Transcultural Health Care: A Culturally Competent Approach, 4th Edition American Indians Alaskan Natives (AI/ANs) Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Amount of Indian blood necessary to be considered a tribal member varies among the tribes—¼ to be a Navajo, which is the largest tribe in United States and live in the Southwest ▪ 556 different tribes in the United States and Canada ▪ Each tribe unique but share similar views regarding cosmology, medicine, and family organization Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Heritage ▪ Forced migration by United States government ▪ Life on MOST reservations is hard with high poverty and high unemployment although a few have significant money due to oil, land leases, gambling casinos, etc. ▪ Children were taken from them and placed in “White Man’s Schools” Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Group, clan, or tribal emphasis Present oriented Time is always with us Age Cooperation Harmony with nature Giving/sharing Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Pragmatic Mythology Patience Mystical Shame Permissiveness Extended family and clan Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Cultural Values ▪ ▪ ▪ ▪ ▪ ▪ ▪ Non-aggressiveness Modesty Silence Respect other’s religion Religion is a way of life Land, water, forest belong to all Beneficial, reasonable use of resources Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Low educational levels for most tribes, preferring children to remain at home and learn Indian ways ▪ For the traditional, health care is an undesirable profession because one should not work with the dead or ill ▪ Navajo sometimes have a special cleansing ceremony to allow them to work in a hospital Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Language and dialect vary by tribe, but most speak English and in the southwest many speak Spanish instead of English ▪ Minor variations in pronunciation can change the meaning of the word ▪ Talking loudly or interrupting someone is considered rude Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Navajos generally do not share thoughts and feelings easily outside family and friends, making it difficult to obtain trust in the healthcare setting ▪ Comfortable with long periods of silence ▪ Touch is unacceptable unless you know the person very well Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ No set pattern for willingness to share tribal ceremonies ▪ Pueblo groups usually do not share any tribal ceremonies ▪ Light passing of the hands for a handshake ▪ Considered rude to point with the finger; instead shift your lips in the desired direction Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ Direct eye contact is rude and confrontational—deadpan facial expression ▪ Proximity for conversations usually greater than 24 inches ▪ Time sequence is present, past, and future Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition AI/AN Communication ▪ The future is out of one’s control. ▪ Very few are future oriented and for the Navajo there is no future verb tense ▪ Time is not something that can be controlled, nor should time control the person; events start when the people arrive Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Navajo, like most Native Indian tribes, is matrilineal in decision-making and land rights ▪ Relationship between brother and sister is more important than that between husband and wife ▪ Children's names are not revealed at birth Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Older people are addressed as grandmother, grandfather, mother, father, or a nickname. ▪ Algonquin are egalitarian society ▪ Dene and Athabascan are patriarchal ▪ Navajo, Iroquois, Pueblos, and Haida are matriarchial societies Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ AI/AN naming traditions vary greatly from tribe to tribe and are frequently determined by nature, animals, or character. ▪ In the past, AI/AN women practiced breastfeeding exclusively. ▪ Since the early to mid-1980s, the use of formula has become popular. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ A primary social premise is that no person has the right to speak for another. ▪ Parents are permissive in childrearing practices and may allow a child decide whether if not go to school or take medicine. ▪ Ceremony plays a vital, essential role in AI/ANs everyday life. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ When a couple marries in the Pueblo tribes, the man goes to live in the woman’s house. ▪ In Navajo tradition, families have separate dwellings but are grouped by familial relationships. ▪ The Navajo family unit consists of the nuclear family and relatives such as sisters, aunts, and their female descendants. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ In all American Indian and Alaska Natives extended family members play an important role in the infants’ life. ▪ Older adults are looked on with clear deference ▪ Elders play an important role in keeping rituals and in instructing children and grandchildren. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Social status is determined by age and life experiences. ▪ Among the Pueblos governors are chosen from a particular clan; unless one is born in the clan they cannot run for tribal governor. Generally, individuals are discouraged from having more possessions than their peers, and those who display more material wealth are ignored. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Standing out is not encouraged among the different tribal groups. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Many AI/ANs remain traditional in their practice of religious activities. Family matters are more important than work, resulting in high rates of absenteeism. ▪ In addition, tribal ceremonies are seen as necessary and they often must take time from work or school. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Tribal members in the community function informally as cultural brokers and assist by helping non– American Indian staff to understand important cultural issues. ▪ Conflict is addressed indirectly through third parties in some tribes Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Group activities are an important norm in AI/AN cultures. ▪ One individual should not be singled out to answer a question because the student’s mistakes are generally not forgotten by the group. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Issues of superior-subordinate roles exist and are related to age. ▪ IHS is the only organization allowed to discriminate in hiring practices; it is required to hire an AI/AN when possible. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck AI/AN tribes and clans are a. Patriarchal. b. Matriarchal. c. Egalitarian. d. Depends on the tribe and clan. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: D Some tribes and clans are patriarchal, some are matriarchal, and some are more egalitarian. Variations exist within the tribe and clan as well. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Skin color among AI/ANs varies from light to very dark brown, depending on the tribe. ▪ Each of the American Indian tribes vary in terms of facial features and height. ▪ Never assume that an AI/AN patient is from a particular tribe, if wrong, he or she will be offended. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Historically, most diseases affecting AI/ANs were infectious such as tuberculosis, smallpox, and influenza. ▪ Diseases of the heart, malignant neoplasm, unintentional injuries, diabetes mellitus, and cerebrovascular disease are the top five leading causes of AI/AN deaths Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Type 1 diabetes mellitus is almost nonexistent in AI/ANs but type 2 diabetes mellitus is the third most prevalent chronic disease affecting all AI/AN tribes. ▪ The incidence of diabetes varies among tribes has steadily increased and is approaching 30 percent. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Albinism occurs in the Navajo and Pueblo tribes. ▪ Navajos who lived in Rainbow Grand Canyon are genetically prone to blindness that develops in individuals during their late teens and early 20s. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ The Zunis have an incidence of cystic fibrosis seven and one-half times that found for Caucasians. ▪ Methamphetamine (meth) abuse and suicide are two top concerns in Indian country. ▪ Suicide rates among American Indians and Alaska Natives (AI/ANs) are 1.7 times higher than the national average. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Alcohol use is more prevalent than any other form of chemical misuse. ▪ Many accidents are attributed to driving while under the influence of alcohol. ▪ Spousal abuse is common and frequently related to alcohol use. The wife is the usual recipient of the abuse, but occasionally, the husband is abused. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Food has major significance beyond nourishment in AI/AN populations. ▪ Food is offered to family and friends or may be burned to feed higher powers and those who have died. ▪ Life events, dances, healing, and religious ceremonies evolve around food. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Corn is an important staple in the diet of American Indians. ▪ Rituals such as the green corn dance of the Cherokees and harvest-time rituals for the Zuni surround the use of corn. ▪ Corn pollen is used in the Blessingway and many other ceremonies by the Navajo. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Each tribe has its own version of fry bread. ▪ Access to fresh fruits and vegetables is minimal during wintertime. ▪ AI/AN diets may be deficient in vitamin D because many members suffer from lactose intolerance or do not drink milk. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Traditional AI/ANs do not practice birth control and often do not limit family size. ▪ In Apache and Navajo tribes, twins are not looked on favorably and are frequently believed to be the work of a witch. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Some want their blood and urine specimens returned to them upon discharge. ▪ Many use herbs during labor and delivery. ▪ A ceremony may be performed by the medicine man during labor and delivery. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Be flexible with positioning for delivery. ▪ Some may want the umbilical cord, meconium, and afterbirth. ▪ Some may use peyote during labor and delivery. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The most common form of substance abuse among AI/ANs is a. Alcohol. b. Peyote. c. Marijuana. d. Methamphetamine. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer The most common substance abuse among AI/AN tribes is alcohol which is 1.7 times higher than other groups who have been studied. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Most AI/AN tribes believe that the souls of the dead pass into a spirit world and became part of the spiritual forces that influenced every aspect of their lives. ▪ Today some tribes maintain their traditional practices but use a mortuary or use the IHS morgue to prepare their dead. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The Pueblo tribes prepare their own dead and only certain family members are allowed to prepare the body. ▪ Hopis bury their dead before the next setting of the sun and bury them in upright sitting positions with food and goods in the grave with the person. ▪ After the Zuni burial, the members must take off three days from work for a cleansing ceremony. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The body must go into the afterlife as whole as possible. ▪ In some tribes, amputated limbs are given to the family for a separate burial and later the limb is buried with the body. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ In some tribes, family members are reluctant to deal with the body because those who work with the dead must have a ceremony to protect them from the deceased’s spirit. ▪ In the Navajo, if the person dies at home, the body must be taken out of the north side of the hogan and a ceremony conducted to cleanse the Hogan or it must be abandoned. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Older adults are reluctant to discuss advance directives once they discover what it means. ▪ Effective discussions require that the issue be discussed in the third person, as if the illness or disorder is happening to someone else. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ If a provider makes a statement such as “if you don’t get medical care, you will die,” this implies that the provider wishes the client dead. ▪ If the patient does die or is extremely ill, the provider might be considered a witch. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The Navajo are not generally open in their expression of grief; they often will not touch or pick up the body or prepare the body for burial. ▪ Grief among the Pueblo and Plains Tribes are expressed openly and involves much crying among extended family members Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ AI/AN religion predominates in many tribes. ▪ When illnesses are severe, consultations with appropriate religious organizations are sought. ▪ Sometimes, hospital admissions are accompanied by traditional ceremonies and consultation with a pastor. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ AI/AN tribal traditional members start the day with prayer, meditation, and corn pollen. ▪ Prayers ask for harmony with nature and for health and invite blessings to help the person exist in harmony with the earth and sky. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ The meaning of life for AI/ANs is derived from being in harmony with nature. ▪ The individual’s source of strength comes from the inner self and depends on being in harmony with one’s surroundings. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Spirituality cannot be separated from the healing process in ceremonies. ▪ Illnesses, especially mental illnesses, result from not being in harmony with nature, from the spirits of evil persons such as a witch, or through violation of taboos. ▪ Healing ceremonies restore an individual’s balance mentally, physically, and spiritually. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Traditional AI/AN beliefs influence biomedical healthcare decisions. ▪ asking patients questions to make a diagnosis fosters mistrust. ▪ This approach is in conflict with the practice of traditional medicine men, who tell people their problem without their having to say anything. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ IHS has attempted to shift its focus from acute care to health promotion, disease prevention, and chronic health conditions. ▪ Wellness-promotion activities include a return to past traditions such as running for health, avoiding alcohol, and using purification ceremonies. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Medicine men, diagnosticians, crystal gazers, and shamans tell them how to restore harmony. ▪ Many families do not have adequate transportation and must wait for others to transport them to their appointments. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Frequently, pain control is ineffective because the intensity of their pain is not obvious to the health-care provider because patients do not request pain medication. ▪ Herbal medicines may be preferred and used without the knowledge of the health-care provider. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Mental illness is perceived as resulting from witches or witching (placing a curse) on a person. ▪ In these instances, a healer who deals with dreams or a crystal gazer is consulted. Individuals may wear turquoise or other items such as a medicine bag to ward off evil. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ The concept of rehabilitation is relatively new to AI/ANs because, in years past, they did not survive to old age to which chronic diseases became an issue. ▪ Autopsy and organ donation are becoming a little more accepted among traditional AI/ANs. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ AI/AN healers are divided primarily into three categories: those working with the power of good, the power of evil, or both. ▪ Some are endowed with supernatural powers, whereas others have knowledge of herbs and specific manipulations to “suck” out the evil spirits. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ Health-care providers must be careful not to open medicine bags or remove them from the patient. ▪ These objects contribute to patients’ mental well-being, and their removal creates undue stress. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ Treatment regimens prescribed by a medicine man not only cure the body but also restore the mind. ▪ Individuals living off reservations frequently return to participate in this ceremony, which returns them to harmony and restores a sense of well-being. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Turkish Culture Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Türkiye, as it is written in Turkish, means “land of Turks.” Referred to as a geographic, religious, and cultural crossroads, the Republic of Türkiye is situated at the geographic intersection of Europe, Asia, the Middle East, and Africa. ▪ While Turks have emigrated throughout the world, many live in Western Europe, largely as a result of “guest worker” programs. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Today, the Republic of Türkiye is politically stable and continues to adapt economically to reforms. ▪ Türkiye remains strategically important to the West and is a strong ally of the United States. ▪ The Turkish immigrant population in the US differs significantly from most of the Turkish population in Europe, both in terms of demographic makeup and socioeconomic status and integration. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Over 202,000 people of Turkish descent live in the United States. ▪ They live in 42 states, with over half living in New York, California, New Jersey, and Florida. ▪ Just over half of the individuals in this group were born outside the United States. ▪ Most arrived in the US before 1980. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ A high proportion of Turks in the United States come from the elite and upper-middle classes, interspersed with smaller groups of middle-class students and skilled laborers who are supported privately or by the government. ▪ Many Turks sought advanced American education in highly technical fields, leading to more abundant employment opportunities in the United States upon completion of their studies. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ A Uralic-Altaic language, Turkish is spoken by 90% of the population and has approximately 20 dialects. ▪ Differences in some of the dialects are so great that they are considered different languages. ▪ The Turkish alphabet is much like the English alphabet, although it does not have a “w” or an “x” and additional sounds are symbolized by an diacritical mark over vowels. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ The Turkish language does not distinguish gender pronouns (ie, “he” from “she” or “her” from “his.”) Therefore, Turks when learning English may inadvertently confuse these pronouns. ▪ Turkish distinguishes a formal from an informal “you,” signifying the importance of status in Turkish society. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Speaking in loud voices is common; this does not always signify anger but rather excitement or deep involvement in a discussion. ▪ More than one person may speak at the same time or interrupt another person; this is not necessarily considered rude. ▪ However, someone of lower status should not interrupt someone of higher status. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Group affiliation is valued over individualism in Turkish society. In fact, identity may be determined by family membership or group, school, and work associations. ▪ Turks generally do not desire much privacy and tend to rely on cooperation between family and friends, although competition between groups can be fierce. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turks value harmony over confrontation. ▪ The outward show of feelings is less restrained. ▪ For women, expressions of anger are usually acceptable only within same-sex friendships and kinship networks or toward those of lower social status. ▪ Generally, women are not free to vent their anger toward their husbands or other powerful men. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Touching, holding hands, and patting one another on the back are acceptable behaviors between same-sex friends and opposite-sex partners. ▪ Same-sex friends, especially among the older generations, are commonly seen holding hands or linking arms while walking. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Very strict Muslims may not shake hands or touch members of the opposite sex, especially if they are not related. ▪ When interacting with someone of higher status, one is expected to maintain occasional eye contact to show attention; however, prolonged eye contact may be considered rude, or may be interpreted as flirting. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turkish people tend to dress formally; men wear suits rather than sports jackets and slacks on social occasions. ▪ Women tend to dress modestly, wearing skirts and dresses rather than slacks. More traditional Muslim women may wear very modest clothing and cover their heads with a scarf, either black or a colorful print. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ However, styles continue to change, and denim jeans and casual dress are becoming common among young people for less formal occasions. ▪ Turks openly display emotions such as happiness, disgust, approval, disapproval, and sadness through facial expressions and gestures. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ No” is indicated by raising the eyebrows or lifting the chin slightly, while making a snapping or “tsk” sound with the mouth. ▪ Appreciation may be expressed by holding the tips of the fingers and thumb together and kissing them and is commonly used to express appreciation for food. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turkish people take pride in keeping their homes immaculately clean, and one is expected to remove one’s shoes inside the home. ▪ Most Turkish hosts in Türkiye and many in the United States offer slippers to their guests. ▪ Whether wearing shoes or not, showing the sole of one’s foot is considered to be offensive in Turkish culture. ▪ Women are expected to sit modestly with knees together and not crossed. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turks tend to have a relaxed attitude about time; social visits can begin late and continue well into the night. ▪ While punctuality in social engagements is not highly important, in business relationships, punctuality among Turkish Americans is gaining in importance. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Turks value status and hierarchy. Demonstrating respect for those of higher status is mandatory and determines the quality of interactions with a person. ▪ Strangers are always greeted with their title, such as Bey (Mr.), Hanim (Mrs., Miss, or Ms.), Doktor, or Profesör. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ When friends or family members greet, it is customary for each to shake hands and to kiss one another on each cheek. ▪ Traditionally, when greeting someone of very high status or an elderly person, one might grasp his or her hand and kiss it, and then bring it to touch one’s forehead in a gesture of respect. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ In a very traditional Turkish home, the father is considered the absolute ruler. ▪ The concept of izin (permission or leave to do something specific) captures this significance. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Less traditional families show more equality between spouses, especially in nuclear families in which the wife is well educated. ▪ Yet, remnants of traditional family structure prevail; the husband often acts as the ultimate decision maker, especially in financial matters. ▪ Women may work full time outside the home in addition to assuming full responsibility for running the daily activities inside the home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Legal marriage in Türkiye does not permit polygamy, although some may practice it outside. ▪ A woman’s age, and the number, age, and gender of her children influence her status in the family and the community. A young “gelin” (woman age 15 to 30) has the lowest status. The “middle-aged” woman (30 to 45) has medium status while the “mature” woman (45 to 65) has the highest status. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ In “old age” (65 or older), a woman is highly respected but is not powerful. ▪ However, this status varies according to education, religious practice, socioeconomic level, urbanization, and professional achievement. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Children are held very dear in the Turkish family and they are expected to act as young children, not small adults. ▪ They are accustomed to receiving attention from family, friends, and visitors. ▪ Kissing children and pinching their cheeks is quite common. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Once children enter school, they are expected to study hard, show respect, and obey their elders, including older siblings. ▪ Girls are expected to help care for younger siblings, to help at mealtimes, and to learn to cook. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Traditionally, children are not allowed to act out or talk back to their superiors. ▪ Light corporal punishment is generally acceptable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Male circumcision is a major rite of passage. ▪ This is a time of celebration within the extended family, and newly circumcised boys are honored with gifts. ▪ Traditionally, boys can be circumcised up to the age of about 12, although the modern trend is to perform the circumcision in the hospital shortly after birth. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Urban adolescents are beginning to date in pairs in addition to the more traditionally accepted practice of group outings. ▪ However, sexual interaction is strongly discouraged among youth and the unmarried, especially for young women. ▪ Virginity in unmarried women is a strong cultural value. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ A key objective among Turks is socioeconomic advancement, including education, better professional opportunities, and material success. ▪ Although financial independence is valued in Turkish culture, independence from the family is not encouraged. ▪ Adult children, especially men, remain an integral part of their parents’ lives, and parents expect their children to care for them in their old age. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Because respect is highly valued in Turkish society, maintaining or improving status in the community is of key importance. ▪ Individuals must always consider what impact their actions will have on the family and often they consult parents or other family members before making major decisions. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Young people living in Türkiye generally live in their parents’ home until they are married, unless school or work necessitates other arrangements. ▪ Family-initiated marriages range from rare contractual agreements between parents to the relatively common introduction and gentle encouragement of a newly formed couple. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Elders in Turkish culture are attributed authority and respect until they become weak or retired, at which time their authoritative roles diminish. ▪ Individuals are socialized to take care of elderly parents, regarding it as normal and not as an added burden. ▪ Grandparents play a significant role in raising their grandchildren, especially if they live in the same home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ The extended family is very important in Turkish culture. ▪ Even the apparent increase in nuclear households does not rule out the networks among closely related families. ▪ Whether or not they live under the same roof, a young family may still live under the supervision of the husband’s parents or at least maintain an interdependent relationship. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Divorce is becoming more common in Turkish society, but remains socially undesirable. ▪ Widows, however, are generally taken care of by their late husband’s family and, depending on their age and socioeconomic background, may have the option to remarry. ▪ Premarital cohabitation and unwed motherhood is strongly discouraged. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles & Organization ▪ Homosexuality is only beginning to be received “at a distance.” In fact, one of the most popular entertainers in Türkiye is a homosexual and a transvestite and is accepted as such. ▪ However, most Turks would be hesitant to associate themselves with the gay community. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Because Türkiye is a group-oriented culture, the Turkish workplace may be more team oriented. ▪ Turkish relationship orientation may lead to dependence on personal contacts and networks to accomplish tasks. ▪ Developing these relationships and networks may appear as nepotism or as too much socializing from the American perspective. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Hierarchical structure is highly pervasive throughout Turkish culture, and the workplace is no exception. ▪ Turkish employees expect an authoritative relationship between superior and subordinates. ▪ However, indirect criticism is expected and appreciated to “save face.” Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ A Turk may be highly offended if openly criticized, especially if done in front of other people. ▪ They may be reticent about asking questions for fear of exposing a lack of knowledge. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Turks perceive that aggressive face-to-face confrontation may cause relationships to deteriorate. ▪ The dominant means of conflict resolution is collaboration reinforced by compromise and forcing. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues Many women do not work because it interferes with child care, the order of the home, and it requires them to be together with men from outside the immediate family. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Turkish population is a mosaic in terms of appearance, complexion, and coloration. ▪ Appearances range from light-skinned with blue or green eyes to olive or darker skin tones with brown eyes. ▪ Mongolian spots, usually found at or near the sacrum, are common among Turkish babies and should not be confused with bruising. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Malaria has not been fully eradicated in Türkiye, especially in the southeast. ▪ Endemic goiter associated with iodine deficiency is a major health problem in Türkiye. ▪ Behçet’s disease, a syndrome of unknown etiology, is prevalent in Mediterranean countries, the Middle East, and Japan and primarily affects males between the ages of 20 and 40. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Common health conditions among Turks are lactose intolerance, thalassemia, cardiovascular diseases, cancer, obesity, hypertension, diabetes, tuberculosis, and conditions related to high smoking rates among men and women. ▪ The most prevalent food- and water-borne diseases are infectious hepatitis and sporadic cases of salmonellosis and dysentery. Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-risk Health Behaviors ▪ Cigarette smoking is widespread in Türkiye and tends to start at an early age. Türkiye, a major producer of tobacco in the world, has instituted very limited anti-tobacco activities. ▪ Turks tend to consume less alcohol than Americans or Europeans, perhaps as a result of the Muslim culture that discourages more than moderate alcohol use. Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-risk Health Behaviors ▪ The tendency of Turkish men to view themselves as strong/immune to disease and the traditional cultural view condoning male promiscuity increases the danger for both the man and his wife. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Turkish cuisine is influenced by the many civilizations encountered by nomadic Turks over the centuries, as well as by a mixture of delicacies from different regions of the vast Ottoman Empire. Therefore, food choices are varied and tend to provide a healthy, balanced diet. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck A common genetic/hereditary condition among Turks is a. Hemophilia. b. Thalassemia. c. Anemia. d. Sickle cell anemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: B A common genetic/hereditary condition among Turks is thalassemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Tea and a snack is always on hand for visitors, and dinner guests may have difficulty finishing everything on their plates ▪ Turkish hostesses may relentlessly offer to replace what has been eaten. ▪ Polite guests refuse the first offer, but the hungry need not worry; offers are made again and again. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Turkish cooking is not terribly spicy and is prepared artfully and fastidiously, as Turkish appetites tend to be discriminating. ▪ Breakfast is typically a simple meal of white feta cheese (beyaz peynir), olives, tomatoes, eggs, cucumbers, toast, jam, honey, and Turkish tea. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Hot midday or evening meals may include any of the foods described below: ▪ Çorba (soups) range from light to substantial. ▪ Meze (hors d’oeuvres) include a great variety of small dishes, either hot or cold, such as yaprak dolma (stuffed grape leaves in olive oil), olives, circassian or çerkez tavuğu (chicken with walnut sauce), çiroz (dried mackerel), leblebi (roasted chick peas), or sigara böreği (a savory cheese pastry fried until crispy). Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Salads include lettuce, tomatoes, cucumbers, onions, and other raw vegetables with a dressing of olive oil and lemon juice or vinegar. ▪ Olive oil and lemon are staples in Turkish culinary preparation. ▪ Turks generally prepare meat in small pieces in combination with other vegetables, potatoes, or rice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Famous Turkish cuisine includes köfte, small spicy meatballs, and kebab, skewered beef or lamb and vegetables. ▪ While poultry is less common, fish has a special place in Turkish cuisine. ▪ Türkiye is the birthplace of yogurt, which is an essential part of the Turkish diet and is generally served with hot meals rather than as cold breakfast food. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Vegetables are served cooked or raw, hot or cold, as part of a stew or casserole, or stuffed (dolma) with meat, rice, and currants. ▪ Rice and börek are important parts of Turkish culinary tradition. Börek is made by wrapping yufka (thin sheets of flour-based dough) around meat, cheese, or spinach and then frying or baking until the dough is flaky. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Turkish desserts fall into 4 categories: 1. 2. 3. 4. Rich and sweet pastry, such as baklava Puddings Komposto (cooked fruits) Fresh fruits. In fact, most meals are concluded with fresh fruit and coffee or tea. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Turkish kahve, from which the English word coffee is derived, is famous for its dark, thick, sweet taste. ▪ The Muslim religion requires abstinence from eating pork and drinking alcohol, but not all Muslims abstain, depending on their degree of religious practice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ The Islamic tradition of Ramazan, or Ramadan in Arabic countries, is a month of fasting (oruç tutmak) observed by practicing Muslims throughout the world. ▪ During Ramazan, one is not allowed to eat or drink anything from sunrise to sunset as a test of willpower and as a reminder of the preciousness of the food provided by a gracious Allah (God). Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Generally, pregnant and postpartum women, travelers, and those who are ill are excused from fasting but may be required to make up lost time at a later date. ▪ The evening meal, iftar, is something to which all look forward with great anticipation, and Turkish women, who almost invariably do all the cooking, create veritable feasts each night. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Motherhood is accorded great respect, and pregnant women are usually made comfortable in any way possible, including satisfying their cravings. ▪ Pregnant women may continue their daily activities or work as long as they are comfortable. ▪ In traditional Turkish culture one of the most important desires of a married woman is to have a child. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ A woman who has not had a child is faced with social pressure and accusations and thus may try to use some traditional practices to increase fertility. ▪ Some women damage their bodies by using these traditional practices and sometimes the damage is permanent. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ The pregnant woman is always encouraged to keep up her strength by eating foods that are rich in nutrients. ▪ Many pregnant women take prenatal vitamins, drink a lot of milk, and apply salves such as Vaseline to avoid stretch marks. ▪ Light exercise, such as walking, is encouraged. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ It is acceptable, though not common, for the husband and the birth mother’s father to be present during the birthing process. ▪ Expressions of discomfort and pain are quite acceptable. ▪ However, Laz women from the Black Sea area tend to be stoic. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ The postpartum period can last up to 40 days. ▪ Light exercise is encouraged during this period and bathing, an important part of the Muslim tradition, is strongly encouraged. ▪ A special food called log˘usalik is served to the postpartum woman to increase milk production. ▪ Breastfeeding women drink hot soups and other fluids such as milk. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ At birth, a small blue bead called a nazar boncuk, believed to protect the child from the “evil eye,” is usually placed on the child’s left shoulder. ▪ Other traditional practices include placing iron under the baby’s mattress to protect against anemia, tying a yellow ribbon to the crib to ward against jaundice, and placing a red bow on the crib to distract any envy or negativity. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Practices used to make childbirth easier include unlocking places that are open, untying the woman's hair ribbons, unbuttoning buttons, standing straight and turning so the child will move, drinking water that has been prayed over by religious leaders, enclosing the woman around her waist and rocking her three times, and putting her in a blanket and rocking her three times. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Water is not given to a newborn infant until the call to prayer has been announced three times; otherwise, the infant will have bad breath. ▪ At the end of the 40 days, she returns to normal life. ▪ She is bathed with abundant water and prayers are read. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The home health nurse found an iron under the mattress of a two month old baby. The iron prevents the baby from a. The evil eye. b. Thalassemia. c. Anemia. d. Jaundice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C Placing an iron under the baby’s mattress prevents anemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ When death occurs, the deceased individual's next of kin cry in the most natural manner. ▪ Neighbors who hear about the death gather at the home of the deceased to share in the suffering of the next of kin, to console them, and to help with the initial preparations. ▪ Having prayers said is a common practice. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Turkish Muslims do not generally practice cremation because the body must remain whole. ▪ Frequently, the body is displayed in the home for a day or two; it is then placed in a coffin and taken to the cami (mosque) to be visited primarily by men. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Preparations for burial include three important procedures: bathing, wrapping in a shroud, and funeral prayers said outside a mosque. ▪ If someone dies in the morning, they are buried after the mid-afternoon prayers; those who die during the night are buried in the morning. ▪ The funeral may be delayed for distant relatives. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Common rituals after death are closing the eyes of the deceased, tying the chin, turning the head towards Mecca, putting the feet next to each other, putting the hands together on the abdomen, and removing clothing. ▪ In some places the bed is changed; a knife, iron or other metal object is placed on the abdomen of the deceased; the Koran is read at the head of the deceased. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ After the burial, a meal honors the deceased, which signifies moving the deceased into the afterlife. ▪ If these rituals are not completed, the spirit of the deceased will be left behind. ▪ The traditional mourning period is 40 days, during which time traditional women may wear black clothes or a black scarf. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Although Muslim Turks believe in the afterlife, death is always an occasion of great mourning. ▪ An expression of sympathy to one who has just lost someone to death is Basiniz sag˘ olsun (may your head be healthy), hoping that one is not overwhelmed with grief. ▪ Mourning is the most important and careful behavior after a death occurs. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Ninety-eight percent of Turks are Muslim, but freedom of religion is mandated by the Turkish secular state. ▪ Most are Sunni Muslims, with a minority from the Alevi Muslim group. ▪ Other religious minority groups include Jews (mostly Sephardic) and Christians. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Traditional prayer is practiced five times each day and can take place anywhere, as long as one is facing the holy city of Mecca. ▪ A special small rug, called seccade, is used for praying. ▪ When entering the cami, shoes are always removed and women must cover their heads. ▪ Men and women go to separate parts of the cami for prayer. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ One prepares for prayer by ritual cleansing called abdest, which, at minimum, includes washing the face, ears, nostrils, neck, hands to the elbow, and feet and legs to the knee, three times each. ▪ A woman does not enter into a religious activity unless she is ritually pure: women who are menstruating or who have recently given birth are excluded. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Turks rely on their religious beliefs and practices and their family and friends for strength and meaning in life. ▪ Spiritual leaders or healers are sought most often for assistance with relationship or emotional problems and, less frequently, for physical problems. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Most Turks rely on Western medicine and highly trained professionals for health and curative care. However, remnants of traditional beliefs continue to have an impact on health-care practices. ▪ A common explanation for the cause of illness is an imbalance of hot and cold. For example, diarrhea is thought to come from too much cold or heat; pneumonia results from extreme cold. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Terminally ill clients are generally not told the severity of their conditions. ▪ Informing a client of a terminal illness may take away the hope, motivation, and energy that should be directed toward healing, or it may cause the client additional anxiety related to the fear of dying and concern about those being left behind. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ In general, women are responsible for the actual care taking of the ill and the elderly in the home. ▪ In traditional households, the mother-in-law or father-in-law, depending on who controls the finances in the family, makes decisions about going to the physician. ▪ The person who is respected as the most educated has primary input into decisions about health care. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Türkiye has one of the highest rates of consumption of over-the-counter antibiotics and painkillers; aspirin is commonly used as a panacea for a variety of ailments, including gastric upset. ▪ Turks commonly consult a pharmacist before visiting a physician. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Using rubbing alcohol or a wet cloth to bring down a fever and warming the back to treat coughing. ▪ Türkiye encourages health tourism at their 1500 thermal spas, which are frequented for treating conditions, such as rheumatism, respiratory and digestive problems, diabetes, skin conditions, gallstones, female diseases, kidney and heart conditions, nerves, obesity, and hyperlipidemia. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ The concept of the “evil eye” is prevalent. ▪ Speaking too well of one’s health may incur misfortune through others’ envy or nazar. ▪ Cologne is sprinkled on the hands of guests before and after eating to provide cleanliness and a fresh lemon scent. ▪ Inhaling from a cloth or handkerchief doused with cologne may be used for relief from motion sickness. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Turkish culture allows freedom to express pain, either through emotional outbursts or through verbal complaints. ▪ Although stigma is attached to mental illness, many families seek treatment or care for the client at home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Seriously ill people are expected to conserve their energy to allow their minds and bodies to fight their illnesses; thus, reducing their energy expenditure. ▪ During hospitalization, refakatçí refers to the person who stays overnight with the client, providing emotional and physical support and comfort. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Turkish people usually prefer to receive blood from family members. ▪ Muslims traditionally prefer that the body remain intact after death; thus, organ donation and transplantation remains controversial among some Turks. However, former Prime Minister and President Turgut Ozal and his wife promoted organ donation by publicly signing donor cards to encourage others to do so too. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Mr. Oktay, age 66 years, is alert and oriented and has terminal heart failure. His wife does notwant him to know. The nurse should a. Abide my the wife’s wishes. b. Directly tell Mr. Oktay. c. Consult his children. d. Ask Mr. Oktay what he knows about his condition. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer D The first step is to determine what Mr. Oktay knows about his condition. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ When modern medicine is not available, accessible, or affordable, or when it has not worked, Turks may seek the care of a traditional healer. ▪ Physicians, and to a lesser extent nurses and midwives, have historically been held in very high esteem. 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 1 Chapter 37 People of Turkish Heritage Marshelle Thobaben And Sema Kuguoglu Overview, Inhabited Localities, and Topography Overview Türkiye (Turkey), as it is written in Turkish, means “land of Turks.” It is located in the Northern Hemisphere, almost equidistant to the North Pole and the equator. The shape of Turkey resembles a rectangle, stretching in the east–west direction for approximately 1565 kilometers (972 miles) and in the north–south direction for nearly 650 kilometers (404 miles). It is bordered by Georgia, Armenia, and Nahcivan (Azerbaijan) to the northeast; the Islamic Republic of Iran to the east; Iraq and Syria to the south; Greece and Bulgaria in the Thrace to the west; and Russia, Ukraine, and Romania to the north and northwest (through the Black Sea). The Anatolian peninsula is the westernmost point of Asia, divided from Europe by the Bosporus and Dardanelles straits. Thrace is in the western part of Turkey on the European continent. Turkey has a diverse geography. It is only slightly larger than Texas with a total area of 783,562 square kilometers (486,882 sq. mi.). Its land area is 769,632 square kilometers (478,227 square miles) and water 13,930 square kilometers (8565 square miles). About 3 percent of Turkey lies in Southeastern Europe (Thrace) and the remainder in Southwestern Asia also called Anatolia or Asia Minor. The sea surrounds Turkey on three sides. The Mediterranean Sea turns into the Aegean Sea along the west coast of Turkey, facing Greece. In the northern part of the Aegean, Çanakkale Bogazi (the Dardanelles) give passage to the Marmara Denizi (Sea of Marmara), which then opens into the Black Sea through the Istanbul Bogazi (the Bosporus) (CIA World Factbook, 2011). A comparable diversity can be seen in the human history of Turkey where over the past ten thousand years various civilizations have risen and fallen due to invasions by newcomers, disease epidemics, and natural disasters such as earthquakes. It continues to be a land of educational, religious, and cultural diversity. The first historical reference to the Turks appears in Chinese records dating back around 200 BC, which refer to tribes called the Hsiung-nu (an early form of the Western term Hun). They lived in an area bounded by the Altai Mountains, Lake Baykal, and the northern edge of the Gobi Desert, and are believed to have been the ancestors of the Turks. In AD 552 many ethnic Turks began to converge under the Gokturks, and later under the Uygurs of Turkistan, followed by the Mongols. In the 10th century, Turkey became fully Muslim and accepted the Arabic script. Under the influence of the Muslim religion, Turkish language and literature were developed, and the building of mosques, schools, and bridges began (CIA World Factbook, 2011). The Seljuk Turks defeated the Christian Byzantine Empire in 1071, resulting in the first of the Christian crusades against Muslims. The Seljuks contributed to medical science and established medical institutions and hospitals in most cities. When the Seljuk Empire collapsed at the end of the 13th century the Ottomans established rule and in 1453 claimed Constantinople as the capital, renaming it Istanbul. The modern Turkish State is a descendent of the Ottoman Empire. Based on a tolerance of differences among its subjects, the Ottoman Empire endured for 600 years and at its height stretched from Poland to Yemen and from Italy to Iran. In 1876 a constitutional monarchy was established under a sovereign sultan, but separatist movements, their subsequent repression, and an emerging Turkish nationalism resulted in the “Young Turk” revolution of 1908 and the erosion of the sultan’s powers. During this time, modest advances in women’s rights began, including the unveiling of nurses in the Balkan Wars and more educational opportunities for women. An armistice at the end of World War I left the Empire stripped of all but present-day Turkey, occupied by Greek, French, British, and Italian armies, and established independence for Armenia and autonomy for Kurds in eastern Anatolia. However, the 1 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 2 2 Aggregate Data for Cultural-Specific Groups Treaty of Lausanne in 1923 officially ended Allied occupation, partitioning Armenia between Russia and Turkey, reinstating the Kurds, and proclaiming an independent Republic of Turkey, with Ankara as its new capital. Although Westernization had begun before independence, Turkey’s president, Mustafa Kemal Atatürk, became synonymous with Westernization and secularism. During his presidency from 1923 to 1938, he initiated many reforms, including banning the fez, outlawing polygamy, instituting marriage as a civil contract, abolishing communal law for ethnic minorities, removing Islam as the state religion, promoting nationalism and pride, instituting educational and cultural reforms, making surnames obligatory, changing the weekly day of rest from Friday to Sunday, and electing 17 female deputies to the National Assembly. Atatürk died on November 10, 1938, but he is still revered as the father of Turkey, and his image can be found in most government and public offices. Turkey remained neutral in World War II, but the postwar economy and Cold War politics prompted U.S. economic and military aid in 1947, forging the political ties that endure today. Despite three bloodless military coups in 1960, 1971, and 1980, Turkey has a multiparty democratic system, a Republican parliamentary democracy. Turkey joined the United Nations (UN) in 1945, became a member of the North Atlantic Treaty Organization (NATO) in 1952, an associate member of the European Community in 1964, and began accession membership talks with the European Union in 2005. Voters approved a referendum in September 2010 that made several constitutional changes including Parliament having increased oversight and diminishing the power of the judiciary and the military; additionally, it provided wider democratic freedoms for Turkey’s citizens (CIA World Factbook, 2011; Information Please, 2011). Turkey remains strategically important to the West and is a strong ally of the United States because of its geopolitical location and its cultural and religious ties. What is presented about the Turkish culture in this chapter is based on studies from Turkey and on observations of and experiences with Turkish immigrants in the United States. remainder in villages (CIA World Factbook, 2011; Turkey’s Statistical Yearbook [TSY], 2010). The capital city of Turkey is Ankara, but the historic capital, Istanbul, remains the financial, economic, and cultural center of the country. Until the 1950s most Turks were peasants living in isolated, self-sufficient villages with their extended family and practical folk-belief system. Depeasantization, migration, and urban settlement have continued, and today squatter housing districts populated by rural “immigrants” in major cities have resulted in permanent low-income neighborhoods juxtaposed against modern urban development. Changes in the social structure and people’s expectations are also shifting. For example, older people’s ability to live in their familiar housing environments, particularly, in large cities and metropolitan areas is forcing the government to change its policy and to strive to provide affordable housing and care centers for them (Turel, 2009). Over the past two decades, Turkey has been hit by several moderate to large earthquakes that resulted in a significant number of casualties and heavily damaged or collapsed buildings. This has been as a result of inadequate seismic performance of multistory reinforced concrete buildings, typically three to seven stories in height. A recent study indicates that a considerable portion of existing building stock may not be safe enough in Turkey (Inel, Ozmen, & Bilgin, 2008). References and further reading may be available for this article. To view references and further reading you must purchase this article. As a result of extensive foreign trade, larger coastal cities are undergoing many changes, which have resulted in an urban environment with a dual character, representing the traditional old way of life and the ensuing new class. Every aspect of life and society is being affected, including changes in values, recreational activities, mass communication and media, and women’s status. Observations suggest that everyday practices of the people, as well as their folk beliefs, are truly changing. However, the Turks still depend on nuclear and extended family and friends for adjustment, job possibilities, and money. Heritage and Residence Reasons for Migration and Associated Economic Factors Turkey is one of the 20 most populated countries in the world and has the second largest population in the Middle East, and in Europe, after Germany. The first national recorded population of the Republic of Turkey was 13.6 million in 1927. The population in 2010 was 73.722.988 with 26 percent of the population age 14 years and younger, and 7 percent age 65 years and older. Roughly, 70 to 75 percent of the population is Turkish, 18 percent Kurdish, and 7 to 12 percent other minorities. Approximately, 75 of the population lives in cities, such as Istanbul, Ankara, Izmir, and the The U.S. Census Bureau (2011) reported 190,000 people of Turkish descent living in the United States. The majority of them lived in the Northeast (39 percent) and the least in the Midwest (13 percent). The Turkish immigrant population in the United States differs significantly from most of the Turkish population that inhabits Europe, in terms of both demographic makeup and socioeconomic status and integration. A high proportion of Turks in the United States come from the elite and upper-middle classes, interspersed 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 3 People of Turkish Heritage with smaller groups of middle-class students and skilled laborers who are supported privately or by the government. Economic reasons, such as unemployment and poor salaries, are the major reasons Turks leave to work in other countries (İcduygu, 2008). Although Turks have emigrated throughout the world, many have lived in Western Europe since the 1960s and in 1970s North Africa and the Middle East, largely as a result of “guest worker” programs. Since the 1990s, Turkish workers have also moved to the neighboring former communists’ countries such as Russian Federation and Ukraine (İcduygu, 2008). A large “Turkic belt” stretches from the Balkans across Turkey, Iran, Central Asia, the former republics of the Soviet Union, and deep into the borders of Mongolia. This belt includes many ethnic Turks who may share cultural, linguistic, religious, and certainly historical links with the people of Turkey. Research studies have indicated that any concern about excessive “brain drain” from the immigration of some of Turkey’s intellectual, academic, and other highly skilled professionals to the United States is unfounded; it has not created a threat to Turkey’s economic, scientific, social, and cultural development. Additionally, Turks living in the United States usually maintain strong bonds with their Turkish families and pass on their Turkish cultural values, traditions. and language to their children born in the United States (Köser-Akçapar, 2006). Turks who have lived or studied in the United States generally have higher status and greater employment opportunities in Turkey. Educational Status and Occupations Education is highly valued in Turkey by all socioeconomic groups. Coeducational primary and secondary education is provided at no cost and is guaranteed under the Constitution. It consists of public and private school at all levels, ranking from preprimary (1 year), primary (8 years), high school (4 years), and universities (4 to 6 years). In 1997, 5 years of compulsory primary school was extended to 8 years including the middle schools. Primary school starts at age of 7 and ends at 13. High schools were extended from 3 to 4 years in 2005. High school includes a number of options, including general, technical, trade, vocational, and theological training. Higher education institutions include universities, faculties, institutes, higher schools, vocational higher schools, conservatories, and research and application centers (TSY, 2009). Students who wish to pursue a university education must take a state examination that determines both their admission to the institution and their subject of study. In a recent study it was reported that only 22 percent of the students who took the nationwide competitive entrance examination were placed in a university program in Turkish universities. Turkey’s university 3 distance education program, one of the largest in the world, annually accepts only about 15 percent of students who apply (Tasçı & Oksuzler, 2010). A high level of education exists among people of Turkish descent living in the United States. Significant numbers hold advanced degrees, and most are employed in professional, managerial, and technical occupations. Turkey’s Statistical Yearbook (2009) reported that of the 48 percent of Turkey’s working age population who participated in the labor force, 70.5 percent were men and 26 percent were women; 45.8 percent worked in urban areas (69.9 percent male and 22.3 percent female) and 52.7 percent in rural areas (72 percent male and 34.6 female). Of those workers employed in the agriculture sector, 46 percent were unpaid family workers; 76.9 percent of the unpaid family workers were female, while 23.1 percent were male. The unemployment rate was estimated to be 14 percent in 2009 (TSY, 2009). Persons not in the labor force composed 52.1 percent of the working-age population. The main subgroups were persons who were busy with household chores (44.9 percent), students, and disabled and retired persons (TSY, 2009). For cultural reasons, many women have continued to maintain their traditional roles and do not work outside the home because it interferes with their household responsibilities, including caring for their children, and it may require them to work with men from outside their immediate family. Communication Dominant Language and Dialects A Uralic-Altaic language, Turkish is spoken by 90 percent of the population. The Turkish language has approximately 20 dialects, including Yakut, Chuvash, Turkoman, Uzbek, Kazakh, and the language of the Gagavuz people. Differences in some of the dialects are so great that they are considered separate languages. Through the centuries, Turks borrowed from Arabic and Persian languages, and bits of “Turkified” French and English can also be found. Until 1928, Turkish was written in Arabic script, but under Atatürk’s direction, a Turkish alphabet was developed based on Latin script. The Turkish alphabet is much like the English alphabet, although it does not have a “w” or an “x,” and additional sounds are symbolized by an “i” without a dot; a “ğ,” an “ö,” and a “ü” with accents; and an “ş” and a “ç” with a cedilla, symbolizing “sh” and “ch,” respectively. The Turkish language does not distinguish gender pronouns such as “he” from “she” or “her” from “his”; therefore, Turks learning English may inadvertently confuse these pronouns. However, Turkish does distinguish a formal from an informal “you,” signifying the importance of status in Turkish society. 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 4 4 Aggregate Data for Cultural-Specific Groups Typical of many Mediterranean cultures, speaking in loud voices is common; this may not signify anger, but rather excitement or deep involvement in a discussion. It can be common for more than one person to speak at the same time or to interrupt another person, which is not necessarily considered rude. However, someone of lower status should not interrupt someone of higher status. Cultural Communication Patterns In the Turkish’s culture group affiliation is valued over individualism. In fact, identity may be determined by family membership, group, school, or work associations. An individual’s behavior is expected to conform to the norms or traditions of the group, and Turks tend to be more people and relationship oriented than Americans. Although Turks may take longer than Americans to form friendships, these relationships last longer, formality is decreased significantly, and interdependence is encouraged as a source of strength. In this group-oriented culture, Turks generally do not desire much privacy and tend to rely on cooperation between family and friends, although competition between groups can be fierce. Turks value harmony over confrontation. However, Turkish communication style is characteristic of Mediterranean cultures in which the outward show of feelings is less restrained. For women, expressions of anger are usually acceptable only within same-sex friendships and kinship networks or toward those of lower social status. Generally, women are not free to vent their anger toward their husbands or other powerful men. Children are very accustomed to being held, hugged, and kissed by family and friends of the family. Touching, holding hands, and patting one another on the back are acceptable behaviors between same-sex friends and opposite sex partners. It is common to see same-sex friends, especially among the older generations, holding hands or linking arms while walking. Likewise, personal space is closer between same-sex friends and opposite-sex partners; physical proximity is valued as a sign of emotional closeness. Very strict Muslims generally do not shake hands or touch members of the opposite sex, especially, if they are not related. Health-care providers are usually looked upon as professionals and touch is allowed and expected when necessary. Eye contact may be used as a way of demonstrating respect. When interacting with someone of higher status, a person is expected to maintain occasional eye contact to show attention; however, prolonged eye contact may be considered rude or interpreted as flirting. Turkish people tend to dress formally; men wear suits rather than sports jackets and slacks on social occasions. Women tend to dress modestly and wear skirts and dresses rather than slacks. Black clothing accented with gold jewelry is quite popular. More traditional Muslim women may wear very modest clothing and cover their heads with a scarf, either black or a colorful print. However, styles continue to change, and denim jeans and casual dress are becoming common among young people for less formal occasions. Turks tend to openly display emotions such as happiness, disgust, approval, disapproval, and sadness through facial expressions and gestures. Two unique gestures in Turkish culture include signals for “no” and signs for approval or appreciation. “No” is indicated by raising the eyebrows or lifting the chin slightly while making a snapping or “tsk” sound with the mouth. Appreciation may be expressed by holding the tips of the fingers and thumb together and kissing them. This signal is commonly used to express appreciation for food. Various phrases are commonly used by Turks. Allahaismarladik (God watch over you) is said to someone leaving and is responded to with gule gule (go with smiles). Ellerine saglik (health to your hands) communicates appreciation for a good meal, and the cook responds with afiyet olsun (good appetite). Cok yasa (live long) is said after someone sneezes with a response of sen de gor (you see a long life, too). Masallah (God protect from the evil eye) is said, for example, when one has a healthy baby or when one has achieved something good, whereas insallah (God willing) is said when something is wished to happen. Turkish people take pride in keeping their homes immaculately clean, and one is expected to remove one’s shoes inside the home. Most hosts in Turkey and many in the United States offer slippers to their guests. Whether wearing shoes or not, showing the sole of one’s foot is considered to be offensive in Turkish culture. Women are expected to sit modestly with knees together and not crossed. Tortumluoğlu, Bedir, and Sevig (2005b) conducted a qualitative study in a village in eastern Turkey by examining individual cultural communication characteristics. Comments from the participants included the following: • According to our religion, men who are not our legal husband are not allowed to listen to our voices. A woman cannot speak out loud and cannot laugh in the community; she would be like bad woman (woman over 65 years old). • We do the duties of the bride (act like a servant) for our husband’s relatives and mother-in-law. We can never speak near them. To speak would be disrespectful (bride, 15 years old). • If the person across from us is a woman, we hug and kiss, but if he is a man outside the family, we don’t touch him. We will not eat at the same table with men outside the family; we won’t be together 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 5 People of Turkish Heritage with them at weddings; we won’t sit next to them on the bus; we wouldn’t go near them without covering our heads and bodies. We don’t look them in the eye (women over 65 years old). • We’re uncomfortable being examined or given a shot by a man because they are strangers. It is very sinful to go to a man even our husband and open what is covered (female, age unknown). • I would not take my wife, daughter, or daughterin-law to a male doctor. I would not show them to unrelated men (man over 65 years old). • Even if I knew my wife would die, I wouldn’t take her to a male obstetrician (boy about 15 years old). Temporal Relationships Turks tend to have a relaxed attitude about time; social visits can begin late and continue well into the night. Whereas punctuality in social engagements is not highly important, in business relationships punctuality among Turkish Americans is gaining in importance. Format for Names Turks value status and hierarchy. Demonstrating respect for those of higher status is mandatory and determines the quality of interactions with a person. A variety of titles are used to show respect and acknowledge status. Strangers are always greeted with their title, such as Bey (Mr.), Hanim (Mrs., Miss, or Ms.), Doktor (Dr.), or Profesör (Professor). Members of the family are also addressed using specific titles that recognize relationships, such as agabey (older brother or older close male friend), amca (uncle or elderly male relative or stranger), abla (older sister or older close female friend), teyze (maternal aunt or older female relative or older female stranger), and yenge (wife of a brother or paternal uncle). When friends or family members greet, it is customary for each to shake hands and to kiss one another on each cheek. Traditionally, when greeting someone of very high status or an elderly person, one might grasp his or her hand and kiss it and then bring it to touch one’s forehead in a gesture of respect. Family Roles and Organization Head of Household and Gender Roles In a very traditional Turkish home the father is considered the absolute ruler. The concept of izin (permission to leave to do something specific) captures this significance. In rural and traditional families, women may require izin from the head of household for doing simple things, such as shopping, traveling, or visiting their nurse midwife, physician, or dentist. The justification is that the one who earns the money may spend the money. The person who bestows izin is responsible for the protection of the izinli (person who requires the izin). Izin exhibits a structure of authority that is 5 both hierarchical and patriarchal; therefore, women typically require izin more often than do men. A young wife (gelin) may require izin from her husband and from her mother-in-law. All are ultimately responsible to the gelin’s father-in-law, who is usually the absolute ruler of the traditional extended family (Tortumluoğlu, Bayat, & Sevig, 2005a; Tortumluoğlu, et al., 2005b). Less-traditional families show more equality between spouses, especially in nuclear families in which the wife is well educated and works outside the home. Yet remnants of traditional family structure prevail and the husband often takes on the role of ultimate decision maker, especially in matters of finance. Women may work full time outside the home in addition to assuming full responsibility for running the daily activities inside the home. Modern Turkish women tend to be more Westernized than some of their Middle Eastern or Muslim counterparts. The first institution for higher learning for women in Turkey was established in 1910. In 1917, women earned the right to divorce and to reject polygamous marriage. Atatürk’s new republic abolished the old legal system based on religion and secularization, giving women equal rights to education and no longer requiring them to wear veils and long overgarments. Legal marriage does not permit polygamy, although some may practice it outside the law. Women have had the right to vote since the early 1930s. In 1966, a charter of the International Labor Organization passed the equivalent of an Equal Rights Amendment, requiring equal wages to both sexes for work of an equal nature. Family Goals and Priorities A woman’s age and the number, age, and gender of her living children can influence her status in the family and the community but varies depending upon such things as education, religious practice, socioeconomic level, urbanization, and professional achievement. Generally, a young gelin (woman aged 15 to 30 years) has the lowest status, middle-aged” woman (30 to 45 years) has intermediate status, a “mature” woman (45 to 65 years) has the highest status, and an “old age” woman (65 years or older) is highly respected but not very powerful. Working outside the home is associated with status positively in the urban context and negatively in the rural context. Professional employment and education raise the status of women. Thus, health-care providers may find significant variations regarding gender roles when working with Turkish American patients. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Children are held very dear in the Turkish family, and they are expected to act as young children, not small 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 6 6 Aggregate Data for Cultural-Specific Groups adults. They are accustomed to receiving attention from family, friends, and visitors. Kissing children and pinching their cheeks is quite common. Once children enter school, they are expected to study hard, show respect, and obey their elders, including older siblings. This concept is referred to as hizmet (duty or service). As children age, they are socialized into more-traditional gender roles. Girls are expected to help care for younger siblings, to help at mealtimes, and to learn to cook. Traditionally, children are not allowed to act out or talk back to their superiors. Light corporal punishment is generally acceptable. Circumcision is a major rite of passage for a male child. This is a time of celebration within the extended family, and newly circumcised boys are honored with gifts. Traditionally, boys can be circumcised up to the age of about 12, although the modern trend is to perform the circumcision in the hospital shortly after birth. Rankina and Aytaç’s (2008) research found that the religiosity of the parents, the vast majority of whom were Muslim, had no effect on the schooling of Turkish children, whether male or female. In contrast, patriarchal family beliefs and practices discouraged the education of children, particularly girls. Their findings also showed a father’s disapproval of daughters going out in public without a headscarf reduced the likelihood of girls finishing or going beyond primary school. Thus, family cultural traits may continue to represent a significant barrier to gender equality in education (Rankina & Aytaç, 2008). As children reach adolescence, they are expected to continue to work hard in school and show respect for superiors. The U.S. and Western culture and lifestyles are exported to Turkey via the various social networks. O’Neil and Güler (2010) explored the meaning high school and university students attached to American popular culture and found no evidence that that American popular culture was in danger of overwhelming Turkish culture. Young adults like to move back and forth between indigenous and foreign products, including American ones, and as a result the researchers felt this continued to embody a multiplicity and hybridity that has characterized Turkish culture for centuries. Young people in the urban areas may talk more about sex and engage more freely in sexual activity than previous generations; however, sexuality largely remains a taboo and is regarded as a forbidden topic for social and cultural reasons. Though not common among rural Turks, urban adolescents are beginning to date in pairs, in addition to the more traditionally accepted practice of group outings. However, sexual interaction is strongly discouraged among youth and the unmarried, especially young women. Virginity in unmarried women is a strong cultural value. According to a study conducted with university students in Turkey, 82.4 percent of female students and 86.5 percent of male students were virgins when they married, because of social rules and religious beliefs. Sixty-two percent of female students practiced sexual abstinence (Tortumluoğlu, Ersay, Pamukçu & Şenyüz, 2006). Parents are expected to provide sexual education within the family but often have insufficient knowledge on the subject. Kukulu, Gursoy, and Gulsen (2009) recommended that structured sex education that incorporated knowledge of specific aspects of the Islamic culture experience would help to promote healthy sexual behavior and decrease sexual myths, such as marrying a virgin increases sexual satisfaction. Successful completion of high school or university education is a first step toward adulthood. Although education earns respect in the family, the concept of hizmet still applies. A further step for men is the completion of required military service (askerlik), the duration of which varies depending on the population and the needs in Turkey. In addition, employment and earning money are symbols of adulthood for both men and women. Marriage is perhaps the most important developmental task for adulthood. Young people generally live in their parents’ home until they are married, unless school or work necessitates other arrangements. This practice may be quite different among assimilated Turks in America. The Turkish word for marriage, evli, translates to “with house.” Family remains an important factor in marriage. Marrying into a “good family,” having a high-status occupation, and achieving wealth are means of attaining higher social status for both the individual and the entire family. Family members’ accomplishments raise the entire family’s status, whereas failures have an equally broad effect. Thus, individuals must always consider what impact their actions will have on the family. Often, they consult parents or other family members before making major decisions. Arranged marriages occurred most often among less-educated, older individuals. Family initiated marriages range from rare contractual agreements between parents to the relatively common introduction and gentle encouragement of a newly formed couple. The more traditional family will “choose” a spouse for a son by considering the individual’s personality, talents, and appearance. For a daughter, it is more important to consider the individual and his family because she marries into the husband’s family. Elders are attributed authority and respect until they become weak or retired, at which time their authoritative roles diminish. However, respect always remains a factor. Although financial independence is valued in Turkish culture, independence from the family is not encouraged. Adult children, especially men, remain an integral 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 7 People of Turkish Heritage 7 part of their parents’ lives and parents expect their children to care for them in their old age which is regarded as normal, not as an added burden. Grandparents play a significant role in raising their grandchildren, especially if they live in the same home. The extended family is very important. Even the apparent increase in nuclear households does not rule out the networks among closely related families. Whether or not they live under the same roof, a young family may still live under the supervision of the husband’s parents or, at least, maintain an interdependent relationship. In many Turkish families, aunts, uncles, cousins, and in-laws form the extended family. Visits with local relatives are assumed and mandatory when traveling. Extended family members have a social relationship and may also play an authoritative role within the network. A cooperative relationship, which includes sharing child care, labor, and food, when necessary, and providing companionship, is essential between women in an extended family or neighborhood. sense of belonging in a less relationship-oriented American work milieu. Hierarchical structure is highly pervasive throughout Turkish culture and the workplace is no exception. Turkish employees expect an authoritative relationship between superior and subordinates. However, indirect criticism is expected and appreciated in order to “save face.” A Turk may be highly offended if openly criticized, especially in front of other people. They may be reticent about asking questions for fear of exposing a lack of knowledge. Yet, Turks may exhibit modesty when applying for a job or a promotion relying more on the recommendations of others than on pointing out their own strengths. Because military service is mandatory for men who wish to maintain their Turkish citizenship (even those living abroad), young Turkish men who reside outside Turkey may need to take an extended leave to complete their military service. Alternative Lifestyles Issues Related to Autonomy Divorce is becoming more common, but it remains socially undesirable, especially for women, for whom remarriage opportunities may be limited to divorced or widowed men. Widows, however, are generally taken care of by their late husband’s families and depending on their age and socioeconomic background may have the option to remarry. Premarital cohabitation and unwed motherhood are strongly discouraged, especially among more-traditional families, although living together before marriage is not uncommon in larger cities and among immigrant Turks. Even though being a gay man or lesbian is not a crime or considered a disease, homosexuality is only beginning to be received “at a distance.” In Oksal’s (2008) study of familial patterns of attitudes toward lesbians and gay men, he found that young adults’ attitudes toward lesbians and gay men were more liberal than those of their parents. However, on the whole, Turkish family members have quite negative attitudes toward homosexuality, most likely linked to religious beliefs. Most Turkish people are in agreement with Islamic values that regard homosexuality as a sin and unacceptable (Oksal, 2008). Because most Turkish immigrants speak English, language barriers in the workplace may be only subtle. However, dealing with differences of opinion between parties of equal hierarchical level may present difficulty. Turks perceive that aggressive face-to-face confrontation may cause relationships to deteriorate; therefore, the dominant means of conflict resolution is collaboration reinforced by compromise and forcing. Compromise and avoidance behaviors are more likely among peers, whereas accommodation behaviors are used with superiors. Their way of handling differences of opinion is brisk and clear-cut when an authority relationship exists between the two parties. Turkey is known for its high-power distance (the psychological and emotional distance between superiors and subordinates), respect for authority, centralized administration, and authoritarian leadership style. In Turkish culture a manager’s authoritative control is often more important than the achievement of organizational goals. Workforce Issues Culture in the Workplace Because Turkey is a group-oriented culture, the Turkish workplace may be more team oriented than in the United States. Turkish relationship orientation may lead to dependence on personal contacts and networks to accomplish tasks, and from the American perspective, developing these relationships and networks may appear as nepotism or as too much socializing. In contrast, the Turkish immigrant employee may not feel a Biocultural Ecology Skin Color and Other Biological Variations The Turkish population is a mosaic in terms of appearance, complexion, and coloration because of historical migration and inhabitance patterns. Appearances range from light-skinned with blue or green eyes to olive or darker skin tones with brown eyes. Mongolian spots, usually found at or near the sacrum, are common among Turkish babies and should not be confused with bruising. Racially, 75.6 percent of the men and 77.7 percent of the women are in the brakisefal (having a short, broad head) category, which is a 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 8 8 Aggregate Data for Cultural-Specific Groups shared symbol of the Dinaric Alpines (Gültekin & Koca, 2003). Diseases and Health Conditions According a recent health survey (TSY, 2008) that was sent to all settlements in the territory of the Republic of Turkey, 71.9 percent of men and 55.5 percent of women stated their general health status was good or very good; 75.2 percent of men and 58.8 percent of women living in urban areas stated their health was good or very good; while only 63.8 percent of men and 48.4 percent of women in rural areas stated their health status was good or very good (TSY, 2008). Life expectancy at birth in 2010 was estimated to be 72.23 years for the total population (70.37 years for males and 74.19 years for females) (CIA World Factbook, 2011). The leading causes of death include major vascular diseases (ischemic heart disease, stroke), chronic obstructive lung disease and lung cancer in men, perinatal problems, lower respiratory infections, and diarrheal diseases. Injuries cause about 6 to 8 percent of deaths, although this may be an underestimate (Akgun et al., 2007). There is also a high prevalence of obesity, hypertension, and diabetes, especially in Turkish women. Malaria is still problematic in the southeast part of the Turkey (CDC, 2011). Lactose intolerance rises among populations farther south and east in Europe. The Black Sea region tends to have a relatively high incidence of helminthiasis (intestinal worm). Endemic goiter associated with iodine deficiency, despite iodine prophylaxis (ID), still exists in 27.8 percent of the Turkish population. It has been eliminated in most of the urban population; however, it is prevalent in rural areas and in particular geographical regions (Erdoğan et al., 2009). Tuberculosis continues to be prevalent in the Aegean areas and in southeastern Anatolia. Behçet’s disease (BD) is a systemic inflammatory disorder of unknown etiology with a strong genetic component. It is characterized by recurrent attacks of oral aphthous ulcers, genital ulcers, skin lesions, uveitis or other manifestations affecting the blood vessels, gastrointestinal tract, and respiratory and central nervous system; the inflammatory lesions at particular sites, such as the eyes, brain, or major vessels can result in permanent tissue damage and cause chronic manifestations or even death (Gul, 2007). It is prevalent in Japan and China in the Far East to the Mediterranean Sea, including countries such as Turkey and Iran, and usually starts in the second and third decade of life. The male-to-female ratio is approximately equal, although BD runs a more severe course in men and in those aged
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