Chapter 14 IRANIAN HERITAGE
HOMEYRA HAFIZI, MARYAM SAYYEDI, and JULIENE G. LIPSON Overview, Inhabited Localities, and
Topography OVERVIEW Iran is a geographically and ethnically diverse, non–Arabicspeaking, Muslim
country. Iran’s 1979 Revolution generated a steady wave of immigration to North America, Europe, and
Australia. Prior to the 1979 Revolution, the main reason for immigration was educational advancement.
The few who immigrated had little impact on the host country’s social make-up and the health-care
system. But in the past 10 to 15 years and with the marked increase in immigration, some Iranian
communities, such as that in Los Angeles, have begun to influence the regional economy. Since the 1979
Revolution, Iran’s socioeconomic and political instability has spurred emigration. Among immigrants, a
deep generation gap, both within the family unit and with the larger population, frequently occurs.
Firstgeneration Iranian-born immigrants often live between the two worlds. Their age and reason for
immigration are mitigating factors. The generation gap has widened as each subgroup adopts the new
culture, tries to fit into the environment, and garners new ways of self-expression. A study of Iranian
immigrants in New South Wales, Australia, noted that women’s roles were changing slowly from the
more traditional roles of home manager and nurturer to those of education and employment (Omeri,
1997). In another study conducted in Los Angeles, Iranian women who left Iran at a young age had more
liberal attitudes toward sex and intimate relationships and more conflicts between their Iranian and
American identities (Hanassab, 1998). Evidence suggests that, in general, women acculturate at a faster
rate than men and begin to undermine the patriarchal and sexist cultural values (Darvishpour, 2002).
Many Iranian immigrants face considerable ethnic bias in the United States, with an intensity directly
linked to the ongoing events in the Middle East. Anger and prejudice toward Iranians began in
November 1979 with the 14-month occupation of the U.S. Embassy in Tehran. The hostility was
manifested in many ways and experienced by Iranians of all ages. Some trilingual immigrants identified
themselves by their ethnicity rather than their place of origin. For example, one would identify himself
or herself as Turkish rather than as an Iranian Turk. The tragic events of 9/11, the ongoing instabilities in
the Middle East, the current Iran’s nuclear ambitions, and the Iraq war have marginalized the Iranian
immigrant. By virtue of its location, predominant religion, and the central government’s reaching out to
neighboring countries, Iran is a figure in international policy making. The U.S. media overemphasize the
influence of Islamic fundamentalism, and the public tends to view Middle Eastern immigrants as a
homogenous population. In actuality, most Iranians are more secular and nationalistic than people from
Sunni Arab nations, who may hold a more common Islamic identity (Sayyedi, 2004). The U.S. Bureau of
the Census estimates the number of Iranians in the United States at 400,000. Unofficially, the estimate is
closer to 1 million. The political climate discourages Iranian immigrants from disclosing their native
origin; hence, they self-identify as “other” or “Caucasian.” The 2002 Census described the California
Iranian American population as largely concentrated in the Los Angeles area, which consequentially has
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F A Davis of Iranians outside of Iran. Totaling 159,016 persons, this population is larger than the
combined number of Iranians in 20 other states. The Los Angeles population is ethnically and religiously
diverse. Although Muslims are still the majority, the Armenian, Jewish, and Baha’i communities have a
strong presence (Bozorgmehr, Sabagh, & Der-Martirosian, 1993). Divided by political, religious, and
social class differences, most live in small social networks. In this chapter, the terms Persian and Iranian
are used interchangeably. For mainly political reasons, some immigrants call themselves Persian. In
1935, the country’s name was changed from Persia to Iran (from the word aryana) to present an image
of progress and to unify the many ethnicities, tribes, and social classes. The original Persians were an
Indo-European group, the Aryans of India. The Persian Empire, founded by Cyrus the Great in 559 BC,
covered an area from the Hindu Kush (now in Afghanistan) to Egypt. Iranians are proud of their heritage,
which includes ancient empires, the Zoroastrian religion, and some of the world’s greatest poets and
leaders in philosophy, astronomy, and medicine. Even though the focus of this chapter is on cultural
commonalities, health-care providers must recognize that Iranians are a highly diverse popluation. We
encourage readers to carefully assess each client’s and each family’s beliefs and circumstances.
Overemphasis on culture, religion, and ethnicity as the defining factors in the expression of health and
illness, treatment-seeking behaviors, and health-maintenance practices can lead to stereotyping
(Hollifield, 2002). Iran covers an area of about 636,000 square miles and is bordered by the Caspian Sea
on the north and the Persian Gulf on the south. Neighboring countries are Turkmenistan, Azerbaijan,
Armenia, Turkey, Iraq, Afghanistan, and Pakistan. Iran is home to many agricultural communities,
nomadic tribes with livestock, and several highly industrial regions. Fertile agricultural lands are found in
the southwest and on the Caspian Sea shore. The dry lakes of the interior regions are less conducive to
farming. Both northern and southern shores are extremely humid. A large area of the country is
mountainous. The climate varies with altitude, including hot, dry summers and extremely cold, snowy
winters. Iran has a population of over 70 million, three-quarters of whom are under the age of 30 and
live in urban areas. The annual population growth rate is 1.4 percent. Almost one-fifth of the inhabitants
live in an impoverished state with no basic public-health infrastructure, including drinking water,
electricity, and sewage. The overwhelming majority of the people practice Shiite Islam. Christianity,
Judaism, and Zoroastrian, an ancient Persian faith, are recognized in Iran, and adherents enjoy a degree
of pseudo-freedom. However, the Baha’i community has experienced discrimination since the religion
was established in the 19th century. HERITAGE AND RESIDENCE In Iran, ethnic groups with differing
dialects and strong heritage coexist in a somewhat conflict-free environment, and the many groups
embrace and identify with the core of the Iranian culture and the Persian civilization. For example,
regardless of ethnicity or religion, the country unifies around Eid Norouz as a symbol of national identity
and as a significant cultural event. The practice of visiting during Eid Norouz is an important expression
of care, both within the family structure and as a community activity (Omeri, 1997). As commonly
practiced in Iran, immigrant families continue to gather for important occasions such as weddings,
births, and funerals. Iran is divided into regions, each inhabited by people of differing ethnicities and
traditions. For example, Iranian Turks live in the northwest, Kurds live along the western borders, and
Arabic-speaking Iranians live in the south and southwest. Ethnic interdependence is being cautiously
tested by the central government in Iran. The many years of occupation by the Greeks, Arabs, Mongols,
and Turks have made Iranians cautiously resilient; the Iranians developed an uncanny ability to
assimiliate without a complete loss of the collective self or their national identity. Most Persians
remained Zoroastrian until the Sunni Arabs conquered the land in the 7th century. Consequently,
Iranians, except for the Shiite sect, converted to Islam. Iran is the only Muslim country in the Middle East
that uses the solar calendar and celebrates Eid Norouz at the spring equinox in celebration of the New
Year without any religious undertones. Centuries of occupation and the void of a central government
committed to the country’s welfare placed Iran at economic and industrial disadvantage. The reality
became painfully noticeable to the people of Iran in the early 1900s when trading expanded to Europe
and the West. The awareness marked the very slow beginning of emigration. In the mid-1900s, several
political parties—Nationalist, Communist, and Religious in ideology—literally pushed Iran toward
becoming a more independent nation. To this day, even though it was short-lived, the nationalistic
movement of Dr. Mosadeq resonates fondly in people’s minds. The Pahlavi Dynasty (father and son)
followed this movement, but it was mired in corruption and unethical alliances with foreign
governments. Moreover, Mohammed Reza Shah reinstituted the secret police and did not tolerate
political opposition. The 1979 Revolution and the establishment of the Islamic Republic of Iran were
direct consequences of Pahlavi’s management of the country. However, some powerful social and
economic reforms were instituted during Pahlavi’s reign, such as national public health, literacy
programs, and a creation of a more secular society with decreased power for the religious clergy.
Women’s rights advanced until they were fully enfranchised in 1963. The 1979 Revolution drove the
social and secular gains underground. Today, Iranian society is facing one of its greatest challenges; this
time the occupying force has originated from within and its people are trapped by friendly fire. To this
day, a central tenet of Iranian social life and personal development is the boundary between
inside/private (baten) and outside/public (zaher). Stimulated by the long history of occupation, the most
private and true self is always kept for intimate spaces and trusted relations. “Inside” and “outside”
define both individuals and families, in which honor and social shame play powerful roles. PEOPLE OF
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F A Davis REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS Three waves of
immigration contribute to the diversity of Iranians in the United States and elsewhere. In addition, each
wave of immigrants appears to respond differently to the stress of migration. The first two waves of
immigrants, 1950s to 1970 and 1970 to 1979, are demographically more cohesive. The second wave was
more varied in social class and included a higher proportion of minority Iranians, such as Baha’is and
Jews. The second wave included mostly young urban technocrats, scientists, professionals seeking
advanced education, and adolescents of upper-middle class or privileged families who came to study at
U.S. universities. Fluent in English, familiar with Western culture, and financially supported by
government grants, scholarships, or family wealth, these individuals were better able to adjust to life in
the United States. For this population of immigrants, a primary source of stress was distance from family
and friends (Jalali, 1996). The third wave immigrated from the early 1980s to the mid-1990s to escape
the Iran-Iraq war and/or the Islamic government’s political persecution. They were forced rather than
voluntary migrants; some sought refugee status and continue to consider themselves in exile. This wave
includes older individuals, fewer professionals, a higher percentage of high-ranking members of the
preRevolution Iranian armed forces, owners of mid-size businesses, industry managers, and clerks.
Challenges particular to this older population of Iranian immigrants have been learning the language,
adapting to the new culture and lifestyle, and redefining the relationship between parents and children
(Emami, Benner, & Ekman, 2001). Older immigrants often express their ambivalence about being in the
United States and may strongly believe they immigrated for the sake of their children and to provide
emotional and financial support, similar to that of older immigrants in Sweden (Emami, Torres, Lipson, &
Ekman, 2000). Older people often feel isolated, and their desire to return home keeps them from
making permanent commitments. They are concerned about how their children will fare as they adopt
less appealing aspects of the new culture. Older people view lack of respect for older people, loose
family ties, and insufficient social support as examples of an unfavorable Western culture (Omeri, 1997).
At times, to avoid isolation and to emulate the past, some immigrants “befriend” other Iranians despite
having little in common but their national heritage and language; hence, creating a community weak in
infrastructure and ties. In summary, lack of fluency in the English language, education, and familiarity
with Western culture are characteristics that differentiate the last wave of immigrants from those who
immigrated prior to the 1980s (Bozorgmehr, 1997). The third wave has experienced multiple losses and
witnessed role reversals between parents and children. These families left Iran under duress and lost
their financial assets and status. Many experienced a profound degree of hardship, such as fleeing Iran
by relying on smugglers and other high-risk means only to seek refugee status (Koser, 1997).
EDUCATIONAL STATUS AND OCCUPATIONS Iranians greatly value education and expect their children to
do well. Individuals who immigrated before the 1979 Revolution have most often obtained college
degrees and are professionally successful and active. Iranian immigrants strive to maintain a social
façade of affluence and upper-class status because family judgment and social shame weigh heavy on
their decision-making. These issues have rarely been mentioned in studies addressing the health and
mental health needs of immigrants in the United States (Sayyedi, 2004). Many middle-aged immigrants
who held white-collar positions in Iran were unable to find comparable work in the United States. As a
result, they are self-employed in businesses such as pizza parlors or gas stations, using their business
acumen to maintain a middle-class or better lifestyle. In Los Angeles, 61 percent of Iranian heads of
household claimed to be self-employed in 1987 and 1988 (Dallalfar, 1994); 82 percent of Iranian Jews
were selfemployed. Only 10 percent reported employment in blue-collar jobs (Bozorgmehr et al., 1993).
Health-care providers should not assume education and social class from occupation alone.
Communication DOMINANT LANGUAGE AND DIALECTS Farsi (Persian) is the national language of Iran,
and all school children are taught in Farsi. An indication of modern Iran’s Indo-European heritage is
found in words similar to English words. As mentioned previously, nearly half the country’s population
speaks different languages and dialects, such as Turkish, Kurdish, Armenian, or Baluchi. Well-educated
and well-traveled immigrants and those who might have stayed in an intermediate country prior to
entering another country may speak three or more languages. CULTURAL COMMUNICATION PATTERNS
The health-care provider should attempt to distinguish cultural patterns from individual personality
characteristics. Communication among Iranians must be understood within the context of their history,
the personality styles valued in the culture, and the structure of social relationships. Iranians are very
cautious in their interactions with outsiders. Not verbalizing one’s thoughts is viewed as a customary
and useful defensive behavior. This form of communication, also known as ta’arof, can effectively hinder
open exchange of feelings with the health provider. Time to complete assessment, history-taking, and
therapeutic approaches must be planned accordingly. Clearly implemented in the practice of ta’arof is
the road map to communication whereby being other-centered, not selfcentered, is expressed with
distinct and respectful forms of speech and behavior. Whereas the constant offers of hospitality and
compliments may sound insincere to non-Iranians, the dynamic is hard at work to set the boundaries of
the relationship (Sayyedi, 2004). 250 • CHAPTER 14 FABK017-C14[248-259].qxd 12/12/2007 10:42am
Page 250 Aptara Inc. © 2008 F A Davis Bagheri (1992) described such highly valued personality
characteristics in Iranians as indirectness, subdued assertiveness, modesty, and politeness. Iranians are
very concerned with respectability, a good appearance of the home, and a good reputation. Social
behavior is also influenced by a constant awareness of others’ judgment. Spontaneity is limited by rules
that clearly define how and when to approach people of different ages and members of the opposite
gender. Communication also occurs on a continuum anchored by baten (inner self) and zaher (public
persona). Baten is personal feelings, and zaher is a collection of proper and controlled behaviors. What
lies in between is a buffer zone. The Persian language and its nonverbal accompaniments have evolved
to help the expression of this complexity. Ta’arof is an example of a tool in verbal communication.
Health-care providers should be aware of the manner in which Iranians handle potentially disturbing
information. Discussing serious diagnoses must be handled with respect to the family dynamics. Care is
expressed in supportive gestures and by maintaining family relationships in times of health and need.
Frequent visiting and keeping in contact by any available means are care practices (Omeri, 1997). More
traditional married couples do not display outward affections to each other in public. Greeting is often
accompanied by a kiss on each cheek and/or a handshake. Strangers and health-care providers may be
greeted with both arms held at the sides. A slight bow or nod while shaking hands shows respect.
Iranians generally stand when someone enters or leaves the room for the first time. It is appropriate to
offer something with both hands. Crossing one’s legs when sitting is acceptable, but slouching in a chair
or stretching one’s legs toward another is considered offensive; showing the sole of one’s foot is rude.
Nonverbal beckoning is done by waving the fingers with the palm down. Tilting the head up quickly
means no. Tilting the head to the side means what?, and tilting it down means yes. Extending the thumb
(like thumbs-up) is considered a vulgar sign. As in other Mediterranean cultures, personal distance is
generally closer than that of Americans or Northern Europeans. The strength of the relationship affects
how freely participants touch each other. Iranians maintain intense eye contact between intimates and
equals of the same gender. This behavior may be observed less in traditional Iranians. Conversations are
expressive, as body language is used and the tone is loud. TEMPORAL RELATIONSHIPS Time orientation
is a combination of emphasis on the present and on the future. In other words, time is continuous; what
is anticipated in the future shapes the current lived experience. The ideal is to maintain a balance
between enjoying life to the fullest and ensuring a comfortable future. Iranians’ understanding of time
as a contextual and directional phenomenon enhances the effectiveness of health promotion and
education. At the same time, a fatalistic theme among many Iranians’ may hinder their understanding of
health risk assessment and risk reduction. Continuity and balance in life is the definition of health and
well-being. Obtaining the diagnosis of a chronic or terminal illness is tolerated as an expected outcome
of aging. Any disappointments in and derailments from the culturally accepted process of caring are
reasons for ill health (Emami et al., 2001). Iranians are feeling oriented. Interestingly, in business, they
portray a strong work ethic; they are time-conscious and intensely competitive. Although social time is
extremely flexible, Iranians respond to time requirements at work. FORMAT FOR NAMES Iranians refrain
from calling older people and those in higher status by their first names. A man may wait before
extending his hand to a woman as a measure of respect for her comfort with the practice. One is
expected to greet every member of the family. To begin an interaction, the younger person initiates the
greeting process. Family Roles and Organization Consistent with traditional collectivistic cultures, Iranian
families value harmony within an established patriarchal hierarchy. Also valued are avoidance of open
conflict, unconditional respect for parents, and indirect and figurative communication to maintain social
hierarchy and group harmony. As a norm, they tend to be fatalistic and have an external locus of control
and destiny (Daneshpour, 1998). HEAD OF HOUSEHOLD AND GENDER ROLES In this patriarchal and
hierarchical culture, the father has authority and expects obedience and respect. In the father’s
absence, the oldest son has authority. Traditionally, families were large in Iran, with male children being
highly desirable. Today’s families have fewer children, and the authority figure may be a working female
adult. As a father ages, he may give control of the business and all property to the oldest son. In more
traditional families, older male siblings have the authority to make decisions about their younger
siblings, even in the father’s presence. However, more acculturated families are more flexible. Most
sibling relationships are deep, trusting, and lively. Health-care providers should understand the decisionmaking dynamics of the family. The process is highly collaborative in enlisting trusted friends and
relatives who are subject-matter experts. Young people are free to select their life (marriage) partners,
but families prefer to have the voice to approve. Husbands are often a few years older than their wives.
Male immigrants experience emotional stress when they lack social status, which is tied to finances and
occupation. PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS
Most immigrant Iranian families are child-oriented, sometimes to a fault, as they become
overprotective. PEOPLE OF IRANIAN HERITAGE • 251 FABK017-C14[248-259].qxd 12/12/2007 10:42am
Page 251 Aptara Inc. © 2008 F A Davis Manners are considered important even outside the home.
Children and teens are usually included in adult gatherings. Young children are rarely left with
babysitters as families rely on friends and family suppport. Taboo behaviors for teens in Iran and in the
United States differ only in degree and intensity. In Iran, parents are concerned about smoking, drugs,
alcohol, and sex. Young women are expected to remain virgins until they marry, but sexual activity by
men outside marriage is tolerated. Dating is not allowed in the most traditional Iranian families but is
tolerated in more acculturated families. Whereas many Iranian adolescents in the United States
resemble their American counterparts in dress and outward behavior, they often behave more
respectfully toward family members, particularly older people and other highly respected individuals.
The fear of shaming the family and losing face in public acts as a strong social constraint. FAMILY GOALS
AND PRIORITIES The family is the most important institution in the Iranian culture. Members often live
in close proximity to minimize isolation and to maintain strong intergenerational ties. The intensity of
such strong relationships can be a double-edged sword; it brings comfort as it generates conflict. The
key is to find a healthy balance. A strong family unit ensures the continuation of the family name and
lineage. If parents are able, they support their children financially by providing assistance with
educational expenses, home buying, or starting a business. The children’s academic or career
achievement is considered the family’s. Parenting values and behaviors vary dramatically across
immigrant Iranian families. Parents are conscientious in meeting their children’s needs for comfort,
safety, and success, but similar to parents from other collectivistic and traditional cultures, they expect
their children’s absolute devotion to the ancestral lineage. Since the mid-1990s, immigrant parents have
become interested in improving their parenting skills by challenging some of the more traditional views.
They attend parenting classes taught by Iranian American psychologists, social workers, and marriage
and family therapists and are learning to rely on such behavioral modification techniques as rewards or
time-outs for discipline (Sayyedi, 2004). Some Iranians have clothing that is worn only inside the home.
Often, they remove their shoes at the door and wear slippers inside. Outside the home, they tend to
dress conservatively. Religious women living outside Iran may avoid bright colors, cover their arms and
legs, and conceal their heads with head covers or scarves (hejab). In Iran, wearing the hejab is
mandatory. Age is a sign of experience, worldliness, and knowledge. Regardless of kinship or
relationship, an older person is treated with respect. Older people are cared for at home. Skilled nursing
facilities are viewed negatively. Despite their esteemed role within the Iranian family, older immigrants
with minimal language skills feel isolated when their adult children work and the grandchildren are in
school. Loneliness and isolation among older people are particularly common in neighborhoods where
transportation is unavailable or walking is unsafe. In some enclaves of Southern California and Sweden,
Iranians have established adult day-care centers in response to this issue (Emami et al., 2000). Iran does
not have a formal caste system; however, social status is both inherited and gained. Some are born into
the upper class, but one can also ascend the class hierarchy through higher education and attainment of
professional status. Parents often try to arrange marriages with families of higher status. ALTERNATIVE
LIFESTYLES The religion of Islam has a conservative point of view about the male-female relationship, as
is true of the Iranian society. Most Iranians strongly disapprove of the practice of living together before
marriage. Although divorce is viewed negatively, the rate has been increasing among Iranians abroad,
partly as a result of the many stressors of immigration and an increase in intercultural marriages.
Rezaian (1989) found that intraculturally married Iranians reported more marital satisfaction than
Iranians married to Americans or other intraculturally married Americans. One reason may be that
cultural mores advocate for ignoring minor marital discord to maintain family stability. Collectivist
cultures place greater emphasis on one’s role in a kinship structure. In Iran, out-of-wedlock teen
pregnancy is neither talked about nor prevalent, and it can have a devastating outcome. Although
homosexuality undoubtedly occurs in Iranians as frequently as in any other group, it is highly
stigmatized. Iranian gays and lesbians do not easily disclose their sexual orientation because they are
going against both a religious and a cultural norm. Since 1979, when the judicial system became one
with the religious doctrine, homosexuality, which is considered unnatural and sacrilegious, is a crime
punishable by death (Clark, 1995). Members of an Iranian gay support group in the San Francisco Bay
area use anonymity and pseudonyms to protect themselves from potential physical harm by
fundamentalist groups. In contrast to the older generation, younger Iranians are increasingly tolerant of
alternative lifestyles. Workforce Issues CULTURE IN THE WORKPLACE Iranian immigrants face several
difficulties, among them are acquiring legal residency and suitable employment opportunities. For
example, a physician who works as a plebotomist experiences continual bitterness that manifests itself
either outwardly as anger and discord or internally with serious outcomes to personal health and
familial relations. Iranians may perceive and actually experience a degree of bias at work. Prejudice is
less evident in highly multicultural and metropolitan areas. There is a general lack of understanding that
the countries of the Middle East and 252 • CHAPTER 14 FABK017-C14[248-259].qxd 12/12/2007
10:42am Page 252 Aptara Inc. © 2008 F A Davis their people are very different in ethnic identity and
culture. For the most part, Iranians are secular and nationalistic and do not adhere to an Islamic identity
common to the Arab nations (Biparva, 1994). More acculturated immigrant professionals respond
flexibly in the workplace. For example, when one of the authors (Hafizi) perceives that a client is
uncomfortable with her background or overtly expresses dislike, she uses ta’arof. Using formal speech,
she addresses clinical tasks with minimal personal touch and interaction. Efficiency and efficacy
supersede personal communication and human connection. ISSUES RELATED TO AUTONOMY Most
newcomers may not be familiar with American vernacular or slang. An ongoing stressor is the
condescending attitudes directed at individuals with a strong accent. For example, a nurse with a
master’s degree described her first year in the United States as follows: I was seen as an ignorant nurse’s
aide who couldn’t even speak English. One nurse used to follow me around, checking everything I did. I
resented being treated that way, and my own self-esteem suffered (Lipson, 1992, p. 16). Biocultural
Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS Iranians are white Indo-Europeans. Their skin
tones and facial features resemble those of other Mediterranean and Southern European groups. Their
coloring ranges from blue or green eyes, light brown hair, and fair skin to nearly black eyes, black hair,
and brown skin. DISEASES AND HEALTH CONDITIONS In Iran, the estimated 2006 birth rate was 17 per
1000 people, and the infant mortality rate was 40.3 deaths per 1000 (CIA, 2007). Heat and humidity in
some provinces provide fertile ground for the spread of cholera, including new and mutant strains.
Malaria is widespread in Baluchistan (in the southeast), with serologic test results sometimes showing
more than one strain in a single client. In rural areas that lack standardized sanitary systems, viral and
bacterial meningitis, hookworm, and gastrointestinal dysenteries caused by parasites are prevalent.
Hypertension is widespread, and in Tehran, 22 percent of adults are affected (Azizi, Ghanbarian, Madjid,
& Rahmani, 2002). Ischemic heart disease is on the rise secondary to the stress of living under economic
and social constraints. Health-care providers should screen newer immigrants for diseases and illnesses
common in their home country. The most common health problems in Iran are linked to
underdevelopment, the recent economic downturn, mental stress, and lack of coordination of scarce
resources. Examples of common health conditions are malnutrition (caused by protein and vitamin
deficiencies), hepatitis A and B (caused by poor sanitary conditions, such as poor aseptic technique, or
public-health measures), rising rates of tuberculosis and syphilis, genetic problems (owing to interfamily
marriages), and genetic blood dyscrasias. Interfamily marriage used to be common; however, increasing
urbanization and scientific data have resulted in a decline. The head of Iran’s Institute of Mental Health
estimates that 1.2 million people in Iran suffer from acute psychological illnesses. Forty to 60 percent of
all Iranians suffer from an episode of mental illness that requires specialized medical intervention. The
prevalence of diabetes is 1.5 percent, but about 50 percent of those diagnosed were unaware of having
this disease despite clear symptoms. Thalassemias, prevalent in the northern and eastern provinces, are
now being addressed through premarital screening for carriers and through genetic counseling.
Individuals are also tested for vitamin B12 or folic acid deficiencies linked to an enzyme deficiency.
Mediterranean glucose-6-phosphate dehydrogenase (G-6-PD) deficiency is also common among people
of Iranian heritage and can precipitate a hemolytic crisis when fava beans are eaten; it can also affect
drug metabolism, such as increasing sensitivity to primaquine. In the United States, many Iranians
experience stressrelated health problems from culture conflict and loss, homesickness, and the previous
conditions of war. Although Northern California Iranians in Lipson’s study (1992) were generally healthy,
many expressed their ongoing stress somatically, through intermittent physical discomfort. Several
articulated a direct connection between their worries and their illness; for example, three of the first
seven people interviewed had suffered from ulcers and attributed their “stomach problems” to their
“worries” and “troubles.” Others complained of headaches, backaches, a racing heart, or other
manifestations of anxiety or depression. Iranians often focus their acute generalized stress on the
alimentary system, attributing illness or its severity to something eaten (Emami et al., 2001). High-Risk
Behaviors Iranians’ high-risk health behaviors are similar to those in the general population. Among both
men and women, smoking is more prevalent in Iran than in the immigrant population residing in the
United States. In general, health education, through the media and the influence of their children,
encourages many to quit smoking. A degree of alcohol and recreational drug use occurs in the Iranian
immigrant population, but the rate is no higher than that of the population at large. Alcohol is
prohibited by the Qur’an, Holy Book of the Islamic faith. However, Iranians who are not devoutly
religious drink socially, a few to excess. In Iran, the most popular street drug among the older generation
is opium, traditionally used for medicinal purposes. However, years of opium use has created both a
psychological and a physical addiction. The prevalent drugs in Iran are heroin PEOPLE OF IRANIAN
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Davis and opium, mostly used by younger, unemployed adults. Family responses to drug use range from
complete support of the family member to disownment. However, more families support their child to
reduce the social burden and to save face. Moderate alcohol use is openly accepted among immigrant
Iranians. Substance abuse in this population is related to low levels of acculturation, a perception or
experience of prejudice, and a sense of helplessness and loneliness. Sometimes Iranian men
demonstrate their “masculinity” by claiming to “hold” their liquor well. The need to assert masculinity
combined with a poor selfesteem increases the risk of alcohol addiction and spousal abuse. HEALTHCARE PRACTICES Because of city planning and self-contained neighborhoods, walking is a great form of
mobility in Iran. Soccer remains a passion, regardless of age and gender. Men continue to play soccer
and encourage their children’s participation to promote family activity. Iranian women participate in a
wide range of physical activities such as walking, swimming, or aerobics depending on finances and time
availability. Mandatory seat belt use on intercity highways in Iran was instituted in the 1990s;
compliance is periodically monitored and enforced. Radio and TV stations are state owned and,
therefore, at the state’s disposal for any form of campaign. In the United States, most Iranians comply
with safety laws such as wearing seat belts and using child seats and restraints. Nutrition MEANING OF
FOOD Food is a symbol of hospitality and kinship. Iranians prepare their best dishes and insist on the
consumption of several servings. More food than necessary is prepared and presented to preserve
public face and to show respect. Tea is the hot beverage of choice and is offered with cubed sugar,
dates, pastries, fruits, and nuts. COMMON FOODS AND FOOD RITUALS Iranian food is flavorful, with a
lengthy preparation time. Working immigrants have created shortcuts and healthier versions of
traditional recipes. Presentation is important. At any given table, a pleasing mixture of foods of different
colors and ingredients, composed of a balance of garm (hot) and sard (cold) (see Dietary Practices for
Health Promotion), are usually served. Tea, fruit, and pastries are served both before and after each
meal. Iranians prefer fresh ingredients, although cost and availablity are determining factors. Canned,
frozen, and fast foods are perceived to be less nutritious and contain preservatives harmful to health
and well-being. Eating fast food is less common, especially among older immigrants, mainly owing to
poor nutritional value, associated cost, and taste preference. The most common carbohydrates are rice
and sheet breads (wheat and white). The art of preparing rice is the measuring stick of a good cook.
Long-grained white rice is preferred. The bread of choice is flat like lavash or pita. Corn and potatoes are
used but are less favored. Beans and legumes (e.g., pinto, mung, kidney, lima, and green beans; and split
and black-eyed peas) make up a high proportion of the dietary intake and are commonly used in rice
mixtures. Dairy products are dietary staples, particularly eggs, milk, yogurt, and feta cheese. Dairy byproducts, such as doog, yogurt soda, and kashk, milk by-product, are other favorites. Meat and protein
choices are beef, lamb, poultry, and fish. Shellfish is also consumed, but it is a regional favorite of Iran’s
southern region. Fresh fruit is always found in Iranian homes. Green, leafy vegetables are used in
cooking, and herbs such as parsley, cilantro (coriander), dill, fenugreek, tarragon, mint, savory, and
green onions are served fresh at a meal or included in stews served over rice. Similar to Judaism, Islam
has a strict set of dietary prescriptions, halal, and proscriptions, haram. Slaughter of poultry, beef, and
lamb must be done in a ritual manner to make the meat halal. Strict Muslims avoid pork and alcoholic
beverages; a few avoid shellfish. Historically, pork was prohibited for hygienic reasons. Compliance with
proscriptive food and beverage items is seen less frequently among the younger generations. Healthcare providers can make simple adjustments to accommodate traditional food practices of Iranians by
making provisions for home-cooked meals or identifying more appealing foods on the hospital menu.
One of the authors (Hafizi) noted by experience that hospitalized Iranian older people would identify
and select one or two food items for the duration of their stay and greatly appreciated any form of spice
to add flavor to their hospital meal. A simple slice of lemon or a cup of hot tea are pleasing items.
DIETARY PRACTICES FOR HEALTH PROMOTION Based on humoral theory, Iranians classify foods into one
of two categories, garm (hot) and sard (cold). The categories sometimes correspond to high-caloric and
low-caloric foods. The key to humoral theory is balance and moderation. The belief is that too much of
any one category can cause symptoms of being “overheated” or “chilled.” Therefore, symptoms are
treated by eating foods from the opposite group. Becoming overheated is manifested by sweating,
itching, and rashes as a result of eating too many walnuts, onions, garlic, spices, honey, or candy.
Conversely, the stomach may become chilled, causing dizziness, weakness, and vomiting after eating too
many grapes, rhubarb, plums, cucumbers, or too much yogurt. Susceptibility is believed to be
genderdependent. Women are more susceptible to sardie, caused by eating too much cold food, than to
garmie, a digestive problem from eating too much hot food. Health-care providers may need to
incorporate Iranian foods and dietary practices into health teachings in order to improve compliance
with special dietary restrictions. 254 • CHAPTER 14 FABK017-C14[248-259].qxd 12/12/2007 10:42am
Page 254 Aptara Inc. © 2008 F A Davis VIGNETTE 14.1 The diabetic nurse educator is teaching Mrs.
Bahrami, a newly diagnosed insulin-dependent Iranian immigrant aged 65 years who immigrated from
Iran in 1986. She has three adult children who live independently of their parents; two are attending
college in another state and the oldest is working as a pharmacist. Mr. Bahrami, aged 72 years, is a
retired educator who is experiencing a new onset of mild dementia. The family lives in a neighborhood
with minimal access to Iranian markets. The family owns an automobile and Mrs. Bahrami is able to
drive; however, her husband has lost his driver’s license owing to his health condition. 1. What specific
cultural communication strategies should the nurse use in teaching Mrs. Bahrami about her diabetes? 2.
How would you go about assisting Mrs. Bahrami with balancing her diabetic diet with garm and sard
food properties? 3. What problems do you foresee with transportation for food purchasing and
appointments with her physician? 4. If Mrs. Bahrami cannot afford or find fresh foods that she prefers,
what might the nurse suggest? NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS Economic
problems and unemployment in Iran have made certain foods unavailable, resulting in an increased
incidence of protein and vitamin deficiencies. Although influenced by food marketing campaigns and
younger people who have traveled abroad, the older generation’s basic food beliefs remain mostly
unchanged. Almost all ingredients used in Iranian cooking are available in Middle Eastern markets or via
the Internet. The same is true for medicinal herbs. Health food stores stock some of the items but at a
higher price. Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD
PREGNANCY Iran adopted a national family planning program in 1967 at a time when traditional values
and low literacy prevented people from clearly understanding the impact of rapid population growth.
High fertility was valued for religious and economic reasons and as insurance against potential loss of
children and poverty in old age. In 1989, the plan was revitalized by the Islamic Republic; however, this
time the populace was markedly educated and urbanized, and the plan was fully supported by the
religious and political leaders. As a result of this plan’s evolution over the years and a combination of
modern and traditional contraceptive use, the fertility rate is on the decline (Mehryar, Roudi,
Aghajanian, & Tajdini, 1997). Vasectomies are slowly beginning to gain acceptance. Traditional Iranian
beliefs and practices are influenced by Galenic or humoral medicine, particularly with regard to hot and
cold temperament and the conditions of pregnancy and birth. Menstrual blood is believed to be
unclean; therefore, menstruating women refrain from participating in religious activities and
intercourse. Menstruation is also considered a time of great fragility for woman. Historically, infertility
was blamed on the woman. Baluch, Al-Shawaf, and Craft (1992) found that reasons for seeking infertility
treatment differed for men and women: Men wanted children to ensure future support, and women
wanted to fulfill social expectations of having babies, especially early in the marriage. PRESCRIPTIVE,
RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY Food cravings during pregnancy are
believed to result from the needs of the fetus; thus, cravings must be satisfied. Women generally avoid
fried foods and foods that cause gas; fruits and vegetables are recommended, with special attention
given to the balance of hot and cold. Heavy work is believed to cause miscarriage. Sexual intercourse is
allowed until the last months. The pregnant woman receives considerable support from female kin both
during the pregnancy and postpartum. During the birthing process in the more traditional families, the
father is usually not present. The choice for delivery is mainly based on the medical status of the mother
and child. The postpartum period can be as long as 30 to 40 days. Some families believe in keeping an
infant home for the first 10 to 15 days, after which time, the infant is strong enough to handle
environmental pathogens. The more-acculturated families utilize mother and child education classes to
prepare for delivery, but their choices greatly depend on the assistance of close family and friends.
Death Rituals DEATH RITUALS AND EXPECTATIONS Family members and friends gather to support the
dying person and one another. Among devote Muslims, the deathbed, or at least, the patient’s face, is
turned to face Mecca. In the 1980s and early 1990s, Muslim burial services were few and scattered. In
some instances, family members assisted in preparing the body for burial. This is less common because
more facilities have been established to handle the many rituals of preparing a body for burial. For
example, when using soap and water, washing proceeds from the head to the toes and from front to
back. The body is then wrapped in a special white cotton shroud while prayers are read. Death and dying
is an anticipated and expected process in the cycle of life among Iranianas (Emami et al., 2001). In a
fatalistic culture and Islam, the locus of control is outside one’s power and ability, commonly referred to
as the will of God. Withdrawal of life support may be considered as “playing God.” However, there may
be no objection to beginning life support, viewing it as a gift of medical technology (Klessig, 1992). As
cultural meanings PEOPLE OF IRANIAN HERITAGE • 255 FABK017-C14[248-259].qxd 12/12/2007
10:42am Page 255 Aptara Inc. © 2008 F A Davis and practices evolve over time, so will one’s perception
of health and illness; therefore, assessing the patient and the family’s beliefs within the context of life
changes and experiences is essential (Emami et al., 2001). No specific religious rules against autopsy
exist. However, the reason to proceed must be clear and legitimate; some families may still refuse. In
Iran, embalming is not practiced, and coffins are not used. The body is buried quickly and directly in the
earth to facilitate the transition from “dust to dust.” Cremation is not practiced in Iran. It is unlikely for
Iranians outside of their mother country to practice cremation. RESPONSES TO DEATH AND GRIEF Loss
of a loved one is met with strong and expressive grieving among family and friends. Death is perceived
as a beginning in which the mortal life gives way to the spiritual existence and unification with God.
After burial, relatives, friends, and acquaintances gather on the 3rd, 7th, and 40th days. Special foods
are served, and grieving may be expressed outwardly and loudly. Attendance at funerals is a sign of
caring as well as a socially expected way to pay respect to the dead and to support survivors. Black is the
customary color for clothing. On the anniversary of the death, the family gathers again. Some families
donate money to charity in lieu of a ceremony. In either case, relatives observe the date by visiting the
gravesite, especially on the first anniversary. Spouses or parents regularly visit the grave site. Spirituality
DOMINANT RELIGION AND USE OF PRAYER Islam exerted its influence on Iran and its culture in terms of
temporality, fate, and dietary practices (Pliskin, 1987). However, certain culturally embedded norms,
such as family loyalty and respect for older people, transcend religious and ethnic boundaries. During
the month of Ramadan, individuals fast from sunrise to sundown, although pregnant women, the young,
older people, and those who are ill are exempt from fasting. The beliefs and practices of Jewish,
Christian, and Baha’i Iranians may be significantly different and must be specifically addressed.
MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH Family, friendship, and social support are
sources of strength and comfort, particularly in times of illness or crisis (Omeri, 1997). Iranians are highly
affiliative and thrive on social relationships. Given the importance of such contact, health-care providers
may need to adjust visiting policies. SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES Tagdir means God
has power over one’s fate in life and death. The belief is more characteristic of older immigrants than
the younger ones. Hafizi’s research (1990) illustrated this concept and the integration of religion and
health. In the words of a highly educated and devout Muslim man: To ask me what health means is to
ask me how I see myself in relation to God, my family, the society as a whole, and my relation to my
material body. Man is the embodiment of the unworldly being. To excel through this journey, the body
and spirit work as a unit. The mortal life represents only one stage of this voyage, while death another.
Death is not the end, death signifies one’s “graduation” to a higher level. I believe in God and His plan
for the future. Simply said, being sick is not having a cold; rather it is not having the vision and the ability
to deal with the cold (Hafizi, 1990). Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS
Traditional Iranian health beliefs and therapeutic practices are a combination of three schools of
medicine: Galenic (humoral), Islamic (sacred), and modern biomedicine. In classic humoral theory,
illness arises from an imbalance, excess or deficiency, in the basic qualities, hot and cold or wet and dry.
The purpose of treatment is to restore balance. The Galenic-Islamic tradition of humoral medicine is
widely practiced throughout Iran and continues to influence the beliefs of the immigrant population. In
Galenic thought, every individual has a distinctive balance of four humors, or mezaj, resulting in a
unique temperament, or tabi’at. An emotional upset can cause physical illness and vice versa. Climate
and weather are believed to significantly affect health. For example, wetness and wind are avoided. Ears
might be covered on a windy day because wind is believed to cause earache or infection. Sacred
medicine is from the Qur’an and hadith, in which holy men are considered healers. The sacred tradition
includes beliefs in the evil eye and jinns as evil spirits. Healing is reached through manipulating
impurities or by prayers. Among Iranians, narahati is a general term used to express a wide range of
undifferentiated, unpleasant emotional or physical feelings such as feeling depressed, uneasy, nervous,
disappointed, or generally speaking, not well. Iranians often use somatization to communicate
emotional distress. In doing so, they construct an illness that is culturally sanctioned and socially
understood. The stressor can be personal, social, spiritual, or psychological. Narahati allows individuals
to distance themselves from the actual problem while putting the responsibility and focus on the
metaphoric body. Because Iranians generally shy away from overt expressions of “personal self,” the
“somatic self” becomes a focal point in the health-care encounter. The concepts of zaher (and baten)
once again manifest themselves in the health arena, creating a safe communication tool. The ritual of
ta’arof creates the same safety zone in social, nonmedical interactions. Somatization is also expressed in
a cultural syndrome called ghalbe gerefteh (narahatiye ghalb, or distress of the heart). Good’s classic
study (1977) in rural Iran found that two-thirds of women of all ages reported experiencing 256 •
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heart distress, the same proportion found in Lipson’s study (1992) of immigrants in California. Heart
distress was attributed to having great sadness, being homesick, or having problems that are
overwhelming or seem impossible to resolve. One woman stated, “I get it when I read Persian
newspapers about the situation in Iran.” A widespread belief among Iranians is that fright or being
startled by bad news negatively affects health outcomes. Symptoms caused by fright range from mild to
extreme fatigue accompanied by chills and fever. When appropriate, identify the family spokesperson
for communicating matters of grave concern, because losing hope is the greatest illness. In some
instances, a sudden ailment may be attributed to the evil eye, cheshm-i-bad, the belief that negative
thoughts and jealousy can cause illness. Cheshm-i-bad can be the result of an intentional or
unintentional thought projection. Acculturated immigrants use the terminology in everyday speech and
encounters; however, most do not fully believe in the concept. Cheshm-i-bad and other folk syndromes
are better understood by viewing the body in the context of its social and supernatural environment.
Similar to somatizing, which distances an individual from the actual problem, cheshm-i-bad attributes
illness to an outside person or force. In reality, the evil eye gives meaning to an occurrence of puzzling
origin and puts the blame on something other than the affected person. Hafizi’s research (1990) found
that Iranians’ concepts of health represented two of Smith’s (1983) four domains: the clinical view,
health as absence of disease, and the adaptive view, health as the ability to cope successfully. Healthy
people are able to cope successfully with their changing world and have a harmonious exchange
between available resources and their ability to use them. Health is a lifestyle marked by demands and
adaptations (Hafizi, 1990). Similar health concepts were found among older Iranian people in Sweden
(Emami et al., 2000). Iranians accept both biomedical diagnoses and cultural illness categories. The
concept of the body is viewed in relation to its total environment: society, God, and the supernatural.
When someone has a discomforting symptom, the first question is often whether she or he ate
something that did not agree with her or his mezaj, humoral temperament. If the answer is no, then
other causes are explored. RESPONSIBILITY FOR HEALTH CARE Iranians often seek treatment relatively
soon after the onset of symptoms. If within their ability, they will “shop around” until they find a
provider of choice. They will seek advice from acquaintenances or family in the medical field and will use
home remedies for symptom management. Self-medication, prescription, over-the-counter, and
homemade herbal remedies are commonly used simultaneously. Antibiotics, codeine-based analgesics,
mood-altering drugs in the benzodiazepine family, and intramuscular vitamins are available over the
counter in Iran. Immigrants commonly bring these medications for personal use. Medication selfadjustment is also a common practice, especially when finances are an issue or symptoms are not
resolved. Health-care providers should carefully consider dosage and medication type. In some
instances, because of previous inappropriate use, a first-generation antibiotic may not affect the
microorganism because of inappropriate and repeated use. When ill, Iranians are more inclined to be
passive and to seek care and attention from family members. The patient may behave passively, while
the family appears demanding. This unceasing and, at times, overbearing attention is an expected
behavior for caring. If a patient is hospitalized, visiting is frequent, sometimes excessive according to
some. Dealing with the patient’s right to privacy and the good intentions of the visiting relatives is a
balancing act. Two cultural traits among the more-traditional and less-acculturated immigrants can
complicate help-seeking behaviors. Ta’arof may keep patients from sharing their personal feelings.
Zaher, a social façade of decorum and composure to hide one’s unwanted negative feelings or attitudes,
may further preclude the communication necessary for a meaningful assessment. More-acculturated
immigrants tend to be more open and direct. FOLK AND TRADITIONAL PRACTICES Herbal remedies are
used in a complementary manner to prevent illness, to maintain health, and to manage symptoms.
Iranians believe strongly in combination therapy. Herbal remedies became increasingly popular in
postRevolutionary Iran because of the economic embargo and scarcity of biomedical supplies. Common
herbal remedies include dried flowers, seeds, leaves, and berries steeped in hot or cold water and drunk
for digestive problems, coughs, aches, and pains, fevers, nerves, or fear. Some common herbal
medications include gol-i-gov zabon, dried foxglove flowers, for digestive problems or nervous upsets,
which is sometimes taken with nabat, a concentrated sugar (Lipson, 1992). Khakshir (flat, brown rocket
seed) is used for stomach problems; razianeh is used for halitosis; quince seeds are sucked or used to
create a thick syrup with hot water for sore throats; and sedr is used to prevent or treat dandruff.
BARRIERS TO HEALTH CARE Lack of adequate language skills, inadequate financial resources, lack of
insurance, immigration status, and lack of transportation are the top five barriers for accessing health
care for most Iranians. Physicians and nurses should work with social workers and community agencies
to help decrease these barriers. CULTURAL RESPONSES TO HEALTH AND ILLNESS Iranians are expressive
about their pain. Some justify suffering in the light of rewards in the afterlife. For example, the
grandmother of a young women with a slow-growing brain tumor consoled herself and her
granddaughter with the statement that “suffering in this world assures her a place in heaven.” PEOPLE
OF IRANIAN HERITAGE • 257 FABK017-C14[248-259].qxd 12/12/2007 10:42am Page 257 Aptara Inc. ©
2008 F A Davis Mental illness is highly stigmatized and is believed to be genetically predisposed. Mental
illness is likely to be called a “neurological disorder” or narahati-e-asa’b in order to emphasize the
physical ailment. Bagheri (1992) found that Iranians consider psychopharmacological treatment to be
most effective for somatic illness. Iranian immigrants experience numerous stressors related to
resettlement in a foreign culture. As measured by the Health Opinion Survey, 44 percent of Lipson’s
(1992) newer immigrant interviewees experienced medium or high stress compared with 14 percent of
the long-term-resident group. With reference to mood, about 35 percent of the informants answered
yes when asked if they considered themselves to be “nervous,” and about the same percentage stated
that they did not have “peace of mind.” The reasons were adjusting to their new life in the United
States, missing family members, and having concerns about relatives left behind. Despite these
problems, most Iranian immigrants had no plans to seek counseling or treatment, preferring to rely on
family support (Lipson & Meleis, 1983). However, in recent years, psychotherapy and counseling have
become acceptable treatment modalities, particularly in dealing with children (Sayyedi, 2004). Since the
return of the injured soldiers from the IranIraq war, physical disability has begun to receive attention.
Before then, the handicapped and the mentally challenged were kept at home with few care and
treatment options. The outcome of the war and the World Health Organization’s Year of the Disabled
stimulated Iran to promulgate the civil rights of people with disabilities and to guarantee access to
health care. Today, physical therapy and art and music therapy are used as adjunct treatments.
VIGNETTE 14.2 Mrs. Rastinpour is a 46-year-old Iranian immigrant. On admission, she self-identified as
being Jewish. She and her family (immediate and extended) immigrated to the United States in 1981.
She is 2 days’ postoperative for mitral valve replacement and is scheduled for discharge in 2 days. Her
wound is healing well. She has a clear understanding of her plan of care at home. Today, the nurse
noticed a degree of anxiety, especially when discussing discharge plans. When the nurse approached
her, she became tearful. Mrs. Rastinpour assured the nurse that both her children are a great help and
that they have a complete understanding of her limitations. When the nurse asked about her husband,
Mrs. Rastinpour avoided eye contact and squirmed in her chair, stating her husband is super busy with
business; her close friend and the many relatives will gladly fill in the gap. Later that day, the nurse
discussed her concerns with the discharge coordinator. The day of discharge, while meeting with the
coordinator and Mr. and Mrs. Rastinpour, the nurse asked Mr. Rastinpour if he had any particular
concerns or questions that had not been addressed. Mr. Rastinpour angrily replied, “Since my wife has
been cut, she is now imperfect. I refuse to share my bed with any woman who has a scar on her chest.”
1. What cultural versus personal issues might exist between Mr. and Mrs. Rastinpour? 2. What recourse
does the nurse have with Mr. Rastinpour’s comment made on discharge? 3. What religious issues might
be present? 4. Should the nurse get the Rastinpour children involved at this stage? 5. How might the
nurse determine the role of extended family and friends in the care of Mrs. Rastinpour? BLOOD
TRANSFUSIONS AND ORGAN DONATION Blood transfusions, organ donations, and organ transplants are
widely accepted among Iranians. In Iran, donation of organs has become a business transaction—if a
kidney is needed, it can be purchased (Zargooshi, 2001). Health-Care Practitioners TRADITIONAL VERSUS
BIOMEDICAL PRACTITIONERS Iranians appreciate state-of-the-art facilities, high-technological
equipment, and skilled professionals. At the same time, the expense of health care is a widespread
concern. Immigrants are confused by differences in the mannerisms and attitudes of the health-care
providers in Iran versus those abroad. According to one woman, “Doctors here don’t listen to you, they
are always careful of malpractice; they don’t want to be specific” (Lipson, 1992). Many Iranian clients
expect to receive a prescription for medication and quick results. Iranian women are modest in front of
men; if possible, male health-care providers should not ask women to undress fully for an examination
or procedure. STATUS OF HEALTH-CARE PROVIDERS Religious and folk practitioners are generally not
sought by most Iranian immigrants. The most respected healthcare provider is an educated and
experienced male physician. In Iran, medical imaging equipment, such as computed tomography
scanners, is scarce. The government of Iran has supported medical school admissions based on
influential kin rather than merit; therefore, graduates are of mixed quality. Nursing as a profession in
Iran remains in its infancy. Nurses are accorded less respect compared with physicians and, as a whole,
receive mixed reviews. Whereas nursing education has evolved from an apprenticeship to a
baccalaureate degree, nurses are still striving for acceptance and recognition as professionals
(Nasrabadi, Lipson, & Emami, 2004). Immigrants have repeatedly stated that nursing care in the United
States is far more interactive, communicative, and people-oriented than it is in Iran. VIGNETTE 14.3
Hamid, his pregnant wife, Jaleh, and their two children moved to the United States within 5 years of the
1984 revolution. The third pregnancy was problematic, and without the support of her sisters and
mother, Jaleh’s recovery has been 258 • CHAPTER 14 FABK017-C14[248-259].qxd 12/12/2007 10:42am
Page 258 Aptara Inc. © 2008 F A Davis slow and troublesome. Jaleh is 2 months’ postpartum, but her
mental and physical states have continuously declined. She feels their situation is worse than what they
would, and could, have had if they had remained in Iran. Hamid works long hours and is rarely home
before 8 p.m. The family lives in a neighborhood isolated from friends and family. Unfortunately, as
Hamid continues to work harder and longer, Jaleh becomes even more depressed and nonattentive to
the three children. Hamid has decided to seek help from a friend, but the friend is so concerned that he
has convinced Hamid to have Jaleh admitted to the hospital and assessed for depression. The nurse
assigned to Jaleh notices that Hamid and the three children, ages 10 and 8 years and 2 months, are
nearby. Hamid is overtly upset, the two children are holding hands, and the baby is starting to fuss. 1.
Should the nurse talk with Jaleh alone or with the family present? Why? Why not? 2. How might the
nurse develop a trusting relationship in order to ask Jaleh personal questions? 3. How might Jaleh
perceive her changing behaviors and mood? 4. What is the name of the Iranian concept of depression
and how is it explained from a cultural perspective? 5. What should the nurse do with Hamid and the
children while the nurse is admitting Jaleh?
CHAPTER 15 HAITIAN HERITAGE
Chapter 15 JESSIE M. COLIN and GHISLAINE PAPERWALLA Overview, Inhabited Localities, and
Topography OVERVIEW Haiti, located on the island of Hispaniola between Cuba and Puerto Rico in the
Caribbean, shares the island with the Dominican Republic. With a population of 8.5 million inhabitants,
Haiti covers an area of 27,750 square kilometers (10,714 square miles), about the size of the state of
Maryland. The capital and largest city, Port-auPrince, has a population of over 800,000. The per capita
annual income is $450, with a daily wage rate of $3 (World Bank Annual Report, 2006). Widespread
unemployment and underemployment exist; more than twothirds of the labor force do not have formal
jobs owing to the marked decrease in assembly sector jobs, plummeting from a high of 80,000 in 1986
to 17,000 in 2006. About 80 percent of the population lives under the poverty line, with 57.4 percent
living in abject poverty. The yearly inflation rate has fallen from 42.7 percent in 2003 to 15 percent in
April of 2006. Nearly 70 percent of all Haitians depend on the agricultural sector, mainly small-scale
subsistence farming, and remain vulnerable to damage from frequent natural disasters, exacerbated by
the country’s widespread deforestation. The infant mortality rate is high with 95.23 deaths per 1000 live
births, the average life expectancy is 53 years, and only 13 percent of the people have access to potable
water (CIA, 2006). Columbus landed on the island in 1492 and named it Hispaniola, which means Little
Spain. Haiti, or Ayti, meaning “land of mountain,” was given its name by the first inhabitants, the Arawak
and the Caribe Indians. Before 1492, there were five well-organized kingdoms: the Magua, the Marien,
the Xaragua, the Managua, and the Higuey (Dorestant, 1998). Two-thirds of Haiti contains mountains,
great valleys, and extensive plateaus; small plains mark the rest of the country. The Haitian population in
the United States is not well documented; this may be because of the U.S. Bureau of the Census’s failure
to track the large numbers of undocumented immigrants. According to the 2000 census, 548,199
Haitians live in the United States. An additional 122,000 live in Canada, of which 90 percent live in
Quebec (Statistics Canada, 2006). In 2001, 7,200 immigrants from Haiti were living in Canada for 5 years
or less. However, Haitian leaders and activists believe that close to 1.5 million Haitians live in the United
States: 500,000 in New York; 150,000 each in Boston and Chicago; 100,000 in California; and the rest
scattered throughout the United States (H. Frank, personal communication, December 2006). An
estimated 267,689 documented Haitians live in Florida. However, if the undocumented population is
included, this number may be as high as 400,000 (Elliot, 2001). Haitians, like other ethnic groups, are
very diverse. They come from urban and rural Haiti and represent all socioeconomic classes. Factors
affecting Haitians’ acculturation and assimilation include the primary and secondary characteristics of
culture (see Chapter 1). HERITAGE AND RESIDENCE Before the time of Columbus, the various indigenous
tribal groups intermarried. With the arrival of Europeans, and then Africans, the people of Haiti became
more diverse. Today, Haitians range from light- to darkskinned, and social identity is shaped by sharp
class stratification and color consciousness. FABK017-C13[231-247].qxd 12/12/2007 10:42am Page 231
Aptara Inc. © 2008 F A Davis In 1697, Haiti came under French rule. By the end of the 18th century, the
slave population numbered 500,000. In 1791, a slave insurrection broke the chain of slavery, and on
January 1, 1804, Haiti gained its independence from France. The French plantation owners were
removed and replaced by the generals of the indigenous Haitian Army, which ruled mercilessly (LouisJuste, 1995). Agricultural workers and peasants were trapped in a semifeudal system: They were
exploited by landowners, terrorized by the section chiefs of police, and forced to obey laws explicitly.
The coffee fields of the peasants served as the primary source of revenue for the government coffers,
thereby guaranteeing all government debt payments between 1826 and 1932 (Louis-Juste, 1995). These
harsh conditions did not prevent the peasants from rising up against injustice and exploitation, as
evidenced by the Goman uprising in 1820, the Acaau in 1880, and the peasant movement of Jean Rabel
(LouisJuste, 1995). Haitian immigrants have a sense of national pride, including a high level of selfesteem regarding their blackness, although in both public and private discourse, they may focus on color
and class division—two painful wedges within Haitian society. Haiti’s independence from France in 1804
did not resolve the division among the descendants of French colonists, the African slaves, and the core
of the population, who were largely of African descent and culture. Many members of the upper class
used the markers of mulatto (color), the French culture, and the French language to differentiate
themselves from the lower class, who were mostly black and Creole and spoke a predominantly African
language. Ti Manno, a Haitian singer who migrated to New York, used satire and irony to expose and
deride the type of thinking that divides Haitians in Haiti and abroad. The following song depicts the
turmoil and struggle that promote the division within the Haitian society (JeanBaptiste, 1985): The Black
Man Neg Kwens dil pa Kanmarad neg Brooklyn. Neg Potopwens dil pa anafe ak neg pwovens. Mon Che
se-m nan fe yon ti pitit. M’rayi ti pitit la A fos li led. Li nwa tankou bombon siwo. Nen-l pa pwenti. Ti neg
mwe ala nou pa gen chans o. La vi nou toujou red o. Nou deyo, pi red. Se neg nwe cont milat o. Nou
deyo nap soufri. Nou lakay se pi red. Haitians in Queens feel superior to those who live in Brooklyn.
Haitians in Port-au-Prince despise those who live in the provinces. My dear, my sister had a little baby. I
hate this little kid. This baby is ugly. He is as dark as sugarcane syrup cake. His nose is not pointy. We
Haitians, we are so unlucky. Life is always hard for us. Away from home we suffer more. It’s black against
mulatto. Abroad we suffer. At home it is even worse. Despite independence, colonial prejudices about
skin color have persisted. Internal social rivalries and the scale of Haitian mobility are tied to a European
color, race, and class model. This model relates to skin pigmentation, hair texture, the shape of the
nose, and the thickness of the lips. Whereas the structure of Haitian society continues to be built on a
neocolonial model, relationships based on color are extremely complex. For example, dark skin color
tends to be associated with underprivileged status. Although more black-skinned people have entered
the circle of the privileged, most blacks are poor, underprivileged, and unemployed. Haiti defines itself
as a black nation. Therefore, all Haitians are members of the black race. In Haiti, the concept of color
differs from the concept of race. The Haitian system has been described as one in which there are no
tight racial categories, but in which skin color and other phenotypic demarcations are significant
variables. In the 1940s, a black middle class emerged in Haiti and claimed to represent the majority. The
development of this class and its rhetoric served as a springboard for Francois Duvalier, a rural physician
who was elected president for a 4-year term in 1957. In 1964, he became president-for-life, using the
issue of black empowerment and a promise to eliminate the color and class privileges of the mulattos.
By the late 1970s, a group of darkskinned, primarily American-educated and Englishspeaking
technocrats had attained positions of prominence and influence in the government. However, the
mulatto retained social prominence, and color continued to play a major role in the perception of class
in Haiti. REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS Haitian immigration and
travel to the United States have continued for many years. Most, but not all, of those who emigrated
were members of the upper class. Before 1920, Haitians traveled to North America and Europe only for
educational purposes. In 1920, the United States occupied Haiti; the first wave of Haitian migration to
North America soon followed. Over the next decade, more than 40,000 Haitian peasants were forced to
go to Cuba and the Dominican Republic to cut sugarcane in the bateys (plantations). Haitian land was
taken and used for apple and banana plantations, and many acres of land throughout Haiti were
controlled by the United States. The atrocities that accompanied the American occupation resulted in a
small group of Haitians leaving Haiti and settling in the Harlem section of New York City, where they
assimilated into American society. The late 1950s showed signs of weakness in Haitian agriculture. The
peasants started leaving the provinces in search of work and a better life. Migrating to the capital, 232 •
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Port-au-Prince, they established Lasalin, the first slum of Port-au-Prince (Aristide, 1995). Today,
approximately 1.5 million people live in and around the capital (Regan, 1995), many in large slums such
as Cite Soley, Lasalin, Karidad, Dedye, Delwi, and Fo Mekredi. A significant turning point in Haitian
migration occurred in 1964 when Duvalier was elected presidentfor-life. As a result of his government,
many Haitians began fleeing the island. These emigrants were primarily relatives of politicians who
opposed the political philosophy of Duvalier. When Duvalier died in 1971, his son, Jean Claude, age 19,
was appointed president-for-life. In addition, during this era, Haiti was suffering from economic
deprivation, which motivated a major exodus of urbanites and peasants. Because many Haitians were
unable to pay for their transportation, passports, and visas, some covertly emigrated to the United
States in small sailboats. From 1980 to the present, Haitian immigrants have been divided into two
groups: those who have arrived in the United States legally and those who have entered through the
underground. An explosion of immigration took place in 1980, in part because of a short-lived (April to
October) change in U.S. immigration policy during the period of the Mariel boat lift from Cuba. The
influx of Cuban refugees required that a special status be created by the State Department called
“Cuban-Haitian entrant: status pending.” According to Health and Rehabilitation Services, Haitian
refugees were included in this status to prevent the policy from being discriminatory. This group of
immigrants were labeled boat people, a term associated with extreme poverty. Today, this term does
not evoke as much negativism, although it continues as a reminder of a painful emigration period in
Haitian history. From 1990s to the present, political unrest, coups, and protests occurred. The tides of
history were changing, Jean-Bertrand Aristide was elected in the first democratically held election in
many years. The democratic process did not last; in that same year, a coup d’état on Aristide and a
hemisphere-wide embargo was imposed on Haiti. In 2001, Aristide was re-elected in a flawed election.
In February 2004, an armed rebellion led to the departure of President Jean-Betrand Aristide; an interim
government took office to organize new elections under the auspices of the United Nations Stabilization
Mission in Haiti (MINUSTAH). Continued violence and technical delays prompted repeated
postponements, but Haiti finally did inaugurate a democratically elected president, Rene Preval, and
parliament in May of 2006. The Prime Minister, Jacques-Edouard Alexis, is appointed by the president
and ratified by the National Assembly to serve a 5-year term, with new elections in 2010. In Haiti, most
major industries are owned and operated by the government. Unemployment is 66 percent. Those who
are employed often work under such poor conditions that they have become unmotivated and take
little pride in their work, which results in low productivity. In general, Haitians are entrepreneurial,
operating their own shops, marketplaces, or schools. Among these entrepreneurs, the motivation, spirit,
and pride in their work are readily apparent. EDUCATIONAL STATUS AND OCCUPATIONS Following
Haiti’s independence in 1804, the new rulers of Haiti began advocating French cultural patterns and
replicating the French value system. A French model of education was informally adopted and codified
in 1860, in accord with the Roman Catholic Church. This resulted in two major changes: The Catholic
Church became the official church of Haiti, and Catholic missionaries became responsible for education.
The accepted language for communication was now French. During this era, Creole, the language of the
uneducated, was perceived as inferior. Social mobility was possible only for Frenchspeaking Haitians.
While the educated elite became acculturated into the European value system, the illiterate masses
tended to perpetuate the traditional values and customs of their African heritage. Even though Haitians
value education, only 15 percent are privileged enough to attain a formal education. In the past, the
government appropriated only 1.8 percent of the total budget for education. The Haitian school system
is based on the French model and offers free primary and secondary education. Public schools include
those operated and controlled by religious orders as well as those under the direct jurisdiction of the
Minister of Education. Children from families with financial means attend private schools. The
educational model emphasizes liberal arts and humanities rather than technical and vocational studies.
The Haitian educational system continues to emphasize 19th-century values, which promote good
manners, the classics, literature, philosophy, Latin, and Greek. It deemphasizes the physical and social
sciences. The Haitian educational system is based on a two-level curriculum. In the first level, the
student receives a certificate of primary education. To receive this certificate, the student must sit for a
rigorous test, which includes spelling, reading comprehension, composition, Haitian history and
geography, general knowledge, arithmetic, and biology. At this level, the student can speak, read, and
write French at the basic level. The next level consists of two parts: The first is reached after 6 years of
secondary education. To receive this diploma, the student must pass examinations in French, English,
and Spanish; Haitian literature and history; mathematics; and sciences such as physics, chemistry,
biology, and botany. Students in the classical track also take Latin and Greek examinations. A student
who has received the first-level certificate should be able to enter the first year of college in American
schools. The secondlevel baccalaureate is likened to the first year of college in North America; the
emphasis is on the liberal arts. Again, the student must pass an examination in all the areas covered in
the first level plus philosophy. The results of these national examinations are announced on the radio
over a 2-day period. Although Haiti has several universities, they are mainly located in Port-au-Prince.
Most of them are state universities. With proper credentials, anyone can enter the university system.
However, since the early 1980s, only those in positions of influence have been able to benefit from the
state universities. Haitian professionals PEOPLE OF HAITIAN HERITAGE • 233 FABK017-C13[231-247].qxd
12/12/2007 10:42am Page 233 Aptara Inc. © 2008 F A Davis mirror those of American society; they are
lawyers, physicians, nurses, engineers, educators, electricians, plumbers, and construction workers. The
literacy rate, which means that those age 15 and over can read and write, is 52.8 percent. The level of
illiteracy continues to be a major concern in Haiti. Since 1940, the government has conducted several
literacy programs. In 1948, Haiti had its first experience with community education. This public
educational system was based on the growth model of development, a UNESCO education project,
which duplicated experiences in Latin America (Jean-Bernard, 1983). Among Haitian immigrants, women
work in hotels, hospitals, and other service industries in domestic and nursing assistant roles. Men work
as laborers and factory helpers. Many more Haitians are in the workforce today than there were in the
early 1980s, although data for the years 1974 and 1994 from the U.S. Immigration and Naturalization
Service (2006) revealed that a disproportionate number of legal Haitians were not employed. In
addition, when comparing data by specific groups, a dramatic increase in the number of Haitians in all
work environments is found. Data about the work structure of undocumented people are not available
because these people technically are “underground” and do not exist. Communication DOMINANT
LANGUAGE AND DIALECTS The two official languages in Haiti are French and Creole. Creole, a rich,
expressive language, is spoken by 100 percent of the population, whereas French is spoken by 15
percent of the population. Since 1957, Creole has been the unofficially accepted language in the internal
affairs of the Haitian government, and in 1987, it was designated in the Haitian Constitution as one of
the official languages. Because Creole is the official language, it is used for internal communication
within the island. In contemporary society, the Haitian dilemma can best be understood through this
dual-language system. Language is one of the vehicles used to depersonalize those of the lower classes.
French is the dominant language of the educated and the elite, whereas Creole is the language of those
who are suppressed, the lower classes. The emphasis on French served as a barrier to the early social
dynamism that permitted Creole to develop and serve as a unifying force among the African slaves, who
came from many different tribes and spoke different languages. In spite of its suppression in formal
education, Creole has inspired a very rich and interesting oral literature comprising songs, proverbs, and
tales. This oral literature is the most significant aspect of Haitian folklore. Understanding the language
dilemma and the literacy issues assists health-care practitioners in developing creative tools for
educating Haitians. Some of these tools may include video programs, audiocassettes, and radio
programs in Creole. Because of the masses of people who are unable to read, printed literature in Creole
is not a helpful educational tool. CULTURAL COMMUNICATION PATTERNS Haiti has an oral culture with a
long tradition of proverbs, jokes, and stories reflecting philosophical systems. These are used to pass on
knowledge, convey messages, and communicate emotions. For example, Pale franse pa di lespri pou sa
means “To speak French does not mean you are smart.” Crayon Bon Die pa gin gum (“God’s pencil has
no eraser”) conveys the concept of fatalism. Another proverb frequently used is sonje lapli ki leve mayi
ou (“remember the rain that made your corn grow”), which means that one must show gratitude to
those who have helped them or done good for them. Haitians are very expressive with their emotions.
By observing them, one can tell whether they are happy, sad, or angry. Haitians’ communication
patterns include loud, animated speech and touching in the form of handshakes and taps on the
shoulder to define or reconfirm social and emotional relationships. Pain and sorrow are very obvious in
facial expressions. Most Haitians are very affectionate, polite, and shy. Uneducated Haitians generally
hide their lack of knowledge to non-Haitians by keeping to themselves, avoiding conflict, and
sometimes, projecting a timid air or attitude. They smile frequently and often respond in this manner
when interacting with Americans or when they do not understand what is being said. Many may pretend
to understand by nodding; this sign of approval is given to hide their limitations. Therefore, health-care
providers must use simple and clear instructions. One strategy to ensure proper understanding is to ask
family members to assist with translation and interpretation if an interpreter is not available. Because
Haitians are very private, especially in health matters, it is inappropriate to share information through
friends. Many may prefer to use professional interpreters who will give an accurate interpretation of
their concerns. Most importantly, the translator should be someone with whom they have no
relationship and will likely never see again. Voice intonations convey emotions. Haitians speak loudly
even in casual conversation among friends and family; the pitch is moderated in formal encounters.
When the conversation is really animated, the conversants speak in close proximity and ignore territorial
space, especially when emphasizing a point or an issue. Sometimes, the conversation is at such a high
pitch and speed that, to an outsider, the conversation may appear disorganized or angry. Haitians love
political discussions. In these instances, the conversation may appear stressful and hostile; however, to
the participants, the conversation is enjoyable, motivating, and meaningful. Traditional Haitians
generally do not maintain eye contact when speaking with those in a position of authority. In the past,
maintaining direct eye contact was considered rude and insolent, especially when speaking with
superiors (e.g., children speaking with parents, students with teachers, or employees with supervisors).
However, the influence of American education seems to be changing this trend. Most adults maintain
eye contact, which means “We are on equal terms, no matter who you are. I respect you and you
respect me as an equal human being.” For children, however, the custom of not maintaining eye 234 •
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contact with superiors remains deferential. Thus, healthcare providers may need to assist children in
dealing with conflicting messages. Haitians touch frequently when speaking with friends. They may
touch you to make you aware that they are speaking to you. Whereas Haitian women occasionally walk
hand-in-hand as an expression of their friendship, this trend is disappearing both in Haiti and in Haitian
communities in North America. This behavior may be changing because of the concept of
homosexuality, which is taboo within the Haitian culture. Haitians greet each other by kissing and
embracing in informal situations. In formal encounters, they shake hands and appear composed and
stern. Men usually do not kiss women unless they are old friends or relatives. Children greet everyone
by kissing them on the cheek. Children refer to adult friends as uncle or auntie out of respect, not
necessarily because they are related by blood. TEMPORAL RELATIONSHIPS The temporal orientation of
Haitians is a balance among the past, the present, and the future. The past is important because it lays
the historical foundation from which one must learn. The present is cherished and savored. The future is
predetermined, and God is the only Supreme Being who can redirect it. One hears Bondye Bon (“God is
good”), meaning if you conduct yourself conservatively and the right way, God will be there for you. The
future is left up to God, who is trusted to do the right thing. In a study by Prudent, Johnson, Carroll, &
Culpepper (2005), several of the informants voiced their belief in God’s will when talking about whether
or not they would survive being HIV positive and/or having AIDS. Haitians have a fatalistic but serene
view of life. Some believe that destiny or spiritual forces are in control of life events such as health and
death, so they say, Si Bondye Vle (“If God wants”). Given the belief in a predetermined path of life, one
can understand this view. Haitians believe that they are passive recipients of God’s decisions. Healthcare practitioners must be clear, honest, and open when assessing Haitian individuals’ perceptions and
how they perceive the forces that have an influence over life, health, and illness. Acceptance of these
beliefs is an important factor in building trust and ensuring compliance. Most Haitians do not respect
clock time; flexibility with time is the norm, and punctuality is not valued. They hold to a relativistic view
of time, and although they try, some find it difficult to respond to predetermined appointments. Arriving
late for appointments, even medical appointments, is not considered impolite. In North America,
Haitians may be more readily compliant with business appointments; but socially, the margin around
expected time is very wide—anything or anyone can wait. It is not unusual to see an invitation to a social
function listed with an invitation time an hour earlier than the actual time of the function. For example,
a wedding invitation may reflect a 6:00 p.m. wedding when, in fact, the ceremony is actually scheduled
for 7:00 p.m. to ensure that all invitees are there for the start of the ceremony. Health-care practitioners
should be mindful of this time orientation by making reminder calls for appointments and encouraging
the client in a respectful and caring manner about the importance of timeliness. A thorough assessment
of time and temporal view helps practitioners to plan appointments so that clinic or office backlogs and
disruptions are minimized. FORMAT FOR NAMES Haitians generally have a first, middle, and last name:
for example, Marie Maude Guinard. Sometimes the first two names are hyphenated as in Marie-Maude.
The family name, or nom de famille, is very important in middle- and upper-class society; it helps to
promote and communicate tradition and prestige. However, friends call individuals by their first names.
Families usually have an affectionate name or nickname for individuals. The father, mother,
grandparent, or any close family member gives this affectionate name at birth. When a woman marries,
she takes on her husband’s full name. For example, if Marie-Carmel Guillaume marries Charles Guy
Lespinasse she is always called Mrs. Lespinasse. In an informal setting, she might even be called Mrs.
Charles. She loses her name except on paper. Her name and identity are subsumed by her husband’s
name. This is a reflection of Haitian society in which women are considered subservient to men. Haitian
names are primarily of French origin, although many Arabic names are now heard since the migration of
Arabs to Haiti in the 1920s. Haitians are formal and respectful and, as such, should be addressed by their
title: Mr., Mrs., Miss, Ms., or Doctor. Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER
ROLES Traditionally, the head of the household was the man, but in reality, most families today are
matriarchal. Haitian men prefer and choose to believe that they make the decisions, but most major
decisions are made by the wife and/or mother, with the man remaining a distant figure with a great deal
of authority. Today, joint decisions are common. The man is generally considered the primary income
provider for the family, and governance, rules, and daily decision-making are considered his province.
Sociopolitical and economic life centers around men. Men are expected to be sexual initiators, and the
concept of machismo prevails in Haitian life. Women are expected to be faithful, honest, and
respectable. Men are usually permitted freedom of social interaction, a freedom not afforded to
women. The opportunities offered in North America for women to become income providers, together
with their observations of different male-female interactional styles, have encouraged many Haitian
women to reject their native, subservient role. This change in the marital interaction has created much
stress on marital relationships and an increase in domestic violence, although domestic violence remains
one of those closeted issues that are not publicly discussed. PEOPLE OF HAITIAN HERITAGE • 235
FABK017-C13[231-247].qxd 12/12/2007 10:42am Page 235 Aptara Inc. © 2008 F A Davis PRESCRIPTIVE,
RESTRICTIVE, AND TABOO PRACTICES FOR CHILDREN AND ADOLESCENTS Children are valued among
Haitians because they are key to the family’s progeny, cultural beliefs, and values. Children are expected
to be high achievers because Sa ki lan men ou se li ki pa ou (“What’s in your hand is what you have”). In
other words, education can never be taken away. Children are expected to be obedient and respectful
to parents and elders, which is their key to a successful future. They are not allowed to express anger to
elders. Madichon is a term used when children are disrespectful; it means that their future will be
marred by misfortune. Another proverb used to scare and compel children to behave is ti moun fwonte
grandi devan baron (“an impudent or insolent child will grow under the Baron’s eye [Baron Samedi is the
guardian of the cemetery in the voodoo religion] and therefore won’t have a long life”). Physical
punishment that is often used as a way of disciplining children is sometimes considered child abuse by
America’s standards. Fear of having their children taken away from them because of their methods of
discipline can cause parents to withdraw or not follow through on health-care appointments if such
abuse is evident (e.g., bruises or belt marks). Haitians need to be educated about American methods of
discipline and laws so that they can learn new ways of disciplining their children without compromising
their beliefs or violating American laws. Many parents feel confused about how to raise their children in
the United States. Their authoritarian behavior is challenged in American society, which they perceive as
being too permissive. They feel powerless in understanding how to raise their children in America, while
retaining Haitian traditions. The liberal American approach to child rearing poses a great dilemma for
Haitian children. They find themselves living in two worlds: the American world, which allows and
supports self-actualization and oneness, and the Haitian world, which promotes silence, respect, and
obedience. In the summer, Haitian parents engage their children in certain health-promotion activities
such as giving them lok (a laxative), a mixture of bitter tea leaves, juice, sugarcane syrup, and oil. In
addition, children are also given lavman (enemas) to ensure cleanliness. This is supposed to rid the
bowel of impurities and refresh it, prevent acne, and rejuvenate the body. Because Haitian life is
centered on male figures, the education of boys is different from that of girls. The family is more
indulgent of the behavioral deviations of boys. Boys are given more freedom and are even expected to
receive outside initiation in social and sexual life. However, girls are educated toward marriage and
respectability. Their relationships are closely watched. Even when they are 16 or 17 years of age, they
cannot go out alone because any mishap can be a threat to the future of the girl and bring shame to her
family. These beliefs increase Haitians’ frustrations and challenges of rearing their children, especially
girls, in America. Health-care practitioners need to be aware of these various challenges and be
prepared to assist children and family members to work through these cultural differences, while
conveying respect for family and cultural beliefs. Health-care practitioners can play a significant role by
helping children and their parents to better understand American practices. FAMILY GOALS AND
PRIORITIES The family is a strong component of the Haitian culture. The expression “blood is thicker
than water” reflects family connectedness. An important unit for decision-making is the conseil de
famille, the family council. This council is generally composed of influential members of the family,
including grandparents. The family structure is authoritarian and includes linear roles and
responsibilities. Any action taken by one family member has repercussions for the entire family;
consequently, all members share prestige and shame. The family system among Haitians is the center of
life and includes the nuclear, consanguine, and affinal relatives, some or all of whom may live under the
same roof. Families deal with all aspects of their members’ lives, including counseling, education, crises,
and marriage. Each family has its own traditions, which form the basis for a family’s reputation and are
generalized to all members of the family. The prestige of a family is very important and is based on
attributes such as honesty, pride, trust, social class, and history. Even families who experience economic
difficulties are well respected if they are from a grande famille. Wealthy families who have no historical
background or tradition are referred to as nouveaux riche and find it difficult to marry into the more
wellestablished grandes familles, even though they have money. The family is an all-encompassing
concept in the Haitian culture. By including family members in the care of loved ones, health-care
practitioners can achieve more trusting relationships, which foster greater compliance with treatment
regimens. Haitians believe that when family members are ill, there is an obligation to be there for them.
If a family member is in the hospital, all family members try to visit. Many visitors may cause concern to
health-care practitioners who are not accustomed to accommodating large numbers of visitors.
Practitioners need to be patient with them and facilitate their visits. When grandparents are no longer
able to function independently, they move in with their children. The house is always open to relatives.
Elders are highly respected and are often addressed by an affectionate title such as aunt, uncle,
grandma, or grandpa, even if they are not related. Their children are expected to care for and provide
for them when self-care becomes a concern. The elderly are family advisers, babysitters, historians, and
consultants. Migration to America poses a tremendous challenge in caring for elderly Haitians. The
nursing home concept does not exist in the Haitian culture; therefore, Haitians are generally very
reluctant to place their elderly family members in nursing homes. ALTERNATIVE LIFESTYLES
Homosexuality is taboo in the Haitian culture, so gay and lesbian individuals usually remain closeted. If a
family ...
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