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
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Group, clan, or tribal emphasis
Present oriented
Time is always with us
Age
Cooperation
Harmony with nature
Giving/sharing
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
AI/AN Cultural Values
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Pragmatic
Mythology
Patience
Mystical
Shame
Permissiveness
Extended family and clan
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
AI/AN Cultural Values
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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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.
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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.
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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.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Family Roles and Organization
▪ Standing out is not encouraged among the
different tribal groups.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
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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).
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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
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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.
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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
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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
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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
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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
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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
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