care, labor, and food, when necessary, and providing companionship, is essential between women in an extended family or neighborhood. sense of belonging in a less relationship-oriented American work milieu. Hierarchical structure is highly pervasive throughout Turkish culture and the workplace is no exception. Turkish employees expect an authoritative relationship between superior and subordinates. However, indirect criticism is expected and appreciated in order to “save face.” A Turk may be highly offended if openly criticized, especially in front of other people. They may be reticent about asking questions for fear of exposing a lack of knowledge. Yet, Turks may exhibit modesty when applying for a job or a promotion relying more on the recommendations of others than on pointing out their own strengths. Because military service is mandatory for men who wish to maintain their Turkish citizenship (even those living abroad), young Turkish men who reside outside Turkey may need to take an extended leave to complete their military service. Alternative Lifestyles Issues Related to Autonomy Divorce is becoming more common, but it remains socially undesirable, especially for women, for whom remarriage opportunities may be limited to divorced or widowed men. Widows, however, are generally taken care of by their late husband’s families and depending on their age and socioeconomic background may have the option to remarry. Premarital cohabitation and unwed motherhood are strongly discouraged, especially among more-traditional families, although living together before marriage is not uncommon in larger cities and among immigrant Turks. Even though being a gay man or lesbian is not a crime or considered a disease, homosexuality is only beginning to be received “at a distance.” In Oksal’s (2008) study of familial patterns of attitudes toward lesbians and gay men, he found that young adults’ attitudes toward lesbians and gay men were more liberal than those of their parents. However, on the whole, Turkish family members have quite negative attitudes toward homosexuality, most likely linked to religious beliefs. Most Turkish people are in agreement with Islamic values that regard homosexuality as a sin and unacceptable (Oksal, 2008). Because most Turkish immigrants speak English, language barriers in the workplace may be only subtle. However, dealing with differences of opinion between parties of equal hierarchical level may present difficulty. Turks perceive that aggressive face-to-face confrontation may cause relationships to deteriorate; therefore, the dominant means of conflict resolution is collaboration reinforced by compromise and forcing. Compromise and avoidance behaviors are more likely among peers, whereas accommodation behaviors are used with superiors. Their way of handling differences of opinion is brisk and clear-cut when an authority relationship exists between the two parties. Turkey is known for its high-power distance (the psychological and emotional distance between superiors and subordinates), respect for authority, centralized administration, and authoritarian leadership style. In Turkish culture a manager’s authoritative control is often more important than the achievement of organizational goals. Workforce Issues Culture in the Workplace Because Turkey is a group-oriented culture, the Turkish workplace may be more team oriented than in the United States. Turkish relationship orientation may lead to dependence on personal contacts and networks to accomplish tasks, and from the American perspective, developing these relationships and networks may appear as nepotism or as too much socializing. In contrast, the Turkish immigrant employee may not feel a Biocultural Ecology Skin Color and Other Biological Variations The Turkish population is a mosaic in terms of appearance, complexion, and coloration because of historical migration and inhabitance patterns. Appearances range from light-skinned with blue or green eyes to olive or darker skin tones with brown eyes. Mongolian spots, usually found at or near the sacrum, are common among Turkish babies and should not be confused with bruising. Racially, 75.6 percent of the men and 77.7 percent of the women are in the brakisefal (having a short, broad head) category, which is a 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 8 8 Aggregate Data for Cultural-Specific Groups shared symbol of the Dinaric Alpines (Gültekin & Koca, 2003). Diseases and Health Conditions According a recent health survey (TSY, 2008) that was sent to all settlements in the territory of the Republic of Turkey, 71.9 percent of men and 55.5 percent of women stated their general health status was good or very good; 75.2 percent of men and 58.8 percent of women living in urban areas stated their health was good or very good; while only 63.8 percent of men and 48.4 percent of women in rural areas stated their health status was good or very good (TSY, 2008). Life expectancy at birth in 2010 was estimated to be 72.23 years for the total population (70.37 years for males and 74.19 years for females) (CIA World Factbook, 2011). The leading causes of death include major vascular diseases (ischemic heart disease, stroke), chronic obstructive lung disease and lung cancer in men, perinatal problems, lower respiratory infections, and diarrheal diseases. Injuries cause about 6 to 8 percent of deaths, although this may be an underestimate (Akgun et al., 2007). There is also a high prevalence of obesity, hypertension, and diabetes, especially in Turkish women. Malaria is still problematic in the southeast part of the Turkey (CDC, 2011). Lactose intolerance rises among populations farther south and east in Europe. The Black Sea region tends to have a relatively high incidence of helminthiasis (intestinal worm). Endemic goiter associated with iodine deficiency, despite iodine prophylaxis (ID), still exists in 27.8 percent of the Turkish population. It has been eliminated in most of the urban population; however, it is prevalent in rural areas and in particular geographical regions (Erdoğan et al., 2009). Tuberculosis continues to be prevalent in the Aegean areas and in southeastern Anatolia. Behçet’s disease (BD) is a systemic inflammatory disorder of unknown etiology with a strong genetic component. It is characterized by recurrent attacks of oral aphthous ulcers, genital ulcers, skin lesions, uveitis or other manifestations affecting the blood vessels, gastrointestinal tract, and respiratory and central nervous system; the inflammatory lesions at particular sites, such as the eyes, brain, or major vessels can result in permanent tissue damage and cause chronic manifestations or even death (Gul, 2007). It is prevalent in Japan and China in the Far East to the Mediterranean Sea, including countries such as Turkey and Iran, and usually starts in the second and third decade of life. The male-to-female ratio is approximately equal, although BD runs a more severe course in men and in those aged <25 years at onset (Gul, 2007). Beta thalassemia is the most common inherited blood disorder in Turkey and represents a major public health problem. It is characterized by reduced or absent beta globin gene expression. Beta thalassemia, alpha thalassemia, and sickle cell anemia are also the most common hemoglobinopathies in Turkey. Although the overall frequency of beta thalassemia in Turkey is 2 percent, there are significant regional differences. The incidence of beta thalassemia in the Denizli province is estimated between 2.6 and 3.7 percent (Bahadir et al., 2009). The Turkish government has national health-care prevention programs for communicable diseases, tobacco control, cardiovascular diseases, chronic respiratory diseases, cancer, and a newly developed Obesity Prevention and Control Program (Ministry of Health of Turkey, 2010). Because of the diversity in climate, topography, and culture in Turkey, it is essential to ascertain the specific geographic origin of a Turkish immigrant. Health-care providers may need to assess newer Turkish immigrants for tuberculosis, malaria, or other potential health problems found in Turkey. Variations in Drug Metabolism The literature reports no studies regarding variations in drug metabolism and interactions for Turks. Given the diversity of ethnicity, one cannot extrapolate data from other ethnic or minority groups and apply them to Turkish peoples. This is one area in which research is needed. High-Risk Behaviors Beser, Bahar, and Buyukkaya (2007) studied healthpromotion lifestyle profiles of 264 Turkish workers to determine the factors that affect their lifestyles. The research found that the workers did not have the desirable degree of health responsibility because they did not consider health controls as a necessity to lead a healthy life. If individuals can do their daily routines and if their health does not prevent them from going to work, they do not consider themselves ill. The workers obtained the highest scores on interpersonal support (family members support each other during difficult times) which is the hallmark of Turkish culture. There is a significant risk among farmers exposed to exogenous carcinogens such as artificial fertilizers and insecticides. Cigarette smoking is widespread in Turkey and tends to start at an early age. Turkey, a major producer of tobacco in the world, has instituted very limited anti-tobacco activities. Passive smoke has been associated with an increased incidence of asthma and allergic diseases among Turkish children. Despite stereotypes promoted in the American film Midnight Express, drug use is not common among mainstream Turks. They tend to consume less alcohol than Americans or Europeans, perhaps as a result of the Muslim culture that discourages more than moderate alcohol use. In general, it is more acceptable for men than women to drink alcohol; however, this 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 9 People of Turkish Heritage is becoming less so as Turkey becomes more Westernized. In a recent national health survey, 63.9 percent of males and 93 percent of females never consumed alcohol (TSY, 2008). There is a high risk for sexually transmitted diseases in Turkey. The tendency of men in Turkey, which has a particularly young population, to view themselves as strong and immune to disease and the positive view of men in traditional Turkish culture to have sexual relationships with more than one woman increases the danger for both the man and his wife. Health-Care Practices Health beliefs and behaviors of the Turkish immigrant may vary according to the variant cultural characteristics (see Chapter 1). Health-seeking behaviors promoted by the Turkish government include a strictly enforced law requiring the wearing of seat belts in motor vehicles. Helmet laws for motorcycle drivers have not been instituted. Aerobics studios and athletic facilities exist in major urban areas, but the idea of cardiovascular fitness is relatively new, and Turks may be more likely to seek outdoor activities such as picnicking or, among men, playing soccer. However, because many Turks, especially in rural areas, do not have modern conveniences such as elevators in apartment buildings, automobiles, or clothes dryers, their daily life inherently requires more caloric output than life in the United States, an important issue to keep in mind when adjusting to life in the United States. Nutrition Meaning of Food Turks take great pride in the fact that French, Chinese, and Turkish cooking are reportedly the three foremost cuisines in the world. Turkish cuisine is influenced by the many civilizations encountered by nomadic Turks over the centuries, as well as by a mixture of delicacies from different regions of the vast Ottoman Empire. Therefore, food choices are varied and tend to provide a healthy, balanced diet. Food is a highly valued symbol of hospitality that communicates love and respect to those for whom it is prepared. Whereas a typical family dinner may be simple, guests are generally served a bountiful array of dishes—more food is always better. Tea and a snack are always on hand for visitors. Dinner guests may have difficulty finishing everything on their plates because hostesses may relentlessly offer to replace what has been eaten. Polite guests refuse the first offer, but the hungry need not worry—offers are made again and again. Food is generally presented in an appetizing manner, and many foods have names intended to be enticing or, at least, entertaining. For example, kadinbudu 9 köfte translates as “lady’s thigh meatballs”; imambayildi, or “the priest fainted,” is an eggplant dish with lots of garlic; and asure, or “Noah’s pudding,” is a dessert in which more than two of everything is included. Turks typically eat their evening meal later than most Americans, at about 8 p.m., something healthcare professionals may need to take into consideration when teaching Turkish American patients about medication therapies. Common Foods and Food Rituals Turkish cooking is quite delicious, not terribly spicy, and prepared artfully and fastidiously, because Turkish appetites tend to be discriminating. Breakfast is typically a simple meal of white feta cheese (beyaz peynir), olives, tomatoes, eggs, cucumbers, toast, jam, honey, Turkish sausage (Turk sucugu), and Turkish tea. Hot midday or evening meals may include any of the following foods: • Çorba (soups) range from light to substantial. Meze (hors d’oeuvres) include a great variety of small dishes, either hot or cold, such as yaprak dolma (sarma) (stuffed grape leaves in olive oil), olives, circassian or çerkez tavuğu (chicken with walnut sauce), çiroz (dried mackerel), leblebi (roasted chick peas), or sigara böreği (a savory cheese pastry fried until crispy). Meze may be accompanied by rakí, traditional anisette liquor distilled from grapes that is served with water over ice and drunk slowly. Sharing a glass of rakí is usually toasted with the phrase Şerefe (to your honor). • Salads include lettuce, tomatoes, cucumbers, onions, and other raw vegetables with a dressing of olive oil and lemon juice or vinegar. Olive oil and lemon are staples in Turkish culinary preparation. • Turks generally prepare meat in small pieces in combination with vegetables, potatoes, or rice. Famous Turkish cuisine includes köfte, small spicy meatballs, and kebab, skewered beef or lamb and vegetables. Whereas poultry is less common, fish has a special place in Turkish cuisine because of its variety, freshness, and availability. • Turkey is the birthplace of yogurt, which is an essential part of the Turkish diet and is generally served with hot meals rather than as cold breakfast food. • With the abundant produce in Turkey, vegetables play a large role in the Turkish kitchen. Vegetables are served cooked or raw, hot or cold, as part of a stew or casserole, or stuffed (dolma) with meat, rice, and currants. • Rice and börek are important parts of Turkish culinary tradition. Börek is made by wrapping yufka (thin sheets of flour-based dough) around meat, cheese, potato, or spinach and then frying or baking until the dough is flaky. 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 10 10 Aggregate Data for Cultural-Specific Groups • Turkish desserts fall into four categories: rich and sweet pastry, such as baklava; puddings; komposto (cooked fruits); and fresh fruits. In fact, most meals conclude with fresh fruit and coffee or tea. • Turkish kahve, from which the English word “coffee” is derived, is famous for its dark, thick, sweet taste. Cooked with a cezve (coffee pot), it is served in small, demitasse cups. Coffee grounds left in the cup can foretell one’s future. Turkish çay (tea) is prepared using a two-tiered çaydanlik (teapot), allowing the hostess to serve guests according to their preference for koyu (dark) or açík (light) tea. Ayran, a mixture of yogurt and milk, is the national cold drink and is drunk by children and adults alike. The Muslim religion requires abstinence from eating pork and drinking alcohol, but not all Muslims abstain, depending on their degree of religious practice. Given the diversity of food options for Turks in America, health-care providers need to provide dietary counseling according to the individual’s unique food choices and practices. The Islamic tradition of Ramazan or Ramadan is a month of fasting (oruç tutmak) observed by practicing Muslims throughout the world. During Ramazan, one is not allowed to eat or drink anything from sunrise to sunset as a test of willpower and as a reminder of the preciousness of the food provided by a gracious Allah (God). Many Muslims also stop smoking during this month. Delicious unleavened bread called pide is sold everywhere only during Ramazan. Observance of this tradition varies from some not observing it to others who strictly follow the ritual and do not bring anything to their mouth during daylight hours. Sunni Muslims, the majority of Muslims in Turkey, start practicing Ramazan at age 10 or 11, and some believe that women have the duty to fast even during pregnancy and the postnatal period. Generally, pregnant and postpartum women, travelers, and those who are ill are excused from fasting, but they may be required to make up lost time at a later date. Ramazan is determined by the lunar calendar and, therefore, can take place at various times in the year. Typically, Turks who are fasting eat breakfast, or sahur, before dawn and before ezan (the call to prayer). The evening meal, iftar, is something all look forward to with great anticipation, and Turkish women who almost invariably do all the cooking create veritable feasts each night. This is a time to visit with friends and relatives, so dinner invitations abound during Ramazan. In a sense, Ramazan is a spiritual and physical cleansing that brings the community together. Despite fasting many Turks actually gain weight during the month because of their inactivity during the day and eating well at the end of each day. Fasting also can cause a variety of digestive problems and may endanger the health of a pregnant or postnatal woman and her baby. Health-care professionals should provide factual information regarding these issues. Another holiday based on Islamic practice is the Kurban Bayram or sacrificial holiday. In Turkey, an animal such as a goat or sheep may be butchered and the meat divided and distributed to the poor. New Year’s Day is celebrated much like American’s Christmas, with a large feast including a turkey dinner, the exchange of gifts, sometimes a tree, and socializing with family and friends. Dietary Practices for Health Promotion Traditional dietary practices linking food to health have carried through to the modern day, even among highly educated Turks. Molasses and baklava, lokum (Turkish delight), tahini, and honey and nuts and raisins are believed to increase strength and sexual vigor. Fruits, especially bananas, oranges, tangerines, and apples, are brought to convalescing people helping them to regain their strength and aid in the healing process. Milk, which is not commonly drunk by adults, is considered more medicinal than yogurt. Chicken soup is a common remedy for cold and flu symptoms. An ebe kadin or kadin ana, a traditional midwife or healer in Turkey, relies on various herbs and home remedies to heal patients. Ebegömeci, a spinach-like leaf or herb, may be prepared for topical or oral use to treat inflammation, infection, and sometimes infertility. Ihlamur tea, tarçin (cinnamon), kant (hot sugar water), ginger, mint, and various roots are used separately or in various combinations to treat rheumatism, low blood pressure, intestinal gas, and colds and flu. Nettles may be used topically for rheumatism, arthritis, and varicose veins. A folk remedy for diabetes involves boiling olive leaves and, after refrigerating, drinking the juice. Lapa, a watery rice mixture with a gruel-like texture, or a boiled potato may be used to treat diarrhea; this is followed by yogurt to replace the natural flora of the intestines. Health-care professionals need to ask Turkish patients if they are using folk dietary practices and may incorporate these into prescription therapies. Some traditional Turkish foods unavailable in most parts of the United States include pastirma (Turkish version of pastrami), sucuk (Turkish sausage), and various types of cheeses such as kaşar. Yufka is an essential ingredient in many Turkish recipes such as börek, although phyllo dough may be an adequate substitute. Nutritional Deficiencies and Food Limitations Population groups at greatest risk for malnutrition are preschool children, female adolescents, mothers, and the economically disadvantaged. Health-care providers may need to consider extensive nutritional assessments for more recent Turkish immigrants. 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 11 People of Turkish Heritage Another important health problem is rickets, caused by vitamin D deficiency. Rickets is seen more frequently in children under 2 years old and has a 6 to 20 percent prevalence, with the leading causes being not taking children outside into the sunshine and not feeding children sufficiently from the dairy food group. Cinar et al. (2006) reported that 62 percent of mothers who had children from 0 to 12 months old in Sakarya, Turkey, believed that sunlight was “harmful” for their children; however, the majority (80 percent) of mothers named one benefit a child received from intentional baby sunning. “Sun causes cutaneous diseases” was the most frequently cited harm (Cinar et al., 2006). Other prevalent nutritional problems in some communities in Turkey are skin, mucosa, eye, and lip symptoms from riboflavin (vitamin B2) and vitamin A deficiencies and bleeding gums from vitamin C deficiency. Turks who are Muslim are forbidden to eat meat from a carcass, blood, pork, or the meat of animals sacrificed in the name of anyone other than Allah. The list of forbidden animals also includes those with tusks, wild game, and those torn apart by wolves, bears, dogs, squirrels, and foxes. The meat of birds that hunt with their claws is also forbidden by religious leaders. Additionally, the list of animals includes animals such as snakes, frogs, turtles, and crabs (Meals in Koran, 2006). Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy In 1975 approximately five children were born to each Turkish woman, but by 2010 that figure dropped to 2.18 children (CIA World Factbook, 2011). According to the 2008 Turkey Demographic and Health Survey, there is a tendency for women to have children early in the childbearing period (7 out of 10 births took place before the age 30); however, the 25- to 29-year age group had the highest age-specific fertility rate, which indicates there is a trend toward postponing childbearing until later years (Turkey Demographic and Health Survey, 2009). Infant mortality rates were 24.84 deaths/1000 live births in 2010 (CIA World Factbook, 2011). There is a diminishing trend in the fertility ratios with the beginning of widespread use of modern contraceptive methods, the births in the very young or advanced ages, and the births frequently are of the foremost causes of maternal death (Kara et al., 2010). Motherhood is accorded great respect and pregnant women are usually made comfortable in any way possible, including satisfying their cravings. Pregnant women may continue their daily activities or work as long as they are comfortable. Education efforts have increased prenatal practices throughout Turkey. In urban areas, monthly prenatal visits are usually made 11 with an obstetrician. In rural areas in which physicians may be scarce, midwives provide care to pregnant women. However, pregnancy is considered by a number of people as a shameful condition that ought to be concealed (Ayaz & Efe, 2008). Folk Practices for Fertility In traditional Turkish culture, one of the most important desires of a married woman is to have a child. A woman who has not had a child is faced with social pressure and accusations and, thus, may try to use some traditional practices to increase fertility. Some women damage their bodies by using these practices; sometimes, the damage is permanent (Kayhan et al., 2006). Some of the traditional practices women use to increase fertility include burying the woman in sand, placing her on heat, taking her to thermal springs, applying a poultice, talking to a religious leader, going to a saint’s gravesite, having an amulet written, putting a mixture inside the womb, eating meat and wheat brought back from the pilgrimage, sitting on the placenta of a newborn baby, boiling parsley and sitting over its steam, sitting over a milk steam, and going to the hamam (Turkish bath) (Kayhan et al., 2006). Modern and Folk Practices for Preventing Pregnancy According to 2008 Turkey Demographic and Health Survey, 73 percent of married women used some method of contraception. Modern contraception was used by 46 percent of the women while 27 percent used traditional methods (25 percent used withdrawal [coitus interruptus]). The most prevalent modern contraceptive methods used were IUDs (17 percent) and the pill (14 percent); additionally, female sterilization was used by 8 percent of the married women (Turkey Demographic and Health Survey, 2009). Women who prefer the traditional method of coitus interruptus to prevent pregnancy believe it is free from side effects, a clean method, and unlike condom use, did not seriously affect the sexual pleasure gained by their partners (Ciftcioglu & Behice, 2009). Other folk practices and beliefs that relate to preventing pregnancy include (1) birth control pills cause cancer and make you fat; (2) an IUD can migrate to the stomach or invalidate ritual cleansing; (3) vasectomy ends a man’s sexual life; and (4) using some methods is a sin (Kayhan et al., 2006). Others include vaginal douche, calendar method, putting lemon or alum on the sexual organs, drinking henna water, putting aspirin in the vagina, and putting honey and horseflies in food and eating it (Kayhan et al., 2006). Modern and Folk Practices for Terminating Pregnancy The risk of unwanted pregnancy increases with inadequate information about birth control, negligence, poverty, low level of education, and inappropriate 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 12 12 Aggregate Data for Cultural-Specific Groups protection methods (Kavlak et al., 2006). According to the law, married women may request to have an abortion with the consent of their husbands; single women who are older than 18 years can have an abortion at their own request; and single women less than 18 years can have an abortion with the consent of their parent (Kavlak et al., 2006; Turkey Population Planning Law, 1983). The rate of voluntary abortion is about 11 percent (Kavlak et al., 2006). The widespread use of abortion has had a significant effect on decreasing the fertility rate. It is common practice that women in families who have chosen to limit the number of children first seek to have an abortion and then they learn about methods to prevent pregnancy and begin to use them (Kavlak et al., 2006). Traditional methods used to terminate pregnancy include pressing on the abdomen with a stone, mixing matches with trash and putting it in the womb, carrying heavy loads, aborting the child with a beetroot branch and chicken wing, boiling poison ivy leaves and standing in its heat (Kayhan et al., 2006). Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family The pregnant Turkish woman is encouraged to keep her strength up by eating foods that are rich in nutrients; however, in poorer families, these nutrients may not be available. Many pregnant women take prenatal vitamins, drink a lot of milk, and apply salves such as Vaseline to avoid stretch marks. Light exercise, such as walking, is encouraged, but weather conditions often hamper such efforts because Turks generally tend to avoid wet or cold weather fearing its ill effects on one’s health. Modern and Folk Practices to Facilitate Childbirth and Postportum Period Most women prefer hospitals for physician-assisted child delivery; however, midwives are accepted in rural areas when a physician is not available. Particularly in rural areas, the more natural squatting or semi-sitting position is preferred to the supine position during delivery. Expressions of discomfort and pain are quite acceptable, although Laz women from the Black Sea area tend to be stoic. Some traditional women believe they should not eat fish, sheep’s heads, sheep’s trotters, and rabbit meat during pregnancy because eating fish would cause the baby to be mute, not to develop bones, and to float like a fish. Eating sheep’s heads or trotters is thought to cause the baby to have a runny nose and consumption of rabbit meat to cause a cleft lip (Ayaz & Efe, 2008). Folk practices used to make childbirth easier include unlocking places that are locked, untying the woman’s hair ribbons, unbuttoning buttons, standing straight and turning so the child will move, drinking water that has been prayed over by religious leaders, enclosing the woman around her waist and rocking her three times, and putting her in a blanket and rocking her three times (Kayhan et al., 2006). Still others include jumping from a high point because it facilitates birth, bumping women in the back and shaking them since it makes birth easier, shaking women in a sheet to facilitate the birth process, and anointing the genitals to make the birthing process easier (Ayaz & Efe, 2008). It is becoming more acceptable and more common for the husband and other relatives to be present during the birthing process as it is with the immigrant Turkish population in the United States. The postpartum period can last up to 40 days. During this time, a woman is under the effect of many supernatural powers. There is a folk saying that for 40 days the grave is open for the woman postpartum. She is not left alone during this time, which is called lohusa. At the end of the 40 days she returns to normal life. She is bathed with abundant water and prayers are read. The infant is also bathed in a similar manner. Eating boiled potatoes, thick rice soup, cola with aspirin, ground coffee–lemon mixture, apricot, roasted chickpeas, or olive paste and spreading herbal dough on the stomach are also widely used (Ogut & Gurkan, 2005). Light exercise is encouraged during the postpartum period, and bathing, an important part of the Muslim tradition, is strongly recommended. A special food called loğusa serbeti or loğusalik is served to the woman. Loğusalik is a sweet, sherbet-like foodstuff, prepared by dissolving loğusalik beads (available in stores in Turkey) in hot water. This high-carbohydrate mixture is said to increase the woman’s strength. Postpartum women drink hot soups and other fluids such as milk, especially when breastfeeding. Most Turks realize the value of breastfeeding, which is practiced modestly. Folk Practices for Newborns and Children Newborns are treated as cherished gifts. Healthy babies are greeted with Masallah (may God bless and protect). The 2008 Turkey Demographic and Health Survey reported that nearly all infants are breastfed for the first months after birth (Turkey Demographic and Health Survey, 2009). The rates of Cesarean delivery are increasing which is having an effect on the initiation and duration of breastfeeding (Cakmak & Kuguoglu, 2007). There are many folk practices associated with newborns. One is to not give water or breastfeed a newborn until the call to prayer has been announced three times; the belief is that this makes the baby become patient, intelligent, and religious. The first milk (colostrum) from the mother’s breast is considered impure so it is discarded and instead the baby is fed with sugary water, cow or goat’s milk, 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 13 People of Turkish Heritage honey, and butter (Ayaz & Efe, 2008). Another traditional practice is to bathe a newborn immediately after birth in salt water to have healthy skin and to prevent sweat from being offensive when they grow older. It is also believed to prevent diaper rash as well as some diseases and to cause future injuries to heal rapidly. This practice is called salting or striking the child with salt. The infant may also have salt put in his or her mouth to prevent bad breath which can cause dehydration (Ayaz & Efe, 2008). When a newborn infant has jaundice, a variety of traditional practices may be used, including tying a yellow ribbon to the crib, dressing the infant in yellow clothes, having the infant drink her or his own urine, using a razor blade to cut between the infant’s eyebrows and between his or her fingers, putting a gold coin on the infant, dressing the infant in yellow clothing, and bathing the infant with gold water and the yellow yolk of egg (Ayaz & Efe, 2008). When the umbilical cord is cut it is given a name; the umbilical cord’s name is used to call the person when they die. The name is given by saying it three times into the right ear during the call to prayer. A small blue bead called a nazar boncuk, believed to protect the child from the “evil eye,” is usually placed on the child’s left shoulder. This practice is believed to protect the child from the evil angel whispering in the left ear, often portrayed in Christian religious art. However, it may be swallowed or aspirated by the infant. A child may be taken to a hoca religious leader to have an amulet written to recover from an evil eye. Dressing the baby with a sand-filled diaper (holluk), which is spreading fine soil over the baby’s diaper to absorb wetness and to keep the baby warm and comfortable,. It is done to prevent diaper rash and is believed it promotes harmony with nature; the earth is regarded as nutritious and a source of power. It can be harmful because it may cause parasitic infections and tetanus in the newborn, whose immune system is not fully developed (Ayaz & Efe, 2008). Other traditional practices are not breastfeeding a baby with diarrhea or feeding a baby with diarrhea a mixture of coffee and yogurt, which can be quite harmful because diarrhea is a common cause of infant mortality. Another is putting soap into the rectum when a child is constipated, which may harm the baby as the soap irritates the intestinal mucous membrane (Ayaz & Efe, 2008). Other folk practices include placing iron under the baby’s mattress to protect against anemia and placing a red bow on the crib to distract any envy or negativity. In eastern Turkey, an infant may be put under soil based on the belief that keeping the infant warm will keep her or him as healthy as the soil. This practice can irritate the infant’s skin and even result in death from tetanus. 13 Swaddling infants, a common practice, has benefits such as helping infants sleep longer, decreasing physiologic distress, improving neuromuscular development, soothing pain, and in excessively crying infants reducing crying and regulating temperature. However, it can also cause hyperthermia, hip dysplasia, and respiratory infections and increase the risk of sudden infant death syndrome with the combination of swaddling with the infant in a prone position, which makes it necessary to warn parents to stop swaddling if infants attempt to turn (van Sleuwen et al., 2007). Herbal therapies are commonly given to children for respiratory and digestive problems (Ozturk & Karayagiz, 2008). Health-care providers must teach mothers to use swaddling properly and with caution. Health-care providers need to assess the use of prescriptive, restrictive, and taboo practices for pregnancy, labor and delivery, and postpartum because some women still carry out traditional practices that may adversely affect them or their infants. It is important to gain an understanding of these potentially harmful customs and cultural beliefs so that health education programs can be implemented that dissuade women from resorting to and continuing these practices. Death Rituals Death Rituals and Expectations When death occurs the deceased individual’s family members cry in the most natural manner. Neighbors who hear about the death gather at the home of the deceased to share in the suffering of the family, to console them, and to help with the initial preparations. In the first week after a death, all close friends and relatives will help with the funeral arrangements, prepare food for the grieving family, assist at household chores, and deal with family and friends who come to pay their respects and be continuously by the family’s side in full support (Cimete & Kuguoglu, 2006). Having prayers said is a common practice. In villages, townships, and small cities, a news reader goes from house to house to announce the death; placing a death notice in the newspaper is more common in large cities. Commercial funeral agencies in large cities make necessary preparations for the burial as well as preparing death notices. Some of the procedures done immediately after death deal directly with the corpse and others involve arranging the environment around the corpse. Turkish Muslims do not generally practice cremation because the body must remain whole. Frequently, the body is displayed in the home for a day or two; it is then placed in a coffin and taken to the cami (mosque) to be visited primarily by men. In rural areas, showing respect for the deceased by participating in the funeral procession is very important. Religious or traditional reasons require the preparations for burial. These preparations include three 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 14 14 Aggregate Data for Cultural-Specific Groups important procedures: bathing, wrapping in a shroud, and saying funeral prayers outside a mosque. After someone dies, he or she is prepared quickly for burial. If a person dies in the morning, he or she is buried after the mid-afternoon prayers; a person who dies during the night is buried in the morning. The funeral may be delayed to await the arrival of distant relatives. Common rituals after death are closing the eyes of the deceased, tying the chin, turning the head toward Mecca, putting the feet next to each other, putting the hands together on the abdomen, and removing clothing. In some places, the bed is changed; a knife, iron, or other metal object is placed on the abdomen of the deceased; the room in which the deceased is lying is cleaned and well lighted; and the Koran is read at the head of the deceased. The majority of those in Anatolia wash the corpse before burial. Women wash a deceased woman, and men wash a deceased man. The people who do this procedure are professional cleansers, religious leaders, experienced people, the religious community, or in some cases, someone from the home of the deceased or a neighbor, or in some places, a person mentioned in the will. In large cities, the washing is done in funeral homes; in villages, however, a sheltered corner in someone’s garden is used. Shrouding is the second important procedure after the washing of the corpse and before burial. The fabric for the shroud is white and the number of pieces of cloth varies for men and women. Again, the majority of the people who live in Anatolia practice this procedure. Funeral prayers are the third procedure. According to the Islamic religion, several conditions need to be met for funeral prayers to be said. After the funeral prayers are said, the corpse is taken to the cemetery in a coffin. The corpse is placed in the grave with the right side facing the direction of Mecca. When the body is placed inside the grave, a wooden board is leaned against one wall to protect the body from the dirt used to fill the grave. The corpse is generally placed in the grave without the coffin; however, it may also be buried in the coffin. Placing a gravestone with inscriptions to give the identity, gender, and fate of the deceased is very common. After a funeral prayer at the mosque, the body is interred. For the first 7 days there will be continuous religious rites and a religious ceremony on the 7th, 40th, and 52nd days. Prayers are said and special food will be prepared and distributed to the guests. The first seven days after death more prayers are said and helva (a sweet dessert) is served in honor of the deceased. The traditional mourning period is 40 days, during which time traditional women may wear black clothes or a black scarf. The clothes and personal belongings of the deceased will be sent to the poor. A few belongings will be saved by close family members as memories of the deceased. Again, donations will be distributed to the poor or to religious organizations. The underlying belief is that food, money, and clothing are distributed to the poor so that the deceased will not be left hungry, naked, and cold (out in the open) in the other world, and that the prayers will help the deceased to be received into Heaven. Although all of these rituals are aimed at supporting the family who is suffering the loss, family members are not given the opportunity to reveal their emotions after a death and even further, they are kept occupied so that they remember the loss as little as possible (Cimete & Kuguoglu, 2006). Responses to Death and Grief Although Muslim Turks believe in the afterlife, death is always an occasion of great sorrow and mourning. An expression of sympathy to one who has just lost someone to death is Basiniz sağolsun (may your head be healthy), hoping that one is not overwhelmed with grief. Mourning, synonymous with grief over the death of someone, is important and is done for a specific period of time for the purpose of adapting to the new situation and decreasing suffering. There are no home care or hospice systems within the health system of Turkey. This may lead families to an isolated state and may keep them from advancing optimally through the stages of the grief process. Spirituality Dominant Religion and Use of Prayer Turks are 99.8 percent Muslim, but freedom of religion is mandated by the Turkish secular state (CIA World Factbook, 2011). Most are Sunni Muslims, with a minority from the Alevi Muslim group. Other religious minority groups include Jews (mostly Sephardic) and Christians. Proselytizing is illegal in Turkey. Most Turks who emigrate to the West tend to be very moderate Muslims. Traditional namaz (prayer) is practiced five times each day and can take place in the cami or elsewhere, as long as one is facing kíble (the holy city of Mecca). A special small rug, called seccade, is used for praying in places other than the cami. When entering the cami, shoes are always removed and women must cover their heads. Men and women go to separate parts of the cami for prayer. One prepares for prayer by a ritual cleansing called abdest, which at a minimum includes washing the face, ears, nostrils, neck, hands to the elbow, and feet and legs to the knee three times each. Sometimes washing facilities are available at the cami. Caregivers may need to make special arrangements and be sensitive to the need for Muslims to practice their religious obligations when they are in a healthcare facility. 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 15 People of Turkish Heritage Tortumluoğlu et al. (2005b) conducted a qualitative study about religious characteristics in a village in Turkey and found that • In the village, everyone knows the command of Allah. They do their ritual cleansing; say their prayers; fast; those who are able, make the pilgrimage; give alms; read the Koran; and do what the Koran says. • In our village, a lot of people keep the fast for 3 months. During Ramazan, we also say the teravi prayer (an extra prayer in addition to those said five times a day). We go to the mosque and we both say our prayers in the designated area and also listen to the sermon. • We do what Allah said and live according to our religion. We don’t show ourselves to those outside the family. We read, pray, and fast, and if Allah allows, we will go to heaven in the afterlife. Meaning of Life and Individual Sources of Strength Turks rely on their religious beliefs and practices and their family and friends for strength and meaning in life. One’s degree of religiosity influences the importance of prayer in giving meaning to life. A little known fact is that St. Nicholas was born and lived in Patara, in southern Turkey, in the 4th century AD where he became known as Santa Claus. Spiritual Beliefs and Health-Care Practices Religious beliefs intertwined with folk beliefs continue to influence Turkish lifestyle. Spiritual leaders or healers are sought most often for assistance with relationship or emotional problems and, less frequently, for physical problems. A muska, a paper inscribed by a hoca (spiritual teacher) with a prayer in Arabic, is wrapped in fabric and then hidden in the home or worn by the person seeking help. Turbe and yatir are the practice of going to the saints’ graves to pray about wishes, mental or emotional problems, or fertility problems. Tesbih, the small beads traditionally used for praying, now take a more-secular meaning and are often referred to as worry beads. Health teaching strategies for Turks in America should include the recognition and prevention of dehydration, bloating, constipation, hypoglycemia, and fatigue during periods of Ramazan fasting. In addition, religious or folk items should not be removed from the health-care facility because they provide comfort for the client, and their removal may increase anxiety. Health-Care Practices Health-Seeking Beliefs and Behaviors Most Turks rely on Western medicine and highly trained professionals for health and curative care. 15 However, remnants of traditional beliefs continue to have an impact on health-care practices. Thus, healthcare providers may wish to incorporate factual information regarding disease causation and treatment into patient education planning. Responsibility for Health Care Turkish children are routinely immunized against diphtheria, tetanus, whooping cough, measles, polio, hepatitis B, mumps, rubella, and TB. There has been significant improvement in the vaccination rates, between 2003 and 2008, the rate for children fully vaccinated rose from 54 percent to 74 percent (TDHS, 2009). For a variety of reasons terminally ill patients are generally not told the severity of their conditions. Many believe that informing a client of a terminal illness may take away the hope, motivation, and energy that should be directed toward healing, or it may cause the client additional anxiety related to the fear of dying and concern about those being left behind. Furthermore, no one can second-guess Allah, for who can know if Allah has a miracle in mind? Turkey has one of the highest rates of consumption of over-the-counter antibiotics and painkillers; aspirin is commonly used as a panacea for a variety of ailments, including gastric upset. Turks, especially those who have difficulty affording the services of a physician, commonly consult a pharmacist before visiting a physician. Fever- and pain-reducing medicines and cough syrups are frequently purchased without professional medical consultation. Health professionals must assess Turkish American patients for their use of over-the-counter medications to prevent conflicting or potentiating effects with prescription medications. Folk and Traditional Practices Turkey is a country where civilizations have been established since the ancient ages resulting in a rich folklore. There is a high prevalence of traditional health-care practices among Turks; these practices are so significant in parts of the culture that they cannot be ignored. They are very common, particularly in rural areas, because they often cannot access health services and do not have the financial resources to see physicians so must rely on the traditional health practices. However, such practices may be harmful to a person’s health and may delay early treatment. Engin and Pasinlioğlu’s (2000) study, conducted in the center of Erzurum with infertile women, showed that 44.6 percent of women were assisted by untrained midwives, 57.8 percent used witch doctor medicine, and 39.1 percent were prayed over by religious people to treat their infertility. The findings from Özyazıcıoğlu’s (2000) study, conducted in the center of Erzurum, was that mothers with at least one child older than 12 months had a high rate of using traditional treatments for such 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 16 16 Aggregate Data for Cultural-Specific Groups health problems as the common cold and nasal congestion (26.39 percent), earache and ear drainage (17.22 percent), stomachache (54.96 percent), constipation (24.88 percent), burns (24.39 percent), poisoning (23.08 percent), cuts and bleeding (67.56 percent), and fractures (41.67 percent). Tortumluoğlu, Karahan, Bakir, and Türk (2004) reported that 82.2 percent of older people in their study used traditional practices for burns, 76.7 percent for insect bites, 64.4 percent for the common cold, 63 percent for stomach problems, 63 percent for high fever, 63 percent for warts, 56.2 percent for sties, and 54.4 percent for constipation. Ugulu and Baslar (2010) found that most people (68 percent) in their study from four Turkish cities continued to use traditional systems of health care including medicinal plants alone or in combination with other ingredients, such as flour, honey, and oil. Phytopreparations (salves, gels, creams), medicinal plants, are used for the treatment of various diseases of skin and mucous membranes. Toprak and Demir found that the most common traditional methods for treating hypertension among their research subjects were eating yogurt with garlic (27.8 percent) and eating sour foods, such as lemon and grapefruit (25 percent). Resting, drinking ayran (a Turkish drink made with yogurt and water), and applying a cold bag to the head were the other methods used for coping with hypertension (Toprak & Demir, 2007). Kara (2009) found that many patients with endstage renal disease undergoing hemodialysis also used herbs to treat their health problems. The majority received the information about which herbs to use from their families and friends. They did not disclose the use of herbal products to their physicians (Kara, 2009). Additional traditional health-care practices to treat illness or symptoms include applying rubbing alcohol or a wet cloth to bring down a fever and warming the back to treat coughing. Health-care providers should be aware of the health risks caused by certain traditional health-care practices and educate the patients and families about the potential risks. Turkey also encourages health tourism at their 1500 thermal spas. These spas treat conditions such as rheumatism, respiratory and digestive problems, diabetes, skin conditions, gallstones, female diseases, kidney and heart conditions, nerves, obesity, and hyperlipidemia. The concept of the evil eye is prevalent in many cultures, including Turkish culture. Specific to health, it is a cultural inclination not to speak too well of one’s health for fear that one may incur misfortune through others envy or nazar. Turkish patients, therefore, may be more inclined than other ethnic groups to complain about health. So pervasive is this concept that taxi drivers and medical doctors alike respect the nazar boncuk, a blue bead used as protection from the evil eye. Some Turks may believe that excessive complaining may bring the benefit of closer medical attention. However, when describing an illness, a person avoids using oneself or another person as an example for fear of inviting the illness or condition upon that person. Kolonya (cologne) is part of a traditional practice that crosses religious and secular lines. Originally derived from the religious value of cleanliness, cologne is sprinkled on the hands of guests before and after eating to provide cleanliness and a fresh lemon scent. Inhaling from a cloth or handkerchief doused with cologne may be used for relief from motion sickness. In the hospital, patients may offer cologne to a physician or nurse prior to examination. An essential part of hospitality, it also has some medicinal intent. In fact, cologne is approximately 70 percent alcohol and does have a bactericidal quality. Cultural Responses to Health and Illness An autonomy-centered approach in Turkish health care is relatively new. The Regulation on Patient Rights was enacted in 1998 but only recently have there been tangible steps toward its implementation in the health-care system. It is becoming more common for patients to want to know their diagnosis and express their wishes and expectations about their health care; traditionally, patients had to be in compliance with the traditions of the paternalistic medical model, which demanded compliance from physicians (if not obedience) without considering patients’ opinions or wishes (Guven, 2010). Seriously ill people are expected to conserve their energy to allow their minds and bodies to fight their illnesses; thus, reducing their workload and avoiding unnecessary energy expenditure are acceptable. During hospitalization, refakatçí refers to the person who stays overnight with the client, providing emotional and physical support and comfort. A show of concern and Şevkat (compassion) for the client eases her or his fears and reduces loneliness. Family members may also attend to physical needs such as bathing. A balanced, healthy diet is considered essential to regaining one’s health; thus, Turks frequently bring food from home for the patient. Although the degree of pain expression varies according to regional origin, Turkish culture allows freedom to express pain, either through emotional outbursts or through verbal complaints. General observations about Turkish culture suggest that although stigma is attached to mental illness, many families seek treatment or care for the client at home. Mental health services are basically curative rather than preventive. There is a concern that the risks for mental disorders and depression in older people will increase in the near future due to factors such as rapidly changing social structure, urban migration, and shifting to nuclear family life. Families will no longer be in a situation to 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 17 People of Turkish Heritage care for older people, physically, psychologically, or economically (Nahcivan & Demirezen, 2005). Postpartum depression (PPD) is common among Turkish women, though the majority of women suffering from PPD receive no treatment and it may go undetected. There is an increased need to educate public and health-care providers about PPD and to develop nursing interventions to provide support to postpartum women (Dindar & Erdogan, 2007). Blood Transfusions and Organ Donation According to Turkish law 2238, which went into effect in 1979, obtaining, storing, grafting, and transplanting organs and tissues for the purpose of treatment, diagnosis, and science are subject to regulations. In 1980, the Ministry of Religious Affairs stated that organ and tissue transplantation is permissible when it is done according to the following conditions: • To save a patient’s life and when no other alternative exists, as established by a licensed physician whose honesty is reliable. • A dominant medical opinion is that the illness cannot be treated in another way. • The donor’s organ or tissue is taken while this procedure is being done. • To prevent the disturbance in the peace and order of society, the donor must have given permission when healthy (prior to their death), or if no declaration was made while alive, the next of kin are willing. • No payment of any kind can be received in exchange for the donated organ or tissue. • The donee must be willing to have the transplantation (Turkish Transplantation Society, 2006). Muslims traditionally prefer that their body remain intact after death, a belief that can conflict with organ donation. Former Prime Minister and President Turgut Ozal and his wife promoted organ donation by publicly signing donor cards and encouraging others to do so. Ağartan, Önder, Memiş, and Baklaya (2006) in their study reported that 39.8 percent of nurses were against organ and tissue transplantation because they believed it was not acceptable in the Islamic religion. Additionally, they would not want their bodies disturbed after death; 31.1 percent were afraid that their organs would be taken before they had died. Blood transfusions are gaining acceptance. However, Turkish people generally prefer to receive blood from family members. 17 In many situations, the person who is respected as the most educated has primary input into decisions about health care. An additional barrier can exist for devout Muslim women when a female health-care provider is not available. An over reliance on folk and traditional practices can also be a barrier. Health-Care Providers Traditional Versus Biomedical Providers Although Turkish people are inclined toward Westernized health-seeking behaviors, medical care in Turkey tends to be holistic. Great value is placed on emotional well-being, especially as it affects physical well-being. Emotional health is considered instrumental to the healing process. Physicians may be “adopted” as members of their patients’ families, and it is common to give gifts (usually food) to physicians as an expression of gratitude. A Turkish physician would never refuse gifts or interpret them as a bribe for better care. When modern medicine is not available, accessible and affordable, or has not been effective, Turks may seek the care of a traditional healer. Generally, physicians are viewed and respected as professionals, so caring for someone of the opposite sex is not an issue among most Turks. However, it is always advisable to ask patients their opinion or preference. Status of Health-Care Providers Physicians and to a lesser extent, nurses and midwives, have historically been held in very high esteem. Patients rarely question the authority of physicians, but the notion of obtaining a second opinion is gaining popularity. The university qualifying examination system allows only the very top academic echelon of students to study medicine. Nursing master’s programs began in 1968 and doctoral programs in 1972. A recent study identified problems nurses faced during their postgraduate education which included the lack of associate professors, lack of foreign language skills, not enough time to do research due to being overworked, physiological stress, conflict within the office, and economical problems (Canbulat et al., 2007). The relationship between physicians and nurses is hierarchical. Currently, this situation is based more on educational level than on gender because a great number of women enter the medical profession. Most male nurses work in community settings. Neither physicians nor nurses share the same financial benefits of health-care professionals in the United States. Barriers to Health Care In general, women are responsible for the actual caregiving of the ill and the elderly in the home. However, in traditional households, the mother-in-law or fatherin-law, depending on who controls the finances in the family, makes decisions about going to the physician. REFERENCES Ağartan, E., Önder, A., Memiş, S., & Baklaya, N. (2006). Hemşireler organ ve doku bağışı konusunda yeterince duyarlımı? Ulusal Hemşirelik Öğrencileri Kongresi. Kongre kitabı. Harran Üniversitesi, Şanlıurfa. [Are nurses sensitive about the 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 18 18 Aggregate Data for Cultural-Specific Groups donation of organs and tissue?] National Nursing Students Congress Book (p. 214). Harran University, Sanlıurfa, Turkey. Akgun, S., Rao, C., Yardim, N., Basara, B. B., Aydin. O., Mollahaliloglu, S., & Lopez, A. D. (2007). Estimating mortality and causes of death in Turkey: Methods, results and policy implications. European Journal of Public Health, 17(6), 593–599. Ayaz, S., & Efe, S. (2008). Potentially harmful traditional practices during pregnancy and postpartum. European Journal of Contraception and Reproductive Health Care, 13(3), 282–288. Bahadir, A., Öztürk, O., Atalay, A., & Atalay, E. (2009). Beta globin gene cluster haplotypes of the beta thalassemia mutations observed in Denizli province of Turkey. Turkish Journal of Haematology, 26(3), 129–137. Beser, A., Bahar, Z., & Buyukkaya, D. (2007) Health promoting behaviors and factors related to lifestyle among Turkish workers and occupational health nurses’ responsibilities in their health promoting activities. Industrial Health, 45, 151–159. Cakmak, H., & Kuguoglu, S. (2007). Comparison of the breastfeeding patterns of mothers who delivered their babies per vagina and via cesarean section: An observational study using the LATCH breastfeeding charting system. International Journal of Nursing Studies, 44(7), 1128–1137. Canbulat, N., Demirgöz, M., Cingil, D., & Saklı, F. (2007). A general overview of the nursing academicians in Turkey. International Journal of Human Sciences, 4(1). Retrieved from http:// www.insanbilimleri.com/ojs/index.php/uib/article/view/49 Centers for Disease Control and Prevention (CDC). (2011). Health Information for Travelers to Turkey. Retrieved from http://wwwnc.cdc.gov/travel/destinations/turkey.aspx. CIA WorldFactbook: Turkey. (2011). https://www.cia.gov/library/ publications/the-world-factbook/geos/tu.html Ciftcioglu, S., & Behice, E. (2009). Coitus interruptus as a contraceptive method: Turkish women’s perceptions and experiences. Journal of Advanced Nursing, 65(8), 1686–1694. Cimete, G., & Kuguoglu, S. ( 2006). Grief responses of Turkish families after the death of their children from cancer. Journal of Loss and Trauma: International Perspectives on Stress & Coping, 11(1), 31–51. Cinar, N. D., Tuncay, M. F., Topsever, P. T., Ucar, F., Akgul, S., & Gorpelioglu, S. (2006). Intentional sun exposure in infancy in Sakarya ,Turkey. Saudi Medical Journal, 27(8), 1222–1225. Dindar, I., & Erdogan, S. (2007). Screening of Turkish women for postpartum depression within the first postpartum year: The risk profile of a community sample. Public Health Nursing, 24(2), 176–183. Engin, R., & Pasinlioğlu, T. (2000). Erzurum ve Yöresinde İnfertil Kadınların İnfertilite [Infertile women’s traditional practices and religious beliefs about infertility in Erzurum and the surroundings]. Master’s thesis, Ataturk University Health Sciences Institute, Erzurum, Turkey. Erdoğan, M. F., Ağbaht, K., Altunsu, T., Ozbağ, S., Yücesan, F., Tezel, B., Sargin, C., Ilbeğ, I., Artik, N., Köse, R., & Erdoğan, G. (2009). Current iodine status in Turkey. Journal of Endocrinological Investigation, 32(7), 617–622. Gul, A. (2007). Standard and novel therapeutic approaches to Behçet’s disease. Drugs, 67(14), 2013–2022. Gültekin, T., & Koca, B. (2003). Cumhuriyet döneminden günümüze ülkemizde gerçeklieştirilen ırk çalışmaları. [Race studies in our country since the constitution of the Republic to nowadays. Journal of Anthropology, 14, 1–24. Guven, T. (2010). Truth-telling in cancer: Examining the cultural incompatibility argument in Turkey. Nursing Ethics, 17(2), 159–166. İcduygu, A. (2008). Circular Migration and Turkey: An Overview of the Past and Present—Some Demo-Economic Implications. Carim Analytic and Synthetic Notes 2008/10. Circular Migration Series. Demographic and Economic Module. Retrieved from http://cadmus.eui.eu/bitstream/handle/1814/8331/CARIM_ AS%26N_2008_10.pdf ?sequence=1 Inel, M., Ozmen, B., & Bilgin, H. (2008). Re-evaluation of building damage during recent earthquakes in Turkey. Engineering Structures, 30(2), 412–427. Information Please. (2011). Turkey. Retrieved from http://www. infoplease.com/ipa/A0108054.html?pageno=1 Kara, B. (2009). Herbal product use in a sample of Turkish patients undergoing haemodialysis. Journal of Clinical Nursing, 18, 2197–2205. Kara, M., Yilmaz, E., Töz, E., & Avci, I. (2010). The contraceptive methods used in A_rı, Turkey. Journal of Gynecology and Obstetrics, 20(1), 10–13. Kavlak, O., Atan, S., Saruhan, A., & Sevil, U. (2006). Preventing and terminating unwanted pregnancies in Turkey. Journal of Nursing Scholarship, 38(1), 6–10. Kayhan, S., Güzlek, C., Özdemir, G., İpsala, E., & Tortumluoğlu, G. (2006). Women’s practices about conception, contraception, terminating of pregnancy, and facilitating of delivery in Çanakkale. Jinekoloji ve Obstetri Dergisi. Baskıda. Journal of Obstetrics and Gynecology, 17(3). Retrieved from http:// jinekoloji.turkiyeklinikleri.com/index.php?lang=tr Köser-Akçapar, S. (2006). Do brains really go down the drain?, Revue européenne des migrations internationales, 22(3). Retrieved from http://remi.revues.org/index3281.html Kukulu, K., Gursoy, E., & Gulsen, S. (2009). Turkish university students’ beliefs in sexual myths. Sex Disabilities, 27, 49–59. Meals in Koran and eating in sects and tradition. (2006). Retrieved from http://www.zpluspartners.com/kosherhalal2.pdf Nahcivan, N., & Demirezen, E. (2005). Depressive symptomatology among Turkish older adults with low incomes in a rural community sample. Journal of Clinical Nursing, 14, 1232–1240. Ministry of Health of Turkey (MHT). (2010). General Directorate of Primary Health Care, Obesity Prevention and Control Program of Turkey (2010–2014), Kurban Matbaacilik Yayincilik, Ankara. Ogut, Y., & Gurkan, A. (2005). A study on the traditional attitudes and applications related to diarrhea. III. Uluslararası—X. Ulusal hemşirelik kongresi. III International—X National Nursing Congress (p. 95).İzmir, Turkey: Eylül. Oksal, K. (2008). Turkish family members’ attitudes toward lesbians and gay men. Sex Roles, 58, 514–525. O’Neil, M., & Güler, F. (2010). Strangers to and producers of their own culture: American popular culture and Turkish young people. Comparative American Studies, 8(3), 230–243. Önder, A. (2006). Türkiye’nin etnik yapısı. 10 basım [Ethnic structure of Turkey] (10th ed.). Ankara, Turkey: FARK Publication. Ozturk, C., & Karayagiz, G. (2008). Exploration of the use of complementary and alternative medicine among Turkish children. Journal of Clinical Nursing, 17, 2558–2564. Özyazıcıoğlu, N. (2000). Erzurum il merkezinde 12 aylık çocuğu olan annelerin çocuk büyütmeye ilişkin yaptıkları geleneksel uygulamalar [Mothers’ traditional practices about fostering 12-months-old child in Erzurum]. Master’s thesis, Ataturk University Health Sciences Institute. Erzurum, Turkey. Rankina, B., & Aytaç, I. (2008). Religiosity, the headscarf, and education in Turkey: An analysis of 1988 data and current implications. British Journal of Sociology of Education, 29(3), 273–287. Tasçı, M., & Oksuzler, O. (2010). Income differentials and education in Turkey: Evidence from individual level data. International Research Journal of Finance and Economics, 51. Retrieved from http://www.eurojournals.com/irjfe_51_10.pdf 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 19 People of Turkish Heritage Toprak, D., & Demir, S. (2007). Treatment choices of hypertensive patients in Turkey. Behavioral Medicine, 33, 5–10. Tortumluoğlu, G., Bayat, M., & Sevig, U. (2005a, September 7–10). The evaluation of the individuals in health viewpoint by “Giger and Davidhizar’s transcultural assessment Model” (p. 141). III. Uluslararası—X. Ulusal Hemşirelik Kongresi. III International—X National Nursing Congress. İzmir, Turkey: Eylül. Tortumluoğlu, G., Bedir, E., & Sevig, U. (2005b). The evaluation of “The guide to definite cultural characteristics of Turkish society with a health viewpoint of individuals in Erzurum.” III. Uluslararası—X. Ulusal hemşirelik kongresi. III International—X National Nursing Conference. Eylül, Yayınlanmamış yayın.İzmir, Turkey. Tortumluoğlu, G., Ersay, A., Pamukçu, K., & Şenyüz, P. (2006). Farklı sağlık alanlarında eğitim gören yüksekokul öğrencilerinde cinsellik. [Sexual behaviors of college students in educating different health fields]. National Nursing Students Congress Book. Harran University. (Vol. 5). April 20–21. Sanlıurfa, Turkey. Tortumluoğlu, G, Karahan, D. E., Bakır, B., & Türk R. (2004) Kırsal alanda yağayan yağlıların yaygın görülen sağlık problemlerine yönelik yaptıkları geleneksel uygulamaların tanımlanması. Uluslararası İnsan Bilimleri Dergisi]. [Defining Traditional Health İmplementation applied by old people living in rural area for their common health problem. International Journal of Human Science, 13(1), 1–16. Turel, G. (2009). Provision of housing and services for the elderly in Turkey. Beykent University. Journal of Science and Technology, 3(1), 90–103 The Turkey Demographic and Health Survey–2008. (TDHS). (2009). Hacettepe University Institute of Population Studies. 19 Tezcan, S. Project Director. Retrieved from http://www.hips. hacettepe.edu.tr/eng/index.html Turkey: Population Planning Law: No. 2827. Retrieved from http:// www.hsph.harvard.edu/population/abortion/TURKEY.abo.htm Turkey’s Statistical Yearbook. (TSY) (2008). Health Survey 2008. Publication Number 3452; Turkish Statistical Institute, Ankara, Turkey, p. 2. Turkey’s Statistical Yearbook. (TSY) (2009). Retrieved from http://www.turkstat.gov.tr/Kitap.do?metod=KitapDetay&KT_ ID=0&KITAP_ID=1 Turkey’s Statistical Yearbook. (TSY) (2010). Retrieved from http://www.turkstat.gov.tr/Start.do Turkish Transplantation Society. (2006). Retrieved from http:// www.tond.org.tr/tr/ Ugulu, I., & Baslar, S. (2010).The determination and fidelity level of medicinal plants used to make traditional Turkish salves. Journal of Alternative and Complementary Medicine, 16(3), 313–322. U.S. Census Bureau: Statistical Abstract of the United States. (USCB). (2011). 52—Population by Selected Ancestry Group and Region: 2008. Retrieved from http://www.census.gov/ compendia/statab/cats/population.html Van Sleuwen, B., Engelberts, A., Boere-Boonekamp, M., Kuis, W., Schulpen, T., & L’Hoir, M. (2007). Swaddling: A systematic review. Pediatrics, 120(4), 1097–1106. For case studies, review questions, and additional information, go to http://davisplus.fadavis.com.
Transcultural Health Care: A Culturally Competent Approach, 4th Edition Vietnamese Americans Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Vietnam is a long narrow country that would stretch from Minneapolis to New Orleans ▪ Majority are closely related to the Chinese ▪ Over 1,200,000 Vietnamese in the United States Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ 1975 Vietnamese War brought 130,000 to the US and mainly came from urban areas and had some familiarity with Western lifestyles and thus adjusted well in the United States ▪ A quarter million more left in 1978–1979 because of the communist regime in Vietnam and became the “boat people” for the next 10 years Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Many remained in squalid concentration camps for years ▪ Later immigrants were less educated, poorer, and came from rural areas of Vietnam and came without their families intact Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Third wave—Orderly Departure Program– provided safe and legal family repatriation in the United States ▪ Fourth wave in 1987—Amerasian Homecoming Act brought military families, political detainees, children of American servicemen, and more women Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Place high value on education and the teacher is well respected ▪ Educational system in Vietnam emphasizes observation, memorization, and repetitive learning ▪ Some continue to experience discrimination in the United States Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications ▪ Vietnamese has several dialects, all of which are understandable to each other but not with other Indochinese countries ▪ Similar in structure to Chinese with borrowed words, polytonal, and one syllable ▪ Only Asian language that uses the English alphabet Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Language translations are not easily and directly translatable—in any language ▪ Blue and green are the same work ▪ No way to say “no,” only “yes” ▪ Hot and cold are not related to temperature but to perceived bodily imbalances that are called am and duong Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Words used in the affective domain are always difficult to translate in any language ▪ Expressing emotions is considered a weakness, and thus may revert to physical symptoms to describe emotional stress ▪ Caution on touching the head, do not put your feet up and bare the soles of your feet, and do not point or beckon with the upturned finger Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Men greet each other with a handshake, but not women or men and women ▪ Men can walk hand in hand as can women without a sexual connotation ▪ Direct eye contact, especially with those in a perceived higher status position, is deemed disrespectful Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Most are present oriented with many becoming more futuristic as they acculturate ▪ Punctuality depends on occupation and educational level and language ability ▪ Age is not so important as in the European American culture, age is calculated at time of conception, not birth; use the 10-month calendar, resulting in many given Jan. 1 as a birth date Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Use a family name, middle name, and first name and written in that order ▪ Relatively few family and middle names, with first name having some meaning ▪ Naming procedure can be confusing for Americans so many Vietnamese give the American order of names; thus adding more confusion—just ask if you are unsure. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles ▪ Traditional families are patriarchal and extended resulting in difficulty for some when women are in authority positions ▪ Women make most of the healthcare decisions; otherwise roles are divided by gender ▪ Reversal of roles in the United States may cause family disharmony until adjustment Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Children are an extension of parents and are expected to be obedient and respectful of elders ▪ Grandparents take a significant role in rearing the grandchildren ▪ Permissive US lifestyle with teenagers and dating can cause family disharmony Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Eldest male has the responsibility for parents to the extent that it is more supreme than his responsibility to his wife and children ▪ Elders may feel alone and be depressed with clash of values from their home country and the United States culture ▪ To smile in the face of diversity is demonstrative of strong moral character Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Lesbian and gay relationships are not discussed —carry a significant stigma for most ▪ Pseudofamilies are formed by gender groups in the United States in order to share resources and improve economic status Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Variations in skin color requiring different assessment techniques than for white-skinned people ▪ Small in stature compared with European Americans with narrower shoulders and wider pelvic structure ▪ Published growth charts are not accurate for Vietnamese—and other groups Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology Continued ▪ Sparse body hair, few apocrine glands, 40% have palatine tori, flat nose bridge causing more difficulty in fitting eye glasses ▪ Betel nut pigmentation among older women from chewing betel leaves ▪ High rates of depression and anxiety-related disorders—especially post-traumatic stress syndrome Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology Continued ▪ High rates of malaria, Tbc, parasitosis, hepatitis B related to the tropics, refugee camps, and crowded living conditions ▪ New arrivals should also be screened for round worm, whipworm, liver flukes, trichinosis, scabies, lice, and impetigo Transcultural Health Care: A Culturally Competent Approach, 4th Edition Drug Metabolism ▪ More sensitive than other groups to propranolol, atropine, diazepam, and psychotropics—beyond body size ▪ More sensitive to the effects of alcohol ▪ Many adults and some children have lactose intolerance Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-Risk Behaviors ▪ Lower socioeconomic rural immigrants may not be aware of tobacco causing cancer or aware for the need of health screening and breast exams and pap smears ▪ High rates of liver and gastrointestinal cancer and “sudden unexplained death syndrome” ▪ Low use of alcohol, tobacco, and recreational drugs Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-Risk Behaviors Continued ▪ Reliance on family for healthcare may mean the illness is more severe when seeking health care ▪ Some may not trust healthcare providers based on situations in refugee camps ▪ Usually have great respect for all healthcare providers Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ ▪ ▪ ▪ ▪ Meal time is a family affair Holidays usually have special foods and dishes Smaller body size means few calories required White rice is the main staple Wide variety of fruits, vegetables, and meats Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Ascribe to the hot (duong) and cold (am) theory of foods requiring different foods for certain illnesses—varies by region of migration so just ask and they will tell you. ▪ Traditional diet may be high in sodium and in the United States low in calcium and high in fat Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Women have children over a longer period of time than European Americans ▪ Abortions common in Vietnam—great stigma to have a child out of wedlock ▪ Many are not familiar with birth control methods in the United States ▪ Women over the age of 40 have an average of 6 abortions and 4 pregnancies Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Specific food practices to have a healthy pregnancy and baby and to balance equilibrium in each trimester of pregnancy ▪ Maintain non-strenuous physical activity to prevent miscarriage, have a healthy and small baby, and quick delivery ▪ Prolonged labor if idle, afternoon napping can cause a large baby Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Invasive procedures during labor are disliked and feared ▪ Many prefer squatting position for birthing ▪ Touching the head can cause distress because the soul resides here ▪ Specific postpartum rituals that vary among rural and urban Vietnamese Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Older women assume responsibility for the baby’s care ▪ Caution on praising the child because jealous spirits will steal the child ▪ Cutting child’s hair or nails can cause an illness Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Death is a normal part of life ▪ Reincarnation and ancestral spirits support the sometimes stoicism seen with death ▪ Prefer to die at home without extensive lifeprolonging measures ▪ May buy casket in advance Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck A Vietnamese friend tells you she balances her food choices according to hot and cold properties. In Vietnamese, the words for hot and cold are a. Yin and yang. b. Am and duong. c. Fret and cho. d. Garm and sard. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: B The Vietnamese words for hot and cold for balancing foods are am and duong. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals Continued ▪ Gather around dying person and express great emotion ▪ Call religious leader only at the request of the family ▪ Flowers are reserved for the rites of the dead ▪ Family wears white for 14 days after death, followed by black arm bands for men and white headbands for women Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Buddhism, Confucianism, and Taoism are the majority ▪ Animism by a few from highland areas of Vietnam ▪ Some may maintain a religious altar in the home ▪ Family is the main reference point throughout life Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices ▪ Good health is achieved by having harmony and balance with the am and duong—an excess of either one may lead to discomfort or illness ▪ Illness can be naturalistic or supernaturalistic ▪ Traditional medicine depends on northern or southern Vietnamese ancestry Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Many fear any invasive procedure ▪ Believe that body fluids cannot be replaced ▪ May discontinue any medicine that causes side effects ▪ Most are reluctant to take medicine on a longterm basis Transcultural Health Care: A Culturally Competent Approach, 4th Edition Responsibility for Health Care ▪ Family care for ill member in the hospital in Vietnam and may wish to do so in the United States ▪ Crisis-oriented care in Vietnam ▪ Many believe Western medicine is too powerful for Vietnamese and therefore say they will take the medicine and then either do not or only take part of it Transcultural Health Care: A Culturally Competent Approach, 4th Edition Common Vietnamese Treatments ▪ ▪ ▪ ▪ ▪ ▪ ▪ Cai gio Be bao or bar gio Giac Zong Moxibustion Acupuncture, acupressure, acumassage Multiple herbal therapies Transcultural Health Care: A Culturally Competent Approach, 4th Edition Cai gio ▪ “Rubbing out the wind” is used for colds, sore throats, flu, sinusitis, etc. ▪ Ointment or hot balm is spread across the back, chest, and/or shoulders and rubbed with the edge of a coin ▪ Dermabrasion procedure to let out bad wind as the blood is brought to the surface Transcultural Health Care: A Culturally Competent Approach, 4th Edition Be bao or bar gio ▪ “Skin pinching” for headaches or sore throat ▪ Produce ecchymosis and petechiae ▪ Very specific technique Transcultural Health Care: A Culturally Competent Approach, 4th Edition Giac ▪ Cupping or cup suction ▪ Dermabrasion procedure to relieve stress, headaches, joint and muscle pain ▪ Small metal or glass cup is heated by placing wormwood or cotton saturated with alcohol and set afire ▪ Cup forms a suction as it is turned upside down on the skin and then removed, leaving large ecchymotic round areas Transcultural Health Care: A Culturally Competent Approach, 4th Edition Zong ▪ An herbal preparation relieves motion sickness or cold-related symptoms ▪ Ointment or herbs are put in boiling water and then inhaled. Can be purchased commercially. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Moxibustion ▪ Used to counter conditions associated with excess cold, including labor and delivery ▪ Pulverized wormwood or incense is heated and placed directly on the skin along certain meridians Transcultural Health Care: A Culturally Competent Approach, 4th Edition Acupuncture, Acupressure, Acumassage ▪ Used for a wide variety of conditions and illnesses—some of which have been proven scientifically—especially for some pain conditions ▪ Needles, pressure, or massage along the Qi channels of energy flow Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The parents of a two year old bring her to the ER because of a persistent productive cough. The nurse finds several quarter-sized ecchymotic area on the child’s back. The nurse recognizes these marks as a. Cai gio b. Be bao or bar gio c. Giac d. Zong Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C Giac, cupping, leave round ecchymotic areas when the cup is removed.
2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 1 Chapter 38 People of Vietnamese Heritage Susan Mattson and Larry D. Purnell Overview, Inhabited Localities, and Topography Overview Vietnam is located at the extreme southeastern corner of the Asian mainland, bordering the Gulf of Thailand, Gulf of Tonkin, and South China Sea, alongside China, Laos, and Cambodia. With a population of over 90 million in a land mass of 127,330 square miles (CIA World Factbook, 2011), it is relatively narrow in width, but its north–south length equals the distance from Minneapolis to New Orleans. Vietnam consists largely of a remarkable blend of rugged mountains and the broad, flat Mekong and Red River deltas, which mainly produce rice. Other features are a long, narrow coastal plain and other riverine lowlands, where most ethnic Vietnamese live. Much of the rest of the country is covered with tropical forests. Longevity for females is 74.92 years, and for males, 69.72 years. The fertility rate is a low 1.91 children per female (CIA World Factbook, 2011). Heritage and Residence The Vietnamese are a Mongolian racial group closely related to the Chinese. The population shares some characteristics with other Asian and Pacific Islander groups, yet many aspects of its history and culture are unique. Vietnam was under Chinese control from 111 BC to AD 939 (Huer, Saenz, & Doan, 2001). At that time, a variety of Chinese beliefs and traditions were introduced to Vietnam, including the religions and philosophies of Confucianism, Buddhism, and Taoism. In addition, the system of Chinese medicine was adopted widely. European merchants and missionaries arrived in Vietnam during the 16th century, and the French established a political foothold and instituted changes in government and education, including Western medical practices (Huer et al., 2001). The terms Indochinese and Vietnamese are not synonymous. Indochina is a supranational region that includes the countries of Vietnam, Laos, and Cambodia. Vietnam alone has eight different ethnic groups, the majority (86 percent) of whom are Viet (CIA World Factbook, 2011). One factor in providing proper health care to Vietnamese in America is understanding that they differ substantially between and among themselves, depending on the variant cultural characteristics of culture (see Chapter 1in this book). Clear differences exist among Vietnamese, Cambodians, and Laotians with respect to premigration experiences, which influence subsequent manifestations of psychological distress. Along with Asian Indians, Vietnamese immigrants have the highest proportion of children under the age of 18, with a median age of 33, yet the poverty rate is highest for Koreans, Vietnamese, and Chinese (13 percent). Within this population, Vietnamese immigrants have the highest proportion of naturalized citizens (50 percent), with the smallest proportion of those who were foreign born and not U.S. citizens at 21 percent; 30 percent are native born Americans. Forty-nine percent of the immigrants arrived before 1990, and 42 percent came between 1990 and 1999 (Office of Minority Health, 2007). Initial Vietnamese immigrants confronted a unique set of problems, including dissimilarity of culture, no family or relatives to offer initial support, and a negative identification with the unpopular Vietnam War. Many Vietnamese were involuntary immigrants, with their expatriation unexpected and unplanned; their departures were often precipitous and tragic. Escape attempts were long, harrowing, and for many, fatal. Survivors were often placed in squalid refugee camps for years. The first wave of Vietnamese immigration began in April 1975, when South Vietnam fell under the Communist control of North Vietnam and the Viet Cong. At that time, many South Vietnamese businessmen, military officers, professionals, and others closely involved with America or the South Vietnamese government feared persecution by the new regime and sought to escape. American ships and aircraft rescued some; many were temporarily located in refugee camps in Southeast Asia, and then sent to relocation camps in the United States. The 130,000 Vietnamese refugees who arrived in the United States in 1975 came mainly 1 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 2 2 Aggregate Data for Cultural-Specific Groups from urban areas, especially Saigon, and consequently had some prior orientation to Western culture. Many spoke English or soon learned English in relocation centers. More than half were Christian. Sixty-two percent consisted of family units of at least five people, and nearly half were female. They were dispersed over much of the United States, often in the care of sponsoring American families. One year after arrival, 90 percent were employed, and by the mid-1980s, their average income matched that of the overall American population. These first-wave immigrants adjusted well in comparison to the subsequent wave. By the 1970s,further events in Vietnam triggered a second wave of immigration. Many Vietnamese grew disenchanted with Communism and their decreased living standard. Great numbers had been forced into labor in new countryside settlements, and young men were often fearful of being called to fight against China or in the new war with Cambodia. Some left by land across Cambodia or Laos, commonly joining refugees from those countries in an effort to reach Thailand. For more than a decade, many others, known as the “boat people,” departed Vietnam in small, often unseaworthy and overcrowded vessels in hopes of reaching Malaysia, Hong Kong, the Philippines, or another non-Communist port. Half died during their journey. Many were forcibly repatriated to Vietnam or eventually returned voluntarily; others continued to languish in camps for years. Most of the second-wave refugees represented lower socioeconomic groups and had less education and little exposure to Western cultures. Most did not speak English. This wave of Vietnamese included far more young men than women, children, or older people, which disrupted intact families and normal gender ratios. Many spent months or years in refugee camps under deplorable and regimented conditions. The United States passed the Refugee Act of 1980 in response to this second wave and widened the scope of resources available to assist refugees or individuals who fled their native country and could not returen for fear of persecution and physical harm (Huer et al., 2001).When they finally arrived in the United States and Canada, many did not fit into American communities, did not learn English effectively, and remained unemployed or obtained menial jobs. These hardships contributed to physical problems, psychological stress, and depression. The contiuing persecution of individuals in Vietnam led to a third wave of immigration, beginning in 1979 with the creation of the Orderly Departure Program, which provided safe and legal exit for Vietnamese seeking to reunite with family members already in America. Former military officers and soldiers in prison or reeducation camps were allowed to come the United States with their families, resulting in the immigration of 200,000 individuals by the mid-1990s. The Humanitarian Operation Program of 1989 also permitted more than 70,000 current and former political prisoners to immigrate. Finally, the Amerasian Homecoming Act of 1988 allowed the children of Vietnamese civilians and American soldiers to immigrate to the United States. Many of the Amerasian children were orphans who had lived on the street, received no formal education, and had been subjected to prejudice and discrimination in Vietnam (Huer et al., 2001). Reasons for Migration and Associated Economic Factors Vietnamese, whether as immigrants or sojourners, have fled their country to escape war, persecution, or possible loss of life. Better-educated, first-wave immigrants from urban areas had professional, technical, or managerial backgrounds. Less-educated, second-wave immigrants from more rural areas were fishermen, farmers, and soldiers and had only minimal exposure to Western culture. Factors influencing the ability of displaced Vietnamese to obtain employment included a higher level of education and the ability to speak English on arrival. Thus, the second-wave immigrants were significantly more disadvantaged. Educational Status and Occupations Vietnamese place a high value on education and accord scholars an honored place in society. The teacher is highly respected as a symbol of learning and culture. In contrast to American schools’ emphasis on experimentation and critical thinking, Vietnamese schools emphasize observation, memorization, and repetitive learning. This style of learning is still predominant in Vietnam, including the universities with schools of medicine and nursing. Most Vietnamese men and women in America are very educationally oriented and take full advantage of educational opportunities when possible. Educational level and occupation continue to vary by the time of arrival in the United States, as described earlier in the discussion of the four waves of immigration. Communication Dominant Languages and Dialects The official language of Vietnam is Vietnamese, with English increasingly being favored as a second language, followed by French and Chinese (CIA World Factbook, 2011). Ethnic Vietnamese speak a single distinctive language, with northern, central, and southern dialects, all of which can be understood by anyone speaking any of these dialects. The Vietnamese language resembles Chinese and contains many borrowed words, but someone speaking one of these languages cannot necessarily understand the other. All words in Vietnamese consist of a single syllable, although two words are commonly joined with a hyphen to form a new word. Verbs do not change 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 3 People of Vietnamese Heritage forms, articles are not used, nouns do not have plural endings, and there are no prefixes, suffixes, definitives, or distinctions among pronouns. Contextually, the Vietnamese language is musical, flowing, and polytonal, with each tone of a vowel conveying a different meaning to the word. The language is spoken softly, and its monosyllabic structure lends itself to rapidity, but spoken pace varies according to the situation. Whereas grammar is mostly simple, pronunciation can be difficult for Westerners, mainly because each vowel can be spoken in five or six tones that may completely change the meaning of the word. Vietnamese is the only language of the Asian mainland that, like English, is regularly written in the Roman alphabet since it was introduced by the French in the 17th century. Although the letters are the same, pronunciation of vowels may vary radically depending on associated marks indicating tone and accent, and certain consonant combinations take on unusual sounds. When speaking Vietnamese, Westerners in particular will often use “hand signals” to indicate an upward inflection or a mark that should appear with the letter being spoken (personal observation, Mattson, 2005, 2007–2009). Even if someone learns how to pronounce and translate Vietnamese, problems may remain with respect to intended meaning of various words. One minor but perennial stumbling point with potential medical connotations is that the words for “blue” and “green” are the same. More important, the word for “yes,” rather than expressing a positive answer or agreement, may simply reflect an avoidance of confrontation or a desire to please the other person. The terms “hot” and “cold,” rather than expressing physical feelings associated with fever and chills, may actually relate to other conditions associated with perceived bodily imbalances. Various medical problems might be described differently from what a Westerner might expect; for example, a “weak heart” may refer to palpitations or dizziness, a “weak kidney” to sexual dysfunction, a “weak nervous system” to headaches, and a “weak stomach or liver” to indigestion (Muecke, 1983b). Most Vietnamese refugees, even those who have been in the United States for many years, do not feel competent in English. Although many refugees eventually learn English, their skills may not be adequate in certain situations. The important subtleties in describing medical conditions and symptoms, or the more abstract presentation of ideas during psychiatric interviews may be particularly difficult. Health-care providers may need to watch patients for behavioral cues, use simple sentences, paraphrase words with multiple meanings, avoid metaphors and idiomatic expressions, ask for correction of understanding, and explain all points carefully. Approaching Vietnamese patients in a quiet, unhurried manner, opening discussions with small talk, and directing 3 the initial conversation to the oldest member of the group facilitate communication. Cultural Communication Patterns Traditional Vietnamese religious beliefs transmitted through generations produce an attitude toward life that may be perceived as passive. For example, whenever confronted with a direct but delicate question, many Vietnamese cannot easily give a blunt “no” as an answer because they feel that such an answer may create disharmony. Self-control, another traditional value, encourages keeping to oneself, whereas expressions of disagreement that may irritate or offend another person are avoided. Individuals may be in pain, distraught, or unhappy, yet they rarely complain except perhaps to friends or relatives. Expressing emotions is considered a weakness and interferes with self-control. Vietnamese are unaccustomed to discussing their personal feelings openly with others. Instead, at times of distress or loss, they often complain of physical discomforts such as headaches, backaches, or insomnia. Vietnamese tend to be very polite and guarded. Sparing one’s feelings is considered more important than factual truth. The strong influence of the Confucian code of ethics means that proper form and appearance are important to Vietnamese people and provide the foundation for nonverbal communication patterns. For example, the head is a sacred part of the body and should not be touched. Similarly, the feet are the lowest part of the body and to place one’s feet on a desk is considered offensive to a Vietnamese person. To signal for someone to come by using an upturned finger is a provocation, usually done to a dog; waving the hand is considered more proper. Hugging and kissing are not seen outside the privacy of the home. Men greet one another with a handshake but do not shake hands with a woman unless she offers her hand first. Women do not usually shake hands. Two men or two women can walk hand in hand without implying sexual connotations. However, for a man to touch a woman in the presence of others is insulting. Looking another person directly in the eyes may be deemed disrespectful. Women may be reluctant to discuss sex, childbearing, or contraception when men are present and demonstrate this unwillingness by giggling, shrugging their shoulders, or averting their eyes. Negative emotions and expressions may be conveyed by silence or a reluctant smile. A smile may express joy, convey stoicism in the face of difficulty, indicate an apology for a minor social offense, or be a response to a scolding to show sincere acknowledgment for the wrongdoing or to convey the absence of ill feelings. Vietnamese prefer more physical distance during personal and social relationships than some other cultures, but extended Vietnamese families of 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 4 4 Aggregate Data for Cultural-Specific Groups many individuals live comfortably together in close quarters. Temporal Relationships Vietnamese religion and tradition place emphasis on continuity, cycles, and worship of ancestors. Traditional Vietnamese may be less concerned about the precise schedules than are European Americans. To cope with their changed situation, many Southeast Asian refugees concentrate on the present and, to some extent, on the future. Asians frequently arrive late for appointments. Noncompliance in keeping appointments may relate to not understanding oral or written instructions or to not knowing how to use the telephone. One other aspect of time involves the concept of age. Vietnamese people pay much less attention to people’s precise ages than do Americans. Actual dates of birth may pass unnoticed, with everyone celebrating their birthdays together during the Lunar New Year (Tet) in January or February. In addition, a person’s age is calculated roughly from the time of conception; most children are considered to be already a year old at birth and gain a year each Tet. A child born just before Tet could be regarded as 2 years old when only a few days old by American standards. Because the practice of determining age is so different in Vietnam, many immigrants who do not know their exact birth date are often assigned January 1 for official records. When a friend is invited on an outing, the bill is paid for by the person offering the invitation. When giving gifts, the giver often discounts the item, even though it may be of great value. The recipient of a gift is expected to display significant gratitude, which sometimes lasts a lifetime. Some may be reluctant to accept a gift because of the burden of gratitude. Vietnamese may refuse a gift on the first offer, even if they intend to accept it eventually, so as not to appear greedy. Format for Names Most Vietnamese names consist of a family name, a middle name, and a given name of one or two words, always written in that order. There are relatively few family names, with Nguyen (pronounced “nwin”) and Tran accounting for more than half of all Vietnamese names. Other common family names are Cao, Dinh, Hoang, Le, Ly, Ngo, Phan, and Pho. Additionally, there is little diversity in middle names, with Van being used regularly for men and Thi (pronounced “tee”) for women. Given names frequently have a direct meaning, such as a season of the year or an object of admiration. Family members often refer to offspring by a numerical nickname indicating their order of birth. This practice may increase the difficulty of modern record-keeping and identification of specific individuals. Therefore, use the family name in combination with the given name. Indeed, Vietnamese refer to one another by given name in both formal and informal situations. For example, a typical woman’s name is Tran Thi Thu, which is how she would write or give her name if requested. She would expect to be called simply Thu or sometimes Chi (sister) Thu by friends and family. In other situations, she would expect to be addressed as Cô (Miss) or Ba (Mrs.) Thu. If married to a man named Nguyen Van Kha, the proper way to address her would be as Mrs. Kha, but she would retain her full three-part maiden name for formal purposes. The man would always be known as Kha or Ong (Mr.) Kha. Some Vietnamese American women have adopted their husband’s family name. Children always take the father’s family name. Family Roles and Organization Head of Household and Gender Roles The traditional Vietnamese family is strictly patriarchal and is almost always an extended family structure, with the man having the duty of carrying on the family name through his progeny. Some families who are not accustomed to female authority figures may have difficulty relating to women as professional health-care providers, although this is changing in Vietnam. Today there are many physicians, dentists, and pharmcists who are women, with an increasing number of men choosing nursing as a career (personal observation, Mattson, 2007–2009). With the move into Western society, the father may no longer be the undisputed head of the household, and the parents’ authority may be undermined. Immigrant Vietnamese families frequently experience role reversals, with wives or children adapting more easily than men. A Vietnamese woman lives with her husband’s family after marriage but retains her own identity. Within the traditional family, the division of labor is gender related: the husband deals with matters outside the home, and the wife is responsible for the actual care of the home, and often makes health-care decisions for the family. While many Vietnamese and Vietnamese American women work outside the home, they also continue as the primary caretaker of the home. Although her role in family affairs increases with time, a Vietnamese wife is expected to be dutiful and respectful toward her husband and his parents throughout the marriage. Vietnamese refugees of all subgroups have experienced degrees of reversal of the provider and recipient roles that existed among family members in Vietnam. “Women’s jobs,” such as hotel maid, sewing machine operator, and food-service worker, are more readily available than male-oriented unskilled occupations; today more men are employed in these jobs. Role reversals between parents and children are also common because children often learn the English language and American customs more rapidly than their parents 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 5 People of Vietnamese Heritage and therefore, may be able to find employment more quickly. Vietnamese families in the United States experience a greater tendency toward nuclearization, growth in spousal interaction and interdependency, more-egalitarian spousal relations, and shared decision making than their traditional counterparts. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Traditionally, children are expected to be obedient and devoted to their parents, their identity being an extension of the parents. Children are obliged to do everything possible to please their parents while they are alive and to worship their memory after death. The eldest son is usually responsible for rituals honoring the memory and invoking the blessings of departed ancestors. This pattern may be ingrained from early childhood. Vietnamese children are prized and valued because they carry the family lineage. For the first 2 years, their mothers primarily care for them; thereafter, their grandmothers and others take on much of the responsibility. Parents usually do not discipline or place extensive limits on their children at a young age. Generally, Vietnamese do not use corporal punishment such as spanking; rather, they speak to the children in a quiet, controlled manner. Young people are expected to continue to respect their elders and to avoid behavior that might dishonor the family. As a result of their exposure to Western cultures, a disproportionate share of young people have difficulty adapting to this expectation. A conflict often develops between the traditional notion of filial piety, with its requisite subordination of self and unquestioning obedience to parental authority, and the pressures and needs associated with adaptation to American life. Ironically, successful relationships with Americans at school have placed Vietnamese adolescents at risk for conflicts with their parents. Conversely, failure to form such relationships with their American peers has sometimes appeared to be a precursor of emotional distress. Parents do, however, show relative approval for adolescent freedom of choice regarding dating, marriage, and career choices. The extreme bipolarities of the adaptation of Vietnamese youth are sometimes overemphasized. Members of one group, usually the children of the first-wave refugees, are often portrayed as academic superstars. At the other end of the social spectrum are the criminal and gang elements, who often direct their activities against other Asian immigrants. Most Vietnamese adolescents, however, fall between these two extremes and have the same pressures and concerns as other youths. Family Goals and Priorities The traditional Vietnamese family is perhaps the most basic, enduring, and self-consciously acknowledged 5 form of national culture among refugees, providing lifelong protection and guidance to the individual. The family, usually large, patriarchal, and extended, includes minor children, married sons, daughtersin-law, unmarried grown daughters, and grandchildren under the same roof. Other close relatives may be included within the extended family structure. The family is explicitly structured with assigned priorities, identifying parental ties as paramount. A son’s obligations and duties to his parents may assume a higher value than those to his wife, children, or siblings. Sibling relationships are considered permanent. Vietnamese self is defined more along the lines of family roles and responsibilities and less along individual lines. These mutual family tasks provide a framework for individual behavior, promoting a sense of interdependence, belonging, and support. The traditional family has been altered as a consequence of Western influence, urbanization, and the war-induced absence of men. Nevertheless, many Vietnamese continue to uphold this social form as the preferable basis of social organization in the United States. As mentioned in the previous section, exposure of the younger generation to American culture can become a source of conflict with considerable family strain as adolescents are influenced by the perceived American values of individuality, independence, self-assertion, and egalitarian relationships. Traditionally, older people are honored and have a key role in transmitting guidelines related to social behavior, preparing younger people for handling stressful life events, and serving as sources of support in coping with life crises. Older people are usually consulted for important decisions. Addressing a client in the presence of an older person, whether they speak English or not, instead of the elder, may be interpreted as disrespectful to the family. Homesickness and bewilderment are especially acute in older refugees when confronted with the strange Western culture and despair about the future (Fig. 38-1). Accustomed to considerable respect and esteem in their homeland, they may feel increasingly alienated and alone as the younger generations adopt new values and ignore the counsel and values of the elders. Living within the family unit facilitates the social adjustment of older refugees into American society. Traditional Vietnamese are class conscious and rarely associate with individuals at different levels of society. Traditional respect is accorded to people in authoritative positions who are well educated or otherwise successful or who have professional titles. However, class distinctions are sometimes blurred in the turmoil of war and resettlement. Two concepts govern the gain and loss of prestige and power, thereby maintaining face: mien, based on wealth and power, and lien, based on demonstration of control over and responsibility for moral character. For example, to smile in the face of adversity is to maintain lien and is considered of great importance. 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 6 6 Aggregate Data for Cultural-Specific Groups However, this emphasis is not a detriment to productivity in work habits, because a good work record and steady pay bring honor and prosperity to the family. The Vietnamese are highly adaptable and adjust their work habits to meet requirements for successful employment. Most Vietnamese respect authority figures with impressive titles, achievement, education, and a harmonious work environment. They may be less concerned about such factors as punctuality, adherence to deadlines, and competition. Other traditions include a willingness to work hard, sacrifice current comforts, and save for the future to ensure that they assimilate well into the workforce. Many seek the same material, financial, and status rewards that beckon native-born Americans. Issues Related to Autonomy Figure 38-1 Elders are honored in traditional Vietnamese culture, but the effects of American culture on immigrant families may sometimes be troubling to older adult Vietnamese Americans. Alternative Lifestyles The complex extended Vietnamese family in America is extremely vulnerable to change. Many young people, frequently unmarried couples, seek their own living accommodations away from the control of older generations. Unattached male refugees may join pseudofamilies, households made up of close and distant relatives and friends who share accommodations, finances, and companionship. These families form an important source of social support in the refugee communities. Because of the high regard for chastity placed on Vietnamese adolescents, the number of single-parent households is low, as is the divorce rate. Differing sexual orientation is difficult for Vietnamese to face because being gay or lesbian brings shame upon the family, causing many gays and lesbians to remain closeted (Miae, 1999). When questioning a gay or lesbian person about his or her sexual activity, an interpreter unknown to the family is an absolute requirement. Workforce Issues Culture in the Workplace First-wave immigrants adjusted well to the American workplace, and within a decade, their average income equaled that of the general U.S. population. Many later immigrants, who had less education and did not know English, ended up working in lower-paying jobs. However, some learned English and opened their own businesses and prospered. Traditionally, priority is given to the concerns of the family rather than to those of the employer. Confucianism and its stress on the maintenance of formal hierarchies within governmental, religious, and educational institutions; commercial establishments; and families have heavily influenced the Vietnamese outlook. This cultural background results in conformity and reluctance to undertake independent action. At the same time, the cultural outlook of company and family values superseding personal values creates a cohesive work group. Moreover, because many fear losing their job if they speak out about inequities, they are likely to be taken advantage of by some moreunscrupulous employers. Vietnamese quickly learn vocabulary for pragmatic communication but may have difficulty with complex verbal skills. Values related to their own culture discourage disclosure of inner thoughts and feelings. These barriers may adversely affect employment opportunities and limit their ability to communicate needs relative to social, psychological, and economic matters. Employers may need to allow extra time and provide visually oriented instructions and programs that enhance communications to promote increased harmony in the workplace. Biocultural Ecology Skin Color and Other Biological Variations Vietnamese are members of the Mongolian or Asian race. Although their skin is often referred to as “yellow,” it varies considerably in color, ranging from pale ivory to dark brown. Mongolian spots, bluish discolorations on the lower back of a newborn child, are normal hyperpigmented areas in many Asians and dark-skinned races. To assess for oxygenation and cyanosis in darkskinned Vietnamese, the health-care provider must examine the sclerae, conjunctivae, buccal mucosa, tongue, lips, nailbeds, palms of the hands, and soles of the feet. These same areas should be observed for 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 7 People of Vietnamese Heritage adverse reactions during blood transfusions, giving special attention to diaphoresis on the forehead, upper lip, and palms, which may signify impending shock. One of the first signs of iron deficiency anemia is pallor, which varies with skin tones. Dark skin loses the normal underlying red tones, so that Vietnamese patients with brown skin will appear yellow-brown. Petechiae and rashes may be hidden in dark-skinned individuals as well, but these can be detected by observing for patches of melanin in the buccal mucosa and on the conjunctivae. Jaundice can be observed in dark-skinned Vietnamese as a yellow discoloration of the conjunctiva. Because many dark-skinned individuals have carotene deposits in the subconjunctival fat and sclera, the hard palate should also be assessed. The Vietnamese are usually small in physical stature and light in build relative to most European Americans. Adult women average 5 feet tall and weigh 80 to 100 lbs. Men average a few inches taller and weigh 110 to 130 lbs. Although Roberts, Copel, Bhutan, and Otis (1985) reported no significant difference in birth weight between refugee babies and those of other parents, Vietnamese children are small by American standards, not fitting the published growth curves. The study by Vangen et al. (2002) of the birth weights for Vietnamese, Pakistani, Norwegian, and African American babies found that the mean birth weights were largely unrelated to perinatal mortality, which was lowest for the Vietnamese (8.2 of 1000; 95 percent confidence interval [CI]: 5.1 to 11.3). They concluded that the differences in perinatal mortality between ethnic groups were not explained by differences in mean birth weight. Paradoxical differences in birth weight–specific mortality rates could be resolved by adjustment to a relative scale. Thus, growth charts commonly used in America cannot provide adequate assessments for evaluating the physical development of Vietnamese children. Other parameters such as parental height and weight, apparent state of health, the energy level of the child, and progressive development over time need to be considered. Typical physical features of the Vietnamese include almond-shaped eyes, sparse body hair, and coarse head hair. Vietnamese also have dry earwax, which is gray and brittle. People with dry earwax have few apocrine glands, especially in the underarm area, and thus produce less sweat and associated body odor. Asians generally have larger teeth than European Americans, creating a normal tendency toward a prognathic profile. In addition, there may be a torus, bony protuberance, on the midline of the palate or on the inner side of the mandible near the second premolar. Hjertstedt et al. (2001) found that 23 percent of Vietnamese subjects in their study had mandibular tori, 13 percent had palatal tori, and 12 percent had both mandibular and palatal tori. Mandibular tori were more common in men, and palatal tori were more common in women. 7 Betel nut pigmentation may be found in some Vietnamese adults, resulting from the practice of chewing betel leaves (chau). This practice is common among older women and has a narcotic effect on diseased gums. Some older women lacquer their teeth, believing that it strengthens the teeth and symbolizes beauty and wealth. Diseases and Health Conditions Vietnamese women have the highest rate of cervical cancer of any female population in the United States that has been surveyed, approximately 43 per 100,000 or six times the national average (Wright, 2000). The prevalence of the disease is the result of lack of education, reluctance to seek early treatment, fear that nothing can be done, low utilization of annual Pap smears, and failure to follow up on abnormal Pap smears. Some evidence also implicates human papillomavirus (HPV), a sexually transmitted etiological factor, in the pathogenesis of cervical cancer. Cancer and other problems common to Vietnamese people may also be associated with the widespread application of chemical agents during the Vietnam War. Vietnamese Americans ages 56 and older are twice as likely as Caucasian Americans to report needing mental health care and also less likely to discuss such issues with a professional. Many of the problems are believed to be related to the Vietnam War and leaving the country in 1975. “They already had pre-war trauma, and they come to the U.S and it’s a new country, a new language and they have to find jobs. What we are finding is that 30 years after the war, there are still people having problems” (Sorkin et al., 2008, p.1). Mental-health research has indicated that Vietnamese refugees have disturbingly high rates of depression, generalized anxiety disorders, and post-traumatic stress associated with military combat, political imprisonment, harrowing events during escapes by sea, and brutal pirate attacks. Chronic personal and emotional problems often stem from post-traumatic stress experiences in this population (Hilton et al., 1997). Of immediate concern to health-care providers working with Vietnamese refugees is the treatment of infectious conditions that jeopardize both the refugee and the resident population. Some refugees suffer from malaria, parasites, and other problems associated with the tropics, although Catanzaro and Moser (1982) reported that the Vietnamese have a lower incidence of intestinal parasites, anemia, and hepatitis B antigenemia than other refugee groups. However, 69 percent of tuberculin tests return positive in the Vietnamese refugees, and this high rate of positive results correlates with their origins from crowded, poorly ventilated cities. Screening of second-wave refugees reveals a higher incidence of tuberculosis, intestinal parasites, anemia, malaria, and hepatitis B. Sutter and Haefliger (1990) reported an estimated 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 8 8 Aggregate Data for Cultural-Specific Groups annual risk of 2.2 percent for developing active tuberculosis in Vietnamese people and also noted that the disease was most likely present before arrival in refugee camps. Hepatitis B virus is hyperendemic in Indochina, with most people being infected during childhood and spreading the infection to others. Hepatitis B virus vaccination is recommended for all newborn refugee children. Other endemic diseases include leprosy (a rate of about 20 to 30 cases per 1000 population compared with a U.S. rate of fewer than 0.25 per 1000 population); high levels of parasitism, particularly the intestinal nematodes Ascaris (roundworm) and Trichuris (whipworm), which are associated with contaminated or poorly cooked foods, the liver fluke Clonorchis, which is introduced in raw, pickled, or dried fish (Dao, Gregory, & McKee, 1984), and Necator (hookworm); and malaria. To determine the presence of parasites, health-care providers must assess for symptoms of anemia, lassitude, failure to thrive, abdominal pain, weight loss, and skin rashes. In the first two waves of refugees, major health problems also included skin infections caused by fungus, impetigo, scabies, and lice (7 to 15 percent); infections of the upper respiratory tract and otitis media (20 percent); anemia including parasitic iron deficiency (16 to 40 percent), with a higher occurrence in young children; hemoglobin disorders (30 percent); chronic diseases (10 percent); and malnutrition and poor immunization status (Ross, 1982). Caution should be used before routinely diagnosing tuberculosis. Two clinical illnesses that may mimic tuberculosis, melioidosis and paragonimiasis, are also reported among refugees. Additionally, Sutherland, Avant, Franz, and Monson (1983) reported that 14 percent of the Vietnamese refugees in their Mayo Clinic study exhibited microcytosis, which can lead to an incorrect diagnosis of iron deficiency and inappropriate treatment with iron. Erythrocytic microcytosis in Southeast Asians is most likely a reflection of the presence of thalassemia or of hemoglobin E trait, conditions that are usually harmless and need no treatment. These disorders should be suspected in people with findings consistent with tuberculosis but with a negative purified protein derivative response (Ross, 1982). Screening immigrants for syphilis shows an incidence as low as 1 to 5 percent. Sporadic cases and limited outbreaks of cholera, measles, diphtheria, epidemic conjunctivitis, and typhoid fever fail to show a notable secondary spread (Ross, 1982). Observations at the Mayo Clinic reported that refugee populations are young and generally healthy, despite a prevalence rate of 82 percent for intestinal parasites (Sutherland et al., 1983). In addition, moderate to severe dental problems may occur in newer immigrants, especially children. The health-care provider should consider screening newer refugees and immigrants from Vietnam for nutritional deficits; hepatitis B; tuberculosis; parasites such as roundworm, hookworm, filaria, flukes, amoebae, and giardia; malaria; HIV; Hansen’s disease; and post-traumatic stress disorder. Recommended laboratory and other tests for refugees include a nutritional assessment, stool for ova and parasites, hemoglobin and hematocrit, and a chest radiograph for tuberculosis. Variations in Drug Metabolism Little pertinent drug research exists specifically on the Vietnamese. Clinical studies comparing other Asians with European Americans provide some idea of what might be expected. For example, the Chinese are twice as sensitive to the effects of propranolol on blood pressure and heart rate; experience a greater increase in heart rate from atropine; require lower doses of benzodiazepines, diazepam, and alprazolam because of their increased sensitivity to the sedative effects of these drugs; require lower doses of imipramine, desipramine, amitriptyline, and clomipramine; and are less sensitive to cardiovascular and respiratory side effects of analgesics (e.g., morphine) but are more sensitive to their gastrointestinal side effects. Asians require lower doses of neuroleptics (e.g., haloperidol) (Levy, 1993). Lin and Shen (1991) expressed concern about the lack of research on pharmacotherapy specifically related to major depressive and post-traumatic stress disorders in Southeast Asian refugees. They suggested that drug metabolism is comparable with that of other Asian groups with important common traits such as genetic, cultural, and environmental influences. Asian diets, for example, are similar in their higher carbohydrate-to-protein ratio, which significantly influences the metabolism of some commonly prescribed drugs. Also, because most Asians come from areas with similar degrees of socioeconomic development, exposure to various enzyme-inducing agents, such as industrial toxins, is likely to be similar. Conversely, the exposure of the refugees to war, trauma, starvation, and other adverse conditions could have an effect on the enzyme systems governing psychotropic medications. One precaution involves the continued extensive use of traditional herbal medicines by the refugees. Some of these herbal drugs have active pharmacologic properties that may interact with psychotropic drugs. For example, some may cause atropine psychosis when ingested concomitantly with tricyclic antidepressants or low-potency neuroleptics. Significantly lower dosages of psychotropic medications are prescribed in Asian countries than are common in Western countries. Low doses of antidepressant medications are often effective. Weight standards for neuroleptic dose ranges are significantly 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 9 People of Vietnamese Heritage lower in Asians than among white Americans (Levy, 1993). Because Vietnamese are considerably smaller than most white Americans, medication dosages may need to be reduced. Vietnamese generally consider American medicines more concentrated than Asian medicines; thus, they may take only half of the dosage prescribed. In addition, many Asian people are slow metabolizers of alcohol. Thus, Asians are more sensitive than European Americans to the adverse effects of alcohol, as expressed by facial flushing, palpitations, and tachycardia. High-Risk Behaviors Alcohol and tobacco use by Vietnamese in general has been reported to be relatively low. However, some adolescents have turned to alcohol, often drinking alone. Yu (1991) reported a substantial increase in smoking among Asian American women in general; traditionally there have been more men than women smokers. Jenkins, McPhee, Dordham, and Hung (1992) found the incidence of smoking among men in California was higher in Vietnamese than in Chinese or Hispanics. The prevalence of alcohol consumption is 67 percent among Vietnamese men and only 18 percent among women, versus 66 percent and 47 percent, respectively, in the general population. Binge drinking is reported by 35 percent of men. Among women, 89 percent say they had never heard of the Pap test; after this procedure is explained, 32 percent say they never had one (versus 9 percent of American women). Vietnamese women living in the United States have a cervical cancer incidence rate that is five times that of Caucasian women. Contibuting to this problem is the low rate of cervical cancer screening among this high-risk population (Solomon, DeJoice, Nguyen, Kwon, & Berlin, 2005).Recent U.S. data indicate that women of Vietnamese descent also have lower levels of Pap testing than Caucasian, Black, and Latina women. Regular Pap testing was strongly associated with having a regular doctor, having a physical in the last year, previous physician recommendation for testing, and having asked a physician for testing. However, women whose regular doctor was a Vietnamese man were no more likely to have recieved a recent Pap smear than those with no regular doctor. The authors of the study recommend that intervention programs should improve patient–provider communication by encouraging health-care providers (especially male Vietnamese physicians serving women living in ethnic enclaves) to recommend Pap testing (Taylor et al., 2009). Solomon et al. (2005) also found that knowledge about the importance of Pap tests was the most influential factor in contributing to why Vietnamese women may not seek a Pap test, and recommended print materials to include both English and Vietnamese translations. In addition, 28 percent of women never had a breast examination and 83 percent never had a 9 mammogram. Findings from a study of the Cancer Prevention Institute of California reveal that Asianborn women in the United States, particularly women from Vietnam, China, and the Philippines, have a much higher risk of dying from breast cancer than U.S.-born Asian Americans. The highest-risk group, women born in Vietnam, had a four times greater risk of dying from breast cancer than U.S.-born Vietnamese (Medical News Today, 2010). The incidence of lung cancer is 18 percent higher among Southeast Asian men than among European American men, most likely associated with smoking and exposure to environmental pollutants. Among Asian American men, lung and bronchial cancer are the leading causes of death (Medical News Today, 2010). Further, the incidence of liver cancer is more than 12 times higher among Southeast Asian men and women. The high rate of liver cancer is associated with the prevalence of hepatitis B (HBV) in Southeast Asian immigrants. Between 7 and 14 percent of Vietnamese American men are chronically infected with HBV (Medical News Today, 2009). Up to 60 percent of liver cancer from HBV can be prevented by immunization, but it was found that low socioeconomic status and use of traditional health care were associated with lower immunization rates (Medical News Today, 2010). High rates of gastrointestinal cancer may be due to asbestos that is used in the process of “polishing” rice in some parts of the world. Colorectal cancer is the fourth most common cancer in the United States, and the third most common among Vietnamese adults in California. Yet Vietnamese Americans have lower rates of screening for colorectal cancer compared to other Asian Americans and Whites (Medical News Today, 2010). Trichinosis risk is 25 times greater in Southeast Asian refugees than in the general population. This increased risk is related to undercooking pork and purchasing pigs directly from farms. Generally, young Asians are less sexually active than other groups and have a lower risk of AIDS. Similarly, Vietnamese also have a lower incidence of AIDS than do Japanese people (Cochran, Mays, & Leung, 1991). Possibly related to psychological pressures on refugees is the occurrence of sudden unexplained death syndrome (SUDS), a phenomenon reported mainly for the Hmong but also affecting Vietnamese and other Asian groups. Nearly all deaths involve physically healthy, young adult men who die at night or during sleep. The Centers for Disease Control and Prevention (1990) reported 117 cases from 1981 to 1988 and suggested that a structural abnormality of the cardiac conduction system and stress may be risk factors for SUDS. The exact cause of the deaths remains unknown. These deaths may be a form of unconscious suicide associated with nightmares brought on by intensive feelings of depression and survivor guilt (Tobin & Friedman, 1983). 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 10 10 Aggregate Data for Cultural-Specific Groups Health-Care Practices The Vietnamese approach to health care is one of ambivalence. Many Vietnamese immigrants are accustomed to depending on the family unit and traditional means of providing for health needs. They may be distrustful of outsiders and Western methods. Most are familiar with immunizations and diagnostic tests, and they do want to avoid health problems and are anxious to follow reasonable procedures. Newly arrived refugees are less likely to seek Western health care, but once established, Vietnamese are the most likely of the Southeast Asians to seek care and to do so earlier (Strand & Jones, 1983). Most Southeast Asian refugees want to go to a physician for an illness, but they rarely seek care when they are asymptomatic (for screeing and prevention services), and few are familiar with the appointment system. Some regard the most-convenient physician as the closest one not requiring an appointment and accepting medical coupons, which usually translates into a hospital emergency room (Muecke, 1983a). In contrast, the Vietnamese family may not seek outside assistance for illness until it has exhausted its own resources. The family may try various home remedies, allowing the condition to become serious, before seeking professional assistance. Once a physician or nurse has been consulted, the Vietnamese are usually quite cooperative and respect the wisdom and experience of health-care professionals. Hospitalization is viewed as a last resort and is acceptable only in case of emergency when everything else has failed. With respect to mental health, Vietnamese do not easily trust authority figures, including treatment staff, because of their refugee experiences. Nutrition Meaning of Food Meals are an important time to the Vietnamese, allowing the entire family to come together and share a common activity. Preparation is precise and may occupy much of the day. Celebrations and holidays involve elaborately prepared meals. Common Foods and Food Rituals Because of their size, the normal daily caloric intake of the Vietnamese is approximately two-thirds that of average Americans. Rice is the main staple in the diet, providing up to 80 percent of daily calories. Other common foods are fish (including shellfish), pork, chicken, soybean curd (tofu), noodles, various soups, and green vegetables. Preferred fruits are bananas, mangoes, papayas, oranges, coconuts, pineapples, and grapefruits. Soy sauce, garlic, onions, ginger root, lemon, and chili peppers are used as seasoning. The Vietnamese eat almost exclusively white or polished rice, disdaining the more nutritious brown or unpolished variety. Rice and other foods are commonly served with nuoc mam, a salty, marinated fish oil sauce. A meal typically consists of rice, nuoc mam and a variety of other seasonings, green vegetables, and sometimes meat cut into slivers. Chicken and duck eggs may be used. The Vietnamese prefer white bread, particularly French loaves and rolls, and pastry. A regular dish is pho, a soup containing rice noodles, thinly sliced beef or chicken, and scallions. Other Vietnamese dishes resemble Chinese foods commonly seen in the United States. Some of these include com chien (fried rice) and thit bo xau ca chua (beef fried with tomatoes). Perhaps the favorite of Americans is cha gio (pronounced “cha-yuh”), a combination of finely chopped vegetables, mushrooms, meat or bean curd, rolled into delicate rice paper and deep fried. If fried, it is also called a “spring” roll, while if left uncooked (the rice paper), it is a “summer” roll. It is served as part of elaborate meals or during celebrations; proper preparation may require many hours. Vietnamese eat three meals a day: a light breakfast, a large lunch, and dinner, with optional snacks. Meals are served communal style, with food being placed in the center of the table or passed around, with everyone taking what they wish. If in a restaurant, the various dishes are often brought out when they are prepared, not necessarily all at once. Children wait for their elders to pass each dish. Chopsticks and sometimes spoons are used for eating. Knives are seldom necessary at the table, because meat and vegetables are usually cut into small pieces before serving. Stir frying, steaming, roasting, and boiling are the preferred methods of cooking. Hot tea is the usual beverage. Dietary Practices for Health Promotion A predominant aspect of the traditional Asian system of health maintenance is the principle of balance between two opposing natural forces, known as am and duong in Vietnamese. As with medicines, these forces are represented by foods that are considered hot (duong) or cold (am). The terms have nothing to do with temperature and are only partly associated with seasoning. Rice, flour, potatoes, most fruits and vegetables, fish, duck, and other things that grow in water are considered cold. Most other meats, fish sauce, eggs, spices, peppers, onions, candies, and sweets are hot. Tea is cold, coffee is hot, water is cold, and ice is hot. Illness or trauma may require therapeutic adjustment of hot–cold balance to restore equilibrium. Hot foods and beverages, used to replace and strengthen the blood, are preferred after surgery or childbirth. During illness, certain foods are consumed in greater quantity, such as a light rice gruel (chao) mixed with sugar or sweetened condensed milk, and a few pieces of salty pork cooked with fish sauce. Fresh fruits and vegetables are usually avoided, being considered too cold. Water, juices, and other cold drinks are 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 11 People of Vietnamese Heritage 11 restricted. Nutritional counseling should take into consideration these factors and other aspects of the usual Vietnamese diet, because advice to simply eat certain kinds of American foods may be ignored. Nutritional Deficiencies and Food Limitations The traditional Vietnamese diet is basically nutritious, comparing favorably with U.S. federal guidelines for a diet low in fat and sugar, high in complex carbohydrates, and moderate in fiber. However, the prevalence of anemia in children may be associated with an iron deficiency (Goldenring, Davis, & McChesney, 1982), although many pregnant women have thalassemia β which may be genetically transmitted to their children. The Vietnamese diet may also be deficient in calcium and zinc but exceedingly high in sodium, with implications relevant to hypertension. Most Vietnamese adults and many children have lactose intolerance, which may cause problems in schools, other institutional settings, and adoptive families. Health-care providers may need to encourage the use of substitute milk products that are based on soybeans. Before 1975, immigrants encountered difficulty in preparing traditional dishes, especially in areas with no established Vietnamese community. Even then, the determined housewife could assemble most necessary ingredients through judicious selections at ethnic American, Chinese, Korean, and Indian groceries. Today, nearly all common Vietnamese foods are available at reasonable cost in the United States, except perhaps for certain native fruits and vegetables. In addition, Vietnamese Americans have changed their diet to a degree, often increasing their fat intake. Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy Indochinese women have children over a longer period of life than European Americans, evidenced by females aged 40 to 44 having a birth rate nearly 14 times that of their European American counterparts (Hopkins & Clarke, 1983). However, in Vietnam, the birth rate is down to 1.91 children per woman (CIA World Factbook, 2011). This is not true for Vietnamese immigrants. They have the highest fertility rate at 72/1000 births in the previous 12 months (Office of Minority Health, 2007). It has been suggested that the high fertility rate is an attempt to replace children lost during the attempts to leave Vietnam. Abortions are commonly performed in their homeland because pregnancy outside of marriage is considered a disgrace to the family. Contraception is also not practiced on a regular basis, and abortion is used as birth control. It is not uncommon for young women to have several abortions before she is in her 20s. While the period of the New Year (Tet) is regarded as a positive time for a marriage, it is not a desirable time to have a child born, so women will often have abortions if they believe they will deliver during this time (Mattson, personal communication, 2007). Fertility practices of the Vietnamese in America in this regard are relatively unknown After arriving in the United States, women often desire information on contraception but are afraid to ask. The problem stems in part from their cultural background and emphasis on premarital modesty and virginity. However, when contraception is addressed and information made available Vietnamese women choose some method of contraception. Providers should avoid forceful family-planning indoctrination on the first encounter, but such information is usually well received on subsequent visits. Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Prescriptive food practices for a healthy pregnancy include noodles, sweets, sour foods, and fruit but avoidance of fish, salty foods, and rice. After birth, to restore equilibrium and provide adequate warmth to the breast milk, women consume soups with chili peppers, salty fish and meat dishes, and wine steeped with herbs. In addition to hot (duong) and cold,(am), foods are classified as tonic and wind. Tonic foods include animal protein, fat, sugar, and carbohydrates; they are usually also hot and sweet. Sour and sometimes raw and cold foods are classified as antitonic. Wind foods, often classified as cold, include leafy vegetables, fruit, beef, mutton, fowl, fish, and glutinous rice. It is considered critical to increase or decrease foods in various categories to restore bodily balances upset by unusual or stressful conditions such as pregnancy. Whereas the balance of foods may be followed, the terminology is not consistently used. During the first trimester, the expectant mother is considered to be in a weak, cold, and antitonic state. Therefore, she should correct the imbalance by eating hot foods such as ripe mangoes, grapes, ginger, peppers, alcohol, and coffee. To provide energy and food for the fetus, she is prescribed tonic foods, including a basic diet of steamed rice and pork. Cold foods, including mung beans, green coconut, spinach, and melon, and antitonic foods, such as vinegar, pineapple, and lemon, are avoided during the first trimester. In the second trimester, the pregnant woman is considered to be in a neutral state. Cold foods are introduced, and the tonic diet is continued. During the third trimester, when the woman may feel hot and suffer from indigestion and constipation, cold foods are prescribed and hot foods are avoided or strictly limited. Tonic foods, which are believed to increase birth weight, are restricted to reduce the chances of a large baby, which would make birthing 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 12 12 Aggregate Data for Cultural-Specific Groups difficult. Wind foods are generally avoided throughout pregnancy, because they are associated with convulsions, allergic reactions, asthma, and other problems. This regimen may appear more complex and restrictive than it actually is in practice. Most women use it only as a general guide, commonly restricting, rather than totally abstaining from, the proscribed foods. A great variety of food, including rice, many kinds of vegetables and fruits, various seasonings, and certain meats and fish, is generally permissible throughout pregnancy. Intensive prenatal care is not the norm in Southeast Asia. Many women do not seek medical attention until the third trimester because of cost, fear, or lack of perceived need. Vietnamese women who are generally better educated seek early prenatal care more than other Southeast Asians (Hopkins & Clarke, 1983). For obstetric and gynecological matters, Vietnamese women feel more comfortable with a female physician or midwife. Traditionally, Vietnamese women maintain physical activity to keep the fetus moving and to prevent edema, miscarriage, or premature delivery. Prolonged labor may result from idleness, and an undesirable large baby may result from afternoon napping. Additional restrictive beliefs include avoiding heavy lifting and strenuous work; raising the arms above the head, which pulls on the placenta causing it to break; and sexual relations late in pregnancy, which may cause respiratory stress in the infant. In Vietnam, many consider it taboo for pregnant women to attend weddings or funerals. However, they often look at pictures of happy families and healthy children, believing that it helps give birth to healthy babies. In Vietnam, some rural children are delivered in a screened-off portion of the home or in a special birth house by certified midwives; more frequently though, more are born in hospitals with Western-trained physicians or midwives in attendance, especially in the cities and towns, although they may receive their prenatal care in the rural clinics. Southeast Asians generally dislike invasive procedures, such as episiotomies, cesarean sections, circumcisions, nasal oxygen, and intravenous fluids. However, unlike some women of other ethnic groups, Vietnamese women may ask for anesthesia during labor and delivery and epidurals are becoming popular if the woman can pay. Otherwise, once in labor, the Vietnamese woman tries to maintain self-control and may even smile continuously. Her period of labor is usually short, and there may be no warning of impending delivery. Although a special bed may be available, the mother may prefer walking around during labor and squatting during the birth process. This position is less traumatic than others, for both mother and baby, and results in fewer and lessserious lacerations. This is a deviation from normal birth practices in the United States and may need to be discussed with the attending physician or midwife prior to birth. Because the head is considered sacred, neither that of the mother nor that of the infant should be touched or stroked. Removal of vernix from the infant’s head can cause distress. The American practice of inserting intravenous devices into infants’ scalps can be particularly stressful to Vietnamese families. Health-care providers need to stress the importance and necessity of this invasive procedure and select other venous routes if possible. Customary practices include clearing the neonate’s throat using the finger, cutting the umbilical cord with a nonmetal instrument, quickly burying the placenta to protect the infant’s health, and ritually cleaning the mother in a manner that does not involve actual bathing with water. Because body heat is lost during delivery, Vietnamese women avoid cold foods and beverages and increase consumption of hot foods to replace and strengthen their blood. Ice water and other cold drinks are usually not welcome, thus the usual practice of offering a newly delivered mother a cold drink should be replaced with something hot—either water or tea is usually available. This can accomplish the nurse’s goal of replacing fluids and maintain the patient’s cultural heritage. Most raw vegetables, fruits, and sour items are taken in lesser amounts. Prescriptive foods include steamed rice, fish sauce, pork, chicken, eggs, soups with chili or black peppers, other highly seasoned and salty items, wine, and sweets. Because water is cold, women traditionally do not fully bathe, shower, or wash their hair for a month after delivery. Some Vietnamese women have complained that they were adversely affected by showering shortly after delivery in American hospitals. Others, however, have welcomed the opportunity to shower and seem willing to give up other traditional practices. Postpartum women also avoid drafts and strenuous activity; wear warm clothing; stay in bed, indoors, or both for about a month; and avoid sexual intercourse for months. In the past, postpartum women remained in a special bed above a slow-burning fire. This practice still continues with the use of hot-water bottles or electric blankets. Other women in the family assume responsibility for the baby’s care. In Vietnam, husbands would never be present at their child’s delivery. For Vietnamese in the United States, this varies and some men do attend deliveries. The mother’s inactivity and dependence on others may be incorrectly interpreted by health-care workers as apathy, depression, or lack of attachment to the baby. A newborn is often dressed in old clothes; it is considered taboo to praise the child lest jealous spirits steal the infant. The mother may be reluctant to cut the child’s hair or nails for fear that this might cause illness. The infant is generally maintained on a 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 13 People of Vietnamese Heritage 13 diet of milk for the first year, with the introduction of rice gruel at around 6 months. There is little formal toilet training; the child usually learns by imitating an older child. One can see mothers holding their naked babies away from them to urinate, and “whispering” in their ears to stimulate a bowel movement. The child is then cleaned and returned to his or her usual clothing. Breastfeeding is customary in Vietnam, but since resettlement, some variations on this practice have been instituted. Some Southeast Asian women discard colostrum and feed the baby rice paste or boiled sugar water for several days. This does not indicate a decision against breastfeeding. After the milk comes in, both mother and baby benefit from the hot foods consumed by the mother for the first month. Then, however, a conflict arises: The mother believes that hot foods benefit her health but that cold foods ensure healthy breast milk. Having the mother change from breastfeeding to formula can easily solve this dilemma; however, it is counterproductive to the medical and nursing community’s efforts to promote breastfeeding during the baby’s first year. If the mother cannot afford formula, she may use fresh milk or rice boiled with water, which may result in anemia and growth retardation. Some health-care professionals, concerned about these developments and their impact on the infant’s health, have recommended educational programs that might restore conditions conducive to traditional breastfeeding. Death Rituals Death Rituals and Expectations Vietnamese accept death as a normal part of the life process. The traditional stoicism of the Vietnamese, the influence of Buddhism with its emphasis on cyclic continuity and reincarnation, and the pervading association of current activities with ancestral spirits and burial places contribute to attitudes toward death Most Vietnamese have an aversion to hospitals and prefer to die at home. Some believe that a person who dies outside the home becomes a wandering soul with no place to rest. Family members think that they can provide more comfort to the dying person at home. Sixty percent of women in one survey said that if someone in their family were dying, they would not want that person told; 95 percent said that they would want a priest or minister with them when they died; and 95 percent indicated a belief in life after death (Calhoun, 1986). Ancestors are commonly honored and worshipped and are believed to bestow protection on the living. Southeast Asians tend not to want to artificially prolong life and suffering, but it may still be difficult for relatives to consent to terminating active intervention, which might be viewed as contributing to the death of an ancestor who would shape the fates of the living (Muecke, 1983a). Few Vietnamese families consent to autopsy unless they know and agree with the reasons for it. Older Vietnamese, on realizing the inevitability of death, sometimes purchase coffins in advance, display them beneath the household altar, and choose burial sites with a favorable position. Although Vietnamese custom is associated with proper burial practices and maintenance of ancestral tombs, cremation is an acceptable practice to some families. Responses to Death and Grief Vietnamese families may wish to gather around the body of a recently deceased relative and express great emotion. Traditional mourning practices include wearing white clothes for 14 days, the subsequent wearing of black armbands by men and white headbands by women, and the yearly celebration of the anniversary of a person’s death. Such observances, together with ritual cleaning and worship at ancestral graves, help reinforce family ties and are deeply woven into Vietnamese culture. Departure from Vietnam has greatly curtailed the observance of these practices, leaving a painful void for many refugees. Priests and monks should be called only at the request of the client or family. Clergy visitation is usually associated with last rites by the Vietnamese, especially those influenced by Catholicism, and can actually be upsetting to hospitalized patients. Sending flowers may be startling, because flowers are usually reserved for the rites of the dead. Spirituality Dominant Religion and Use of Prayer Although some Vietnamese refugees are Catholic, or have converted to other branches of Christianity, many Vietnamese follow Buddhist concepts. Buddhism on the whole is best understood not as a religion in the Western sense but more a philosophy of life and impacts profoundly on the health-care beliefs and practices of the Vietnamese. If one lives in adherence to the Buddhist path one can expect less suffering in future existences. Buddhsim stresses disconnection to the present, especially materialism and self-aggandizement. Thus pain and illness are sometime endured and health-seeking remedies delayed because of this belief in fate. Similarly, preventive health care has little meaning in this philosophy. Respect for and veneration of ancestors is associated with Buddhism and Confucianism. The prospect of burial away from ancestral burial sites is a source of significant distress to older Vietnamese. Difficulty visiting burial sites in Vietnam is also distressful (Rasbridge, 2004). 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 14 14 Aggregate Data for Cultural-Specific Groups Religions practiced by the Vietnamese are Buddhism (9.3 percent), Catholic, (6.7 percent), Hao Hao (1.5 percent), Cao Dai (1.1 percent), Protestant (0.5 percent), Muslim (0.1 percent), and none (80.8 percent) (CIA World Factbook, 2011). There are a number of other religions, including Taoism and Confucianism, which are basically offshoots and combinations of the major faiths. Animism is found mainly among the highland tribes. Many Vietnamese believe that deities and spirits control the universe and that the spirits of dead relatives continue to dwell in the home. Most Vietnamese who practice a religion are Buddhists, but some almost never visit temples or perform rituals. Others, both Buddhist and Christian, may maintain a religious altar in the home and conduct regular religious observances. In cases of severe illness, prayers and offerings may be made at a temple. Meaning of Life and Individual Sources of Strength Whereas the wish to bring honor and prosperity to the family remains a dominant force for most Vietnamese, some find meaning in life from the practice of Buddhism or other religions. Some are driven by the desire to learn, to relieve suffering, to produce beauty, to assist the progress of civilization, and to gain strength from participating in ethnic community activities. A tenet of Buddhism holds that the family unit is more important than the individual, with less emphasis on the “self.” Accordingly, health-care decision making is frequently a family matter. Concordantly, the family is typically involved in treatment. (Bankston & Zhou, 2000). The family is the fundamental social unit and the primary source of cohesion and continuity. Spiritual Beliefs and Health-Care Practices Vietnamese religious practices are influenced by the Eastern philosophies of Buddhism, Confucianism, and Taoism. Central to Buddhism is the concept of following the correct path of life, thus eliminating suffering that is caused by desire. Another tenet is that the world is a cycle of ordeals: to be born, grow old, fall ill, and die. In addition, people’s present lives predetermine their own and their dependents’ future lives. Confucianism stresses harmony through maintenance of the proper order of social hierarchies, ethics, worship of ancestors, and the virtues of chastity and faithfulness. Taoism teaches harmony, allowing events to follow a natural course that one should not attempt to change. These beliefs have contributed to an attitude that may be perceived as passive by Westerners, characterized by maintenance of self-control, acceptance of one’s destiny, and fatalism toward illness and death. Health-Care Practices Health-Seeking Beliefs and Behaviors The diagnosis of illness is frequently understood in three different, although overlapping models. The first, the least common, could be considered supernatural or spiritual, where illness can be brought on by a curse or sorcery, or failure to observe a religious ethic or belief. Traditional medical providers are common, both in the United States and Vietnam; some are specialists in the more magico-religious realm, and may be called upon to exorcise a bad spirit via chanting, a potion, or consultation from an ancient Chinese text. The use of amulets and other forms of spiritual protection is also commonly employed. For example, babies and children often wear bua, an amulet of cloth containing a Buddhist verse, or that has been blessed by a monk. It is worn on a string around the wrist or neck. Vietnamese traditionally do not have a concept of mental illness as discrete from somatic illness, and thus rarely utilize Western-based psychological and psychiatric services. Instead, most mental health issues such as depression or anxiety fall into this spiritual health realm and are treated appropriately. Similarly, somatization is common, and treatments overlap with Western treatments and metaphysical interventions described below. Second, a widespread belief is that the universe is composed of opposing elements held in balance; health is a state of balance between these forces, know as am and duong, based on the more familiar concepts of yin and yang in China. In health, these concepts are frequently translated as “hot” and “cold,” although they do not necessarily refer to temperature. Illness results when there is an inbalance of the “vital” forces; the imbalance can be a result of a physiological state, such as pregnancy or fatigue, or it can be brought on by extrinsic factores like diet or overexposure to “wind,” one of the body forces or humors first described by Galen. Balance can be restored by a number of means, including diet changes to compensate for the exess of “hot” or “cold” Western medicines and injections, and tradtional medicines, herbs, and medical practices. Naturalistic explanations for poor health include eating spoiled food and exposure to inclement weather. The natural element known as cao gio is associated with bad weather Third, most Vietnamese Americans also recognize the more Western concept of disease causation such as the germ theory. There is widespread understanding that disease can come from contaminants in the environment, even if full concepts of microbiology or virology are not grasped. Thus, through decades of French occupation 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 15 People of Vietnamese Heritage 15 and more recently the American influence, even the most rural Vietnamese has come to know the power of antibiotics. When Vietnamese enter the American health-care setting, they do so frequently with the goal to relieve symptoms; in general, the patient expects a medicine to cure the illness immediately. When something is not prescribed initially, the patient is likely to seek care elsewhere, either directly from a Vietnamese pharmacist or specialized “injectionists.” Newly arrived immigrants are used to receiving the medication directly from the doctor; the concept of a “prescription” written on a piece of paper to take to a pharmacy to be “filled” is foreign to them. They may feel that this piece of paper contains instructions for the patient, and not follow through with obtaining the medication. Vietnamese frequently discontinue medicines after the symptoms disappear; similarly, if symptoms are not perceived, there is no illness. Thus, preventive, long-term medications like antihypertensives must be prescribed with culturally sensitive education. It is quite common for Vietnamese patients to amass large quantities of half-used prescription drugs, even antibiotics, many of which are shared with friends and may be sent back to family in Vietnam. Additionally, Vietnamese commonly believe that Western pharmaceuticals are developed for Americans and Europeans, and hence dosages are too strong for more slightly built Vietnamese, resulting in self-adjustment of dosages. The Vietnamese hold great respect for those with education, especially physicians. The doctor is considered the expert on health; diagnosis and treatment should happen at the first visit, with little examination or personally invasive laboratory or other diagnostic tests. Commonly, laboratory procedures involving the drawing of blood are feared and resisted by Vietnamese, who believe the blood loss will make them sicker, and that the body cannot replace what was lost. Surgery is especially feared for this reason. Overall, as health is believed to be a function of balance, surgery would be considered an option of last resort, as the removal of an organ would alter the internal balance. Vietnamese view health and illness from a variety of different perspectives, sometimes simultaneously. It is not uncommon for a sick person to interpret their illness as an interaction of spiritual factors, internal balance inequities, and even an infective process. They will thus combine diagnostic and treament elements from all three models in order to get the maximum health benefits (Rasbridge, 2004). The belief that life is predetermined is a deterrent to seeking health care. For many Vietnamese, diagnostic tests are baffling, inconvenient, and often unnecessary. Procedures such as circumcision or tonsillectomy, which biomedicine considers simple, are generally unknown to the Vietnamese. Invasive procedures are frightening. The prospect of surgery can be terrifying. The fear of mutilation stems from widespread beliefs among non-Christians that souls are attached to different parts of the body and can leave the body, causing illness or death. Loss of blood from any route is feared, and the Vietnamese may refuse to have blood drawn for laboratory tests. The client may complain, though not to the health-care worker, of feeling weak for months. A Vietnamese client in America may feel that any body tissue or fluid removed cannot be replaced, and the body suffers the loss in this life as well as into the next. The concept of long-term medication for chronic illnesses and acceptance of unpleasant side effects and increased autonomic symptoms, which are standard components of modern Western medicine, are not congruent with traditional notions of safe and effective treatment of illnesses. Responsibility for Health Care In Vietnam, the family is the primary provider of health care, even in hospitals. This practice survives because of tradition and a shortage of professional personnel. Their own families attend hospitalized patients day and night. The importance of involving family members, including elder family members or clan leaders, in all major treatment decisions regarding physical and mental health must be stressed. Health care in Vietnam is crisis oriented, with symptom relief as the goal. Vietnamese typically deal with illness by means of self-care, self-medication, and the use of herbal medicines. Facsimiles of Western prescription drugs are sold over the counter throughout Southeast Asia, which may explain the increasing resistance of bacteria to several readily available antibiotics. Many Vietnamese believe that Western medicine is very powerful and cures quickly, but few understand the risks of overdosages or underdosages. Patients being treated for depression who fail to take their antidepressants evidence improvement after receiving instructions for taking their medication. Vietnamese patients may not follow prescribed schedules of medication for the treatment and prevention of tuberculosis. Extensive education, repetition of instructions, and home visitations are necessary. Unfortunately, most Vietnamese women who have abnormal Pap smears fail to return for follow-up care, thereby contributing to the shockingly high incidence of cervical cancer in the population (Wright, 2000). That problem has been associated with lack of organized language services and, thus, a failure by the women to comprehend the severity of the situation and the potential for recovery if regular treatment begins early enough. To increase follow-up visits and 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 16 16 Aggregate Data for Cultural-Specific Groups care, it may be necessary to carefully explain the problems that may result if they do not follow up after an abnormal Pap smear. Women should understand that lack of symptoms or pain may be only temporary and that experiences of acquaintances may not apply to them. Persistent reminding, as part of an overall effort to improve communication and information dissemination, has been suggested as the best way to encourage Vietnamese women to undergo regular cancer screening and follow-up treatment. Folk and Traditional Practices The forces of am (cold) and duong (hot) are pervasive forces in the practice of traditional Vietnamese medicine. Am represents factors that are considered negative, feminine, dark, and empty, whereas duong represents those that are positive, masculine, light, and full. These terms are applied to various parts, organs, and processes of the body. For example, the inside of the body is am, and the surface is duong. The front part of the body is am, and the back is duong. The liver, heart, spleen, lungs, and kidneys are am, and the gallbladder, stomach, intestines, bladder, and lymph system are duong. Am stores strength, and care must be taken not to use it up too quickly. Duong protects the body from outside forces, and if it is not cared for, the organs are thrown into disorder. Proper balance of these two life forces ensures the correct circulation of blood and good health. If the balance is not proper, life is short. Diseases and other debilitating conditions result from either cold or hot influences. For example, diarrhea and some febrile diseases are due to an excess of cold, whereas pimples and other skin problems result from an excess of hot. Countermeasures involve using foods, medications, and treatments that have properties opposite those of the problem and avoiding foods that would intensify the problem. Asian herbs are cold, and Western medicines are hot. A widely held belief among Vietnamese refugees is that Asian medicine relieves symptoms of a disease more quickly than Western medicine but that Western medications can actually cure the illness. Many prefer Asian methods for children. Reliance on traditional folk medicine is declining in the United States, partly because of the unavailability of suitable shamans and traditional herbs. The following are common treatments practiced in Vietnam and continued to some degree in the United States: Cao gio (or coining) literally meaning “rubbing out the wind,” is used for treating colds, sore throats, flu, sinusitis, and similar ailments. An ointment or hot balm oil is spread across the back, chest, or shoulders and rubbed with the edge of a coin (preferably silver) in short, firm strokes. This technique brings blood under the skin, resulting in dark ecchymotic stripes, so the offending wind can escape. Health-care professionals must be careful not to interpret these ecchymotic areas as evidence of child abuse. However, dermabrasion may provide a portal for infection. Be bao or bat gio, skin pinching, is a treatment for headache or sore throat. The skin of the affected area is repeatedly squeezed between the thumb and the forefinger of both hands, as the hands converge toward the center of the face. The objective is to produce ecchymoses or petechiae. Giac (or cup suctioning) another dermabrasive procedure, is used to relieve stress, headaches, and joint and muscle pain. A small cup is heated and placed on the skin with the open side down. As the cup cools, it contracts the skin and draws unwanted hot energy into the cup. This treatment leaves marks that may appear as large bruises. Xong(or steaming) relieves motion sickness or cold-related problems. Herbs or an agent such as Vicks® VapoRub is put into boiling water, and the vapor is inhaled. Small containers of aromatic oils or liniments are sometimes carried and inhaled directly. Moxibustion is used to counter conditions associated with excess cold, including labor and delivery. Pulverized wormwood or incense is heated and placed directly on the skin at certain meridians (Fig. 38-2) Acupuncture, acupressure, and acumassage relieve symptomatic stress and pain. Balms and oils, such as Red Tiger balm, available in Asian shops, are applied to affected areas for relief of bone and muscle ailments. Herbal teas, soups, and other concoctions are taken for various problems, generally in the sense of using cold measures to overcome hot illnesses. Eating organ meats such as liver, kidneys, testes, brains, and bones of an animal is said to increase the strength of the corresponding human part. Two additional practices in Vietnam are consuming gelatinized tiger bones to gain strength and taking powdered rhinoceros horn to reduce fever. At least 430 folk medicines used by Vietnamese contain ingredients from endangered, threatened, or protected species (Gaski & Johnson, 1994). Barriers to Health Care Barriers to adequate health care for Vietnamese people include 1. Subjective beliefs and the cost of health care 2. Lack of access to a primary health-care provider 3. Differences between Western and Asian healthcare practices 4. Caregivers’ judgment of Vietnamese as deviant and unmotivated because of noncompliance with 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 17 People of Vietnamese Heritage 17 Figure 38-2 Moxibustion is used to counter conditions associated with excess cold, including labor and delivery. Pulverized wormwood or incense is heated and placed directly on the skin at certain meridians. (From Ancient Way Acupuncture and Herbs. Klamath Falls, Oregon. Retrieved from www.AncientWay.com) medication schedules, diagnostic tests, follow-up care, and their failure to keep appointments 5. Inability to communicate effectively in the English language by recent immigrants who lack confidence in their ability to communicate their needs; failure of providers to communicate adequately or lack of an interpreter 6. Avoidance of Western providers out of fear that traditional methods will be criticized 7. Fear of conflicts and ridicule resulting in loss of face 8. Lack of knowledge of the availability of resources Additional barriers exist for Vietnamese people when seeking mental-health care. These include fear of stigmatization, difficulty locating agencies that can provide assistance without distorted professional and cultural communication, and reluctance to express inner feelings. Cultural Responses to Health and Illness Fatalistic attitudes and the belief that problems are punishment may reduce the degree of complaining and expression of pain among the Vietnamese, who view endurance as an indicator of strong character. One accepts pain as part of life and attempts to maintain self-control as a means of relief. A deep cultural restraint against showing weakness limits the use of pain medication. However, the sick person is allowed to depend on family and receives a great deal of attention and care. Many Vietnamese believe that mental illness results from offending a deity and that it brings disgrace to the family and, therefore, must be concealed. A shaman may be enlisted to help, and additional therapy is sought only with the greatest discretion and often after a dangerous delay. Emotional disturbance is usually attributed to possession by malicious spirits, the bad luck of familial inheritance, or for Buddhists, bad karma accumulated by misdeeds in past lives. The term psychiatrist has no direct translation in Vietnamese and may be interpreted to mean nerve physician or specialist who treats crazy people. The nervous system is sometimes seen as the source of mental problems—neurosis being thought of as “weakness of the nerves” and psychosis as “turmoil of the nerves.” To overcome these problems, Kinzie and Manson (1982) and Buchwald and colleagues (1993) developed a Vietnamese depression scale, which uses terms that allow an English-speaking practitioner to make a crosscultural assessment of the clinical characteristics of depressed Vietnamese patients. Health-care providers working with Vietnamese patients may find this scale useful when providing mental-health services. Physically disabled people are common and readily seen in Vietnam. Some are veterans or survivors of the Vietnam War, and others have been affected by congenital disabilities (often from environmental toxins) or birth injuries. To the extent that resources allow, they are treated well and cared for by their families and the government. In contrast, a mentally disabled person may be stigmatized by the family and society and can jeopardize the ability of relatives to find marriage partners. The mentally disabled are usually harbored within their families unless they become destructive; then, they may be admitted to a hospital. Blood Transfusions and Organ Donation Because many Vietnamese believe that the body must be kept intact even after death, they are averse to blood transfusions and organ donation. Many Vietnamese, even those whose families have long been Christian, may object to removal of body parts or organ donation. However, some staff in a rural hospital in Vietnam donated blood after learning that the body replenished its blood supply. The smaller size of Vietnamese adults makes many of them ineligible to donate a full unit of blood. Other Vietnamese people, who may prefer cremation, will donate body parts under certain circumstances. 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 18 18 Aggregate Data for Cultural-Specific Groups Health-Care Providers Traditional Versus Biomedical Providers Four kinds of traditional and folk providers exist in Vietnam. The first group includes Asian physicians who are learned individuals and employ herbal medication and acupuncture. The second group consists of more informal folk healers who use special herbs and diets as cures based on natural or pragmatic approaches. The secrets of folk medicine are passed down through the generations. The third group includes various forms of spiritual healers, some with a specific religious outlook and others with powers to drive away malevolent spirits. The fourth group is made up of magicians or sorcerers who have magical curative powers but no communication with the spirits. Many Vietnamese consult one or more of these healers in an attempt to find a cure. Whereas many Vietnamese have great respect for professional, well-educated people, they may be distrustful of outside authority figures. Most Vietnamese have come to America to escape oppressive authority. Refugees generally expect health-care professionals to be experts. A common suspicion is that divulging personal information for a medical history could jeopardize their legal rights. Respect and mistrust are not mutually exclusive concepts for Vietnamese seeking care from Western providers. Because of the need to build trust with a Vietnamese client, it is particularly important to acknowledge and support traditional belief systems. Traditional Asian male providers do not usually touch the bodies of female patients and sometimes use a doll to point out the nature of a problem. Whereas most Vietnamese may no longer insist on the use of this practice, adults, particularly young and unmarried women, are more comfortable with health-care providers of the same gender. Pelvic examinations on unmarried women should not be made on the first visit or without careful advance explanation and preparation. When such an examination is necessary, the woman may want her husband present. If possible, the practitioner and an interpreter should both be female. Women may not want to even discuss sexual problems, reproductive matters, and birth control techniques until after an initial visit and after confidence has been established in the practitioner. Status of Health-Care Providers Because of the shortage of physicians in Vietnam, medical assistants, nurses, village health-care workers, self-trained individuals, and injectionists practice Western medicine. Paralleling these approaches are the traditional systems of Asian and folk medicine. Traditional healers often provide the Vietnamese with necessary social support that may be lacking with Western providers. However, all are respected and have high status and may be used concurrently or separately, according to the illness and varying beliefs of each individual. REFERENCES Bankston, C. L., & Zhou, M. (2000). De facto congregationalism and socioeconomic mobility in Laotian and Vietnamese immigrant communities: A study of religious institutions and economic change. Review of Religious Research, 41(4), 453–470. Buchwald, D., Manson, S. M., Dinges, N. G., Kean, E. M., & Kinzie, J. D. (1993). Prevalence of depressive symptoms among established Vietnamese refugees in the United States. Journal of General Internal Medicine, 8(2), 76–81. Calhoun, M. A. (1986). Providing health care to Vietnamese in America: What practitioners need to know. Home Health-care Nurse, 4(5), 14–22. Catanzaro, A., & Moser, R. J. (1982). Health status of refugees from Vietnam, Laos, and Cambodia. Journal of the American Medical Association, 247(9), 1303–1308. Centers for Disease Control and Prevention. (1990). Update: Sudden unexplained death syndrome among Southeast Asian refugees—United States. Journal of the American Medical Association, 260(14), 2033. CIA World Factbook. (2011). Vietnam. Retrieved from https:// www.cia.gov/library/publications/the-world-factbook/ geos/vm.html Cochran, S. D., Mays, V. M., & Leung, L. (1991). Sexual practices of heterosexual Asian-American young adults: Implications for risk of HIV infection. Archives of Sexual Behavior, 20(4), 381–391. Dao, A. H., Gregory, D. W., & McKee, C. (1984). Specific health problems of Southeast Asian refugees in middle Tennessee. Southern Medical Journal, 77(8), 995–997. Gaski, A. L., & Johnson, K. A. (1994). Prescription for extinction: Endangered species and patented Oriental medicines in trade. Washington, DC: Traffic USA. Goldenring, J. M., Davis, J., & McChesney, M. (1982). Pediatric screening of Southeast Asian immigrants. Clinical Pediatrics, 21(10), 613–616. Hilton, W., Ladosn, M., Tiet, Q., Tran, C., Giaouyen, M., & Chesney, M. (1997). Predictors of depression among refugees from Vietnam: A longitudinal study. Journal of Nervous and Mental Disease, 185(1), 39–45. Hjertstedt, J., Burns, E., Fleming, R., Raff, H., Rudman, H., Duthie, E. H., & Wilson, C. R. (2001). Mandibular and palatal tori, bone mineral density, and salivary cortisol in communitydwelling elderly men and women. Journal of Gerontology, (56), M731–M735. Hopkins, D. D., & Clarke, N. G. (1983). Indochinese refugee fertility rates and pregnancy risk factors: Oregon. American Journal of Public Health, 73(11), 1307–1309. Huer, M., Saenz, T., & Doan, J. (2001). Understanding the Vietnamese American community: Implications for training eductional personnel providing services to children with disabilities. Communication Disorders Quarterly. September 22. Retrieved from http://www.accessmylibrary.com/article-1G181826791 Jenkins, C. N. H., McPhee, S., Dordham, D. C., & Hung, S. (1992). Cigarette smoking among Chinese, Vietnamese, and Hispanics: California 1989–1991. MMWR. Morbidity and Mortality Weekly Report, 41(20), 362–367. 2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 19 People of Vietnamese Heritage 19 Kinzie, J. D., & Manson, S. M. (1982). Development and validation of a Vietnamese-language depression rating scale. American Journal of Psychiatry, 139(10), 1276–1281. Levy, R. A. (1993). Ethnic and racial differences in response to medicines: Preserving individualized therapy in managed pharmaceutical programmes. Pharmaceutical Medicine, 7, 139–165. Lin, K., & Shen, W. W. (1991). Pharmacotherapy for Southeast Asian psychiatric patients. Journal of Nervous and Mental Disease, 179(6), 346–350. Medical News Today (2009, November 2). Study shows how differing Asian cultures and attitudes impact cancer screening rates. Retrieved from http://www.medicalnewstoday.com/articles/ 169449.php Medical News Today (2010, March 19). Huge health disparities revealed among Asian-Americans, Native Hawaiians, Asian immigrants. Retrieved from http://www.medicalnewstoday. com//articles/182881.php Miae, K. (1999, August 9). Gay Pride: A/PLG [Asian/Pacific Lesbians and Gays] is a safe place for Asian gays, lesbians. Asian Reporter, 31(9), 9. Migration Information Source. (2004). Retrieved from http:// www.migrationinformation.org/USfocus/display.cfm?id=197 Muecke, M. A. (1983a). Caring for Southeast Asian refugees in the American health care system. American Journal of Public Health, 73(4), 431–438. Muecke, M. A. (1983b). In search of healers: Southeast Asian refugees in the American health care system. Western Journal of Medicine, 139(6), 835–840. Office of Minority Health (2007). The American community: Asians. Retrieved from http://minorityhealth.hhs.gov Rasbridge, L. (2004). Vietnamese. In C. Kemp & L. Rasbridge (Eds.), Refugee and immigrant health: A handbook for health professionals (pp. 346–358). Cambridge, UK: University of Cambridge Press. Roberts, N. S., Copel, J. A., Bhutan, Y., & Otis, S. (1985). Intestinal parasites and other infections during pregnancy in Southeast Asian refugees. Journal of Reproductive Medicine, 30(10), 720–725. Ross, T. F. (1982). Health care problems of Southeast Asian refugees. Western Journal of Medicine, 136(1), 35–43. Solomon, F., DeJoice, R., Nguyen, S., Kwon, H., & Berlin, N. (2005). Findings from the National Cancer Institute and Vietnamese American medical association Pap test barriers survey for health care providers. Presented at American Public Health Association 133rd annual meeting, Philadelphia, PA. Sorkin, D., Tan, A., Hays, R., Mangione, C., & Ngo-Metzger, Q. (2008). Self-reported health status of Vietnamese and nonHispanic white older adults in California. Journal of the American Geriatrics Society (56)8, 1543–1548. Unbold journal Strand, P. J., & Jones, W. (1983). Health service utilization by Indochinese refugees. Medical Care, 21(11), 1089–1098. Sutherland, J. E., Avant, R. F., Franz, W. B., & Monson, C. M. (1983). Indochinese refugee health assessment and treatment. Journal of Family Practice, 16(1), 61–67. Sutter, R. W., & Haefliger, E. (1990). Tuberculosis morbidity and infection in Vietnamese in Southeast Asian refugee camps. American Review of Respiratory Disease, 141(6), 1483–1486. Taylor, V., Yasui, Y., Nguyen, T., Woodall, E., Do, H., Acorda, E., Li, L., Choe, J., & Jackson, J. (2009). Pap smear receipt among Vietnamese imigrants: The importance of health care factors. Ethnicity & Health, 14(6), 575–589. Tobin, J. J., & Friedman, J. (1983). Spirits, shamans, and nightmare death: Survivor stress in a Hmong refugee. American Journal of Orthopsychiatry, 53(3), 439–448. Vangen, S., Stoltenberg, C., Rolv Skjaerven, R., Magnus, P., Harris, J. R., & Stray-Pedersen, B. (2002). The heavier the better? Birthweight and perinatal mortality in different ethnic groups. International Journal of Epidemiology, (31), 654–660. Wright, J. B. (2000). 2000 Assembly on cervical cancer among Vietnamese-American women. Annandale, VA: National Asian Women’s Health Organization. Yu, E. S. H. (1991). The health risks of Asian Americans. American Journal of Public Health, 81(11), 1391–1393. For case studies, review questions, and additional information, go to http://davisplus.fadavis.com

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lemaiyanaomi
School: UCLA

Have a look at this and get back to me if you nee anything changed

THE INFLUENCE OF DIFFERENT HERITAGES ON DELIVERY OF EVIDENCE
BASED HEALTH CARE

Influence of Cultures on Evidence Based Healthcare
Evidence based healthcare is the provision of health services based on current available
evidence of the patients exposure, with knowledge of what specific things may have caused the
illness. It is basically healthcare without second guessing. Its three main components are;

research-based evidence, clinical expertise and the patient’s values and preferences. Certain
cultures have certain beliefs that might hinder delivery of evidence based healthcare. Some of
these beliefs have been passed on from generation to generation, and has not been overtaken by
modern medical practices. The following are some of the ways that people of different heritages
have been affected by their cultures, such that the efficiency of evidence based healthcare is
undermined.
The people of Vietnamese culture believe that good health is caused by the balance of am
and duong, and that illness can either be caused by natural or supernatural things. This is a
community that is still conservative and the use of traditional medicine is practiced, specifically
administered depending on the ancestry, whether...

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Tutor went the extra mile to help me with this essay. Citations were a bit shaky but I appreciated how well he handled APA styles and how ok he was to change them even though I didnt specify. Got a B+ which is believable and acceptable.

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