Transcultural Health Care: A Culturally Competent Approach, 4th Edition Irish American Culture Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ The Republic of Ireland, also known as Eire and the Emerald Isle, covers most of the island bearing its name. ▪ The remainder of the island, Northern Ireland, is part of Great Britain. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ During the potato famine between 1846 and 1848, thousands of Irish died from malnutrition, typhus, dysentery, and scurvy; millions immigrated to America. ▪ Over 38 million people of Irish descent live in the United States. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Most Irish immigrants initially settled in industrial areas in the northeastern United States along the Atlantic coast. ▪ The Irish attained success in America because they spoke the same language, had the same physical appearance as other European Americans, and mastered the political system. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ The major languages spoken in Ireland are English and Irish (Gaelic); the latter is the official language and is spoken primarily in West Ireland. ▪ The Irish enjoy puns, riddles, limericks, and storytelling. ▪ This Irish accent has a nasal quality, spoken with a strong inflection on the first syllable of Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ When one becomes accustomed to hearing the Irish-accented English used by newer immigrants, there is little difficulty in understanding the speaker. ▪ Irish is low-context English, using many words to express a thought. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Some common Gaelic words and their meanings are shamrock for “emblem,” limer for “folklore character,” colleen or lassie for “girl,” sonsie or sonsy for “handsome,” cess for “luck,” brogue for “shoe,” dudeen for “pipe tobacco,” and paddy for “Irishman.” Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Even though most Irish delight in telling long stories, when discussing personal matters, they are much less expressive unless they are talking with close friends and family. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Humility and emotional reserve are considered virtues. ▪ Displays of emotion and affection in public are avoided and are often difficult in private. ▪ Even then, many are still reluctant to express their innermost thoughts and feelings. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ To many, caring actions are more important than verbal expressions. ▪ Direct eye contact when speaking with each other. ▪ Not maintaining eye contact may be interpreted as a sign of disrespect, guilt, or evidence that the other person cannot be trusted. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Personal space is important to the Irish, who may require greater distance in spatial relationships than other ethnocultural groups. ▪ Although the Irish may be less physically expressive with hand and body gesturing, facial expressions are readily displayed, with frequent smiling even during times of adversity. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ The Irish in America, with their strong sense of tradition, are typically past-oriented. ▪ They have an allegiance to the past, their ancestors, and their history. ▪ While respecting the past, they balance “being” with “doing,” and they plan for the future by investing in education and saving money. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communication ▪ Many Irish see time as being elastic and flexible. ▪ Mac before a family name means “son of,” whereas the letter O in front of a name means “descended from.” ▪ Women usually take the name of their husband when they marry. Some keep their last name and other use both their surname and that of her husband. Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ The traditional Irish family is nuclear with parents and children living in the same household. ▪ Irish families emphasize independence and selfreliance in children. ▪ Boys are allowed and expected to be more aggressive than girls, who are raised to be respectable, responsible, and resilient. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Children are expected to have self-restraint and self-discipline and to be respectful and obedient to their parents, elders, church, and community figures. ▪ Adolescent years are a time for experiencing emotional autonomy, independence, and attachment outside the family while remaining loyal to the family and maintaining the traditional Irish belief in the importance of family. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ Provisions are made in Irish homes for care of elderly family members, a task that becomes increasingly difficult when both parents work outside the home. ▪ Irish respect the experience of elderly people and seek their counsel for decision-making. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles and Organization ▪ The Irish value physical strength, endurance, work, the ability to perform work, children, and the ability to provide their children with the needed education to attain respectable socioeconomic status and accomplishments. ▪ Same-sex relationships continue to carry a stigma for some. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ Because cultural differences between Ireland and the United States are minimal, Irish assimilate into the American workforce easily. ▪ When change is necessary to improve the status quo, the Irish readily relinquish traditional beliefs and adjust to the workforce. ▪ Even though the Irish are typical of past-oriented groups in other ways, they tended to question the status quo of the American workforce. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Workforce Issues ▪ The low contextual use of language, where most of the message is in an explicit mode rather than an implicit mode, enhances pragmatic communications in the workforce. ▪ Personal space is important to the Irish, who may require greater distance in spatial relationships than other ethnocultural groups. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck The Irish are noted for their low-context English. Low contexted language means a. Few words are used to express a thought. b. May words are used to express a thought. c. Nonverbal communication is common. d. Nonverbal communication is rare. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: B Low contexted English means that the majority of the message is verbal and many words are used to express a thought. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Most Irish have dark hair and fair skin or red hair, ruddy cheeks, and fair skin; however, other variations exist in hair and skin color. ▪ The fair complexion of the Irish places them at risk for skin cancer. ▪ The Irish are taller and broader in stature than average European Americans, Asians, or Pacific Islanders. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Because mining is an important economic activity in Ireland, miners are at increased risk for respiratory diseases. ▪ The cool maritime climate of Ireland increases susceptibility to respiratory diseases. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Commonly occurring health conditions for Irish Americans are coronary heart disease, phenylketonuria, osteoporosis, alcoholism, and skin cancer. ▪ The major cause of infant mortality in Ireland is congenital abnormalities. ▪ Other conditions with a high incidence among Irish newborns are phenylketonuria (PKU), neural tube defects, and fetal alcohol syndrome. Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-Risk Health Behaviors ▪ Smoking has been identified as a major risk factor causing premature mortality from cancer in Ireland and among the Irish in America. ▪ The use of alcohol and intravenous drugs are major health problems among Irish Americans. ▪ Alcohol problems in Ireland are among the highest internationally. Transcultural Health Care: A Culturally Competent Approach, 4th Edition High-Risk Health Behaviors ▪ Alcoholism researchers generally agree that Irish ancestry puts individuals at risk for developing drinking problems. ▪ Irish pubs are popular establishments that have become synonymous with alcohol intake, lively music, and a vivacious time. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Irish food is unpretentious and wholesome if eaten in recommended proportions. ▪ Food is an important part of health maintenance and celebrations. ▪ Vitamins are commonly used as a dietary supplement. ▪ Meat, potatoes, and vegetables are dietary staples. ▪ Lamb, mutton, pork, and poultry are common meats. ▪ Seafood includes salmon, mussels, mackerel, oysters, and scallops. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Popular Irish dishes include Irish stew made with lamb, potatoes, and onions. ▪ Potatoes are used in a variety of ways. Colcannon is made with hot potatoes, mashed with cabbage, butter, and milk, and seasoned with nutmeg. This dish may be served at Halloween. ▪ Champ is a popular dish made with mashed potatoes and scallions. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Potato cakes, made with mashed potatoes, flour, salt, and butter, are shaped into patties and fried in bacon grease. ▪ Potato cakes are served hot or cold with butter and sometimes with molasses or maple syrup. ▪ Another popular dish is Dublin coddle, made with bacon, pork sausage, potatoes, and onions. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Oatmeal is popular in Ireland. ▪ Soda bread, another popular food, is made with flour, baking soda, salt, sugar, cream of tartar, and sour milk. ▪ Mealtimes are important occasions for Irish families to socialize and discuss family concerns. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Meals are eaten three times a day with a large breakfast in rural areas, lunch around noon, and a late dinner. ▪ Some Irish Americans continue the afternoon tradition of “tea,” a light sandwich or biscuit with hot tea. Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Health conditions with a high prevalence among Irish and Irish Americans include all of the following except a. Alcohol misuse. b. PKU c. Skin cancer d. Aortic anyerisms Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: D No documentation exists that indicate Irish and Irish American have an increased risk for Aortic aneurysms. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Not eating a well-balanced diet or not eating the right kinds of food may cause the baby to be deformed. ▪ A belief common to many other ethnic groups is that the mother should not reach over her head during pregnancy because the baby’s cord may wrap around its neck. ▪ A taboo behavior in the past, which some women still respect, is that if the pregnant woman sees or experiences a tragedy during pregnancy, a congenital anomaly may occur. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Pregnancy and Childbearing Practices ▪ Eating a well-balanced diet after delivery continues to be a prescriptive practice for ensuring a healthy baby and maintaining the mother’s health. ▪ Plenty of rest, fresh air, and sunshine are also important for maintaining the mother’s health. ▪ Going to bed with wet hair or wet feet causes illness in the mother. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ The Irish are fatalists and acknowledge the inevitability of death. ▪ The American emphasis on technology and dying in the hospital may be incongruent with the Irish American belief that family members should stay with the dying person. ▪ Whereas men are expected to be more stoical in their bereavement, women are more expressive. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ A wake continues as an important phenomenon in contemporary Irish families and is a time of melancholy, rejoicing, pain, and hopefulness. The occasion is a celebration of the person’s life. ▪ Cremation is an individual choice, and there are no proscriptions against autopsy, if required. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ The predominant religion of most Irish is Catholicism, and the church is a source of strength and solace. ▪ Other religions common among Irish in America include various Protestant denominations, such as the Church of Ireland, Presbyterian, Quaker, and Episcopalian. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ In times of illness, Irish Catholics receive the Sacrament of the Sick, which includes anointing, communion, and a blessing by the priest. ▪ The Eucharist, a small wafer made from flour and water, is given to the sick as the food of healing and health. ▪ Family members can participate if they wish. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Attending Mass daily is a common practice among many traditional and devout Irish Catholic families. ▪ Prayer is an individual and private matter. ▪ In times of illness, the clergy may offer prayers with the sick as well as with the family. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ For Catholics, holy day worship begins at 4 PM the evening preceding the holy day of obligation; all Sundays are considered holy days. ▪ The obligation to fast and abstain from meat on specified days is relinquished during times of illness. ▪ Some Irish may wear religious medals to maintain health. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Many Irish use denial as a way of coping with physical and psychological problems. ▪ The Irish view of life is illustrated in the belief that life is black with long suffering, and the less said about it, the better. ▪ Many Irish ignore symptoms and delay seeking medical attention until symptoms interfere with the ability to carry out activities of daily living. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Irish Americans limit and understate problems and handle problems by using denial. ▪ Because Irish people may not be very descriptive about their symptoms, treatment may be more difficult. ▪ Illness or injury may be linked to guilt and considered to be the result of having done something morally wrong. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ Most Irish believe one is obligated to use ordinary means to preserve life. ▪ Extraordinary means may be withheld to allow the person to die a natural death. ▪ The sick person and family define extraordinary means; finances, quality of life, and effects on the family usually influence the decision. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ In most Irish families, nuclear family members are consulted first about health problems. ▪ Mothers and older women are usually sought for their knowledge of folk practices to alleviate common problems, such as colds. ▪ Having a strong religious faith, keeping one’s feet warm and dry, dressing warmly, eating a balanced diet, getting enough sleep, and exercising are important for staying healthy. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices Irish practices include— ▪ ▪ ▪ ▪ ▪ ▪ Wearing religious medals to prevent illness Using cough syrup made from honey and whiskey Taking honey and lemon for a sore throat Drinking hot tea with whiskey and eating toast for a cold Drinking hot tea for nausea Putting a damp cloth on the forehead for a headache. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practices ▪ The behavioral response of the Irish to pain is stoic, usually ignoring or minimizing it. ▪ One explanation for high rates of mental illness may be associated with the Irish having difficulty describing emotions and expressing feelings. ▪ Blood transfusions are acceptable to most Irish Americans. ▪ Many participate in organ donation and indicate their willingness to do so on their driver’s licenses. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Health-care Practitioners ▪ The Irish respect all health-care professionals. ▪ Although the Irish are not noted for being overly modest, some may prefer to receive intimate care from someone of the same gender. ▪ In general, men and women may care for each other in health-care settings as long as privacy and sensitivity are maintained. 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 1 Chapter 30 People of Greek Heritage Irena Papadopoulos and Larry D. Purnell We wish to acknowledge Maria Athanasopoulou’s contribution in obtaining data that helped to update this chapter. Overview, Inhabited Localities, and Topography Overview This chapter presents two groups of people with Greek heritage. The first group refers to those people or their ancestors who emigrated from Greece. The second group originated in Cyprus. Both groups share the same history and have a common language and religion. The Greek and Greek Cypriot diaspora is of considerable size and is spread to all continents and numerous countries. The largest Greek community outside Greece is in America; the largest Greek Cypriot community outside Greece is in Britain. Therefore, the main focus of this chapter is on the large Greek American community, with a secondary focus on the British Cypriot community. Although geographic location and social context are important, many of the issues and principles discussed in this chapter can be applied to the broader diaspora. When the term American is used in this chapter, it refers to residents of both Canada and the United States. Greece, a small country in southern Europe with a climate similar to that of southern California, covers slightly more than 50,000 square miles (131,940 sq km) and has a population of over 10.7 million (CIA World Factbook, 2011a). The capital, Athens, has a population of 3.252 million. The population is 93 percent Greek and the rest other. Greece does not collect data on ethnicity (CIA World Factbook, 2011a). The land is very mountainous with small patches of fertile land separated by hills, mountains, and a plethora of small and medium-sized islands. The main crops are wheat, grapes, olives, cotton, and tobacco. Geopolitical boundaries have shifted dramatically over time. Greeks struggled under 400 years of Turkish rule, which ended in 1829. At that time, the Peloponnese, central Greece, and some of the Aegean Islands were freed. Later, Thessaly, Macedonia, Crete, the Ionian Islands, Epirus, Thrace, and the Dodecanese were incorporated into Greece’s boundaries. Greece joined the European Union in 1981. Cyprus, located in the most eastern part of the Mediterranean Sea, is a small mountainous island with an area of 3572 square miles (9251 sq km). The capital is Nicosia with a population of 240,000 people. The total population of Cypriots is 1,240,000 million of whom 77 percent are Greek Cypriots, 18 percent are Turkish Cypriots, and 5 percent other (CIA World Factbook, 2011b). Since the entry of Cyprus into the European Union, a significant increase of economic migrants and asylum seekers has been recorded (Cyprus Statistical Services, 2011). Cyprus has a rich history and culture, the result of many influences over 9000 years. Mycenean and Achaean Greeks settled in Cyprus around the 14th century B.C. After the Trojan War, legendary Greek heroes visited the island, where they were associated with the founding of great cities such as Salamis, Kourion, and Paphos. The Achaean Greeks had a profound and lasting influence on the culture of Cyprus, introducing their language, religion, and customs. After the death of Christ, St. Paul traveled to Cyprus, where he was joined by St. Barnabas and St. Mark. The island was the first country to have a Christian ruler when Sergius Paulus was converted. The Greek Orthodox Church stems from Cyprus. Cyprus gained its independence from Britain in 1960; however, the Constitution of the Republic of Cyprus proved unworkable, making a smooth implementation impossible. Following episodes of ethnic conflict between Greek and Turkish Cypriots, Cyprus was divided in 1974 following the invasion of Turkey. Almost half the population was displaced, with Greek Cypriots settling in the south and west of the island and Turkish Cypriots settling in the north and east. The characteristics of members of the Greek and Greek Cypriot communities vary considerably according to the time of immigration (with earlier immigrants being predominantly younger, rural males), the characteristics of the site of immigration (rural, 1 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 2 2 Aggregate Data for Cultural-Specific Groups island, or urban), the variant cultural characteristics (refer to chapter 1 in this book ), and the number of generations since initial immigration. Despite considerable temporal and geographic variation, several core themes are common to people who retain affiliation with a Greek community—emphasis on family, honor, religion, education, and Greek heritage. The core values of philotimo (honor and respect) and endropi (shame) are key when considering the experience of Greeks and Greek Cypriots. Although values of honor and shame are found in all societies, these attain immense importance among Mediterranean groups. Although philotimo is a characteristic of one’s family, community, and nation, it most centrally implies concern for other human beings. Philotimo is a Greek’s sense of honor and worth, derived from one’s selfimage, reflected image (respect), and sense of pride. Philotimo is enhanced through courage, strength, fulfilling family obligations, competition with other people, hospitality, and right behavior. Shame results REFLECTIVE EXERCISE 30.1 Mr. Marios Stavrakis is a 49-year-old Greek who arrived in New York from Crete at the age of 21. After working very hard doing different jobs for a number of years he saved enough money with which he started a business with his best friend Mr. Soteris Ioannou, who is also his son’s godfather. As the business grew the partners spent less time with each other since each one had separate responsibilities within the company. About a year ago Mr. Stavrakis developed signs of depression. His wife noticed that he was worried about something, was frequently anxious, and at the same time appeared to have less energy and vitality than usual. When he started neglecting the business he so much loved and had worked so hard to make successful, his wife insisted that he see a doctor. Mr. Stavrakis was prescribed antidepressants but took the medication infrequently and then he stopped it all together. His condition deteriorated and he began to obsessively talk about philotimo. When he eventually saw a psychiatrist he explained that he discovered that his best friend and business partner was making deals behind his back and that he was embezzling money from the company. He had suspected this some time ago but did not want to report his best friend to the police while at the same time he could not deal with his anger and disappointment as he felt totally betrayed by a man whom he trusted. 1. How has the belief about the importance of philotimo influenced the behavior of Mr. Stavrakis? 2. Why was Mr. Stavrakis reluctant to report his friend to the police? What cultural values influenced his actions? 3. Why did he not seek medical help and why was he eventually persuaded by his wife to see a doctor? from any conduct that is considered deviant. The system of honor and shame in the Mediterranean countries derives from the complementary opposition of the sexes, the solidarity of the family, and the relationships of hostility and competition between unrelated or unconnected families. Heritage and Residence Today, Greeks in America are a composite of three immigrant groups: an older group who came before or just after World War I, a second group who arrived after the relaxation of immigration laws in the mid1960s and who constitute the main group in the Greek American community, and the American-born children and grandchildren of these immigrants. The earlier Greek immigrants congregated for the most part in the western states of Utah, Colorado, and Nevada, where they worked in mines and on railroad crews; in the New England states of New Hampshire, Massachusetts, and Connecticut, where they worked in shoe and textile factories; and in the large northern cities of Chicago, Detroit, Toledo, Milwaukee, Philadelphia, Buffalo, Cleveland, and New York, where they worked in factories or found jobs as shoe shiners or peddlers. The greatest proportion of Greeks in America continues to live in the Northeast and the Midwest. Most live in large urban areas such as New York and Chicago. Whereas new immigrants still tend to gravitate toward the established Greek communities in cities, many Greeks in America have relocated to the suburbs (Moskos, 1989). The Greek communities in the United States and Canada are the biggest Greek diasporic communities. It is estimated that there are 1.2 million people of Greek heritage living in the United States and around 350,000 in Canada (Kitroef, 2009). Reasons for Migration and Associated Economic Factors Significant Greek migration occurred during the late 19th and early 20th centuries. During this period, migration depleted the population of Greece by about one-fifth. Economic factors were largely responsible for this mass exodus. In the latter part of the 19th century, Greece suffered a major economic crisis resulting from a nearly complete failure of its major crop, currants; relatively heavy governmental taxation to sustain an army against hostilities with Turkey; and family pressure on fathers and brothers to supply a substantial dowry for unmarried women in the family. Before the 1880s, relatively few Greek immigrants entered the United States. It was not until the start of the 20th century that massive numbers of Greek immigrants came to America. Between 1900 and 1920, almost 350,000 Greeks came to America, 95 percent of them men (Scourby, 1984). They came with dreams of economic opportunity in 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 3 People of Greek Heritage America, hoping to make enough money to provide good dowries for their sisters and daughters and to be able to return to Greece with enough money to live comfortably in their villages. At the time, Greece was beleaguered by turbulent internal politics and was a difficult place for the average Greek peasant to earn a decent living. Most Greek migrants planned to stay in the United States for a short period of time, and one in four of them managed to achieve this. As the arrival of young Greek women—potential wives—post 1920s increased, a number of men decided to put more permanent roots in their host country. With growing communities, and the establishment of small family businesses, Greek migrants began to integrate into American society (Kitroef, 2009). Legislation passed in 1921 and 1924 transformed America’s open-door policy toward European immigrants into a closed-door policy greatly affecting the number of Greek immigrants who came into the country. While in 1921, 28,000 Greek immigrants came to America, the next year, the quota of Greeks allowed into the country was reduced to 100. This was raised to 307 in 1929, and remained at that level for three decades (Moskos, 1989). Greek immigrants who had cared little about becoming American citizens saw citizenship as the only chance to bring other family members to America or to be able to return to America after visiting Greece. In addition, because fewer people were emigrating from Greece, membership in the Greek American community consisted of increasing numbers of American-born Greeks. During most of the 1930s, the number of Greeks returning to Greece exceeded the number coming to America (Moskos, 1989). Despite the economic downturn in the United States, Greeks in America managed to invest a great deal of energy in their communities. Greek-language schools were started for their children, the Greek Orthodox Archdiocese centralized, and charitable organizations were established for the poor. When the Great Depression came, however, everyone in America was affected, including the Greek immigrants. Many businesses failed, jobs were lost, and fortunes disappeared. The Italian invasion of Greece in 1940 precipitated Greece’s entry into World War II and a great outpouring of support from the Greek American community for the home country. After America entered the war in 1941, the intermingling of Greek and American interests produced a combination of American patriotism with Greek ethnic pride, which underscored the great love that Greeks in America felt for both their home and their adopted countries. The immigration laws, however, kept the actual number of new Greek immigrants to a minimum until the 1950s (U.S. Immigration and Naturalization Service, 1993). 3 Although the quota system was maintained, special legislation in 1953 allowed those who had been displaced by the war and those who wished to reunite with their families to enter America. In addition, countries were allowed to “borrow” on quotas for future years. As a result, approximately 70,000 Greeks entered the United States between World War II and 1965. During this time, the immigration laws dating from the 1920s were liberalized. This large influx rejuvenated the Greek American community’s ties to Greece and changed the composition of the Greek community from Greeks with American citizenship to Americans of Greek descent. By this time, the third generation of Greek Americans was being born. The Immigration Act of 1965 lifted the earlier restrictive quotas, allowing more Greeks to immigrate to America. Whereas the U.S. Census 2000 reported that 1,153,307 people of Greek descent lived in America, in 2006, 12,723 Greeks emigrated to the United States (Statistical Yearbook, 2006). The decline in Greek immigration to the United States is attributed to several factors that are largely economic. Improvement of economic conditions in Greece has lessened the impetus to emigrate. Canada and Australia have more lenient visa requirements than the United States. Finally, with the entry of Greece into the European Union (EU) in 1981, Greeks were able to freely move within the EU, thus reducing the number of people emigrating to the United States to an estimated 2000 per year. Greece in the 21st century is changing from a country of outward emigration to one of inward immigration. Immigration for Greek Cypriots is a very old phenomenon (Panayides, 1988). This is exemplified by the figures from a survey published by the Ministry of Education in Cyprus and cited by the Cyprus High Commission in Britain (1986), which numbered the Cypriot population in London as 208 in 1911; 1059 in 1931; 10,208 in 1941; 41,898 in 1961; and 78,476 in 1964. The first major group of Greek Cypriots who emigrated to Britain arrived in the 1930s. Because Cyprus was a British colony, young men seeking employment made their way to Britain and primarily settled in the Camden Town and Soho areas of London but later spread to Islington, Hackney, and northward to Haringey. The second wave of emigration occurred in 1960 to 1961 when 25,000 Cypriots left for Britain when Cyprus became a republic. This number was reduced to less than 2000 a year after the Commonwealth Immigrants Act of 1962. The last wave of emigration occurred in 1974 following the troubles between the Turkish and the Greek Cypriots, when an estimated 50 percent of Cypriot people became refugees in their own country. By 1974, an estimated 120,000 Cypriots were in Britain, of whom five out of six were of Greek origin and the remainder of Turkish origin. 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 4 4 Aggregate Data for Cultural-Specific Groups In 1986, the Cyprus High Commission reported that some 200,000 Cypriot-born people and descendants of Cypriots (Greek and Turkish) were living in Britain. In 1996, the Greek Orthodox Archdiocese in Great Britain reported that London alone was home to more than 250,000 Greek and Greek Cypriot people. These figures were derived from church attendance, numbers of weddings, baptisms, and funerals performed, as well as by the number of children attending the church-run and independent Greek schools. In addition to the Londonbased Greek Cypriot population, large communities are found in many other British cities, particularly Birmingham, Bristol, Manchester, Great Yarmouth, and Glasgow. The Greek and Greek Cypriot communities in Great Britain continue to increase, and in 2011 they are estimated to be in excess of 300,000. Educational Status and Occupations Most early Greek and Greek Cypriot immigrants were poor men who had limited education. However, they had a very strong work ethic, determination, and ethnic pride. Their achievements are evident in the schooling patterns of Greek immigrants and fostered by the competitive dimension of the Greek character. Greek children are expected to succeed in school. This attitude is fostered by an achievement orientation, high educational and occupational aspirations, a cohesive family unit that exhorts children to succeed, nationalistic identification with the cultural glories of ancient Greece, and private schools that teach the Greek language and culture (Marjoribanks, 1994). Typically, this pattern of achievement continues into adulthood and is reflected in career success. Most third-generation Greeks in America have attended college. During the 1965 immigration, Greeks coming to America included educated professionals and students in professional fields such as engineering, medicine and surgery, and other academic areas (Moskos, 1989). A common theme (repeated so often it has become an archetype) is that of Greek parents who came from an impoverished land with no money or education. Lacking English language skills, most of these immigrants had no recourse except to accept low-paying jobs as peddlers pushing carts and shoe shiners. Greek and Greek Cypriot men disliked working for others and considered it a violation of pride (philotimo). They were industrious and frugal and eventually saved enough money to start their own businesses, such as restaurants and cigar and candy stores (Lovell-Troy, 1990). In Britain, a number of Greek Cypriots established small clothing factories, and some opened food shops specializing in foods imported from Cyprus. Greek and Greek Cypriot people take pride in controlling their own businesses and have done very well economically. Initially, they sought these opportunities to save money to return to their homeland, but the more successful they became, the more likely they were to remain in America and Britain. In America, Greek immigrants who earned only marginal wages were more likely to return to Greece. This description represents the typical pattern in the eastern and northern parts of America. In the west, men worked on railroads and in mines and exhibited greater rates of marriage outside the Greek community because of their smaller numbers in these more-remote communities. Often, once they had settled, worked hard, and acquired some capital, these Greeks too became entrepreneurs, opening shops and small businesses and eventually acquiring American citizenship. In the United States, Greek immigrants attained middle-class status more rapidly than most of their fellow immigrants. As America grew more affluent in the 1920s, so did the Greek immigrants. During the 1950s, even more Greeks in America ascended into the middle class. American-born Greeks held mostly white-collar jobs, and many Greek immigrants owned small businesses. Professions such as engineering, medicine, pharmacy, scientific research, and teaching are favored by Greek Americans (Kunkelman, 1990). Second and subsequent generations of Greeks and Greek Cypriots continue to establish their own or run family businesses (Kapa Research, 2007), although more of them are currently entering professions such as medicine, accounting, and law. Communication Dominant Languages and Dialects Although all Greeks, whether in Greece, Cyprus, or the diaspora, use the same form of written Greek, regional and country variations in spoken Greek do exist. Diasporic Greek communities regard the retention of the Greek language as an essential part of their Greek identity, so numerous efforts are continually being made to encourage second and subsequent generations to speak Greek. Papadopoulos and Papadopoulos (2000) surveyed young British-born Greeks and Greek Cypriots living in Britain to determine how they defined themselves in terms of ethnic identity. Of the 94 people who responded, 87 defined themselves as British Greek/Greek Cypriots or just Greek/Greek Cypriots. Forty-six reported that they spoke Greek fluently, 35 spoke enough to “get by,” and 10 spoke “basic” Greek. Only three respondents reported not being able to speak any Greek. The spread of the Greek language is achieved by attending Greek-language schools, using Greek in the home, and regularly visiting Greece or Cyprus. Robins and Askoy (2001) argued that people of second and subsequent generations of any migrant community who are able to speak their mother tongue are more successful as they achieve greater cultural mobility. Knowledge of both Greek and English (or any other 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 5 People of Greek Heritage language, depending on the country of residence) enables people of Greek heritage to move through the cultural spaces both of their ancestors and of their adopted country. This is a helpful and nourishing process for both the individual and the collective. Cultural Communication Patterns Because Greeks and Greek Cypriots value warmth, expressiveness, and spontaneity, northern Europeans are often viewed as “cold” and lacking compassion. Protection of family members and maintenance of family solidarity tend to be foremost among their values. As a consequence, they are often friendly but somewhat superficial and distant with those considered “outsiders.” Greek and Greek Cypriot people tend to be expressive in both speech and gestures. They embrace family, friends, and others to indicate solidarity. Eye contact is generally direct, and speaking and sitting distances are closer than those of other European Americans. They gesture frequently with their hands while talking. Whereas innermost feelings such as anxiety or depression are often shielded from outsiders, anger is expressed freely, sometimes to the discomfort of those from less-expressive groups. In health-care situations, patients often appear to be compliant in the presence of the health-care worker, but this may be only a superficial compliance, employed to ensure a smooth relationship. Greeks consider deeds to be much more important than what one says. Temporal Relationships Greeks and Greek Cypriots demonstrate a variety of temporal orientations. First, they are oriented to the past because they are highly conscious of the glories of ancient Greece. They are present oriented with regard to philotimo, family life, and situations involving family members. Finally, they tend to be future oriented with regard to educational and occupational achievements. Greek Americans differentiate between “Greek time,” which is used in family and social situations, and “American time,” which is used in business situations. Greek time emphasizes participating in activities until they reach a natural breaking point, whereas American time emphasizes punctuality. 5 such as Eleni (Helen) and Alexandros (Alexander). Ideally, first daughters are named for the mother’s mother, and first sons after the father’s father. Following tradition, middle names are the first name of the father; thus, all children of Stavros might carry his first name as their middle name. In health-care situations, it is not appropriate to call older women or men by their first names. The prefix “Kyria” (Mrs) or “Kyrie” (Mr) should be used with the first name, for example, Kyria Maria or Kyrie Alexandre; the preferred mode of address is to use their surname preceded by Mr., Mrs., or Miss. Family Roles and Organization Head of Household and Gender Roles The father is considered the head of the household in Greek and Greek Cypriot families. However, the complexity of household dynamics is noted in the wellknown folk phrase “the man is the head, but the wife is the neck that decides which way the head will turn.” This saying acknowledges the primacy of fathers in the public sphere and the strong influence of women in the private sphere. In recent years, increased recognition of a trend toward more equality in decision making has occurred. Most important, however, in consideration of gender roles are the complementary values of honor (philotimo) and shame (endropi). These core values tend to set the pattern for the family and for the enactment of gender roles. Although the educational levels of women have often matched those of their brothers in the past, women usually did not work outside the home, particularly after they married. A woman may, however, have worked in her husband’s store or restaurant. Women of later generations who obtained professional degrees tended to work after their children were in school. The roles of husband and wife are characterized by mutual respect (a partnership). However, their relationship is less significant than that of the family as a unit. Fathers are responsible for providing for the family, whereas women are responsible for management of the home and children. Traditionally, the cleanliness and order of the home reflect the moral character of the woman. Format for Names Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents It is customary for honorific titles to be given to members of the community who are older people or otherwise respected. Terms such as Thia (aunt), Kyria (Mrs.), or Giagia (grandma) may be used. For Greeks and Greek Cypriots everywhere, having a Greek name is an important sign of their heritage. First names come either from the Bible, such as Maria and Petros (Peter), or from ancient Greek mythology and history, Children are included in most family social activities and tend not to be left with babysitters. The child is the recipient of intense affection, helpful interventions, and strong admiration. The child may be disciplined through teasing, which is believed to “toughen” children and make them highly conscious of public opinion. The family environment has been identified as strongly pressuring for dependence and achievement. 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 6 6 Aggregate Data for Cultural-Specific Groups REFLECTIVE EXERCISE 30.2 Mr. Andreas Georgiou was born in the United States in 1955. His parents had left Greece in 1952 to join his father’s brother, who had migrated a few years earlier. They both worked in his uncle’s small restaurant until they were able to open their own in partnership with his uncle. Andreas has two younger sisters. His parents spent whatever little time they had helping at the local Greek Orthodox Church and insisted that he and his sisters attend the Saturday Greek school. Andreas remembers his father saying, “We must never forget where we come from.” He also remembers how protective his parents were, particularly toward his sisters who, in his view, did not have the freedoms he had. “My parents always said that young women with sexual freedom have bad reputations and decent men do not want to marry them.” Both his sisters did well at school and were able to find good jobs and good husbands. He studied art at the university and has his own printing business. Ten years ago, Andreas suffered from depression. “This started when I found out that my second child was severely disabled. I could not cope with it. We consulted numerous specialists searching for a cure. We prayed and prayed. At first, I could not speak about my son to anyone other than my closest family. I never shared my emotional turmoil with my work colleagues, and this was a major stress for me. When I eventually had to share my ‘secret,’ they were all very understanding.” Today, Andreas was visiting his therapist for the last time. The therapist had helped him work through his self-blame, anxiety, and sadness. He has come to love his son for who he is. 1. What cultural values drove Andreas’ parents after their migration to the United States? 2. Why were his parents so protective toward their daughters? 3. What cultural values might have led Andreas to feel so devastated that he tried to hide his son’s disabilities? The family goals of achievement are directed toward and internalized by the children. Greek American and British Greek Cypriot families stay intact longer than other American or British families because adolescents, particularly young women, tend to reside with their parents until they get married. Formerly, men did not marry until their sisters’ prika (dowry) was established and they had married. Among first-generation immigrants, single men often returned to Greece or Cyprus for a bride. A proxenistra (matchmaker) and the families, pending the approval of the young person involved, usually arranged these marriages. Today, spouse selection is left to the young person, with parental approval. Girls have considerably less freedom than their brothers in dating, and it is common for them to be prohibited from dating until they are in the upper grades in high school. Adolescents in more-traditional families may experience stress as the differences in family and peer values precipitate family conflict. In fact, suppression of personal freedom by parents is a major risk factor for suicidal attempts among Greek and Greek Cypriot adolescent girls (Beratis, 1990). Additional areas of high stress for Greek adolescents include extreme dependence on the family, intense pressure for school achievement, and a lack of sexual education in the home. Family Goals and Priorities Greek and Greek Cypriot families tend to be very close. Within the family, members are expected to express unlimited respect, concern, and loyalty. Sym-betheri (in-laws) are considered first-degree relatives. Family solidarity is the context in which the values of honor and shame are measured. Prestige is connected to the idea that honor is not individualistic but collective. Because a person loses honor if kin act improperly, the honor of each family member is a matter of concern for all family members. Older people hold positions of respect within the Greek and Greek Cypriot communities. Their stories, whether as pioneers, veterans, or hard-working businessmen, are well known throughout the community. Their notable deeds are heralded and documented in community histories, which are usually maintained by the Greek Orthodox churches in each local community. Treatment of the giagia (grandmother) and the pappou (grandfather) reflects the themes of closeness and respect emphasized in the family. Grandparents tend to participate fully in family activities. Families feel responsible for caring for their parents in old age, and children are expected to take in widowed parents. Failure to do so results in a sense of dishonor for the son and guilt for the daughter. If the older person is ill, living with the family is the first preference, followed by residential-care facilities. Although living alone is often the least-preferred residential pattern, many older people are choosing to live alone in their own home, supported by family, friends, and healthcare providers. Older Greek and Greek Cypriot widows and widowers, particularly those who speak little or no English, may experience social isolation if they do not have close contact with their children. An important role is that of fictive kin, termed koumbari (coparents), who serve as sponsors in either (or both) of two religious ceremonies: baptism and marriage. Ideally, the baptismal sponsor also serves as the sponsor of the child’s marriage. The relationship of sponsor is so important that families who are joined by this bond of fictive kinship are prohibited from intermarrying, although this is not always adhered to nowadays. The basis of social status and prestige is family philotimo and cohesiveness. However, social status is also 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 7 People of Greek Heritage received from attributes such as wealth, educational achievement, and achievements of its members. Honor is the social worth of the family as judged by the community. A family’s status and integrity are validated when they support one another during times of misfortune such as poverty or dishonor. Alternative Lifestyles Greek and Greek Cypriot communities tend to be relatively conservative. As a consequence, alternative lifestyles encompassing premarital sex, same-sex relationships, and to a lesser extent divorce, are considered sources of concern for family members and the community. A number of religious and community support organizations in the United States and elsewhere provide support (See Resources on DavisPlus). No specific information or resources specific to Greek gay, lesbian, and transgendered people in the United States could be located. The only resources in Greece and Cyprus were travel sites that provided little information on cultural beliefs and values. Workforce Issues Culture in the Workplace In the United States, the high achievement orientation and work ethic have resulted in Greeks serving as a “model” ethnic group. However, more-recent immigrants with little education have not been as upwardly mobile. Workforce issues in which the interplay between gender and poverty are at work have been well described. Although incidents of discrimination and segregation, including acts of physical violence and murder directed at Greek immigrants, were common early in the 20th century, less discrimination occurs in the workplace today. The Greeks’ and Greek Cypriots’ rapid, selective acculturation has been addressed in earlier sections on migration, occupation, and education. Issues Related to Autonomy Probably no single characteristic applies so completely to members of the Greek and Greek Cypriot communities as the emphasis on self-reliance within a family context. Greeks and Greek Cypriots in North America, Britain, Australia, and Sweden stress this trait. It is seen as reluctance to be told what to do and is given as a major reason for their pattern of establishing their own businesses as soon as possible. Biocultural Ecology Skin Color and Other Biological Variations Greeks and Greek Cypriots are most commonly of medium stature, shorter than northern Europeans but taller than other populations of southern Europe. Although some Greeks are blue eyed and blond, usually 7 those from the northern provinces of Greece, most Greeks have dark hair and dark skin. Diseases and Health Conditions Current causes of death among Greeks and Greek Cypriots are those of developed countries and include cancer and cardiovascular and cerebrovascular diseases (World Health Organization, 1994). Since the early 1970s, an increase in diabetes and heart disease has occurred in both Greece and Cyprus. Tokas (1995) reported that in Cyprus, 2000 people die each year from heart disease, whereas each year 600 Greek Cypriots are sent abroad for cardiac surgery. In a study of the health needs of Greek Cypriots living in London, Papadopoulos (1998) found that 96 percent of the respondents ate red meat; of these, 35 percent did so on most days of the week. Nearly 50 percent of the women and 36 percent of the men in the study were overweight. Allender and colleagues (2008) reported that cardiovascular diseases continue to be the main reason for deaths in Greece and Cyprus and that this is due to bad dietary habits, smoking, and lack of exercise. In Cyprus 37 percent of the deaths in men and 40 percent of those in women are due to cardiovascular conditions. In Greece the corresponding figures are 45 percent and 52.2 percent (Allender et al., 2008). Two important genetic conditions, thalassemia and glucose-6-phosphate dehydrogenase (G-6-PD), are seen in relatively high proportions among Greek populations. They likely result from the selective advantage against malaria that these diseases confer on hemizygotic carriers. In the red blood cell, G-6-PD is a key enzyme in the hexose monophosphate shunt, which prevents oxidation of hemoglobin to methemoglobin. This pathway is essential to maintaining the integrity of the red blood cell and to preventing hemolysis. G-6-PD is important in the metabolism of glutation, an antioxidant agent. G-6-PD deficiency leads to hemolysis, which is generally well tolerated except under specific circumstances, including exercise, infections, and the presence of oxidant drugs. The genetic locus for the deficiency is on the X chromosome, making it more common among males than females. The possibility of G-6-PD deficiency should be considered in Greek patients with unconjugated jaundice (Todd, Samaratunga, & Pembroke, 1994). Thalassemia is an inherited genetic disorder manifested by a slow production of or failure to synthesize hemoglobin A or B chains. Two main types are commonly known: thalassemia major (sometimes known as Cooley’s anemia, homozygous, or beta thalassemia major) and thalassemia minor (referred to as thalassemia trait, or beta thalassemia minor). Thalassemia major is a serious condition that, if untreated, will result in death owing to very low levels of hemoglobin and the fragility of the abnormal red blood cells. 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 8 8 Aggregate Data for Cultural-Specific Groups Undiagnosed infants become pale and irritable, do not eat, suffer from recurrent fever, and fail to thrive. Eventually, the liver, spleen, and heart are damaged as a result of the accumulation of iron contained in the red blood cells. However, if the child is correctly diagnosed, treatment with regular blood transfusions (usually monthly) and prevention of iron overload with deferoxamine (Desferal) will provide an average life expectancy. Various other treatments such as bone marrow transplants have recently become available. Conversely, most individuals with thalassemia minor are not aware of it unless they are tested for it. The UK Thalassemia Society reports that 1 in 7 Cypriots (including Turkish Cypriots) and 1 in 12 Greeks are thalassemia carriers (Todd et al., 1994). In recent years, prenatal screening programs in Greece and Cyprus, as well as other countries such as Britain, America, Canada, and Australia, where most of the diaspora resides, have drastically reduced the number of babies being born with thalassemia major. Most Greek and Greek Cypriot women choose to have an abortion if they are found to carry an affected fetus. Variations in Drug Metabolism G-6-PD deficiency can result in a life-threatening hemolytic crisis after oxidating drugs (including primaquine, quinidine, thiazolsulfone, dapsone, furzolidone, nitrofural, naphthalene, toluidine blue, phenylhydrazine, and chloramphenicol) are taken. Even common medications such as aspirin can induce a hemolytic crisis. This threat is sufficiently severe that the World Health Organization (WHO) recommends that all hospital populations in areas with high proportions of Greeks and Greek Cypriots be screened for G-6-PD deficiency before drug therapy is instituted (Todd et al., 1994). High-Risk Behaviors Greeks in Greece, the United States, Canada, and Australia demonstrate lower rates of nontherapeutic drug use, alcoholism, and high-risk sexual behaviors than other groups in European or North American countries (Rosenthal, Moore, & Buzwell, 1994). These patterns are not due to an emphasis on health promotion, but rather to a hyperawareness of the social consequences of these behaviors for the family. For example, alcohol is most often considered a food item and is consumed with meals. However, losing control by being “under the influence” engenders considerable gossip and social disgrace, focused not only on the individual but also on the family (Tripp-Reimer & Sorofman, 1994). Concern for the reputation and standing of the family is a prime deterrent to many high-risk behaviors. Conversely, high-risk behaviors such as obesity among both sexes and smoking among men are higher among Greeks (Wilson, Bakiaris, Gleeson, Papasavva, Wise, & Hawe, 1993). Despite the concern for the family reputation, many of the Greek Cypriots who took part in Papadopoulos’ (1999) study described themselves as “risk takers” or “living dangerously.” This may be due to a mixture of cultural and religious beliefs and the experiences of migration. The narratives of first-generation migrants describe the risks they had to take to survive in a foreign and often hostile land. Whereas a high level of risk taking appeared to be part of survival, it was perpetuated by the belief that “God will look after me”—that God will prevent anything untoward happening, but if anything should happen, God will heal and sustain the person. Knowing these behavioral characteristics can assist health-care providers in planning culturally sensitive interventions. REFLECTIVE EXERCISE 30.3 Mr. and Mrs. Christou have a 17-year-old daughter, Helen, and a 15-year-old son, George. Mr. Christou is a second-generation British-born Greek Cypriot, while Mrs. Christou moved to England from Cyprus at the age of 18. Both children are attending the same school that is located in a predominantly middle-class area of London. The couple and the children’s grandparents, who also live in London, are very proud of the children. Helen and George are given a generous allowance each week, but lately George has been borrowing money from his sister. At first she did not mind, but when this became more frequent she began to wonder what George did with the extra money. She also saw him asking his grandmother for money. George frequently told his parents that he was going to the snooker club with his friends after school and on Saturdays. One day, while waiting to catch the bus home after school, she saw George with a group of boys smoking behind the bus shelter. That evening she confronted her brother who admitted that he occasionally used cannabis. She told him that unless he gives this up within 2 weeks she will tell their parents. He promised to do so, but after 2 weeks he was still using cannabis. Helen informed their parents. Their first reaction was one of surprise; they could not believe that their “perfect and clever” son whom they brought up to know right from wrong, whom they trusted and had a loving relationship with, could get into “bad company” and take drugs. Following their disbelief, they had a very angry argument with their son who told them that he realized how hurt they would be if they found out. The parents told him that although they were concerned about his health they were also concerned about the effect that his behavior might have on family and friends if they found out about his drug taking. When the parents calmed down, they told George that they still loved him and that they would do whatever they could to help him stop using cannabis. They also told him and Helen that this incident must stay within their home and they should not discuss this with anyone else. 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 9 People of Greek Heritage 1. What cultural value is guiding and influencing the parents’ decision to keep their son’s problem within the confines of the nuclear family and not seek help from their extended family and friends? 2. What cultural values underpin the parent’s decision to support their son even though they are angry with him? 3. Should the grandmother be informed of the situation and told not to give George any money? 4. At this time with the conflict, would you recommend professional counseling? 9 from fasting. Some first-generation Greeks and Greek Cypriots observe the three major fasting periods, including The Great Fast, Lent, for 7 weeks before Easter The Assumption fast, from August 1 to August 14 The Christmas fast, 40 days before Christmas Many second and subsequent generations of Greeks and Greek Cypriots usually fast only the last week before Easter, when most will also take Holy Communion. Common Foods and Food Rituals Health-Care Practices Greeks and Greek Cypriots have tended to disregard standard health-promotion behaviors. Safety measures for adults, such as seat belts and helmets, are often viewed as infringements on personal freedom and are frequently ignored, particularly by the older generation. The first most common cause of deaths in Greece and the second in Cyprus for those aged 15 to 44 are road traffic accidents. However, relevant legislation and severe penalties are having a positive effect, and a reduction in these deaths was recently recorded (Kouta, Papadopoulos, & Sourtzi, 2010). However, the gap between health-related knowledge and appropriate health action remains. Papadopoulos et al. (1998) found that Greek Cypriot people had a good knowledge of health-promotion practices. However, good knowledge did not correlate with positive health behaviors. For example, people who know what a balanced diet is often do not eat a balanced diet. Worryingly, the new generations of Greek and Greek Cypriots, while not abandoning the traditional Mediterranian diet that is characterized by low levels of meat and fat intakes and high levels of fresh fruit and vegetables, are regularly consuming fast foods, a phenomenon that is now global. Encouragingly, Papadopoulos (1999) found that the use of screening for problems such as blood pressure, cervical cytology, and breast cancer was high. Nutrition Meaning of Food Greeks describe their culture as an “eating culture.” By this they mean that food is a centerpiece of everyday life as well as of social and ritual events. Greek hospitality nearly always includes a ritual of food and drink. Fasting is an integral part of the Greek Orthodox religion. General fast days are Wednesdays and Fridays; nowadays, these are observed only by some older people. During fasts, it is forbidden to eat meat, fish, and animal products such as eggs, cheese, and milk. Greek Orthodox wishing to take Holy Communion will observe at least 3 days of fasting. However, people with health conditions and small children are exempt Greeks and Greek Cypriots have based their diet on cereals, pulses (such as lentils, peas, and beans), vegetables, fruits, olive oil, cheese, milk, and some fish and meat. They are also relatively high consumers of sweets and snacks. In both Greece and Cyprus, consumption of pulses has decreased, and consumption of meats has increased. The consequences of this trend are not yet fully known. For adults, dairy products are consumed in the form of yogurt or cheeses such as feta, kopanisti, kefaloteri, kasseri, and halloumi. Fats are consumed in the form of olive oil, butter, and olives. Meats include chicken, lamb, pork, and beef. Eggs, lentils, fish such as shrimp and other shellfish, and white fish are additional sources of protein. Vegetables such as potatoes, eggplant, courgettes (zucchini), spinach, garlic, onions, peas, artichokes, cucumbers, asparagus, cabbage, and cauliflower are common Greek food choices. Bread choices include pita, crescent rolls, and egg breads. Other foods include rice, tabouli, macaroni, and cracked wheat (bourgouri). Papadopoulos et al. (1998) found that the level of vegetable consumption of Greek Cypriots was almost twice that of their meat and poultry consumption. Common seasonings used by Greeks are aniseed, basil, lemon, mint, cumin, cinnamon, citron, cloves, coriander, dill, fennel, ginger, garlic, marjoram, mustard, REFLECTIVE EXERCISE 30.4 Mrs. Glitnatsis, age 82, has diabetes mellitus and takes insulin. She is quite underweight and does not follow her recommended diet because she is Orthodox and follows the fasting schedule of the Orthodox Church. During fasting, she does not take her insulin. She is currently seeing the diabetic nurse specialist because of her uncontrolled diabetes. 1. What are the required fast days for the Orthodox Greek religion? 2. What foods are forbidden to eat during fast days? 3. If Mrs. Glitnatsis insists on fasting, what is your recommendation for food intake and insulin administration? 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 10 10 Aggregate Data for Cultural-Specific Groups nutmeg, oregano, parsley, rosemary, sage, sesame, thyme, vinegar, bay leaf, and honey. Fruit preferences include grapes and currants, figs, prunes, oranges, lemons, melons, watermelons, peaches, and apricots. Beverages such as coffee, tea, chocolate milk, and wine are common choices. Common food items are listed in Table 30-1. Specific foods are linked with holidays or ceremonies throughout the year. For example, several different special breads, pastries, and cakes are served at traditional ceremonies: New Year’s bread, vasilopita; Easter pastries, tsoureki and flaouna; Christmas bread, chistosomo; prosfora, a traditional bread for funerals and remembrance ceremonies, which is served with koliva, a ❙❙◗ Table 30-1 Common Greek Foods Name Avgholemono Description Soup Hummus Thick sauce for dipping bread Maroulousalata Salad Tsatziki Dip Spanakopita Cheese tarts Dolmathes Stuffed grape leaves Meatballs Keftedes Souvlaki Moussaka Pastichio Psiti kota Loukomades Kourambiethes Baklava Greek coffee Ingredients Chicken stock, eggs, lemon, rice Chick peas (mashed), tahini sauce (sesame and olive oil), garlic, lemon Lettuce, onions, cucumbers, radishes, parsley, tomatoes, feta cheese, olives, olive oil Cucumbers, yogurt, vinegar, mint, garlic, salt Spinach and feta cheese in phyllo dough pastry Meat, rice, grape leaves Ground beef/pork, grated potatoes, onions, bread, parsley, oregano, eggs, garlic Meat Marinated pork or lamb on skewer Casserole Eggplant, potatoes, ground lamb, onions, tomato, garlic, parsley, white sauce Casserole Ground beef, macaroni, cinnamon, white sauce, cheese, parsley, tomato sauce, butter Lemon chicken Chicken, lemon, oil Pastry Flour, water, honey, oil, sugar, cinnamon Wedding cookie Flour, almonds, cloves, powdered sugar, egg, brandy Sweet dessert Phyllo dough, pistachio nuts, honey, sugar, cinnamon, cloves, butter Coffee Ground coffee, sugar mixture of boiled wheat, almonds, pomegranate seeds, sesame seeds, and raisins; and traditional, small, individual wedding cakes called kourapiedes. Dietary Practices for Health Promotion Although no specific classification exists of foods for health or illness, a general consensus is that people will naturally choose foods that are healthy. Therefore, an effort is made to provide ill people with the food they request. This pattern is most pronounced for pregnant women. In fact, numerous folk prescriptions exist regarding the provision of food for pregnant women, even if they are not close family or friends. Nutritional Deficiencies and Food Limitations Although nutritional deficiencies per se are rare among Greeks and Greek Cypriots, two important enzymatic conditions merit attention. First, for people with G-6-PD deficiency, broad beans (fava beans) can induce hemolysis and an acute anemic crisis (Riepl, Schreiner, Muller, Hildemann, & Loeschke, 1993). Second, the prevalence of lactose maldigestion in Greek adults is about 75 percent; however, milk intolerance is rarely seen in children (Ladas & Katsiyiannaki-Latoufi, 1991). Health-care providers should use this knowledge when counseling patients with these conditions. Virtually all food items used in the traditional Greek diet are available in the United States, Britain, Australia, and Canada. Even specialty items such as phyllo dough for pastries and appetizers, grape leaves in brine, and olives can be found in specialty areas of major supermarkets. A trend has moved away from lamb to beef for many dishes among the U.S. population. The popularity of Greek food is evidenced by the success of Greek restaurants wherever there is a Greek community. Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy The trend for smaller families in Greece has been noted at least since the turn of the 21st century, whereas in Cyprus, this is a more recent phenomenon. In large part, this decreased fertility has resulted from the desire of parents to provide adequately for their children and to have them educated so they can achieve professional status. In North America, family size has been deliberately limited in order to adequately care for and educate children. In Britain, early immigrants had small families primarily because of housing problems. Many families lived in very cramped conditions, and many landlords did not rent to those with children. The method of limiting pregnancies has changed from control of gestation to control of conception. In 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 11 People of Greek Heritage North America, a wide variety of birth control measures, such as intrauterine devices, birth control pills, and condoms, are preferred. The strong pro-life Greek Orthodox Church condemns birth control, while at the same time silently accepting the reality. However, abortion is absolutely condemned as an act of murder except in certain circumstances such as when the life of the mother is in grave danger or a young woman becomes pregnant as a result of rape. In practice, a number of women, particularly those who are unmarried, have legal abortions because of the negative consequences of having a baby out of wedlock. Inflicting endropi on the family is believed to be more severe than the consequences of abortion. Although adoption is rare among Greeks and Greek Cypriots, it is becoming a more acceptable option for couples who cannot conceive. Whereas the family may experience shame and dishonor if an unmarried woman becomes pregnant, also of concern is infertility in a married couple. For these couples, the reputation of the husband may be at risk, and the woman is unable to achieve her highest role. Infertile couples are reported to experience mental stress, evidenced as depression for women and anxiety for men. In vitro fertilization is often not disclosed to members of the extended family to avoid gossip and stigmatization. In a group with such a strong emphasis on fertility, the attitude toward the pregnant woman is very positive and protective. Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Pregnancy is a time of great respect for women and a time when they are given special considerations. For example, strangers may offer pregnant women their seats on a bus. Proscriptions include not attending funerals or viewing a corpse, refraining from sinful activity as a precaution against infant deformity, and praying to St. Simeon. However, most pregnancy admonitions are related to diet. Pregnant women are encouraged to eat large quantities; foods high in iron and protein are particularly important. A number of tales surround the provision of food to pregnant women. It is commonly believed that giving meat to a pregnant woman makes the dish turn out well. In addition, if a pregnant woman remarks that a food smells good, or if she has a craving for a particular food, it should be offered to her; otherwise, the child may be “marked.” This is the usual explanation for birthmarks. During childbirth in rural Greece, a midwife and female kin generally attend a woman. The pattern of the noninvolvement of the fathers may still hold in immigrant generations but is being replaced with greater participation. After delivery, the mother, termed lehoosa, is considered by most traditional Greeks to be ritually impure 11 and particularly susceptible to illness for 40 days. During this time, she is admonished to stay at home and not attend church. At the end of the 40 days, the mother and child attend church and receive a ritual blessing. For breastfeeding mothers, early showering is sometimes believed to result in the infant’s developing diarrhea and becoming allergic to milk. Newborns are generally breastfed, and solids are not introduced early. When relatives visit a child in the hospital, silver objects or coins may be placed in the crib for good luck. Death Rituals Death Rituals and Expectations Last rites are administered in the sacrament of Holy Communion given by a priest or, occasionally, a deacon. On the death of a community member, close relatives are notified in person, whereas other community members are notified by telephone. The wake, klama, is held in the family home or, more commonly in North America today, a funeral home. All relatives and friends are expected to attend for at least a brief time. Even people with whom the deceased had considerable strife are expected to attend. The wake ends when the priest arrives and offers prayers. In Greece and Cyprus, the funeral, kidia, is held the following day at the Orthodox church, with internment in a cemetery. For practical reasons, it is not always possible for the burial to occur the day after death. Furthermore, many Greek Cypriots living in Britain wish to be buried in Cyprus. After internment, family and friends gather for a meal of fish (symbolizing Christianity), wine, cheese, and olives in the family home or a restaurant. On the basis of the Orthodox belief in the physical resurrection of the body, Greeks and Greek Cypriots reject cremation. The degree of adherence to this precept may vary in North America, but cremation is not practiced by Greeks and Greek Cypriots in Britain. Responses to Death and Grief After a death, pictures and mirrors may be turned over. During the wake, women may sing dirges or chant. In some regions, people practice “screaming the dead,” in which they cry a lament, the miroloyi. This ritual may involve screaming, lamenting, and sobbing by female kin. After death, family and close relatives, who may stay at home, mourn for 40 days. Close male relatives do not shave, as a mark of respect. Black is the color of mourning dress and is often worn by family members throughout the 40-day mourning period; for widows, it may be worn longer. Formerly, a widow was expected to wear black and no jewelry or makeup for the rest of her life. Whereas black armbands are still worn in Greece and Cyprus, that custom is virtually nonexistent in immigrant communities. Widows generally look to their family for 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 12 12 Aggregate Data for Cultural-Specific Groups support; widowers often remarry. These practices should be encouraged and respected by health-care providers. A memorial service follows 40 days after burial and at 3 months, 6 months, and yearly thereafter. At the end of this service, koliva, boiled wheat with powdered sugar, almonds, sesame, raisins, and pomegranate seeds, is served to participants, and mourning is conducted with joyful reverence. Dreams have special importance to family members after a death. Family members may even experience visitations by the deceased in their dreams. Often, these dreams provide reasons for the deceased to leave the earth, because the first 40 days following death is a transitional period when the deceased is between earth and heaven. Spirituality Dominant Religion and Use of Prayer In Greece, 98 percent of the population belongs to the Greek Orthodox religion; 1.3 percent of the population is Muslim (CIA World Factbook, 2011a). In Cyprus, 78 percent of the population identifies with the Greek Orthodox religion, 18 percent are Muslim, and 4 percent are other (Maronite, Armenian Christian, Catholic, and Protestant) (CIA World Factbook, 2011b). Greeks in America are affiliated with the Greek Orthodox Church, and Greeks and Greek Cypriots in Britain are affiliated with the Archdiocese of Thyateria and Great Britain. The central religious experience is the Sunday morning liturgy, which is a high church service with icons, incense, and singing or chanting by the choir. Services that previously lasted over 3 hours are now generally shortened to 1 to 2 hours. The Greek Orthodox religion emphasizes faith rather than specific tenets. Unlike most Protestant denominations, Greek faith does not emphasize Bible reading and study. Whereas some parishioners attend church services weekly, others attend only a few times a year. Easter is considered the most important of holy days, and nearly all Greeks and Greek Cypriots in America and Britain attempt to honor the day. Daily prayers may be offered to the saints. Women often consider faith an important factor in regaining health. Family members may make “bargains” with saints, such as promises to fast, be faithful, or make church donations if the saint acts on behalf of the ill family member. They may call on an individual’s namesake or a saint believed to have special affinity with healing. Two saints frequently invoked are Cosmas and Damian, early Christian physicians. In invoking the saint, the supplicant may say special prayers, light candles, place small gold medals at the base of the icon, or carry out some combination of these rituals. There is also a strong belief in miracles, even among second and subsequent generations of Greeks and Greek Cypriots in America and Britain. Meaning of Life and Individual Sources of Strength The world is viewed as a cosmic battleground in which the individual must be continuously vigilant and resourceful. Based on the principle of limited good, one family’s gain is another’s loss. Only within the bonds of the family can an individual find protection from a dangerous world. The primary set of relationships, even in an extended household, is between members of the nuclear family. From this central group, relationships radiate outward, lessening in strength to include all affinity, consanguineous, and koumbaros relationships to the second degree (e.g., second cousins). Life has meaning as family roles are enacted successfully. Parents strive to provide for their children, and in turn, they expect the children to achieve success in academic and occupational endeavors. Through wrong behaviors or misfortunes individuals can bring public sanction and shame (endropi) on the family. The Greek concept of self consists of the interrelationship of the three values: self-respect, a sense of freedom, and the concept of the ideal person. The self emerges through relationships with other people, but primarily from the family. Freedom is a central element in the self-concept. Self-reliance, that is, nonreliance on people outside the family, is a virtue. For Greeks and Greek Cypriots, sources of strength are the family, the close network of extended family and friends, and the history of the glories of ancient Greece. Particularly in immigrant communities, the Greek Orthodox Church serves as a base for spirituality, language, social and political organization, and an ongoing identity with Greece and Cyprus. Spiritual Beliefs and Health-Care Practices A distinctive feature of the Greek Orthodox religion is the place it assigns to icons, such as paintings of saints, the Virgin Mary, and Christ. These icons are not religious art but have sacred significance as sources of connection to the spiritual world. Icons grace the walls and ceilings of churches and cathedrals and are also found in personal altars in homes. In the homes, holy vigil candles are often kept burning. To ensure safety and health, many begin each day by kissing the blessed icons and making the sign of the Greek cross. When a person is ill, the icon of the family saint or the Virgin Mary may be placed above the bed. Many Greeks and Greek Cypriots, regardless of where they live, also may sprinkle their homes with holy water from Epiphany Day church services to protect the members of their household from evil. They may also perform the ceremony of kapnisma, in which dried olive leaves, which had been kept in church during the fasting periods before Christmas and Easter, are placed in a small container called kapnistiri and are lighted while they say a prayer. The person who 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 13 People of Greek Heritage performs this ceremony (usually the older woman of the household) first goes outside to offer the kapnisma to God, then each member of the family will cross themselves and accept the kapnisma. The person performing the ceremony then goes around to all the rooms in the house to allow the smoke from the burning leaves to penetrate the atmosphere. It is believed that any bad spirits present will leave the house, and thus, the ceremony will protect members of the household. Health-Care Practices Health-Seeking Beliefs and Behaviors The degree of acceptance and use of biomedicine is highly related to one’s level of education and generation of immigration. For example, although fourthgeneration Greek Americans in Ohio are highly traditional in many aspects of their lives, such as religion, language retention, and food preferences, they have not retained many of the folk beliefs and practices concerning health care. The traditional practices discussed subsequently tend to apply to earlier immigrant generations. Greek immigrants tend to be anxious about health, to lack trust in health professionals, and to rely on family and community for advice and remedies. Problems are seen as originating outside the individual’s control and are attributed to God, the devil, spirits, and envy or malice of others. The gods may punish the nonreligious with illness (asthenia or arrostia), but more often, the forces of evil are believed to cause illness. Another example of an external cause of illness is that of the matiasma (evil eye), which is often unintentionally caused through the envy of others. To be healthy means to feel strong, joyful, and content; to be able to take care of oneself; and to be free from pain (Tripp-Reimer & Sorofman, 1989). Threats to health result from a lack of balance in life; departure from family; neglect of education or work; and failure to demonstrate right behaviors, such as respect toward parents, sharing with family, upholding religious precepts, and staying out too late (Tripp-Reimer & Sorofman, 1989). Responsibility for Health Care Central to issues of responsibility is the orientation toward honor, independence, and distrust of people outside the family. In traditional thought, the cause of illness and misfortune falls outside the person. The family generally assumes responsibility and care for a sick member and works to control interactions with health professionals. In the United States, insurance enrollment among Greek Americans is high, which correlates with high rates of employment among this group. Even when coverage is available, however, they often delay in seeking professional care. Greek Americans are extremely 13 reluctant to use welfare services or other forms of governmental assistance to meet their health-care needs. Reliance on public assistance would indicate that the sick person and family are not self-reliant. Greeks in America are also reluctant to rely on Greek community organizations, such as the women’s Philoptochos Society (Friends of the Poor), for support. In Britain, the National Health Service (NHS) provides free health care to all citizens. Greek Cypriots readily take their children to the family doctor and do not delay seeing the physician for their own health problems when these are severe enough to prevent them from going to work or from executing important family functions and roles. However, men in particular tend to delay seeking medical help when they can selfcare for something considered nonacute or when they suspect they may be suffering from something more serious such as cancer (Papadopoulos & Lees, 2002). Many first-generation Greek Cypriots speak very little or no English, and if a member of their family or a friend is unable to accompany them to the doctor or hospital, an interpreter must be found. First-generation Greek and Greek Cypriots in Britain use voluntary organizations to obtain information and advice in Greek and to receive help completing various documents that enable them to receive the financial and other benefits to which they are entitled. No stigma is attached to the utilization of Greek/Greek Cypriot community organizations in Britain because their function is not associated with the philoptochos movement, whose function is to help the poor. Folk and Traditional Practices Three traditional folk-healing practices are particularly notable: those related to matiasma (bad eye or evil eye), practika (herbal remedies), and vendouses (cupping). Matiasma results from the envy or admiration of others. Whereas the eye is able to harm a wide variety of things including inanimate objects, children and pretty young women are particularly susceptible to attack. Common symptoms of matiasma include headache, chills, irritability, restlessness, and lethargy; in extreme cases, matiasma has resulted in death. Greeks employ a variety of preventive mechanisms to thwart the effects of envy or evil eye, including protective charms in the form of phylacto, amulets consisting of blessed wood or incense, or blue “eye” beads, which “reflect” the eye. When the diagnosis of matiasma is suspected, the most common method of detection consists of placing olive oil in a glass of water. If the oil disperses, then the eye has been cast. Subsequent treatment consists of physical acts such as making the sign of the Greek cross over the glass of water or reciting ritual prayers. In particularly severe cases, the Orthodox priest may recite special prayers of exorcism and use incense to fumigate the afflicted person. 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 14 14 Aggregate Data for Cultural-Specific Groups Practika are herbal and humoral treatments used for initial self-treatment. Chamomile, the most popular herb, is generally used in teas for gastric distress or abdominal pain, including infant colic and menstrual cramps. It is also used as an expectorant to treat colds. Liquors, such as anisette, ouzo, raki, and mastiha are used primarily for colds, sore throats, and coughs and are consumed alone or in combination with tea, lemon, honey, or sugar (either alone or in some combination). Occasionally, liquors are used for treatment of nevra (nerves). Raki is also used as a massage fluid to rub on painful joints. Raw garlic is used as a preventive for colds, and cooked garlic is used for blood pressure and heart disease. Other practika include those described in Table 30-2. Vendouses is a healing practice known throughout the Mediterranean area. Most frequently, it is used as a treatment for colds, but other indications include high blood pressure and backache. The technique consists of lighting a swab of cotton held on a fork, then placing the swab in an inverted glass, creating a vacuum in the glass, which is then placed on the back of the ill person. The skin on the back is drawn into the glass. This procedure is repeated 8 to 12 times. An alternative method, for particularly serious cases, is the koftes (cut vendouses). Here, the same procedure is followed, except that a cut in the shape of a small cross is made on the skin. When the glass is placed over this cut, blood is drawn into the glass. The therapeutic rationale for using vendouses surrounds its counterirritant effect; the technique increases and revitalizes the circulation, draws out poisons and “cold,” and prevents coagulation of blood. Fourth-generation community members rarely use vendouses. Lists of herbs and recipes for Greek home remedies can be found on many Internet sites (Greek herbs, 2011). ❙❙◗ Table 30-2 Practika Used in Greek Folk Medicine Practice Frascomilo (sage) tea Moroha Linden tea Mustard plasters Rice (boiled) Cinnamon tea Tobacco Indication Colds Stomachache Stomachache Colds Diarrhea Menstrual cramps Inhibition of infection Source: Adapted from Tripp-Reimer, T. (1981). Ethnomedical beliefs among Greek imigrants: Implications for nursing interventions. Transcultural Nursing Care, 6, 129–140; and Tripp-Reimer, T., & Sorofman, B. (1989). Illness related self-care responses in four ethnic groups. Final report no. R01Nu 1101. Submitted to National Institute of Nursing Research. Bethesda, MD: National Institutes of Health. Barriers to Health Care The primary barriers to health care for Greek and Greek Cypriots in America and Britain include a reliance on self-care in the family context and a general distrust of bureaucracies. Self-medicating behaviors are normative, with herbal remedies and over-the-counter medications used widely for specific symptoms. Selfcare, however, is usually undertaken with the advice of family members. Inability to speak English is an additional barrier for a number of first-generation Greek and Greek Cypriot migrants. In Greece and Cyprus, pharmacies are a common source of self-medication. In both countries, pharmacies have considerably greater authorization to advise and dispense medications. Self-treatment is still used as a first-line response to illness. When self-care fails, families often bring the ill person to a specialist rather than a primary-care physician. The rate of use of all physicians is lower for Greeks than for other groups of European descent; however, their infrequent use of physicians for primary care is remarkable. However, in Britain, people do not have direct access to specialist medicine unless they first consult their family doctor. One of the main barriers to health care in Britain is racism. This is now well documented and accepted by the British government, which has been trying through various policies to eliminate it. In a study that examined the primary health-care needs of Greek and Greek Cypriot women in London, Papadopoulos and Worrall (1996) found numerous cases of racist behavior by primary health-care staff, particularly toward first-generation immigrant women. Cultural Responses to Health and Illness Mental illness is accompanied by social stigma with negative consequences for the afflicted person as well as the family and relatives. Shame (endropi) originates in the notion that mental illness is hereditary; afflicted people are viewed as having lifelong conditions that “pollute” the bloodline. The stigma is so wide-ranging that people labeled as mentally ill and their families may experience the loss of friends and social isolation. As a result, families place a wide variety of behaviors within the range of “normal” to delay receiving the stigmatized label. Individuals with mental illness often present with somatic complaints such as dizziness and parasthesias on initial visits to health-care practitioners (Marmanidis, Holme, & Hafner, 1994). Recent immigrants tend to have higher rates of mental disorders, which perhaps result from the stress of culture change (Mavreas, Bebbington, & Der, 1990). However, a folk model for nevra (nerves) is a socially acceptable and culturally condoned medium for the expression of otherwise unacceptable emotions. Nevra is experienced most commonly by those in positions of least power, such as women and people 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 15 People of Greek Heritage living in poverty. It encompasses a wide variety of symptoms and provides a metaphor for social disorder, such as conflict between close kin or intergenerational conflict. Ideally, nevra are treated through medications for the relief of symptoms instead of through talk therapy. Greek culture socially stratifies people by the nature of their disorders. Individuals with physical illnesses such as asthma, diabetes, and arthritis are most accepted, followed by people with disfiguring illnesses such as cerebral palsy. Individuals and families experiencing mental retardation, psychiatric illness, and AIDS are less accepted. However, people in the moststigmatized group are those with social deviance, such as addictions or delinquency. Ponos (pain) is the cardinal symptom of ill health. It is viewed not as something to be endured, but as an evil that needs eradication. Pain mobilizes considerable family concern. The person in pain is not expected to suffer quietly or stoically in the presence of family. The family is relied on to find resources to relieve the pain or, failing that, to share in the experience of suffering. However, in the presence of outsiders, the lack of restraint in pain expression suggests lack of self-control and, therefore, is considered endropi. Although the experience of physical pain is acknowledged publicly, emotional pain is hidden within the privacy of the family. The key aspect of the sick role is for sick people to fully rely on the family to sustain them. Solitude is considered unpleasant and is avoided even when people are well. When an individual is ill, it is considered particularly important that he or she not be left alone. A small crowd of family and neighbors often surrounds sick people. Family and visitors provide advice regarding appropriate treatments and recall similar situations experienced by themselves or others. When hospitalization occurs, family members expect to stay with sick people, even during examinations and therapeutic procedures. They are expected to ensure that sick people are not harmed and are receiving the best care possible. Protection of patients even includes shielding them from a serious diagnosis, such as cancer, until the family feels they are ready to learn about the diagnosis. Blood Transfusions and Organ Donation On the basis of the Christian Orthodox belief in the physical resurrection of the body, some Greeks and Greek Cypriots in the past rejected the concept of autopsy and did not readily accept organ donation. However, the Greek Orthodox Church is strongly pro-life and lately has been encouraging organ donation as an act of love. Blood transfusions are wholly acceptable and are common for people with thalassemia. 15 REFLECTIVE EXERCISE 30.5 Mrs. Fotini Papanicolaou, a 69-year-old Greek Cypriot who emigrated to England in 1962, was admitted to a surgical unit following several episodes of rectal bleeding and weight loss. She delayed going to the physician because she felt embarrassed owing to the nature of her problem. She treated herself with rice soup while also praying to God for healing. Upon admission, she was dressed in a smart black dress and was accompanied by her daughter. Mrs. Papanicolaou’s husband died 2 years earlier from a heart attack. She told the nurse that although she lived on her own, her married daughter lived nearby. She also has two married sons and several grandchildren. She is very proud of her children, one of whom is a dentist, another an accountant, and her daughter is a teacher. She is particularly proud that they all did very well, despite her and her husband’s having to work very hard to raise them. She said, “I have a wonderful and loyal family. I am very happy because my children and grandchildren are honorable human beings.They always follow my advice and guidance, and they all speak Greek, even my English daughter-in-law. My grandchildren’s Greek is not perfect but we understand each other.”The nurse noticed that Mrs. Papanicolaou carefully unpacked an icon of St. Cosmas and St. Damian and placed it with great care on her bedside table. “They will look after me,” she told her while crossing herself. In the meantime, her daughter went to the reception desk to speak to the manager whom she told that under no circumstances should anyone tell her mother she has cancer, if this were the diagnosis. She explained that her mother was still very sad following the death of her husband, and if she were given bad news, “this would kill her. My brothers and I want my mother to keep up her hopes that she will recover. We would like to handle any information about her condition as we know our mother very well and we know what is best for her.” 1. What cultural and religious values underpin Mrs. Papanicolaou’s health beliefs? 2. Is the fact that Mrs. Papanicolaou emphasizes that her children and grandchildren speak Greek important to the nurse? 3. Should nurses and other health-care providers go along with the request of Mrs. Papanicolaou’s children not to tell her what is wrong with her if her diagnosis happens to be cancer? 4. How can they deal with this if the patient asks to know exactly what is wrong with her? Health-Care Providers Traditional Versus Biomedical Providers In rural Greece, lay providers included midwives, bonesetters, and herbalists (who peddle herbs and tonics around neighborhoods). A woman who cures, particularly the evil eye, is known as a magissa, which is usually 2780_BC_Ch30_001-017 03/07/12 9:55 AM Page 16 16 Aggregate Data for Cultural-Specific Groups translated as “witch” but means “magician”; she may also be called doctor. However, in modern Greece, it is becoming rare to find people who practice traditional “medicine” (Athanasopoulou & Papadopou...
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