People of Indian Heritage. People of Turkish Heritage. People of Vietnamese Heritage. 900 words minimum

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

 You must cite at least 3 evidence-based references without counting the class textbook.

1

Chapter 37

People of Turkish Heritage
Marshelle Thobaben And Sema Kuguoglu

Overview, Inhabited Localities,
and Topography
Overview
Türkiye (Turkey), as it is written in Turkish, means
“land of Turks.” It is located in the Northern Hemi-
sphere, almost equidistant to the North Pole and the
equator. The shape of Turkey resembles a rectangle,
stretching in the east–west direction for approximately
1565 kilometers (972 miles) and in the north–south di-
rection for nearly 650 kilometers (404 miles). It is bor-
dered by Georgia, Armenia, and Nahcivan (Azerbaijan)
to the northeast; the Islamic Republic of Iran to the
east; Iraq and Syria to the south; Greece and Bulgaria
in the Thrace to the west; and Russia, Ukraine, and
Romania to the north and northwest (through the Black
Sea). The Anatolian peninsula is the westernmost
point of Asia, divided from Europe by the Bosporus
and Dardanelles straits. Thrace is in the western part of
Turkey on the European continent.

Turkey has a diverse geography. It is only slightly
larger than Texas with a total area of 783,562 square
kilometers (486,882 sq. mi.). Its land area is 769,632
square kilometers (478,227 square miles) and water
13,930 square kilometers (8565 square miles). About
3 percent of Turkey lies in Southeastern Europe
(Thrace) and the remainder in Southwestern Asia also
called Anatolia or Asia Minor. The sea surrounds
Turkey on three sides. The Mediterranean Sea turns
into the Aegean Sea along the west coast of Turkey,
facing Greece. In the northern part of the Aegean,
Çanakkale Bogazi (the Dardanelles) give passage to
the Marmara Denizi (Sea of Marmara), which then
opens into the Black Sea through the Istanbul Bogazi
(the Bosporus) (CIA World Factbook, 2011).

A comparable diversity can be seen in the human
history of Turkey where over the past ten thousand
years various civilizations have risen and fallen due to
invasions by newcomers, disease epidemics, and natu-
ral disasters such as earthquakes. It continues to be a
land of educational, religious, and cultural diversity.

The first historical reference to the Turks appears
in Chinese records dating back around 200 BC, which
refer to tribes called the Hsiung-nu (an early form of
the Western term Hun). They lived in an area bounded
by the Altai Mountains, Lake Baykal, and the north-
ern edge of the Gobi Desert, and are believed to have
been the ancestors of the Turks. In AD 552 many
ethnic Turks began to converge under the Gokturks,
and later under the Uygurs of Turkistan, followed by
the Mongols. In the 10th century, Turkey became fully
Muslim and accepted the Arabic script. Under the in-
fluence of the Muslim religion, Turkish language and
literature were developed, and the building of
mosques, schools, and bridges began (CIA World
Factbook, 2011).

The Seljuk Turks defeated the Christian Byzantine
Empire in 1071, resulting in the first of the Christian
crusades against Muslims. The Seljuks contributed to
medical science and established medical institutions
and hospitals in most cities. When the Seljuk Empire
collapsed at the end of the 13th century the Ottomans
established rule and in 1453 claimed Constantinople
as the capital, renaming it Istanbul. The modern
Turkish State is a descendent of the Ottoman Empire.
Based on a tolerance of differences among its sub-
jects, the Ottoman Empire endured for 600 years and
at its height stretched from Poland to Yemen and
from Italy to Iran.

In 1876 a constitutional monarchy was established
under a sovereign sultan, but separatist movements,
their subsequent repression, and an emerging Turkish
nationalism resulted in the “Young Turk” revolution
of 1908 and the erosion of the sultan’s powers. During
this time, modest advances in women’s rights began,
including the unveiling of nurses in the Balkan Wars
and more educational opportunities for women.

An armistice at the end of World War I left the
Empire stripped of all but present-day Turkey, occu-
pied by Greek, French, British, and Italian armies,
and established independence for Armenia and auton-
omy for Kurds in eastern Anatolia. However, the

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2 Aggregate Data for Cultural-Specific Groups

Treaty of Lausanne in 1923 officially ended Allied oc-
cupation, partitioning Armenia between Russia and
Turkey, reinstating the Kurds, and proclaiming an
independent Republic of Turkey, with Ankara as its
new capital.

Although Westernization had begun before inde-
pendence, Turkey’s president, Mustafa Kemal Atatürk,
became synonymous with Westernization and secular-
ism. During his presidency from 1923 to 1938, he
initiated many reforms, including banning the fez, out-
lawing polygamy, instituting marriage as a civil con-
tract, abolishing communal law for ethnic minorities,
removing Islam as the state religion, promoting nation-
alism and pride, instituting educational and cultural
reforms, making surnames obligatory, changing the
weekly day of rest from Friday to Sunday, and electing
17 female deputies to the National Assembly. Atatürk
died on November 10, 1938, but he is still revered as
the father of Turkey, and his image can be found in
most government and public offices. Turkey remained
neutral in World War II, but the postwar economy and
Cold War politics prompted U.S. economic and mili-
tary aid in 1947, forging the political ties that endure
today. Despite three bloodless military coups in 1960,
1971, and 1980, Turkey has a multiparty democratic
system, a Republican parliamentary democracy.

Turkey joined the United Nations (UN) in 1945,
became a member of the North Atlantic Treaty
Organization (NATO) in 1952, an associate member
of the European Community in 1964, and began acces-
sion membership talks with the European Union in
2005. Voters approved a referendum in September 2010
that made several constitutional changes including
Parliament having increased oversight and diminish-
ing the power of the judiciary and the military; addi-
tionally, it provided wider democratic freedoms for
Turkey’s citizens (CIA World Factbook, 2011; Infor-
mation Please, 2011). Turkey remains strategically
important to the West and is a strong ally of the
United States because of its geopolitical location and
its cultural and religious ties. What is presented about
the Turkish culture in this chapter is based on studies
from Turkey and on observations of and experiences
with Turkish immigrants in the United States.

Heritage and Residence
Turkey is one of the 20 most populated countries in
the world and has the second largest population in the
Middle East, and in Europe, after Germany. The first
national recorded population of the Republic of
Turkey was 13.6 million in 1927. The population in
2010 was 73.722.988 with 26 percent of the population
age 14 years and younger, and 7 percent age 65 years
and older. Roughly, 70 to 75 percent of the population
is Turkish, 18 percent Kurdish, and 7 to 12 percent
other minorities. Approximately, 75 of the population
lives in cities, such as Istanbul, Ankara, Izmir, and the

remainder in villages (CIA World Factbook, 2011;
Turkey’s Statistical Yearbook [TSY], 2010). The capital
city of Turkey is Ankara, but the historic capital, Is-
tanbul, remains the financial, economic, and cultural
center of the country.

Until the 1950s most Turks were peasants living in
isolated, self-sufficient villages with their extended fam-
ily and practical folk-belief system. Depeasantization,
migration, and urban settlement have continued, and
today squatter housing districts populated by rural
“immigrants” in major cities have resulted in perma-
nent low-income neighborhoods juxtaposed against
modern urban development. Changes in the social
structure and people’s expectations are also shifting.
For example, older people’s ability to live in their
familiar housing environments, particularly, in large
cities and metropolitan areas is forcing the government
to change its policy and to strive to provide affordable
housing and care centers for them (Turel, 2009).

Over the past two decades, Turkey has been hit by
several moderate to large earthquakes that resulted in
a significant number of casualties and heavily damaged
or collapsed buildings. This has been as a result of in-
adequate seismic performance of multistory reinforced
concrete buildings, typically three to seven stories in
height. A recent study indicates that a considerable
portion of existing building stock may not be safe
enough in Turkey (Inel, Ozmen, & Bilgin, 2008).

References and further reading may be available for
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As a result of extensive foreign trade, larger coastal
cities are undergoing many changes, which have re-
sulted in an urban environment with a dual character,
representing the traditional old way of life and the
ensuing new class. Every aspect of life and society is
being affected, including changes in values, recre-
ational activities, mass communication and media, and
women’s status.

Observations suggest that everyday practices of
the people, as well as their folk beliefs, are truly
changing. However, the Turks still depend on nuclear
and extended family and friends for adjustment, job
possibilities, and money.

Reasons for Migration and Associated
Economic Factors
The U.S. Census Bureau (2011) reported 190,000 peo-
ple of Turkish descent living in the United States. The
majority of them lived in the Northeast (39 percent)
and the least in the Midwest (13 percent). The Turkish
immigrant population in the United States differs sig-
nificantly from most of the Turkish population that
inhabits Europe, in terms of both demographic
makeup and socioeconomic status and integration. A
high proportion of Turks in the United States come
from the elite and upper-middle classes, interspersed

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People of Turkish Heritage 3

with smaller groups of middle-class students and
skilled laborers who are supported privately or by the
government.

Economic reasons, such as unemployment and
poor salaries, are the major reasons Turks leave to
work in other countries (İcduygu, 2008). Although
Turks have emigrated throughout the world, many
have lived in Western Europe since the 1960s and in
1970s North Africa and the Middle East, largely as a
result of “guest worker” programs. Since the 1990s,
Turkish workers have also moved to the neighboring
former communists’ countries such as Russian Feder-
ation and Ukraine (İcduygu, 2008). A large “Turkic
belt” stretches from the Balkans across Turkey, Iran,
Central Asia, the former republics of the Soviet
Union, and deep into the borders of Mongolia. This
belt includes many ethnic Turks who may share cul-
tural, linguistic, religious, and certainly historical links
with the people of Turkey.

Research studies have indicated that any concern
about excessive “brain drain” from the immigration
of some of Turkey’s intellectual, academic, and other
highly skilled professionals to the United States is
unfounded; it has not created a threat to Turkey’s eco-
nomic, scientific, social, and cultural development.
Additionally, Turks living in the United States usually
maintain strong bonds with their Turkish families and
pass on their Turkish cultural values, traditions. and
language to their children born in the United States
(Köser-Akçapar, 2006). Turks who have lived or stud-
ied in the United States generally have higher status
and greater employment opportunities in Turkey.

Educational Status and Occupations
Education is highly valued in Turkey by all socioeco-
nomic groups. Coeducational primary and secondary
education is provided at no cost and is guaranteed
under the Constitution. It consists of public and pri-
vate school at all levels, ranking from preprimary
(1 year), primary (8 years), high school (4 years), and
universities (4 to 6 years). In 1997, 5 years of compul-
sory primary school was extended to 8 years including
the middle schools. Primary school starts at age of 7
and ends at 13. High schools were extended from 3 to
4 years in 2005. High school includes a number of op-
tions, including general, technical, trade, vocational,
and theological training. Higher education institu-
tions include universities, faculties, institutes, higher
schools, vocational higher schools, conservatories, and
research and application centers (TSY, 2009). Students
who wish to pursue a university education must take
a state examination that determines both their admis-
sion to the institution and their subject of study. In a
recent study it was reported that only 22 percent of
the students who took the nationwide competitive en-
trance examination were placed in a university pro-
gram in Turkish universities. Turkey’s university

distance education program, one of the largest in the
world, annually accepts only about 15 percent of
students who apply (Tasçı & Oksuzler, 2010).

A high level of education exists among people of
Turkish descent living in the United States. Significant
numbers hold advanced degrees, and most are employed
in professional, managerial, and technical occupations.

Turkey’s Statistical Yearbook (2009) reported that
of the 48 percent of Turkey’s working age population
who participated in the labor force, 70.5 percent were
men and 26 percent were women; 45.8 percent worked
in urban areas (69.9 percent male and 22.3 percent
female) and 52.7 percent in rural areas (72 percent
male and 34.6 female). Of those workers employed in
the agriculture sector, 46 percent were unpaid family
workers; 76.9 percent of the unpaid family workers
were female, while 23.1 percent were male. The unem-
ployment rate was estimated to be 14 percent in 2009
(TSY, 2009).

Persons not in the labor force composed 52.1 percent
of the working-age population. The main subgroups
were persons who were busy with household chores
(44.9 percent), students, and disabled and retired per-
sons (TSY, 2009). For cultural reasons, many women
have continued to maintain their traditional roles and
do not work outside the home because it interferes with
their household responsibilities, including caring for
their children, and it may require them to work with
men from outside their immediate family.

Communication
Dominant Language and Dialects
A Uralic-Altaic language, Turkish is spoken by
90 percent of the population. The Turkish language
has approximately 20 dialects, including Yakut,
Chuvash, Turkoman, Uzbek, Kazakh, and the lan-
guage of the Gagavuz people. Differences in some of
the dialects are so great that they are considered
separate languages.

Through the centuries, Turks borrowed from
Arabic and Persian languages, and bits of “Turkified”
French and English can also be found. Until 1928,
Turkish was written in Arabic script, but under
Atatürk’s direction, a Turkish alphabet was developed
based on Latin script. The Turkish alphabet is much
like the English alphabet, although it does not have a
“w” or an “x,” and additional sounds are symbolized
by an “i” without a dot; a “ğ,” an “ö,” and a “ü” with
accents; and an “ş” and a “ç” with a cedilla, symbol-
izing “sh” and “ch,” respectively. The Turkish lan-
guage does not distinguish gender pronouns such as
“he” from “she” or “her” from “his”; therefore, Turks
learning English may inadvertently confuse these pro-
nouns. However, Turkish does distinguish a formal
from an informal “you,” signifying the importance of
status in Turkish society.

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Typical of many Mediterranean cultures, speaking
in loud voices is common; this may not signify anger,
but rather excitement or deep involvement in a discus-
sion. It can be common for more than one person to
speak at the same time or to interrupt another person,
which is not necessarily considered rude. However,
someone of lower status should not interrupt some-
one of higher status.

Cultural Communication Patterns
In the Turkish’s culture group affiliation is valued over
individualism. In fact, identity may be determined by
family membership, group, school, or work associa-
tions. An individual’s behavior is expected to conform
to the norms or traditions of the group, and Turks
tend to be more people and relationship oriented than
Americans. Although Turks may take longer than
Americans to form friendships, these relationships last
longer, formality is decreased significantly, and inter-
dependence is encouraged as a source of strength. In
this group-oriented culture, Turks generally do not
desire much privacy and tend to rely on cooperation
between family and friends, although competition
between groups can be fierce.

Turks value harmony over confrontation. How-
ever, Turkish communication style is characteristic of
Mediterranean cultures in which the outward show
of feelings is less restrained. For women, expressions
of anger are usually acceptable only within same-sex
friendships and kinship networks or toward those of
lower social status. Generally, women are not free
to vent their anger toward their husbands or other
powerful men.

Children are very accustomed to being held,
hugged, and kissed by family and friends of the
family. Touching, holding hands, and patting one an-
other on the back are acceptable behaviors between
same-sex friends and opposite sex partners. It is com-
mon to see same-sex friends, especially among the
older generations, holding hands or linking arms while
walking. Likewise, personal space is closer between
same-sex friends and opposite-sex partners; physical
proximity is valued as a sign of emotional closeness.
Very strict Muslims generally do not shake hands or
touch members of the opposite sex, especially, if they
are not related. Health-care providers are usually
looked upon as professionals and touch is allowed and
expected when necessary.

Eye contact may be used as a way of demonstrating
respect. When interacting with someone of higher sta-
tus, a person is expected to maintain occasional eye
contact to show attention; however, prolonged eye con-
tact may be considered rude or interpreted as flirting.

Turkish people tend to dress formally; men wear
suits rather than sports jackets and slacks on social
occasions. Women tend to dress modestly and wear

skirts and dresses rather than slacks. Black clothing
accented with gold jewelry is quite popular. More tra-
ditional Muslim women may wear very modest cloth-
ing and cover their heads with a scarf, either black or
a colorful print. However, styles continue to change,
and denim jeans and casual dress are becoming com-
mon among young people for less formal occasions.

Turks tend to openly display emotions such as hap-
piness, disgust, approval, disapproval, and sadness
through facial expressions and gestures. Two unique
gestures in Turkish culture include signals for “no”
and signs for approval or appreciation. “No” is indi-
cated by raising the eyebrows or lifting the chin
slightly while making a snapping or “tsk” sound with
the mouth. Appreciation may be expressed by holding
the tips of the fingers and thumb together and kissing
them. This signal is commonly used to express appre-
ciation for food.

Various phrases are commonly used by Turks.
Allahaismarladik (God watch over you) is said to
someone leaving and is responded to with gule gule
(go with smiles). Ellerine saglik (health to your hands)
communicates appreciation for a good meal, and
the cook responds with afiyet olsun (good appetite).
Cok yasa (live long) is said after someone sneezes with
a response of sen de gor (you see a long life, too).
Masallah (God protect from the evil eye) is said, for
example, when one has a healthy baby or when one
has achieved something good, whereas insallah (God
willing) is said when something is wished to happen.

Turkish people take pride in keeping their homes
immaculately clean, and one is expected to remove
one’s shoes inside the home. Most hosts in Turkey and
many in the United States offer slippers to their guests.
Whether wearing shoes or not, showing the sole of
one’s foot is considered to be offensive in Turkish cul-
ture. Women are expected to sit modestly with knees
together and not crossed.

Tortumluoğlu, Bedir, and Sevig (2005b) conducted
a qualitative study in a village in eastern Turkey by
examining individual cultural communication charac-
teristics. Comments from the participants included the
following:

• According to our religion, men who are not our
legal husband are not allowed to listen to our
voices. A woman cannot speak out loud and can-
not laugh in the community; she would be like bad
woman (woman over 65 years old).

• We do the duties of the bride (act like a servant)
for our husband’s relatives and mother-in-law. We
can never speak near them. To speak would be
disrespectful (bride, 15 years old).

• If the person across from us is a woman, we hug
and kiss, but if he is a man outside the family, we
don’t touch him. We will not eat at the same table
with men outside the family; we won’t be together

4 Aggregate Data for Cultural-Specific Groups

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People of Turkish Heritage 5

with them at weddings; we won’t sit next to them
on the bus; we wouldn’t go near them without cov-
ering our heads and bodies. We don’t look them in
the eye (women over 65 years old).

• We’re uncomfortable being examined or given a
shot by a man because they are strangers. It is very
sinful to go to a man even our husband and open
what is covered (female, age unknown).

• I would not take my wife, daughter, or daughter-
in-law to a male doctor. I would not show them to
unrelated men (man over 65 years old).

• Even if I knew my wife would die, I wouldn’t take
her to a male obstetrician (boy about 15 years old).

Temporal Relationships
Turks tend to have a relaxed attitude about time; social
visits can begin late and continue well into the night.
Whereas punctuality in social engagements is not
highly important, in business relationships punctuality
among Turkish Americans is gaining in importance.

Format for Names
Turks value status and hierarchy. Demonstrating
respect for those of higher status is mandatory and
determines the quality of interactions with a person.
A variety of titles are used to show respect and ac-
knowledge status. Strangers are always greeted with
their title, such as Bey (Mr.), Hanim (Mrs., Miss, or Ms.),
Doktor (Dr.), or Profesör (Professor). Members of the
family are also addressed using specific titles that rec-
ognize relationships, such as agabey (older brother or
older close male friend), amca (uncle or elderly male
relative or stranger), abla (older sister or older close
female friend), teyze (maternal aunt or older female
relative or older female stranger), and yenge (wife of
a brother or paternal uncle).

When friends or family members greet, it is custom-
ary for each to shake hands and to kiss one another
on each cheek. Traditionally, when greeting someone
of very high status or an elderly person, one might
grasp his or her hand and kiss it and then bring it to
touch one’s forehead in a gesture of respect.

Family Roles and Organization
Head of Household and Gender Roles
In a very traditional Turkish home the father is con-
sidered the absolute ruler. The concept of izin (per-
mission to leave to do something specific) captures this
significance. In rural and traditional families, women
may require izin from the head of household for doing
simple things, such as shopping, traveling, or visiting
their nurse midwife, physician, or dentist. The justifi-
cation is that the one who earns the money may spend
the money. The person who bestows izin is responsible
for the protection of the izinli (person who requires
the izin). Izin exhibits a structure of authority that is

both hierarchical and patriarchal; therefore, women
typically require izin more often than do men. A
young wife (gelin) may require izin from her husband
and from her mother-in-law. All are ultimately respon-
sible to the gelin’s father-in-law, who is usually the ab-
solute ruler of the traditional extended family
(Tortumluoğlu, Bayat, & Sevig, 2005a; Tortumluoğlu,
et al., 2005b).

Less-traditional families show more equality be-
tween spouses, especially in nuclear families in which
the wife is well educated and works outside the home.
Yet remnants of traditional family structure prevail
and the husband often takes on the role of ultimate
decision maker, especially in matters of finance.
Women may work full time outside the home in addi-
tion to assuming full responsibility for running the
daily activities inside the home.

Modern Turkish women tend to be more Western-
ized than some of their Middle Eastern or Muslim
counterparts. The first institution for higher learning
for women in Turkey was established in 1910. In 1917,
women earned the right to divorce and to reject polyg-
amous marriage. Atatürk’s new republic abolished the
old legal system based on religion and secularization,
giving women equal rights to education and no longer
requiring them to wear veils and long overgarments.
Legal marriage does not permit polygamy, although
some may practice it outside the law. Women have had
the right to vote since the early 1930s. In 1966, a charter
of the International Labor Organization passed the
equivalent of an Equal Rights Amendment, requiring
equal wages to both sexes for work of an equal nature.

Family Goals and Priorities
A woman’s age and the number, age, and gender of
her living children can influence her status in the fam-
ily and the community but varies depending upon
such things as education, religious practice, socioeco-
nomic level, urbanization, and professional achieve-
ment. Generally, a young gelin (woman aged 15 to
30 years) has the lowest status, middle-aged” woman
(30 to 45 years) has intermediate status, a “mature”
woman (45 to 65 years) has the highest status, and an
“old age” woman (65 years or older) is highly re-
spected but not very powerful. Working outside the
home is associated with status positively in the urban
context and negatively in the rural context. Profes-
sional employment and education raise the status of
women. Thus, health-care providers may find signifi-
cant variations regarding gender roles when working
with Turkish American patients.

Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Children are held very dear in the Turkish family, and
they are expected to act as young children, not small

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adults. They are accustomed to receiving attention
from family, friends, and visitors. Kissing children and
pinching their cheeks is quite common.

Once children enter school, they are expected to
study hard, show respect, and obey their elders,
including older siblings. This concept is referred to as
hizmet (duty or service). As children age, they are
socialized into more-traditional gender roles. Girls are
expected to help care for younger siblings, to help
at mealtimes, and to learn to cook. Traditionally,
children are not allowed to act out or talk back to
their superiors. Light corporal punishment is generally
acceptable. Circumcision is a major rite of passage for
a male child. This is a time of celebration within the
extended family, and newly circumcised boys are hon-
ored with gifts. Traditionally, boys can be circumcised
up to the age of about 12, although the modern trend
is to perform the circumcision in the hospital shortly
after birth.

Rankina and Aytaç’s (2008) research found that
the religiosity of the parents, the vast majority of
whom were Muslim, had no effect on the schooling of
Turkish children, whether male or female. In contrast,
patriarchal family beliefs and practices discouraged
the education of children, particularly girls. Their
findings also showed a father’s disapproval of daugh-
ters going out in public without a headscarf reduced
the likelihood of girls finishing or going beyond pri-
mary school. Thus, family cultural traits may continue
to represent a significant barrier to gender equality in
education (Rankina & Aytaç, 2008).

As children reach adolescence, they are expected to
continue to work hard in school and show respect for
superiors. The U.S. and Western culture and lifestyles
are exported to Turkey via the various social networks.
O’Neil and Güler (2010) explored the meaning high
school and university students attached to American
popular culture and found no evidence that that
American popular culture was in danger of over-
whelming Turkish culture. Young adults like to move
back and forth between indigenous and foreign prod-
ucts, including American ones, and as a result the re-
searchers felt this continued to embody a multiplicity
and hybridity that has characterized Turkish culture
for centuries.

Young people in the urban areas may talk more
about sex and engage more freely in sexual activity
than previous generations; however, sexuality largely
remains a taboo and is regarded as a forbidden topic
for social and cultural reasons. Though not common
among rural Turks, urban adolescents are beginning
to date in pairs, in addition to the more traditionally
accepted practice of group outings. However, sexual
interaction is strongly discouraged among youth and
the unmarried, especially young women. Virginity in
unmarried women is a strong cultural value. Accord-
ing to a study conducted with university students in

Turkey, 82.4 percent of female students and 86.5 percent
of male students were virgins when they married,
because of social rules and religious beliefs. Sixty-two
percent of female students practiced sexual abstinence
(Tortumluoğlu, Ersay, Pamukçu & Şenyüz, 2006).

Parents are expected to provide sexual education
within the family but often have insufficient knowl-
edge on the subject. Kukulu, Gursoy, and Gulsen
(2009) recommended that structured sex education
that incorporated knowledge of specific aspects of
the Islamic culture experience would help to pro-
mote healthy sexual behavior and decrease sexual
myths, such as marrying a virgin increases sexual
satisfaction.

Successful completion of high school or university
education is a first step toward adulthood. Although
education earns respect in the family, the concept of
hizmet still applies. A further step for men is the
completion of required military service (askerlik), the
duration of which varies depending on the population
and the needs in Turkey. In addition, employment and
earning money are symbols of adulthood for both
men and women.

Marriage is perhaps the most important develop-
mental task for adulthood. Young people generally
live in their parents’ home until they are married,
unless school or work necessitates other arrange-
ments. This practice may be quite different among
assimilated Turks in America. The Turkish word for
marriage, evli, translates to “with house.” Family re-
mains an important factor in marriage. Marrying into
a “good family,” having a high-status occupation, and
achieving wealth are means of attaining higher social
status for both the individual and the entire family.
Family members’ accomplishments raise the entire
family’s status, whereas failures have an equally broad
effect. Thus, individuals must always consider what
impact their actions will have on the family. Often,
they consult parents or other family members before
making major decisions.

Arranged marriages occurred most often among
less-educated, older individuals. Family initiated mar-
riages range from rare contractual agreements between
parents to the relatively common introduction and
gentle encouragement of a newly formed couple. The
more traditional family will “choose” a spouse for a
son by considering the individual’s personality, talents,
and appearance. For a daughter, it is more important
to consider the individual and his family because she
marries into the husband’s family.

Elders are attributed authority and respect until
they become weak or retired, at which time their
authoritative roles diminish. However, respect always
remains a factor.

Although financial independence is valued in Turkish
culture, independence from the family is not encour-
aged. Adult children, especially men, remain an integral

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People of Turkish Heritage 7

part of their parents’ lives and parents expect their chil-
dren to care for them in their old age which is regarded
as normal, not as an added burden. Grandparents
play a significant role in raising their grandchildren,
especially if they live in the same home.

The extended family is very important. Even the ap-
parent increase in nuclear households does not rule
out the networks among closely related families.
Whether or not they live under the same roof, a young
family may still live under the supervision of the hus-
band’s parents or, at least, maintain an interdependent
relationship. In many Turkish families, aunts, uncles,
cousins, and in-laws form the extended family. Visits
with local relatives are assumed and mandatory when
traveling. Extended family members have a social re-
lationship and may also play an authoritative role
within the network. A cooperative relationship, which
includes sharing child care, labor, and food, when
necessary, and providing companionship, is essential be-
tween women in an extended family or neighborhood.

Alternative Lifestyles
Divorce is becoming more common, but it remains
socially undesirable, especially for women, for whom
remarriage opportunities may be limited to divorced
or widowed men. Widows, however, are generally
taken care of by their late husband’s families and de-
pending on their age and socioeconomic background
may have the option to remarry. Premarital cohabita-
tion and unwed motherhood are strongly discouraged,
especially among more-traditional families, although
living together before marriage is not uncommon in
larger cities and among immigrant Turks.

Even though being a gay man or lesbian is not a
crime or considered a disease, homosexuality is only
beginning to be received “at a distance.” In Oksal’s
(2008) study of familial patterns of attitudes toward
lesbians and gay men, he found that young adults’ at-
titudes toward lesbians and gay men were more liberal
than those of their parents. However, on the whole,
Turkish family members have quite negative attitudes
toward homosexuality, most likely linked to religious
beliefs. Most Turkish people are in agreement with
Islamic values that regard homosexuality as a sin and
unacceptable (Oksal, 2008).

Workforce Issues
Culture in the Workplace
Because Turkey is a group-oriented culture, the Turkish
workplace may be more team oriented than in the
United States. Turkish relationship orientation may
lead to dependence on personal contacts and networks
to accomplish tasks, and from the American perspec-
tive, developing these relationships and networks may
appear as nepotism or as too much socializing. In con-
trast, the Turkish immigrant employee may not feel a

sense of belonging in a less relationship-oriented
American work milieu.

Hierarchical structure is highly pervasive through-
out Turkish culture and the workplace is no excep-
tion. Turkish employees expect an authoritative
relationship between superior and subordinates.
However, indirect criticism is expected and appreci-
ated in order to “save face.” A Turk may be highly
offended if openly criticized, especially in front of
other people. They may be reticent about asking
questions for fear of exposing a lack of knowledge.
Yet, Turks may exhibit modesty when applying for
a job or a promotion relying more on the recommen-
dations of others than on pointing out their own
strengths.

Because military service is mandatory for men who
wish to maintain their Turkish citizenship (even those
living abroad), young Turkish men who reside outside
Turkey may need to take an extended leave to com-
plete their military service.

Issues Related to Autonomy
Because most Turkish immigrants speak English,
language barriers in the workplace may be only sub-
tle. However, dealing with differences of opinion be-
tween parties of equal hierarchical level may present
difficulty. Turks perceive that aggressive face-to-face
confrontation may cause relationships to deteriorate;
therefore, the dominant means of conflict resolution
is collaboration reinforced by compromise and
forcing. Compromise and avoidance behaviors are
more likely among peers, whereas accommodation
behaviors are used with superiors. Their way of han-
dling differences of opinion is brisk and clear-cut
when an authority relationship exists between the
two parties.

Turkey is known for its high-power distance (the
psychological and emotional distance between supe-
riors and subordinates), respect for authority, central-
ized administration, and authoritarian leadership
style. In Turkish culture a manager’s authoritative
control is often more important than the achievement
of organizational goals.

Biocultural Ecology
Skin Color and Other Biological Variations
The Turkish population is a mosaic in terms of
appearance, complexion, and coloration because of
historical migration and inhabitance patterns. Ap-
pearances range from light-skinned with blue or green
eyes to olive or darker skin tones with brown eyes.
Mongolian spots, usually found at or near the sacrum,
are common among Turkish babies and should not be
confused with bruising. Racially, 75.6 percent of the
men and 77.7 percent of the women are in the brakise-
fal (having a short, broad head) category, which is a

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shared symbol of the Dinaric Alpines (Gültekin &
Koca, 2003).

Diseases and Health Conditions
According a recent health survey (TSY, 2008) that was
sent to all settlements in the territory of the Republic of
Turkey, 71.9 percent of men and 55.5 percent of women
stated their general health status was good or very good;
75.2 percent of men and 58.8 percent of women living
in urban areas stated their health was good or very
good; while only 63.8 percent of men and 48.4 percent
of women in rural areas stated their health status was
good or very good (TSY, 2008). Life expectancy at birth
in 2010 was estimated to be 72.23 years for the total
population (70.37 years for males and 74.19 years for
females) (CIA World Factbook, 2011).

The leading causes of death include major vascular
diseases (ischemic heart disease, stroke), chronic ob-
structive lung disease and lung cancer in men, perinatal
problems, lower respiratory infections, and diarrheal
diseases. Injuries cause about 6 to 8 percent of deaths,
although this may be an underestimate (Akgun et al.,
2007). There is also a high prevalence of obesity, hyper-
tension, and diabetes, especially in Turkish women.

Malaria is still problematic in the southeast part of
the Turkey (CDC, 2011). Lactose intolerance rises
among populations farther south and east in Europe.
The Black Sea region tends to have a relatively high
incidence of helminthiasis (intestinal worm). Endemic
goiter associated with iodine deficiency, despite iodine
prophylaxis (ID), still exists in 27.8 percent of the
Turkish population. It has been eliminated in most of
the urban population; however, it is prevalent in rural
areas and in particular geographical regions (Erdoğan
et al., 2009). Tuberculosis continues to be prevalent in
the Aegean areas and in southeastern Anatolia.

Behçet’s disease (BD) is a systemic inflammatory
disorder of unknown etiology with a strong genetic
component. It is characterized by recurrent attacks of
oral aphthous ulcers, genital ulcers, skin lesions,
uveitis or other manifestations affecting the blood ves-
sels, gastrointestinal tract, and respiratory and central
nervous system; the inflammatory lesions at particular
sites, such as the eyes, brain, or major vessels can re-
sult in permanent tissue damage and cause chronic
manifestations or even death (Gul, 2007). It is preva-
lent in Japan and China in the Far East to the
Mediterranean Sea, including countries such as
Turkey and Iran, and usually starts in the second and
third decade of life. The male-to-female ratio is ap-
proximately equal, although BD runs a more severe
course in men and in those aged <25 years at onset (Gul, 2007).

Beta thalassemia is the most common inherited
blood disorder in Turkey and represents a major pub-
lic health problem. It is characterized by reduced or
absent beta globin gene expression. Beta thalassemia,

alpha thalassemia, and sickle cell anemia are also
the most common hemoglobinopathies in Turkey.
Although the overall frequency of beta thalassemia in
Turkey is 2 percent, there are significant regional
differences. The incidence of beta thalassemia in
the Denizli province is estimated between 2.6 and
3.7 percent (Bahadir et al., 2009).

The Turkish government has national health-care
prevention programs for communicable diseases, to-
bacco control, cardiovascular diseases, chronic respi-
ratory diseases, cancer, and a newly developed Obesity
Prevention and Control Program (Ministry of Health
of Turkey, 2010).

Because of the diversity in climate, topography, and
culture in Turkey, it is essential to ascertain the specific
geographic origin of a Turkish immigrant. Health-care
providers may need to assess newer Turkish immi-
grants for tuberculosis, malaria, or other potential
health problems found in Turkey.

Variations in Drug Metabolism
The literature reports no studies regarding variations
in drug metabolism and interactions for Turks. Given
the diversity of ethnicity, one cannot extrapolate data
from other ethnic or minority groups and apply them
to Turkish peoples. This is one area in which research
is needed.

High-Risk Behaviors
Beser, Bahar, and Buyukkaya (2007) studied health-
promotion lifestyle profiles of 264 Turkish workers to
determine the factors that affect their lifestyles. The re-
search found that the workers did not have the desirable
degree of health responsibility because they did not
consider health controls as a necessity to lead a healthy
life. If individuals can do their daily routines and if
their health does not prevent them from going to work,
they do not consider themselves ill. The workers ob-
tained the highest scores on interpersonal support
(family members support each other during difficult
times) which is the hallmark of Turkish culture.

There is a significant risk among farmers exposed
to exogenous carcinogens such as artificial fertilizers
and insecticides.

Cigarette smoking is widespread in Turkey and
tends to start at an early age. Turkey, a major producer
of tobacco in the world, has instituted very limited
anti-tobacco activities. Passive smoke has been asso-
ciated with an increased incidence of asthma and
allergic diseases among Turkish children.

Despite stereotypes promoted in the American film
Midnight Express, drug use is not common among
mainstream Turks. They tend to consume less alcohol
than Americans or Europeans, perhaps as a result of
the Muslim culture that discourages more than mod-
erate alcohol use. In general, it is more acceptable
for men than women to drink alcohol; however, this

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is becoming less so as Turkey becomes more Western-
ized. In a recent national health survey, 63.9 percent
of males and 93 percent of females never consumed
alcohol (TSY, 2008).

There is a high risk for sexually transmitted diseases
in Turkey. The tendency of men in Turkey, which has
a particularly young population, to view themselves
as strong and immune to disease and the positive view
of men in traditional Turkish culture to have sexual
relationships with more than one woman increases the
danger for both the man and his wife.

Health-Care Practices
Health beliefs and behaviors of the Turkish immigrant
may vary according to the variant cultural character-
istics (see Chapter 1). Health-seeking behaviors pro-
moted by the Turkish government include a strictly
enforced law requiring the wearing of seat belts in
motor vehicles. Helmet laws for motorcycle drivers
have not been instituted.

Aerobics studios and athletic facilities exist in major
urban areas, but the idea of cardiovascular fitness is
relatively new, and Turks may be more likely to seek
outdoor activities such as picnicking or, among men,
playing soccer. However, because many Turks, espe-
cially in rural areas, do not have modern conveniences
such as elevators in apartment buildings, automobiles,
or clothes dryers, their daily life inherently requires
more caloric output than life in the United States, an
important issue to keep in mind when adjusting to life
in the United States.

Nutrition
Meaning of Food
Turks take great pride in the fact that French, Chinese,
and Turkish cooking are reportedly the three foremost
cuisines in the world. Turkish cuisine is influenced by
the many civilizations encountered by nomadic Turks
over the centuries, as well as by a mixture of delicacies
from different regions of the vast Ottoman Empire.
Therefore, food choices are varied and tend to provide
a healthy, balanced diet.

Food is a highly valued symbol of hospitality that
communicates love and respect to those for whom it
is prepared. Whereas a typical family dinner may be
simple, guests are generally served a bountiful array
of dishes—more food is always better. Tea and a
snack are always on hand for visitors. Dinner guests
may have difficulty finishing everything on their plates
because hostesses may relentlessly offer to replace
what has been eaten. Polite guests refuse the first offer,
but the hungry need not worry—offers are made again
and again.

Food is generally presented in an appetizing man-
ner, and many foods have names intended to be entic-
ing or, at least, entertaining. For example, kadinbudu

köfte translates as “lady’s thigh meatballs”; imambay-
ildi, or “the priest fainted,” is an eggplant dish
with lots of garlic; and asure, or “Noah’s pudding,”
is a dessert in which more than two of everything
is included.

Turks typically eat their evening meal later than
most Americans, at about 8 p.m., something health-
care professionals may need to take into considera-
tion when teaching Turkish American patients about
medication therapies.

Common Foods and Food Rituals
Turkish cooking is quite delicious, not terribly spicy,
and prepared artfully and fastidiously, because Turkish
appetites tend to be discriminating. Breakfast is typi-
cally a simple meal of white feta cheese (beyaz peynir),
olives, tomatoes, eggs, cucumbers, toast, jam, honey,
Turkish sausage (Turk sucugu), and Turkish tea. Hot
midday or evening meals may include any of the
following foods:

• Çorba (soups) range from light to substantial.
Meze (hors d’oeuvres) include a great variety of
small dishes, either hot or cold, such as yaprak
dolma (sarma) (stuffed grape leaves in olive oil),
olives, circassian or çerkez tavuğu (chicken with
walnut sauce), çiroz (dried mackerel), leblebi
(roasted chick peas), or sigara böreği (a savory
cheese pastry fried until crispy). Meze may be ac-
companied by rakí, traditional anisette liquor dis-
tilled from grapes that is served with water over ice
and drunk slowly. Sharing a glass of rakí is usually
toasted with the phrase Şerefe (to your honor).

• Salads include lettuce, tomatoes, cucumbers,
onions, and other raw vegetables with a dressing of
olive oil and lemon juice or vinegar. Olive oil and
lemon are staples in Turkish culinary preparation.

• Turks generally prepare meat in small pieces in
combination with vegetables, potatoes, or rice.
Famous Turkish cuisine includes köfte, small spicy
meatballs, and kebab, skewered beef or lamb and
vegetables. Whereas poultry is less common, fish
has a special place in Turkish cuisine because of its
variety, freshness, and availability.

• Turkey is the birthplace of yogurt, which is an essen-
tial part of the Turkish diet and is generally served
with hot meals rather than as cold breakfast food.

• With the abundant produce in Turkey, vegetables
play a large role in the Turkish kitchen. Vegetables
are served cooked or raw, hot or cold, as part of a
stew or casserole, or stuffed (dolma) with meat,
rice, and currants.

• Rice and börek are important parts of Turkish
culinary tradition. Börek is made by wrapping
yufka (thin sheets of flour-based dough) around
meat, cheese, potato, or spinach and then frying
or baking until the dough is flaky.

People of Turkish Heritage 9

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• Turkish desserts fall into four categories: rich and
sweet pastry, such as baklava; puddings; komposto
(cooked fruits); and fresh fruits. In fact, most meals
conclude with fresh fruit and coffee or tea.

• Turkish kahve, from which the English word “cof-
fee” is derived, is famous for its dark, thick, sweet
taste. Cooked with a cezve (coffee pot), it is served
in small, demitasse cups. Coffee grounds left in the
cup can foretell one’s future. Turkish çay (tea) is
prepared using a two-tiered çaydanlik (teapot),
allowing the hostess to serve guests according to
their preference for koyu (dark) or açík (light)
tea. Ayran, a mixture of yogurt and milk, is the
national cold drink and is drunk by children and
adults alike.

The Muslim religion requires abstinence from eat-
ing pork and drinking alcohol, but not all Muslims
abstain, depending on their degree of religious prac-
tice. Given the diversity of food options for Turks in
America, health-care providers need to provide di-
etary counseling according to the individual’s unique
food choices and practices.

The Islamic tradition of Ramazan or Ramadan is
a month of fasting (oruç tutmak) observed by practic-
ing Muslims throughout the world. During Ramazan,
one is not allowed to eat or drink anything from sun-
rise to sunset as a test of willpower and as a reminder
of the preciousness of the food provided by a gracious
Allah (God). Many Muslims also stop smoking dur-
ing this month. Delicious unleavened bread called pide
is sold everywhere only during Ramazan. Observance
of this tradition varies from some not observing it to
others who strictly follow the ritual and do not bring
anything to their mouth during daylight hours. Sunni
Muslims, the majority of Muslims in Turkey, start
practicing Ramazan at age 10 or 11, and some believe
that women have the duty to fast even during preg-
nancy and the postnatal period. Generally, pregnant
and postpartum women, travelers, and those who are
ill are excused from fasting, but they may be required
to make up lost time at a later date.

Ramazan is determined by the lunar calendar and,
therefore, can take place at various times in the year.
Typically, Turks who are fasting eat breakfast, or
sahur, before dawn and before ezan (the call to prayer).
The evening meal, iftar, is something all look forward
to with great anticipation, and Turkish women who
almost invariably do all the cooking create veritable
feasts each night. This is a time to visit with friends
and relatives, so dinner invitations abound during Ra-
mazan. In a sense, Ramazan is a spiritual and physical
cleansing that brings the community together.

Despite fasting many Turks actually gain weight
during the month because of their inactivity during the
day and eating well at the end of each day. Fasting
also can cause a variety of digestive problems and may

endanger the health of a pregnant or postnatal woman
and her baby. Health-care professionals should provide
factual information regarding these issues.

Another holiday based on Islamic practice is the
Kurban Bayram or sacrificial holiday. In Turkey, an
animal such as a goat or sheep may be butchered
and the meat divided and distributed to the poor.
New Year’s Day is celebrated much like American’s
Christmas, with a large feast including a turkey dinner,
the exchange of gifts, sometimes a tree, and socializing
with family and friends.

Dietary Practices for Health Promotion
Traditional dietary practices linking food to health
have carried through to the modern day, even among
highly educated Turks. Molasses and baklava, lokum
(Turkish delight), tahini, and honey and nuts and
raisins are believed to increase strength and sexual
vigor. Fruits, especially bananas, oranges, tangerines,
and apples, are brought to convalescing people help-
ing them to regain their strength and aid in the healing
process. Milk, which is not commonly drunk by
adults, is considered more medicinal than yogurt.
Chicken soup is a common remedy for cold and flu
symptoms. An ebe kadin or kadin ana, a traditional
midwife or healer in Turkey, relies on various herbs
and home remedies to heal patients. Ebegömeci, a
spinach-like leaf or herb, may be prepared for topical
or oral use to treat inflammation, infection, and some-
times infertility. Ihlamur tea, tarçin (cinnamon), kant
(hot sugar water), ginger, mint, and various roots are
used separately or in various combinations to treat
rheumatism, low blood pressure, intestinal gas, and
colds and flu. Nettles may be used topically for
rheumatism, arthritis, and varicose veins.

A folk remedy for diabetes involves boiling olive
leaves and, after refrigerating, drinking the juice. Lapa,
a watery rice mixture with a gruel-like texture, or a
boiled potato may be used to treat diarrhea; this is fol-
lowed by yogurt to replace the natural flora of the in-
testines. Health-care professionals need to ask Turkish
patients if they are using folk dietary practices and may
incorporate these into prescription therapies. Some tra-
ditional Turkish foods unavailable in most parts of the
United States include pastirma (Turkish version of
pastrami), sucuk (Turkish sausage), and various types
of cheeses such as kaşar. Yufka is an essential ingredi-
ent in many Turkish recipes such as börek, although
phyllo dough may be an adequate substitute.

Nutritional Deficiencies and Food Limitations
Population groups at greatest risk for malnutrition are
preschool children, female adolescents, mothers, and
the economically disadvantaged. Health-care providers
may need to consider extensive nutritional assessments
for more recent Turkish immigrants.

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Another important health problem is rickets,
caused by vitamin D deficiency. Rickets is seen more
frequently in children under 2 years old and has a 6 to
20 percent prevalence, with the leading causes being
not taking children outside into the sunshine and not
feeding children sufficiently from the dairy food
group. Cinar et al. (2006) reported that 62 percent of
mothers who had children from 0 to 12 months old in
Sakarya, Turkey, believed that sunlight was “harmful”
for their children; however, the majority (80 percent)
of mothers named one benefit a child received from
intentional baby sunning. “Sun causes cutaneous
diseases” was the most frequently cited harm (Cinar
et al., 2006). Other prevalent nutritional problems in
some communities in Turkey are skin, mucosa, eye,
and lip symptoms from riboflavin (vitamin B2) and
vitamin A deficiencies and bleeding gums from
vitamin C deficiency.

Turks who are Muslim are forbidden to eat meat
from a carcass, blood, pork, or the meat of animals
sacrificed in the name of anyone other than Allah.
The list of forbidden animals also includes those with
tusks, wild game, and those torn apart by wolves,
bears, dogs, squirrels, and foxes. The meat of birds
that hunt with their claws is also forbidden by reli-
gious leaders. Additionally, the list of animals includes
animals such as snakes, frogs, turtles, and crabs (Meals
in Koran, 2006).

Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
In 1975 approximately five children were born to each
Turkish woman, but by 2010 that figure dropped to 2.18
children (CIA World Factbook, 2011). According to the
2008 Turkey Demographic and Health Survey, there is a
tendency for women to have children early in the child-
bearing period (7 out of 10 births took place before the
age 30); however, the 25- to 29-year age group had the
highest age-specific fertility rate, which indicates there is
a trend toward postponing childbearing until later years
(Turkey Demographic and Health Survey, 2009). Infant
mortality rates were 24.84 deaths/1000 live births in 2010
(CIA World Factbook, 2011). There is a diminishing
trend in the fertility ratios with the beginning of wide-
spread use of modern contraceptive methods, the births
in the very young or advanced ages, and the births fre-
quently are of the foremost causes of maternal death
(Kara et al., 2010).

Motherhood is accorded great respect and preg-
nant women are usually made comfortable in any way
possible, including satisfying their cravings. Pregnant
women may continue their daily activities or work as
long as they are comfortable. Education efforts have
increased prenatal practices throughout Turkey. In
urban areas, monthly prenatal visits are usually made

with an obstetrician. In rural areas in which physicians
may be scarce, midwives provide care to pregnant
women. However, pregnancy is considered by a num-
ber of people as a shameful condition that ought to
be concealed (Ayaz & Efe, 2008).

Folk Practices for Fertility
In traditional Turkish culture, one of the most impor-
tant desires of a married woman is to have a child. A
woman who has not had a child is faced with social
pressure and accusations and, thus, may try to use
some traditional practices to increase fertility. Some
women damage their bodies by using these practices;
sometimes, the damage is permanent (Kayhan et al.,
2006). Some of the traditional practices women use to
increase fertility include burying the woman in sand,
placing her on heat, taking her to thermal springs, ap-
plying a poultice, talking to a religious leader, going
to a saint’s gravesite, having an amulet written, putting
a mixture inside the womb, eating meat and wheat
brought back from the pilgrimage, sitting on the pla-
centa of a newborn baby, boiling parsley and sitting
over its steam, sitting over a milk steam, and going to
the hamam (Turkish bath) (Kayhan et al., 2006).

Modern and Folk Practices for Preventing Pregnancy
According to 2008 Turkey Demographic and Health
Survey, 73 percent of married women used some
method of contraception. Modern contraception was
used by 46 percent of the women while 27 percent
used traditional methods (25 percent used withdrawal
[coitus interruptus]). The most prevalent modern con-
traceptive methods used were IUDs (17 percent) and
the pill (14 percent); additionally, female sterilization
was used by 8 percent of the married women (Turkey
Demographic and Health Survey, 2009). Women who
prefer the traditional method of coitus interruptus to
prevent pregnancy believe it is free from side effects,
a clean method, and unlike condom use, did not
seriously affect the sexual pleasure gained by their
partners (Ciftcioglu & Behice, 2009).

Other folk practices and beliefs that relate to pre-
venting pregnancy include (1) birth control pills cause
cancer and make you fat; (2) an IUD can migrate to
the stomach or invalidate ritual cleansing; (3) vasec-
tomy ends a man’s sexual life; and (4) using some
methods is a sin (Kayhan et al., 2006). Others include
vaginal douche, calendar method, putting lemon or
alum on the sexual organs, drinking henna water, put-
ting aspirin in the vagina, and putting honey and
horseflies in food and eating it (Kayhan et al., 2006).

Modern and Folk Practices for Terminating
Pregnancy
The risk of unwanted pregnancy increases with inad-
equate information about birth control, negligence,
poverty, low level of education, and inappropriate

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protection methods (Kavlak et al., 2006). According
to the law, married women may request to have an
abortion with the consent of their husbands; single
women who are older than 18 years can have an abor-
tion at their own request; and single women less than
18 years can have an abortion with the consent of
their parent (Kavlak et al., 2006; Turkey Population
Planning Law, 1983). The rate of voluntary abortion
is about 11 percent (Kavlak et al., 2006). The wide-
spread use of abortion has had a significant effect on
decreasing the fertility rate. It is common practice that
women in families who have chosen to limit the num-
ber of children first seek to have an abortion and then
they learn about methods to prevent pregnancy and
begin to use them (Kavlak et al., 2006).

Traditional methods used to terminate pregnancy
include pressing on the abdomen with a stone, mixing
matches with trash and putting it in the womb, carry-
ing heavy loads, aborting the child with a beetroot
branch and chicken wing, boiling poison ivy leaves
and standing in its heat (Kayhan et al., 2006).

Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
The pregnant Turkish woman is encouraged to keep
her strength up by eating foods that are rich in nutri-
ents; however, in poorer families, these nutrients may
not be available. Many pregnant women take prenatal
vitamins, drink a lot of milk, and apply salves such as
Vaseline to avoid stretch marks. Light exercise, such
as walking, is encouraged, but weather conditions
often hamper such efforts because Turks generally
tend to avoid wet or cold weather fearing its ill effects
on one’s health.

Modern and Folk Practices to Facilitate Childbirth
and Postportum Period
Most women prefer hospitals for physician-assisted
child delivery; however, midwives are accepted in rural
areas when a physician is not available. Particularly in
rural areas, the more natural squatting or semi-sitting
position is preferred to the supine position during de-
livery. Expressions of discomfort and pain are quite
acceptable, although Laz women from the Black Sea
area tend to be stoic.

Some traditional women believe they should not eat
fish, sheep’s heads, sheep’s trotters, and rabbit meat
during pregnancy because eating fish would cause the
baby to be mute, not to develop bones, and to float
like a fish. Eating sheep’s heads or trotters is thought
to cause the baby to have a runny nose and consump-
tion of rabbit meat to cause a cleft lip (Ayaz &
Efe, 2008).

Folk practices used to make childbirth easier in-
clude unlocking places that are locked, untying the
woman’s hair ribbons, unbuttoning buttons, standing
straight and turning so the child will move, drinking

water that has been prayed over by religious leaders,
enclosing the woman around her waist and rocking
her three times, and putting her in a blanket and rock-
ing her three times (Kayhan et al., 2006). Still others
include jumping from a high point because it facili-
tates birth, bumping women in the back and shaking
them since it makes birth easier, shaking women in a
sheet to facilitate the birth process, and anointing the
genitals to make the birthing process easier (Ayaz &
Efe, 2008).

It is becoming more acceptable and more common
for the husband and other relatives to be present dur-
ing the birthing process as it is with the immigrant
Turkish population in the United States.

The postpartum period can last up to 40 days.
During this time, a woman is under the effect of many
supernatural powers. There is a folk saying that for
40 days the grave is open for the woman postpartum.
She is not left alone during this time, which is called
lohusa. At the end of the 40 days she returns to nor-
mal life. She is bathed with abundant water and
prayers are read. The infant is also bathed in a similar
manner. Eating boiled potatoes, thick rice soup, cola
with aspirin, ground coffee–lemon mixture, apricot,
roasted chickpeas, or olive paste and spreading herbal
dough on the stomach are also widely used (Ogut &
Gurkan, 2005).

Light exercise is encouraged during the postpartum
period, and bathing, an important part of the Muslim
tradition, is strongly recommended. A special food
called loğusa serbeti or loğusalik is served to the
woman. Loğusalik is a sweet, sherbet-like foodstuff,
prepared by dissolving loğusalik beads (available in
stores in Turkey) in hot water. This high-carbohydrate
mixture is said to increase the woman’s strength. Post-
partum women drink hot soups and other fluids such
as milk, especially when breastfeeding. Most Turks re-
alize the value of breastfeeding, which is practiced
modestly.

Folk Practices for Newborns and Children
Newborns are treated as cherished gifts. Healthy ba-
bies are greeted with Masallah (may God bless and
protect). The 2008 Turkey Demographic and Health
Survey reported that nearly all infants are breastfed
for the first months after birth (Turkey Demographic
and Health Survey, 2009). The rates of Cesarean de-
livery are increasing which is having an effect on the
initiation and duration of breastfeeding (Cakmak &
Kuguoglu, 2007). There are many folk practices asso-
ciated with newborns. One is to not give water or
breastfeed a newborn until the call to prayer has been
announced three times; the belief is that this makes
the baby become patient, intelligent, and religious.
The first milk (colostrum) from the mother’s breast is
considered impure so it is discarded and instead the
baby is fed with sugary water, cow or goat’s milk,

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honey, and butter (Ayaz & Efe, 2008). Another tradi-
tional practice is to bathe a newborn immediately after
birth in salt water to have healthy skin and to prevent
sweat from being offensive when they grow older. It is
also believed to prevent diaper rash as well as some
diseases and to cause future injuries to heal rapidly.
This practice is called salting or striking the child
with salt. The infant may also have salt put in his or
her mouth to prevent bad breath which can cause
dehydration (Ayaz & Efe, 2008).

When a newborn infant has jaundice, a variety of
traditional practices may be used, including tying a
yellow ribbon to the crib, dressing the infant in yellow
clothes, having the infant drink her or his own urine,
using a razor blade to cut between the infant’s eye-
brows and between his or her fingers, putting a gold
coin on the infant, dressing the infant in yellow cloth-
ing, and bathing the infant with gold water and the
yellow yolk of egg (Ayaz & Efe, 2008).

When the umbilical cord is cut it is given a name;
the umbilical cord’s name is used to call the person
when they die. The name is given by saying it three
times into the right ear during the call to prayer.

A small blue bead called a nazar boncuk, believed
to protect the child from the “evil eye,” is usually
placed on the child’s left shoulder. This practice is
believed to protect the child from the evil angel whis-
pering in the left ear, often portrayed in Christian
religious art. However, it may be swallowed or aspi-
rated by the infant. A child may be taken to a hoca
religious leader to have an amulet written to recover
from an evil eye.

Dressing the baby with a sand-filled diaper (holluk),
which is spreading fine soil over the baby’s diaper to
absorb wetness and to keep the baby warm and com-
fortable,. It is done to prevent diaper rash and is be-
lieved it promotes harmony with nature; the earth is
regarded as nutritious and a source of power. It can
be harmful because it may cause parasitic infections
and tetanus in the newborn, whose immune system is
not fully developed (Ayaz & Efe, 2008).

Other traditional practices are not breastfeeding a
baby with diarrhea or feeding a baby with diarrhea a
mixture of coffee and yogurt, which can be quite
harmful because diarrhea is a common cause of infant
mortality. Another is putting soap into the rectum
when a child is constipated, which may harm the baby
as the soap irritates the intestinal mucous membrane
(Ayaz & Efe, 2008).

Other folk practices include placing iron under the
baby’s mattress to protect against anemia and placing
a red bow on the crib to distract any envy or negativ-
ity. In eastern Turkey, an infant may be put under soil
based on the belief that keeping the infant warm will
keep her or him as healthy as the soil. This practice
can irritate the infant’s skin and even result in death
from tetanus.

Swaddling infants, a common practice, has benefits
such as helping infants sleep longer, decreasing phys-
iologic distress, improving neuromuscular develop-
ment, soothing pain, and in excessively crying infants
reducing crying and regulating temperature. However,
it can also cause hyperthermia, hip dysplasia, and
respiratory infections and increase the risk of sudden
infant death syndrome with the combination of swad-
dling with the infant in a prone position, which makes
it necessary to warn parents to stop swaddling if in-
fants attempt to turn (van Sleuwen et al., 2007). Herbal
therapies are commonly given to children for respira-
tory and digestive problems (Ozturk & Karayagiz,
2008). Health-care providers must teach mothers to
use swaddling properly and with caution.

Health-care providers need to assess the use of pre-
scriptive, restrictive, and taboo practices for pregnancy,
labor and delivery, and postpartum because some
women still carry out traditional practices that may ad-
versely affect them or their infants. It is important to
gain an understanding of these potentially harmful
customs and cultural beliefs so that health education
programs can be implemented that dissuade women
from resorting to and continuing these practices.

Death Rituals
Death Rituals and Expectations
When death occurs the deceased individual’s family
members cry in the most natural manner. Neighbors
who hear about the death gather at the home of the
deceased to share in the suffering of the family, to con-
sole them, and to help with the initial preparations. In
the first week after a death, all close friends and rela-
tives will help with the funeral arrangements, prepare
food for the grieving family, assist at household
chores, and deal with family and friends who come to
pay their respects and be continuously by the family’s
side in full support (Cimete & Kuguoglu, 2006).

Having prayers said is a common practice. In vil-
lages, townships, and small cities, a news reader goes
from house to house to announce the death; placing a
death notice in the newspaper is more common in
large cities. Commercial funeral agencies in large cities
make necessary preparations for the burial as well as
preparing death notices. Some of the procedures done
immediately after death deal directly with the corpse
and others involve arranging the environment around
the corpse. Turkish Muslims do not generally practice
cremation because the body must remain whole.
Frequently, the body is displayed in the home for a day
or two; it is then placed in a coffin and taken to the
cami (mosque) to be visited primarily by men. In rural
areas, showing respect for the deceased by participat-
ing in the funeral procession is very important.

Religious or traditional reasons require the prepa-
rations for burial. These preparations include three

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important procedures: bathing, wrapping in a shroud,
and saying funeral prayers outside a mosque. After
someone dies, he or she is prepared quickly for burial.
If a person dies in the morning, he or she is buried
after the mid-afternoon prayers; a person who dies
during the night is buried in the morning. The funeral
may be delayed to await the arrival of distant relatives.

Common rituals after death are closing the eyes of
the deceased, tying the chin, turning the head toward
Mecca, putting the feet next to each other, putting the
hands together on the abdomen, and removing cloth-
ing. In some places, the bed is changed; a knife, iron,
or other metal object is placed on the abdomen of the
deceased; the room in which the deceased is lying is
cleaned and well lighted; and the Koran is read at the
head of the deceased.

The majority of those in Anatolia wash the corpse
before burial. Women wash a deceased woman, and
men wash a deceased man. The people who do this
procedure are professional cleansers, religious leaders,
experienced people, the religious community, or in
some cases, someone from the home of the deceased
or a neighbor, or in some places, a person mentioned
in the will. In large cities, the washing is done in fu-
neral homes; in villages, however, a sheltered corner
in someone’s garden is used.

Shrouding is the second important procedure
after the washing of the corpse and before burial.
The fabric for the shroud is white and the number
of pieces of cloth varies for men and women. Again,
the majority of the people who live in Anatolia prac-
tice this procedure.

Funeral prayers are the third procedure. According
to the Islamic religion, several conditions need to be
met for funeral prayers to be said. After the funeral
prayers are said, the corpse is taken to the cemetery in
a coffin. The corpse is placed in the grave with the
right side facing the direction of Mecca. When the
body is placed inside the grave, a wooden board is
leaned against one wall to protect the body from the
dirt used to fill the grave. The corpse is generally
placed in the grave without the coffin; however, it may
also be buried in the coffin. Placing a gravestone with
inscriptions to give the identity, gender, and fate of the
deceased is very common.

After a funeral prayer at the mosque, the body is
interred. For the first 7 days there will be continuous
religious rites and a religious ceremony on the 7th,
40th, and 52nd days. Prayers are said and special food
will be prepared and distributed to the guests. The first
seven days after death more prayers are said and helva
(a sweet dessert) is served in honor of the deceased.
The traditional mourning period is 40 days, during
which time traditional women may wear black clothes
or a black scarf.

The clothes and personal belongings of the de-
ceased will be sent to the poor. A few belongings will

be saved by close family members as memories of the
deceased. Again, donations will be distributed to the
poor or to religious organizations. The underlying be-
lief is that food, money, and clothing are distributed
to the poor so that the deceased will not be left hun-
gry, naked, and cold (out in the open) in the other
world, and that the prayers will help the deceased to
be received into Heaven. Although all of these rituals
are aimed at supporting the family who is suffering
the loss, family members are not given the opportunity
to reveal their emotions after a death and even further,
they are kept occupied so that they remember the loss
as little as possible (Cimete & Kuguoglu, 2006).

Responses to Death and Grief
Although Muslim Turks believe in the afterlife, death
is always an occasion of great sorrow and mourning.
An expression of sympathy to one who has just lost
someone to death is Basiniz sağolsun (may your head
be healthy), hoping that one is not overwhelmed with
grief. Mourning, synonymous with grief over the
death of someone, is important and is done for a spe-
cific period of time for the purpose of adapting to the
new situation and decreasing suffering.

There are no home care or hospice systems within
the health system of Turkey. This may lead families to
an isolated state and may keep them from advancing
optimally through the stages of the grief process.

Spirituality
Dominant Religion and Use of Prayer
Turks are 99.8 percent Muslim, but freedom of reli-
gion is mandated by the Turkish secular state (CIA
World Factbook, 2011). Most are Sunni Muslims,
with a minority from the Alevi Muslim group. Other
religious minority groups include Jews (mostly
Sephardic) and Christians. Proselytizing is illegal in
Turkey.

Most Turks who emigrate to the West tend to be
very moderate Muslims. Traditional namaz (prayer)
is practiced five times each day and can take place
in the cami or elsewhere, as long as one is facing
kíble (the holy city of Mecca). A special small rug,
called seccade, is used for praying in places other
than the cami. When entering the cami, shoes are al-
ways removed and women must cover their heads.
Men and women go to separate parts of the cami for
prayer. One prepares for prayer by a ritual cleansing
called abdest, which at a minimum includes washing
the face, ears, nostrils, neck, hands to the elbow, and
feet and legs to the knee three times each. Some-
times washing facilities are available at the cami.
Caregivers may need to make special arrangements
and be sensitive to the need for Muslims to practice
their religious obligations when they are in a health-
care facility.

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Tortumluoğlu et al. (2005b) conducted a qualitative
study about religious characteristics in a village in
Turkey and found that

• In the village, everyone knows the command of
Allah. They do their ritual cleansing; say their
prayers; fast; those who are able, make the pilgrim-
age; give alms; read the Koran; and do what the
Koran says.

• In our village, a lot of people keep the fast for
3 months. During Ramazan, we also say the teravi
prayer (an extra prayer in addition to those said
five times a day). We go to the mosque and we
both say our prayers in the designated area and
also listen to the sermon.

• We do what Allah said and live according to our
religion. We don’t show ourselves to those outside
the family. We read, pray, and fast, and if Allah
allows, we will go to heaven in the afterlife.

Meaning of Life and Individual Sources
of Strength
Turks rely on their religious beliefs and practices and
their family and friends for strength and meaning in
life. One’s degree of religiosity influences the impor-
tance of prayer in giving meaning to life. A little
known fact is that St. Nicholas was born and lived in
Patara, in southern Turkey, in the 4th century AD
where he became known as Santa Claus.

Spiritual Beliefs and Health-Care Practices
Religious beliefs intertwined with folk beliefs continue
to influence Turkish lifestyle. Spiritual leaders or heal-
ers are sought most often for assistance with relation-
ship or emotional problems and, less frequently, for
physical problems. A muska, a paper inscribed by a
hoca (spiritual teacher) with a prayer in Arabic, is
wrapped in fabric and then hidden in the home or
worn by the person seeking help. Turbe and yatir are
the practice of going to the saints’ graves to pray
about wishes, mental or emotional problems, or fer-
tility problems. Tesbih, the small beads traditionally
used for praying, now take a more-secular meaning
and are often referred to as worry beads.

Health teaching strategies for Turks in America
should include the recognition and prevention of de-
hydration, bloating, constipation, hypoglycemia, and
fatigue during periods of Ramazan fasting. In addi-
tion, religious or folk items should not be removed
from the health-care facility because they provide
comfort for the client, and their removal may increase
anxiety.

Health-Care Practices
Health-Seeking Beliefs and Behaviors
Most Turks rely on Western medicine and highly
trained professionals for health and curative care.

However, remnants of traditional beliefs continue to
have an impact on health-care practices. Thus, health-
care providers may wish to incorporate factual infor-
mation regarding disease causation and treatment into
patient education planning.

Responsibility for Health Care
Turkish children are routinely immunized against
diphtheria, tetanus, whooping cough, measles, polio,
hepatitis B, mumps, rubella, and TB. There has been
significant improvement in the vaccination rates, be-
tween 2003 and 2008, the rate for children fully vacci-
nated rose from 54 percent to 74 percent (TDHS, 2009).

For a variety of reasons terminally ill patients are
generally not told the severity of their conditions.
Many believe that informing a client of a terminal ill-
ness may take away the hope, motivation, and energy
that should be directed toward healing, or it may
cause the client additional anxiety related to the fear
of dying and concern about those being left behind.
Furthermore, no one can second-guess Allah, for who
can know if Allah has a miracle in mind?

Turkey has one of the highest rates of consumption
of over-the-counter antibiotics and painkillers; aspirin
is commonly used as a panacea for a variety of ail-
ments, including gastric upset. Turks, especially those
who have difficulty affording the services of a physi-
cian, commonly consult a pharmacist before visiting a
physician. Fever- and pain-reducing medicines and
cough syrups are frequently purchased without profes-
sional medical consultation. Health professionals
must assess Turkish American patients for their use of
over-the-counter medications to prevent conflicting or
potentiating effects with prescription medications.

Folk and Traditional Practices
Turkey is a country where civilizations have been estab-
lished since the ancient ages resulting in a rich folklore.
There is a high prevalence of traditional health-care
practices among Turks; these practices are so significant
in parts of the culture that they cannot be ignored.
They are very common, particularly in rural areas, be-
cause they often cannot access health services and do
not have the financial resources to see physicians so
must rely on the traditional health practices. However,
such practices may be harmful to a person’s health and
may delay early treatment.

Engin and Pasinlioğlu’s (2000) study, conducted in
the center of Erzurum with infertile women, showed
that 44.6 percent of women were assisted by untrained
midwives, 57.8 percent used witch doctor medicine,
and 39.1 percent were prayed over by religious people
to treat their infertility.

The findings from Özyazıcıoğlu’s (2000) study, con-
ducted in the center of Erzurum, was that mothers
with at least one child older than 12 months had a
high rate of using traditional treatments for such

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health problems as the common cold and nasal con-
gestion (26.39 percent), earache and ear drainage
(17.22 percent), stomachache (54.96 percent), constipa-
tion (24.88 percent), burns (24.39 percent), poisoning
(23.08 percent), cuts and bleeding (67.56 percent), and
fractures (41.67 percent). Tortumluoğlu, Karahan,
Bakir, and Türk (2004) reported that 82.2 percent of
older people in their study used traditional practices
for burns, 76.7 percent for insect bites, 64.4 percent for
the common cold, 63 percent for stomach problems,
63 percent for high fever, 63 percent for warts, 56.2 percent
for sties, and 54.4 percent for constipation.

Ugulu and Baslar (2010) found that most people
(68 percent) in their study from four Turkish cities
continued to use traditional systems of health care in-
cluding medicinal plants alone or in combination with
other ingredients, such as flour, honey, and oil. Phyto-
preparations (salves, gels, creams), medicinal plants,
are used for the treatment of various diseases of skin
and mucous membranes.

Toprak and Demir found that the most common
traditional methods for treating hypertension among
their research subjects were eating yogurt with garlic
(27.8 percent) and eating sour foods, such as lemon
and grapefruit (25 percent). Resting, drinking ayran
(a Turkish drink made with yogurt and water), and
applying a cold bag to the head were the other meth-
ods used for coping with hypertension (Toprak &
Demir, 2007).

Kara (2009) found that many patients with end-
stage renal disease undergoing hemodialysis also used
herbs to treat their health problems. The majority re-
ceived the information about which herbs to use from
their families and friends. They did not disclose the
use of herbal products to their physicians (Kara,
2009). Additional traditional health-care practices to
treat illness or symptoms include applying rubbing
alcohol or a wet cloth to bring down a fever and
warming the back to treat coughing. Health-care
providers should be aware of the health risks caused
by certain traditional health-care practices and edu-
cate the patients and families about the potential risks.

Turkey also encourages health tourism at their
1500 thermal spas. These spas treat conditions such
as rheumatism, respiratory and digestive problems,
diabetes, skin conditions, gallstones, female diseases,
kidney and heart conditions, nerves, obesity, and
hyperlipidemia.

The concept of the evil eye is prevalent in many cul-
tures, including Turkish culture. Specific to health, it
is a cultural inclination not to speak too well of one’s
health for fear that one may incur misfortune through
others envy or nazar. Turkish patients, therefore, may
be more inclined than other ethnic groups to complain
about health. So pervasive is this concept that taxi
drivers and medical doctors alike respect the nazar
boncuk, a blue bead used as protection from the evil

eye. Some Turks may believe that excessive complain-
ing may bring the benefit of closer medical attention.
However, when describing an illness, a person avoids
using oneself or another person as an example for fear
of inviting the illness or condition upon that person.

Kolonya (cologne) is part of a traditional practice
that crosses religious and secular lines. Originally de-
rived from the religious value of cleanliness, cologne
is sprinkled on the hands of guests before and after
eating to provide cleanliness and a fresh lemon scent.
Inhaling from a cloth or handkerchief doused with
cologne may be used for relief from motion sickness.
In the hospital, patients may offer cologne to a physi-
cian or nurse prior to examination. An essential part
of hospitality, it also has some medicinal intent. In
fact, cologne is approximately 70 percent alcohol and
does have a bactericidal quality.

Cultural Responses to Health and Illness
An autonomy-centered approach in Turkish health
care is relatively new. The Regulation on Patient
Rights was enacted in 1998 but only recently have
there been tangible steps toward its implementation in
the health-care system. It is becoming more common
for patients to want to know their diagnosis and ex-
press their wishes and expectations about their health
care; traditionally, patients had to be in compliance
with the traditions of the paternalistic medical model,
which demanded compliance from physicians (if not
obedience) without considering patients’ opinions or
wishes (Guven, 2010).

Seriously ill people are expected to conserve their
energy to allow their minds and bodies to fight their
illnesses; thus, reducing their workload and avoiding
unnecessary energy expenditure are acceptable. Dur-
ing hospitalization, refakatçí refers to the person who
stays overnight with the client, providing emotional
and physical support and comfort. A show of concern
and Şevkat (compassion) for the client eases her or his
fears and reduces loneliness. Family members may
also attend to physical needs such as bathing. A bal-
anced, healthy diet is considered essential to regaining
one’s health; thus, Turks frequently bring food from
home for the patient.

Although the degree of pain expression varies ac-
cording to regional origin, Turkish culture allows free-
dom to express pain, either through emotional
outbursts or through verbal complaints. General ob-
servations about Turkish culture suggest that although
stigma is attached to mental illness, many families seek
treatment or care for the client at home. Mental health
services are basically curative rather than preventive.

There is a concern that the risks for mental disor-
ders and depression in older people will increase in the
near future due to factors such as rapidly changing so-
cial structure, urban migration, and shifting to nuclear
family life. Families will no longer be in a situation to

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care for older people, physically, psychologically, or
economically (Nahcivan & Demirezen, 2005).

Postpartum depression (PPD) is common among
Turkish women, though the majority of women suf-
fering from PPD receive no treatment and it may go
undetected. There is an increased need to educate pub-
lic and health-care providers about PPD and to de-
velop nursing interventions to provide support to
postpartum women (Dindar & Erdogan, 2007).

Blood Transfusions and Organ Donation
According to Turkish law 2238, which went into effect
in 1979, obtaining, storing, grafting, and transplant-
ing organs and tissues for the purpose of treatment,
diagnosis, and science are subject to regulations. In
1980, the Ministry of Religious Affairs stated that
organ and tissue transplantation is permissible when
it is done according to the following conditions:

• To save a patient’s life and when no other alterna-
tive exists, as established by a licensed physician
whose honesty is reliable.

• A dominant medical opinion is that the illness
cannot be treated in another way.

• The donor’s organ or tissue is taken while this
procedure is being done.

• To prevent the disturbance in the peace and order
of society, the donor must have given permission
when healthy (prior to their death), or if no
declaration was made while alive, the next of kin
are willing.

• No payment of any kind can be received in
exchange for the donated organ or tissue.

• The donee must be willing to have the transplanta-
tion (Turkish Transplantation Society, 2006).

Muslims traditionally prefer that their body remain
intact after death, a belief that can conflict with organ
donation. Former Prime Minister and President
Turgut Ozal and his wife promoted organ donation by
publicly signing donor cards and encouraging others
to do so. Ağartan, Önder, Memiş, and Baklaya (2006)
in their study reported that 39.8 percent of nurses were
against organ and tissue transplantation because they
believed it was not acceptable in the Islamic religion.
Additionally, they would not want their bodies dis-
turbed after death; 31.1 percent were afraid that their
organs would be taken before they had died.

Blood transfusions are gaining acceptance. How-
ever, Turkish people generally prefer to receive blood
from family members.

Barriers to Health Care
In general, women are responsible for the actual care-
giving of the ill and the elderly in the home. However,
in traditional households, the mother-in-law or father-
in-law, depending on who controls the finances in the
family, makes decisions about going to the physician.

In many situations, the person who is respected as the
most educated has primary input into decisions about
health care. An additional barrier can exist for devout
Muslim women when a female health-care provider is
not available. An over reliance on folk and traditional
practices can also be a barrier.

Health-Care Providers
Traditional Versus Biomedical Providers
Although Turkish people are inclined toward Western-
ized health-seeking behaviors, medical care in Turkey
tends to be holistic. Great value is placed on emotional
well-being, especially as it affects physical well-being.
Emotional health is considered instrumental to the heal-
ing process. Physicians may be “adopted” as members
of their patients’ families, and it is common to give gifts
(usually food) to physicians as an expression of grati-
tude. A Turkish physician would never refuse gifts or in-
terpret them as a bribe for better care. When modern
medicine is not available, accessible and affordable, or
has not been effective, Turks may seek the care of a tra-
ditional healer.

Generally, physicians are viewed and respected as
professionals, so caring for someone of the opposite sex
is not an issue among most Turks. However, it is always
advisable to ask patients their opinion or preference.

Status of Health-Care Providers
Physicians and to a lesser extent, nurses and midwives,
have historically been held in very high esteem. Pa-
tients rarely question the authority of physicians, but
the notion of obtaining a second opinion is gaining
popularity.

The university qualifying examination system al-
lows only the very top academic echelon of students
to study medicine. Nursing master’s programs began
in 1968 and doctoral programs in 1972. A recent study
identified problems nurses faced during their post-
graduate education which included the lack of asso-
ciate professors, lack of foreign language skills, not
enough time to do research due to being overworked,
physiological stress, conflict within the office, and
economical problems (Canbulat et al., 2007).

The relationship between physicians and nurses is
hierarchical. Currently, this situation is based more on
educational level than on gender because a great num-
ber of women enter the medical profession. Most
male nurses work in community settings. Neither
physicians nor nurses share the same financial benefits
of health-care professionals in the United States.

R E F E R E N C E S

Ağartan, E., Önder, A., Memiş, S., & Baklaya, N. (2006).
Hemşireler organ ve doku bağışı konusunda yeterince du-
yarlımı? Ulusal Hemşirelik Öğrencileri Kongresi. Kongre kitabı.
Harran Üniversitesi, Şanlıurfa. [Are nurses sensitive about the

People of Turkish Heritage 17

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donation of organs and tissue?] National Nursing Students
Congress Book (p. 214). Harran University, Sanlıurfa, Turkey.

Akgun, S., Rao, C., Yardim, N., Basara, B. B., Aydin. O.,
Mollahaliloglu, S., & Lopez, A. D. (2007). Estimating mortality
and causes of death in Turkey: Methods, results and policy im-
plications. European Journal of Public Health, 17(6), 593–599.

Ayaz, S., & Efe, S. (2008). Potentially harmful traditional practices
during pregnancy and postpartum. European Journal of Con-
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http://davisplus.fadavis.com.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company

American Indians
Alaskan Natives (AI/ANs)
Larry Purnell, PhD, RN, FAAN

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Overview/Heritage
Amount of Indian blood necessary to be considered a tribal member varies among the tribes—¼ to be a Navajo, which is the largest tribe in United States and live in the Southwest
556 different tribes in the United States and Canada
Each tribe unique but share similar views regarding cosmology, medicine, and family organization

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Overview Heritage
Forced migration by United States government
Life on MOST reservations is hard with high poverty and high unemployment although a few have significant money due to oil, land leases, gambling casinos, etc.
Children were taken from them and placed in “White Man’s Schools”

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AI/AN Cultural Values
Group, clan, or tribal emphasis
Present oriented
Time is always with us
Age
Cooperation
Harmony with nature
Giving/sharing

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AI/AN Cultural Values
Pragmatic
Mythology
Patience
Mystical
Shame
Permissiveness
Extended family and clan

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AI/AN Cultural Values
Non-aggressiveness
Modesty
Silence
Respect other’s religion
Religion is a way of life
Land, water, forest belong to all
Beneficial, reasonable use of resources

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Overview/Heritage Continued
Low educational levels for most tribes, preferring children to remain at home and learn Indian ways
For the traditional, health care is an undesirable profession because one should not work with the dead or ill
Navajo sometimes have a special cleansing ceremony to allow them to work in a hospital

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AI/AN Communication
Language and dialect vary by tribe, but most speak English and in the southwest many speak Spanish instead of English
Minor variations in pronunciation can change the meaning of the word
Talking loudly or interrupting someone is considered rude

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AI/AN Communication
Navajos generally do not share thoughts and feelings easily outside family and friends, making it difficult to obtain trust in the healthcare setting
Comfortable with long periods of silence
Touch is unacceptable unless you know the person very well

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AI/AN Communication
No set pattern for willingness to share tribal ceremonies
Pueblo groups usually do not share any tribal ceremonies
Light passing of the hands for a handshake
Considered rude to point with the finger; instead shift your lips in the desired direction

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AI/AN Communication
Direct eye contact is rude and confrontational—deadpan facial expression
Proximity for conversations usually greater than 24 inches
Time sequence is present, past, and future

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AI/AN Communication
The future is out of one’s control.
Very few are future oriented and for the Navajo there is no future verb tense
Time is not something that can be controlled, nor should time control the person; events start when the people arrive

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Family Roles and Organization
Navajo, like most Native Indian tribes, is matrilineal in decision-making and land rights
Relationship between brother and sister is more important than that between husband and wife
Children’s names are not revealed at birth

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Family Roles and Organization
Older people are addressed as grandmother, grandfather, mother, father, or a nickname.
Algonquin are egalitarian society
Dene and Athabascan are patriarchal
Navajo, Iroquois, Pueblos, and Haida are matriarchial societies

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Family Roles and Organization
AI/AN naming traditions vary greatly from tribe to tribe and are frequently determined by nature, animals, or character.
In the past, AI/AN women practiced breastfeeding exclusively.
Since the early to mid-1980s, the use of formula has become popular.

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Family Roles and Organization
A primary social premise is that no person has the right to speak for another.
Parents are permissive in childrearing practices and may allow a child decide whether if not go to school or take medicine.
Ceremony plays a vital, essential role in AI/ANs everyday life.

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Family Roles and Organization
When a couple marries in the Pueblo tribes, the man goes to live in the woman’s house.
In Navajo tradition, families have separate dwellings but are grouped by familial relationships.
The Navajo family unit consists of the nuclear family and relatives such as sisters, aunts, and their female descendants.

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Family Roles and Organization
In all American Indian and Alaska Natives extended family members play an important role in the infants’ life.
Older adults are looked on with clear deference
Elders play an important role in keeping rituals and in instructing children and grandchildren.

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Family Roles and Organization
Social status is determined by age and life experiences.
Among the Pueblos governors are chosen from a particular clan; unless one is born in the clan they cannot run for tribal governor. Generally, individuals are discouraged from having more possessions than their peers, and those who display more material wealth are ignored.

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Family Roles and Organization
Standing out is not encouraged among the different tribal groups.

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Workforce Issues
Many AI/ANs remain traditional in their practice of religious activities. Family matters are more important than work, resulting in high rates of absenteeism.
In addition, tribal ceremonies are seen as necessary and they often must take time from work or school.

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Workforce Issues
Tribal members in the community function informally as cultural brokers and assist by helping non–American Indian staff to understand important cultural issues.
Conflict is addressed indirectly through third parties in some tribes

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Workforce Issues
Group activities are an important norm in AI/AN cultures.
One individual should not be singled out to answer a question because the student’s mistakes are generally not forgotten by the group.

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Workforce Issues
Issues of superior-subordinate roles exist and are related to age.
IHS is the only organization allowed to discriminate in hiring practices; it is required to hire an AI/AN when possible.

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ClickerCheck
AI/AN tribes and clans are
Patriarchal.
Matriarchal.
Egalitarian.
Depends on the tribe and clan.

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Correct Answer
Correct answer: D
Some tribes and clans are patriarchal, some are matriarchal, and some are more egalitarian. Variations exist within the tribe and clan as well.

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Biocultural Ecology
Skin color among AI/ANs varies from light to very dark brown, depending on the tribe.
Each of the American Indian tribes vary in terms of facial features and height.
Never assume that an AI/AN patient is from a particular tribe, if wrong, he or she will be offended.

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Biocultural Ecology
Historically, most diseases affecting AI/ANs were infectious such as tuberculosis, smallpox, and influenza.
Diseases of the heart, malignant neoplasm, unintentional injuries, diabetes mellitus, and cerebrovascular disease are the top five leading causes of AI/AN deaths

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Biocultural Ecology
Type 1 diabetes mellitus is almost nonexistent in AI/ANs but type 2 diabetes mellitus is the third most prevalent chronic disease affecting all AI/AN tribes.
The incidence of diabetes varies among tribes has steadily increased and is approaching 30 percent.

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Biocultural Ecology
Albinism occurs in the Navajo and Pueblo tribes.
Navajos who lived in Rainbow Grand Canyon are genetically prone to blindness that develops in individuals during their late teens and early 20s.

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Biocultural Ecology
The Zunis have an incidence of cystic fibrosis seven and one-half times that found for Caucasians.
Methamphetamine (meth) abuse and suicide are two top concerns in Indian country.
Suicide rates among American Indians and Alaska Natives (AI/ANs) are 1.7 times higher than the national average.

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Biocultural Ecology
Alcohol use is more prevalent than any other form of chemical misuse.
Many accidents are attributed to driving while under the influence of alcohol.
Spousal abuse is common and frequently related to alcohol use. The wife is the usual recipient of the abuse, but occasionally, the husband is abused.

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Nutrition
Food has major significance beyond nourishment in AI/AN populations.
Food is offered to family and friends or may be burned to feed higher powers and those who have died.
Life events, dances, healing, and religious ceremonies evolve around food.

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Nutrition
Corn is an important staple in the diet of American Indians.
Rituals such as the green corn dance of the Cherokees and harvest-time rituals for the Zuni surround the use of corn.
Corn pollen is used in the Blessingway and many other ceremonies by the Navajo.

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Nutrition
Each tribe has its own version of fry bread.
Access to fresh fruits and vegetables is minimal during wintertime.
AI/AN diets may be deficient in vitamin D because many members suffer from lactose intolerance or do not drink milk.

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Childbearing Family
Traditional AI/ANs do not practice birth control and often do not limit family size.
In Apache and Navajo tribes, twins are not looked on favorably and are frequently believed to be the work of a witch.

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Childbearing Family
Some want their blood and urine specimens returned to them upon discharge.
Many use herbs during labor and delivery.
A ceremony may be performed by the medicine man during labor and delivery.

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Childbearing Family
Be flexible with positioning for delivery.
Some may want the umbilical cord, meconium, and afterbirth.
Some may use peyote during labor and delivery.

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ClickerCheck
The most common form of substance abuse among AI/ANs is
Alcohol.
Peyote.
Marijuana.
Methamphetamine.

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Correct Answer
The most common substance abuse among AI/AN tribes is alcohol which is 1.7 times higher than other groups who have been studied.

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Death Rituals
Most AI/AN tribes believe that the souls of the dead pass into a spirit world and became part of the spiritual forces that influenced every aspect of their lives.
Today some tribes maintain their traditional practices but use a mortuary or use the IHS morgue to prepare their dead.

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Death Rituals
The Pueblo tribes prepare their own dead and only certain family members are allowed to prepare the body.
Hopis bury their dead before the next setting of the sun and bury them in upright sitting positions with food and goods in the grave with the person.
After the Zuni burial, the members must take off three days from work for a cleansing ceremony.

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Death Rituals
The body must go into the afterlife as whole as possible.
In some tribes, amputated limbs are given to the family for a separate burial and later the limb is buried with the body.

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Death Rituals
In some tribes, family members are reluctant to deal with the body because those who work with the dead must have a ceremony to protect them from the deceased’s spirit.
In the Navajo, if the person dies at home, the body must be taken out of the north side of the hogan and a ceremony conducted to cleanse the Hogan or it must be abandoned.

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Death Rituals
Older adults are reluctant to discuss advance directives once they discover what it means.
Effective discussions require that the issue be discussed in the third person, as if the illness or disorder is happening to someone else.

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Death Rituals
If a provider makes a statement such as “if you don’t get medical care, you will die,” this implies that the provider wishes the client dead.
If the patient does die or is extremely ill, the provider might be considered a witch.

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Death Rituals
The Navajo are not generally open in their expression of grief; they often will not touch or pick up the body or prepare the body for burial.
Grief among the Pueblo and Plains Tribes are expressed openly and involves much crying among extended family members

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Spirituality
AI/AN religion predominates in many tribes.
When illnesses are severe, consultations with appropriate religious organizations are sought.
Sometimes, hospital admissions are accompanied by traditional ceremonies and consultation with a pastor.

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Spirituality
AI/AN tribal traditional members start the day with prayer, meditation, and corn pollen.
Prayers ask for harmony with nature and for health and invite blessings to help the person exist in harmony with the earth and sky.

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Spirituality
The meaning of life for AI/ANs is derived from being in harmony with nature.
The individual’s source of strength comes from the inner self and depends on being in harmony with one’s surroundings.

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Spirituality
Spirituality cannot be separated from the healing process in ceremonies.
Illnesses, especially mental illnesses, result from not being in harmony with nature, from the spirits of evil persons such as a witch, or through violation of taboos.
Healing ceremonies restore an individual’s balance mentally, physically, and spiritually.

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Health-care Practices
Traditional AI/AN beliefs influence biomedical health-care decisions.
asking patients questions to make a diagnosis fosters mistrust.
This approach is in conflict with the practice of traditional medicine men, who tell people their problem without their having to say anything.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company

Health-care Practices
IHS has attempted to shift its focus from acute care to health promotion, disease prevention, and chronic health conditions.
Wellness-promotion activities include a return to past traditions such as running for health, avoiding alcohol, and using purification ceremonies.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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Health-care Practices
Medicine men, diagnosticians, crystal gazers, and shamans tell them how to restore harmony.
Many families do not have adequate transportation and must wait for others to transport them to their appointments.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company

Health-care Practices
Frequently, pain control is ineffective because the intensity of their pain is not obvious to the health-care provider because patients do not request pain medication.
Herbal medicines may be preferred and used without the knowledge of the health-care provider.

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Health-care Practices
Mental illness is perceived as resulting from witches or witching (placing a curse) on a person.
In these instances, a healer who deals with dreams or a crystal gazer is consulted. Individuals may wear turquoise or other items such as a medicine bag to ward off evil.

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Health-care Practices
The concept of rehabilitation is relatively new to AI/ANs because, in years past, they did not survive to old age to which chronic diseases became an issue.
Autopsy and organ donation are becoming a little more accepted among traditional AI/ANs.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
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Health-care Practitioners
AI/AN healers are divided primarily into three categories: those working with the power of good, the power of evil, or both.
Some are endowed with supernatural powers, whereas others have knowledge of herbs and specific manipulations to “suck” out the evil spirits.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company

Health-care Practitioners
Health-care providers must be careful not to open medicine bags or remove them from the patient.
These objects contribute to patients’ mental well-being, and their removal creates undue stress.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company

Health-care Practitioners
Treatment regimens prescribed by a medicine man not only cure the body but also restore the mind.
Individuals living off reservations frequently return to participate in this ceremony, which returns them to harmony and restores a sense of well-being.

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Turkish Culture

Larry Purnell, PhD, RN, FAAN

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Copyright © 2013 F.A. Davis Company

1

Overview/Heritage
Türkiye, as it is written in Turkish, means “land of Turks.” Referred to as a geographic, religious, and cultural crossroads, the Republic of Türkiye is situated at the geographic intersection of Europe, Asia, the Middle East, and Africa.
While Turks have emigrated throughout the world, many live in Western Europe, largely as a result of “guest worker” programs.

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Overview/Heritage
Today, the Republic of Türkiye is politically stable and continues to adapt economically to reforms.
Türkiye remains strategically important to the West and is a strong ally of the United States.
The Turkish immigrant population in the US differs significantly from most of the Turkish population in Europe, both in terms of demographic makeup and socioeconomic status and integration.

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3

Overview/Heritage
Over 202,000 people of Turkish descent live in the United States.
They live in 42 states, with over half living in New York, California, New Jersey, and Florida.
Just over half of the individuals in this group were born outside the United States.
Most arrived in the US before 1980.

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Overview/Heritage
A high proportion of Turks in the United States come from the elite and upper-middle classes, interspersed with smaller groups of middle-class students and skilled laborers who are supported privately or by the government.
Many Turks sought advanced American education in highly technical fields, leading to more abundant employment opportunities in the United States upon completion of their studies.

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5

Communication
A Uralic-Altaic language, Turkish is spoken by 90% of the population and has approximately 20 dialects.
Differences in some of the dialects are so great that they are considered different languages.
The Turkish alphabet is much like the English alphabet, although it does not have a “w” or an “x” and additional sounds are symbolized by an diacritical mark over vowels.

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6

Communication
The Turkish language does not distinguish gender pronouns (ie, “he” from “she” or “her” from “his.”) Therefore, Turks when learning English may inadvertently confuse these pronouns.
Turkish distinguishes a formal from an informal “you,” signifying the importance of status in Turkish society.

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7

Communication
Speaking in loud voices is common; this does not always signify anger but rather excitement or deep involvement in a discussion.
More than one person may speak at the same time or interrupt another person; this is not necessarily considered rude.
However, someone of lower status should not interrupt someone of higher status.

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8

Communication
Group affiliation is valued over individualism in Turkish society. In fact, identity may be determined by family membership or group, school, and work associations.
Turks generally do not desire much privacy and tend to rely on cooperation between family and friends, although competition between groups can be fierce.

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9

Communication
Turks value harmony over confrontation.
The outward show of feelings is less restrained.
For women, expressions of anger are usually acceptable only within same-sex friendships and kinship networks or toward those of lower social status.
Generally, women are not free to vent their anger toward their husbands or other powerful men.

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10

Communication
Touching, holding hands, and patting one another on the back are acceptable behaviors between same-sex friends and opposite-sex partners.
Same-sex friends, especially among the older generations, are commonly seen holding hands or linking arms while walking.

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11

Communication
Very strict Muslims may not shake hands or touch members of the opposite sex, especially if they are not related.
When interacting with someone of higher status, one is expected to maintain occasional eye contact to show attention; however, prolonged eye contact may be considered rude, or may be interpreted as flirting.

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12

Communication
Turkish people tend to dress formally; men wear suits rather than sports jackets and slacks on social occasions.
Women tend to dress modestly, wearing skirts and dresses rather than slacks. More traditional Muslim women may wear very modest clothing and cover their heads with a scarf, either black or a colorful print.

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13

Communication
However, styles continue to change, and denim jeans and casual dress are becoming common among young people for less formal occasions.
Turks openly display emotions such as happiness, disgust, approval, disapproval, and sadness through facial expressions and gestures.

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14

Communication
No” is indicated by raising the eyebrows or lifting the chin slightly, while making a snapping or “tsk” sound with the mouth.
Appreciation may be expressed by holding the tips of the fingers and thumb together and kissing them and is commonly used to express appreciation for food.

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15

Communication
Turkish people take pride in keeping their homes immaculately clean, and one is expected to remove one’s shoes inside the home.
Most Turkish hosts in Türkiye and many in the United States offer slippers to their guests.
Whether wearing shoes or not, showing the sole of one’s foot is considered to be offensive in Turkish culture.
Women are expected to sit modestly with knees together and not crossed.

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16

Communication
Turks tend to have a relaxed attitude about time; social visits can begin late and continue well into the night.
While punctuality in social engagements is not highly important, in business relationships, punctuality among Turkish Americans is gaining in importance.

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17

Communication
Turks value status and hierarchy. Demonstrating respect for those of higher status is mandatory and determines the quality of interactions with a person.
Strangers are always greeted with their title, such as Bey (Mr.), Hanim (Mrs., Miss, or Ms.), Doktor, or Profesör.

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18

Communication
When friends or family members greet, it is customary for each to shake hands and to kiss one another on each cheek.
Traditionally, when greeting someone of very high status or an elderly person, one might grasp his or her hand and kiss it, and then bring it to touch one’s forehead in a gesture of respect.

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19

Family Roles & Organization
In a very traditional Turkish home, the father is considered the absolute ruler.
The concept of izin (permission or leave to do something specific) captures this significance.

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20

Family Roles & Organization
Less traditional families show more equality between spouses, especially in nuclear families in which the wife is well educated.
Yet, remnants of traditional family structure prevail; the husband often acts as the ultimate decision maker, especially in financial matters.
Women may work full time outside the home in addition to assuming full responsibility for running the daily activities inside the home.

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21

Family Roles & Organization
Legal marriage in Türkiye does not permit polygamy, although some may practice it outside.
A woman’s age, and the number, age, and gender of her children influence her status in the family and the community. A young “gelin” (woman age 15 to 30) has the lowest status. The “middle-aged” woman (30 to 45) has medium status while the “mature” woman (45 to 65) has the highest status.

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Family Roles & Organization
In “old age” (65 or older), a woman is highly respected but is not powerful.
However, this status varies according to education, religious practice, socioeconomic level, urbanization, and professional achievement.

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Family Roles & Organization
Children are held very dear in the Turkish family and they are expected to act as young children, not small adults.
They are accustomed to receiving attention from family, friends, and visitors.
Kissing children and pinching their cheeks is quite common.

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Family Roles & Organization
Once children enter school, they are expected to study hard, show respect, and obey their elders, including older siblings.
Girls are expected to help care for younger siblings, to help at mealtimes, and to learn to cook.

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Family Roles & Organization
Traditionally, children are not allowed to act out or talk back to their superiors.
Light corporal punishment is generally acceptable.

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Family Roles & Organization
Male circumcision is a major rite of passage.
This is a time of celebration within the extended family, and newly circumcised boys are honored with gifts.
Traditionally, boys can be circumcised up to the age of about 12, although the modern trend is to perform the circumcision in the hospital shortly after birth.

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Family Roles & Organization
Urban adolescents are beginning to date in pairs in addition to the more traditionally accepted practice of group outings.
However, sexual interaction is strongly discouraged among youth and the unmarried, especially for young women.
Virginity in unmarried women is a strong cultural value.

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Family Roles & Organization
A key objective among Turks is socioeconomic advancement, including education, better professional opportunities, and material success.
Although financial independence is valued in Turkish culture, independence from the family is not encouraged.
Adult children, especially men, remain an integral part of their parents’ lives, and parents expect their children to care for them in their old age.

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Family Roles & Organization
Because respect is highly valued in Turkish society, maintaining or improving status in the community is of key importance.
Individuals must always consider what impact their actions will have on the family and often they consult parents or other family members before making major decisions.

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Family Roles & Organization
Young people living in Türkiye generally live in their parents’ home until they are married, unless school or work necessitates other arrangements.
Family-initiated marriages range from rare contractual agreements between parents to the relatively common introduction and gentle encouragement of a newly formed couple.

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Family Roles & Organization
Elders in Turkish culture are attributed authority and respect until they become weak or retired, at which time their authoritative roles diminish.
Individuals are socialized to take care of elderly parents, regarding it as normal and not as an added burden.
Grandparents play a significant role in raising their grandchildren, especially if they live in the same home.

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Family Roles & Organization
The extended family is very important in Turkish culture.
Even the apparent increase in nuclear households does not rule out the networks among closely related families.
Whether or not they live under the same roof, a young family may still live under the supervision of the husband’s parents or at least maintain an interdependent relationship.

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Family Roles & Organization
Divorce is becoming more common in Turkish society, but remains socially undesirable.
Widows, however, are generally taken care of by their late husband’s family and, depending on their age and socioeconomic background, may have the option to remarry.
Premarital cohabitation and unwed motherhood is strongly discouraged.

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Family Roles & Organization
Homosexuality is only beginning to be received “at a distance.” In fact, one of the most popular entertainers in Türkiye is a homosexual and a transvestite and is accepted as such.
However, most Turks would be hesitant to associate themselves with the gay community.

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35

Workforce Issues
Because Türkiye is a group-oriented culture, the Turkish workplace may be more team oriented.
Turkish relationship orientation may lead to dependence on personal contacts and networks to accomplish tasks.
Developing these relationships and networks may appear as nepotism or as too much socializing from the American perspective.

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Copyright © 2013 F.A. Davis Company

36

Workforce Issues
Hierarchical structure is highly pervasive throughout Turkish culture, and the workplace is no exception.
Turkish employees expect an authoritative relationship between superior and subordinates.
However, indirect criticism is expected and appreciated to “save face.”

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37

Workforce Issues
A Turk may be highly offended if openly criticized, especially if done in front of other people.
They may be reticent about asking questions for fear of exposing a lack of knowledge.

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38

Workforce Issues
Turks perceive that aggressive face-to-face confrontation may cause relationships to deteriorate.
The dominant means of conflict resolution is collaboration reinforced by compromise and forcing.

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39

Workforce Issues
Many women do not work because it interferes with child care, the order of the home, and it requires them to be together with men from outside the immediate family.

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40

Biocultural Ecology
Turkish population is a mosaic in terms of appearance, complexion, and coloration.
Appearances range from light-skinned with blue or green eyes to olive or darker skin tones with brown eyes.
Mongolian spots, usually found at or near the sacrum, are common among Turkish babies and should not be confused with bruising.

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Biocultural Ecology
Malaria has not been fully eradicated in Türkiye, especially in the southeast.
Endemic goiter associated with iodine deficiency is a major health problem in Türkiye.
Behçet’s disease, a syndrome of unknown etiology, is prevalent in Mediterranean countries, the Middle East, and Japan and primarily affects males between the ages of 20 and 40.

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Biocultural Ecology
Common health conditions among Turks are lactose intolerance, thalassemia, cardiovascular diseases, cancer, obesity, hypertension, diabetes, tuberculosis, and conditions related to high smoking rates among men and women.
The most prevalent food- and water-borne diseases are infectious hepatitis and sporadic cases of salmonellosis and dysentery.

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High-risk Health Behaviors
Cigarette smoking is widespread in Türkiye and tends to start at an early age. Türkiye, a major producer of tobacco in the world, has instituted very limited anti-tobacco activities.
Turks tend to consume less alcohol than Americans or Europeans, perhaps as a result of the Muslim culture that discourages more than moderate alcohol use.

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44

High-risk Health Behaviors
The tendency of Turkish men to view themselves as strong/immune to disease and the traditional cultural view condoning male promiscuity increases the danger for both the man and his wife.

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Nutrition
Turkish cuisine is influenced by the many civilizations encountered by nomadic Turks over the centuries, as well as by a mixture of delicacies from different regions of the vast Ottoman Empire.
Therefore, food choices are varied and tend to provide a healthy, balanced diet.

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46

ClickerCheck
A common genetic/hereditary condition among Turks is
Hemophilia.
Thalassemia.
Anemia.
Sickle cell anemia.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

47

Correct Answer
Correct answer: B
A common genetic/hereditary condition among Turks is thalassemia.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

48

Nutrition
Tea and a snack is always on hand for visitors, and dinner guests may have difficulty finishing everything on their plates
Turkish hostesses may relentlessly offer to replace what has been eaten.
Polite guests refuse the first offer, but the hungry need not worry; offers are made again and again.

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Nutrition
Turkish cooking is not terribly spicy and is prepared artfully and fastidiously, as Turkish appetites tend to be discriminating.
Breakfast is typically a simple meal of white feta cheese (beyaz peynir), olives, tomatoes, eggs, cucumbers, toast, jam, honey, and Turkish tea.

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Nutrition
Hot midday or evening meals may include any of the foods described below:
Çorba (soups) range from light to substantial.
Meze (hors d’oeuvres) include a great variety of small dishes, either hot or cold, such as yaprak dolma (stuffed grape leaves in olive oil), olives, circassian or çerkez tavuğu (chicken with walnut sauce), çiroz (dried mackerel), leblebi (roasted chick peas), or sigara böreği (a savory cheese pastry fried until crispy).

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Nutrition
Salads include lettuce, tomatoes, cucumbers, onions, and other raw vegetables with a dressing of olive oil and lemon juice or vinegar.
Olive oil and lemon are staples in Turkish culinary preparation.
Turks generally prepare meat in small pieces in combination with other vegetables, potatoes, or rice.

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52

Nutrition
Famous Turkish cuisine includes köfte, small spicy meatballs, and kebab, skewered beef or lamb and vegetables.
While poultry is less common, fish has a special place in Turkish cuisine.
Türkiye is the birthplace of yogurt, which is an essential part of the Turkish diet and is generally served with hot meals rather than as cold breakfast food.

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Nutrition
Vegetables are served cooked or raw, hot or cold, as part of a stew or casserole, or stuffed (dolma) with meat, rice, and currants.
Rice and börek are important parts of Turkish culinary tradition. Börek is made by wrapping yufka (thin sheets of flour-based dough) around meat, cheese, or spinach and then frying or baking until the dough is flaky.

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Nutrition
Turkish desserts fall into 4 categories:
Rich and sweet pastry, such as baklava
Puddings
Komposto (cooked fruits)
Fresh fruits. In fact, most meals are concluded with fresh fruit and coffee or tea.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

55

Nutrition
Turkish kahve, from which the English word coffee is derived, is famous for its dark, thick, sweet taste.
The Muslim religion requires abstinence from eating pork and drinking alcohol, but not all Muslims abstain, depending on their degree of religious practice.

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Nutrition
The Islamic tradition of Ramazan, or Ramadan in Arabic countries, is a month of fasting (oruç tutmak) observed by practicing Muslims throughout the world.
During Ramazan, one is not allowed to eat or drink anything from sunrise to sunset as a test of willpower and as a reminder of the preciousness of the food provided by a gracious Allah (God).

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Nutrition
Generally, pregnant and postpartum women, travelers, and those who are ill are excused from fasting but may be required to make up lost time at a later date.
The evening meal, iftar, is something to which all look forward with great anticipation, and Turkish women, who almost invariably do all the cooking, create veritable feasts each night.

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Pregnancy and Childbearing Practices
Motherhood is accorded great respect, and pregnant women are usually made comfortable in any way possible, including satisfying their cravings.
Pregnant women may continue their daily activities or work as long as they are comfortable.
In traditional Turkish culture one of the most important desires of a married woman is to have a child.

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Pregnancy and Childbearing Practices
A woman who has not had a child is faced with social pressure and accusations and thus may try to use some traditional practices to increase fertility.
Some women damage their bodies by using these traditional practices and sometimes the damage is permanent.

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Pregnancy and Childbearing Practices
The pregnant woman is always encouraged to keep up her strength by eating foods that are rich in nutrients.
Many pregnant women take prenatal vitamins, drink a lot of milk, and apply salves such as Vaseline to avoid stretch marks.
Light exercise, such as walking, is encouraged.

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Pregnancy and Childbearing Practices
It is acceptable, though not common, for the husband and the birth mother’s father to be present during the birthing process.
Expressions of discomfort and pain are quite acceptable.
However, Laz women from the Black Sea area tend to be stoic.

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Pregnancy and Childbearing Practices
The postpartum period can last up to 40 days.
Light exercise is encouraged during this period and bathing, an important part of the Muslim tradition, is strongly encouraged.
A special food called log˘usalik is served to the postpartum woman to increase milk production.
Breastfeeding women drink hot soups and other fluids such as milk.

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Pregnancy and Childbearing Practices
At birth, a small blue bead called a nazar boncuk, believed to protect the child from the “evil eye,” is usually placed on the child’s left shoulder.
Other traditional practices include placing iron under the baby’s mattress to protect against anemia, tying a yellow ribbon to the crib to ward against jaundice, and placing a red bow on the crib to distract any envy or negativity.

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Pregnancy and Childbearing Practices
Practices used to make childbirth easier include unlocking places that are open, untying the woman’s hair ribbons, unbuttoning buttons, standing straight and turning so the child will move, drinking water that has been prayed over by religious leaders, enclosing the woman around her waist and rocking her three times, and putting her in a blanket and rocking her three times.

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Pregnancy and Childbearing Practices
Water is not given to a newborn infant until the call to prayer has been announced three times; otherwise, the infant will have bad breath.
At the end of the 40 days, she returns to normal life.
She is bathed with abundant water and prayers are read.

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66

ClickerCheck
The home health nurse found an iron under the mattress of a two month old baby. The iron prevents the baby from
The evil eye.
Thalassemia.
Anemia.
Jaundice.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

67

Correct Answer
Correct answer: C
Placing an iron under the baby’s mattress prevents anemia.

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68

Death Rituals
When death occurs, the deceased individual’s next of kin cry in the most natural manner.
Neighbors who hear about the death gather at the home of the deceased to share in the suffering of the next of kin, to console them, and to help with the initial preparations.
Having prayers said is a common practice.

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Death Rituals
Turkish Muslims do not generally practice cremation because the body must remain whole.
Frequently, the body is displayed in the home for a day or two; it is then placed in a coffin and taken to the cami (mosque) to be visited primarily by men.

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Death Rituals
Preparations for burial include three important procedures: bathing, wrapping in a shroud, and funeral prayers said outside a mosque.
If someone dies in the morning, they are buried after the mid-afternoon prayers; those who die during the night are buried in the morning.
The funeral may be delayed for distant relatives.

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Death Rituals
Common rituals after death are closing the eyes of the deceased, tying the chin, turning the head towards Mecca, putting the feet next to each other, putting the hands together on the abdomen, and removing clothing.
In some places the bed is changed; a knife, iron or other metal object is placed on the abdomen of the deceased; the Koran is read at the head of the deceased.

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Death Rituals
After the burial, a meal honors the deceased, which signifies moving the deceased into the afterlife.
If these rituals are not completed, the spirit of the deceased will be left behind.
The traditional mourning period is 40 days, during which time traditional women may wear black clothes or a black scarf.

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Death Rituals
Although Muslim Turks believe in the afterlife, death is always an occasion of great mourning.
An expression of sympathy to one who has just lost someone to death is Basiniz sag˘ olsun (may your head be healthy), hoping that one is not overwhelmed with grief.
Mourning is the most important and careful behavior after a death occurs.

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Spirituality
Ninety-eight percent of Turks are Muslim, but freedom of religion is mandated by the Turkish secular state.
Most are Sunni Muslims, with a minority from the Alevi Muslim group.
Other religious minority groups include Jews (mostly Sephardic) and Christians.

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Spirituality
Traditional prayer is practiced five times each day and can take place anywhere, as long as one is facing the holy city of Mecca.
A special small rug, called seccade, is used for praying.
When entering the cami, shoes are always removed and women must cover their heads.
Men and women go to separate parts of the cami for prayer.

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Spirituality
One prepares for prayer by ritual cleansing called abdest, which, at minimum, includes washing the face, ears, nostrils, neck, hands to the elbow, and feet and legs to the knee, three times each.
A woman does not enter into a religious activity unless she is ritually pure: women who are menstruating or who have recently given birth are excluded.

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Spirituality
Turks rely on their religious beliefs and practices and their family and friends for strength and meaning in life.
Spiritual leaders or healers are sought most often for assistance with relationship or emotional problems and, less frequently, for physical problems.

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Health-care Practices
Most Turks rely on Western medicine and highly trained professionals for health and curative care. However, remnants of traditional beliefs continue to have an impact on health-care practices.
A common explanation for the cause of illness is an imbalance of hot and cold. For example, diarrhea is thought to come from too much cold or heat; pneumonia results from extreme cold.

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Health-care Practices
Terminally ill clients are generally not told the severity of their conditions.
Informing a client of a terminal illness may take away the hope, motivation, and energy that should be directed toward healing, or it may cause the client additional anxiety related to the fear of dying and concern about those being left behind.

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Health-care Practices
In general, women are responsible for the actual care taking of the ill and the elderly in the home.
In traditional households, the mother-in-law or father-in-law, depending on who controls the finances in the family, makes decisions about going to the physician.
The person who is respected as the most educated has primary input into decisions about health care.

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Health-care Practices
Türkiye has one of the highest rates of consumption of over-the-counter antibiotics and painkillers; aspirin is commonly used as a panacea for a variety of ailments, including gastric upset.
Turks commonly consult a pharmacist before visiting a physician.

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Health-care Practices
Using rubbing alcohol or a wet cloth to bring down a fever and warming the back to treat coughing.
Türkiye encourages health tourism at their 1500 thermal spas, which are frequented for treating conditions, such as rheumatism, respiratory and digestive problems, diabetes, skin conditions, gallstones, female diseases, kidney and heart conditions, nerves, obesity, and hyperlipidemia.

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Health-care Practices
The concept of the “evil eye” is prevalent.
Speaking too well of one’s health may incur misfortune through others’ envy or nazar.
Cologne is sprinkled on the hands of guests before and after eating to provide cleanliness and a fresh lemon scent.
Inhaling from a cloth or handkerchief doused with cologne may be used for relief from motion sickness.

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Health-care Practices
Turkish culture allows freedom to express pain, either through emotional outbursts or through verbal complaints.
Although stigma is attached to mental illness, many families seek treatment or care for the client at home.

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Health-care Practices
Seriously ill people are expected to conserve their energy to allow their minds and bodies to fight their illnesses; thus, reducing their energy expenditure.
During hospitalization, refakatçí refers to the person who stays overnight with the client, providing emotional and physical support and comfort.

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Health-care Practices
Turkish people usually prefer to receive blood from family members.
Muslims traditionally prefer that the body remain intact after death; thus, organ donation and transplantation remains controversial among some Turks. However, former Prime Minister and President Turgut Ozal and his wife promoted organ donation by publicly signing donor cards to encourage others to do so too.

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ClickerCheck
Mr. Oktay, age 66 years, is alert and oriented and has terminal heart failure. His wife does notwant him to know. The nurse should
Abide my the wife’s wishes.
Directly tell Mr. Oktay.
Consult his children.
Ask Mr. Oktay what he knows about his condition.

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88

Correct Answer
Correct answer D
The first step is to determine what Mr. Oktay knows about his condition.

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89

Health-care Practitioners
When modern medicine is not available, accessible, or affordable, or when it has not worked, Turks may seek the care of a traditional healer.
Physicians, and to a lesser extent nurses and midwives, have historically been held in very high esteem.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company

Vietnamese Americans
Larry Purnell, PhD, RN, FAAN

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage
Vietnam is a long narrow country that would stretch from Minneapolis to New Orleans
Majority are closely related to the Chinese
Over 1,200,000 Vietnamese in the United States

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage Continued
1975 Vietnamese War brought 130,000 to the US and mainly came from urban areas and had some familiarity with Western lifestyles and thus adjusted well in the United States
A quarter million more left in 1978–1979 because of the communist regime in Vietnam and became the “boat people” for the next 10 years

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage Continued
Many remained in squalid concentration camps for years
Later immigrants were less educated, poorer, and came from rural areas of Vietnam and came without their families intact

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage Continued
Third wave—Orderly Departure Program–provided safe and legal family repatriation in the United States
Fourth wave in 1987—Amerasian Homecoming Act brought military families, political detainees, children of American servicemen, and more women

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage Continued
Place high value on education and the teacher is well respected
Educational system in Vietnam emphasizes observation, memorization, and repetitive learning
Some continue to experience discrimination in the United States

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications
Vietnamese has several dialects, all of which are understandable to each other but not with other Indochinese countries
Similar in structure to Chinese with borrowed words, polytonal, and one syllable
Only Asian language that uses the English alphabet

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued
Language translations are not easily and directly translatable—in any language
Blue and green are the same work
No way to say “no,” only “yes”
Hot and cold are not related to temperature but to perceived bodily imbalances that are called am and duong

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued
Words used in the affective domain are always difficult to translate in any language
Expressing emotions is considered a weakness, and thus may revert to physical symptoms to describe emotional stress
Caution on touching the head, do not put your feet up and bare the soles of your feet, and do not point or beckon with the upturned finger

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued
Men greet each other with a handshake, but not women or men and women
Men can walk hand in hand as can women without a sexual connotation
Direct eye contact, especially with those in a perceived higher status position, is deemed disrespectful

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued
Most are present oriented with many becoming more futuristic as they acculturate
Punctuality depends on occupation and educational level and language ability
Age is not so important as in the European American culture, age is calculated at time of conception, not birth; use the 10-month calendar, resulting in many given Jan. 1 as a birth date

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued
Use a family name, middle name, and first name and written in that order
Relatively few family and middle names, with first name having some meaning
Naming procedure can be confusing for Americans so many Vietnamese give the American order of names; thus adding more confusion—just ask if you are unsure.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles
Traditional families are patriarchal and extended resulting in difficulty for some when women are in authority positions
Women make most of the healthcare decisions; otherwise roles are divided by gender
Reversal of roles in the United States may cause family disharmony until adjustment

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles Continued
Children are an extension of parents and are expected to be obedient and respectful of elders
Grandparents take a significant role in rearing the grandchildren
Permissive US lifestyle with teenagers and dating can cause family disharmony

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles Continued
Eldest male has the responsibility for parents to the extent that it is more supreme than his responsibility to his wife and children
Elders may feel alone and be depressed with clash of values from their home country and the United States culture
To smile in the face of diversity is demonstrative of strong moral character

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles Continued
Lesbian and gay relationships are not discussed —carry a significant stigma for most
Pseudofamilies are formed by gender groups in the United States in order to share resources and improve economic status

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology
Variations in skin color requiring different assessment techniques than for white-skinned people
Small in stature compared with European Americans with narrower shoulders and wider pelvic structure
Published growth charts are not accurate for Vietnamese—and other groups

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology Continued
Sparse body hair, few apocrine glands, 40% have palatine tori, flat nose bridge causing more difficulty in fitting eye glasses
Betel nut pigmentation among older women from chewing betel leaves
High rates of depression and anxiety-related disorders—especially post-traumatic stress syndrome

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology Continued
High rates of malaria, Tbc, parasitosis, hepatitis B related to the tropics, refugee camps, and crowded living conditions
New arrivals should also be screened for round worm, whipworm, liver flukes, trichinosis, scabies, lice, and impetigo

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Drug Metabolism
More sensitive than other groups to propranolol, atropine, diazepam, and psychotropics—beyond body size
More sensitive to the effects of alcohol
Many adults and some children have lactose intolerance

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

High-Risk Behaviors
Lower socioeconomic rural immigrants may not be aware of tobacco causing cancer or aware for the need of health screening and breast exams and pap smears
High rates of liver and gastrointestinal cancer and “sudden unexplained death syndrome”
Low use of alcohol, tobacco, and recreational drugs

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

High-Risk Behaviors Continued
Reliance on family for healthcare may mean the illness is more severe when seeking health care
Some may not trust healthcare providers based on situations in refugee camps
Usually have great respect for all healthcare providers

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition
Meal time is a family affair
Holidays usually have special foods and dishes
Smaller body size means few calories required
White rice is the main staple
Wide variety of fruits, vegetables, and meats

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition Continued
Ascribe to the hot (duong) and cold (am) theory of foods requiring different foods for certain illnesses—varies by region of migration so just ask and they will tell you.
Traditional diet may be high in sodium and in the United States low in calcium and high in fat

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family
Women have children over a longer period of time than European Americans
Abortions common in Vietnam—great stigma to have a child out of wedlock
Many are not familiar with birth control methods in the United States
Women over the age of 40 have an average of 6 abortions and 4 pregnancies

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family Continued
Specific food practices to have a healthy pregnancy and baby and to balance equilibrium in each trimester of pregnancy
Maintain non-strenuous physical activity to prevent miscarriage, have a healthy and small baby, and quick delivery
Prolonged labor if idle, afternoon napping can cause a large baby

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family Continued
Invasive procedures during labor are disliked and feared
Many prefer squatting position for birthing
Touching the head can cause distress because the soul resides here
Specific postpartum rituals that vary among rural and urban Vietnamese

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family Continued
Older women assume responsibility for the baby’s care
Caution on praising the child because jealous spirits will steal the child
Cutting child’s hair or nails can cause an illness

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals
Death is a normal part of life
Reincarnation and ancestral spirits support the sometimes stoicism seen with death
Prefer to die at home without extensive life- prolonging measures
May buy casket in advance

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

ClickerCheck
A Vietnamese friend tells you she balances her food choices according to hot and cold properties. In Vietnamese, the words for hot and cold are
Yin and yang.
Am and duong.
Fret and cho.
Garm and sard.

*

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Correct Answer
Correct answer: B
The Vietnamese words for hot and cold for balancing foods are am and duong.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals Continued
Gather around dying person and express great emotion
Call religious leader only at the request of the family
Flowers are reserved for the rites of the dead
Family wears white for 14 days after death, followed by black arm bands for men and white headbands for women

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality
Buddhism, Confucianism, and Taoism are the majority
Animism by a few from highland areas of Vietnam
Some may maintain a religious altar in the home
Family is the main reference point throughout life

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices
Good health is achieved by having harmony and balance with the am and duong—an excess of either one may lead to discomfort or illness
Illness can be naturalistic or supernaturalistic
Traditional medicine depends on northern or southern Vietnamese ancestry

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices Continued
Many fear any invasive procedure
Believe that body fluids cannot be replaced
May discontinue any medicine that causes side effects
Most are reluctant to take medicine on a long-term basis

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Responsibility for Health Care
Family care for ill member in the hospital in Vietnam and may wish to do so in the United States
Crisis-oriented care in Vietnam
Many believe Western medicine is too powerful for Vietnamese and therefore say they will take the medicine and then either do not or only take part of it

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Common Vietnamese Treatments
Cai gio
Be bao or bar gio
Giac
Zong
Moxibustion
Acupuncture, acupressure, acumassage
Multiple herbal therapies

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Cai gio
“Rubbing out the wind” is used for colds, sore throats, flu, sinusitis, etc.
Ointment or hot balm is spread across the back, chest, and/or shoulders and rubbed with the edge of a coin
Dermabrasion procedure to let out bad wind as the blood is brought to the surface

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Be bao or bar gio
“Skin pinching” for headaches or sore throat
Produce ecchymosis and petechiae
Very specific technique

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Giac
Cupping or cup suction
Dermabrasion procedure to relieve stress, headaches, joint and muscle pain
Small metal or glass cup is heated by placing wormwood or cotton saturated with alcohol and set afire
Cup forms a suction as it is turned upside down on the skin and then removed, leaving large ecchymotic round areas

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Zong
An herbal preparation relieves motion sickness or cold-related symptoms
Ointment or herbs are put in boiling water and then inhaled. Can be purchased commercially.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Moxibustion
Used to counter conditions associated with excess cold, including labor and delivery
Pulverized wormwood or incense is heated and placed directly on the skin along certain meridians

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Acupuncture, Acupressure, Acumassage
Used for a wide variety of conditions and illnesses—some of which have been proven scientifically—especially for some pain conditions
Needles, pressure, or massage along the Qi channels of energy flow

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

ClickerCheck
The parents of a two year old bring her to the ER because of a persistent productive cough. The nurse finds several quarter-sized ecchymotic area on the child’s back. The nurse recognizes these marks as
a. Cai gio
b. Be bao or bar gio
c. Giac
d. Zong

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Correct Answer
Correct answer: C
Giac, cupping, leave round ecchymotic areas when the cup is removed.

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1

Chapter 38

People of Vietnamese Heritage
Susan Mattson and Larry D. Purnell

Overview, Inhabited Localities,
and Topography
Overview
Vietnam is located at the extreme southeastern corner
of the Asian mainland, bordering the Gulf of Thailand,
Gulf of Tonkin, and South China Sea, alongside
China, Laos, and Cambodia. With a population of over
90 million in a land mass of 127,330 square miles (CIA
World Factbook, 2011), it is relatively narrow in width,
but its north–south length equals the distance from
Minneapolis to New Orleans. Vietnam consists largely
of a remarkable blend of rugged mountains and the
broad, flat Mekong and Red River deltas, which mainly
produce rice. Other features are a long, narrow coastal
plain and other riverine lowlands, where most ethnic
Vietnamese live. Much of the rest of the country is
covered with tropical forests.

Longevity for females is 74.92 years, and for males,
69.72 years. The fertility rate is a low 1.91 children per
female (CIA World Factbook, 2011).

Heritage and Residence
The Vietnamese are a Mongolian racial group closely
related to the Chinese. The population shares some
characteristics with other Asian and Pacific Islander
groups, yet many aspects of its history and culture
are unique. Vietnam was under Chinese control from
111 BC to AD 939 (Huer, Saenz, & Doan, 2001). At
that time, a variety of Chinese beliefs and traditions
were introduced to Vietnam, including the religions
and philosophies of Confucianism, Buddhism, and
Taoism. In addition, the system of Chinese medicine
was adopted widely. European merchants and mis-
sionaries arrived in Vietnam during the 16th century,
and the French established a political foothold and
instituted changes in government and education, includ-
ing Western medical practices (Huer et al., 2001).

The terms Indochinese and Vietnamese are not syn-
onymous. Indochina is a supranational region that in-
cludes the countries of Vietnam, Laos, and Cambodia.
Vietnam alone has eight different ethnic groups, the

majority (86 percent) of whom are Viet (CIA World
Factbook, 2011). One factor in providing proper health
care to Vietnamese in America is understanding that
they differ substantially between and among themselves,
depending on the variant cultural characteristics of cul-
ture (see Chapter 1in this book). Clear differences exist
among Vietnamese, Cambodians, and Laotians with
respect to premigration experiences, which influence
subsequent manifestations of psychological distress.

Along with Asian Indians, Vietnamese immigrants
have the highest proportion of children under the
age of 18, with a median age of 33, yet the poverty
rate is highest for Koreans, Vietnamese, and Chinese
(13 percent). Within this population, Vietnamese im-
migrants have the highest proportion of naturalized
citizens (50 percent), with the smallest proportion of
those who were foreign born and not U.S. citizens at
21 percent; 30 percent are native born Americans.
Forty-nine percent of the immigrants arrived before
1990, and 42 percent came between 1990 and 1999
(Office of Minority Health, 2007).

Initial Vietnamese immigrants confronted a unique
set of problems, including dissimilarity of culture, no
family or relatives to offer initial support, and a negative
identification with the unpopular Vietnam War. Many
Vietnamese were involuntary immigrants, with their ex-
patriation unexpected and unplanned; their departures
were often precipitous and tragic. Escape attempts were
long, harrowing, and for many, fatal. Survivors were
often placed in squalid refugee camps for years.

The first wave of Vietnamese immigration began in
April 1975, when South Vietnam fell under the Com-
munist control of North Vietnam and the Viet Cong.
At that time, many South Vietnamese businessmen,
military officers, professionals, and others closely
involved with America or the South Vietnamese gov-
ernment feared persecution by the new regime and
sought to escape. American ships and aircraft rescued
some; many were temporarily located in refugee camps
in Southeast Asia, and then sent to relocation camps in
the United States. The 130,000 Vietnamese refugees
who arrived in the United States in 1975 came mainly

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2 Aggregate Data for Cultural-Specific Groups

from urban areas, especially Saigon, and consequently
had some prior orientation to Western culture. Many
spoke English or soon learned English in relocation
centers. More than half were Christian. Sixty-two
percent consisted of family units of at least five people,
and nearly half were female. They were dispersed over
much of the United States, often in the care of sponsor-
ing American families. One year after arrival, 90 percent
were employed, and by the mid-1980s, their average in-
come matched that of the overall American population.
These first-wave immigrants adjusted well in comparison
to the subsequent wave.

By the 1970s,further events in Vietnam triggered a
second wave of immigration. Many Vietnamese grew
disenchanted with Communism and their decreased
living standard. Great numbers had been forced into
labor in new countryside settlements, and young men
were often fearful of being called to fight against
China or in the new war with Cambodia. Some left by
land across Cambodia or Laos, commonly joining
refugees from those countries in an effort to reach
Thailand. For more than a decade, many others, known
as the “boat people,” departed Vietnam in small, often
unseaworthy and overcrowded vessels in hopes of
reaching Malaysia, Hong Kong, the Philippines, or an-
other non-Communist port. Half died during their
journey. Many were forcibly repatriated to Vietnam or
eventually returned voluntarily; others continued to
languish in camps for years. Most of the second-wave
refugees represented lower socioeconomic groups and
had less education and little exposure to Western
cultures. Most did not speak English. This wave of
Vietnamese included far more young men than
women, children, or older people, which disrupted in-
tact families and normal gender ratios. Many spent
months or years in refugee camps under deplorable
and regimented conditions. The United States passed
the Refugee Act of 1980 in response to this second
wave and widened the scope of resources available to
assist refugees or individuals who fled their native
country and could not returen for fear of persecution
and physical harm (Huer et al., 2001).When they finally
arrived in the United States and Canada, many did not
fit into American communities, did not learn English
effectively, and remained unemployed or obtained me-
nial jobs. These hardships contributed to physical prob-
lems, psychological stress, and depression.

The contiuing persecution of individuals in Vietnam
led to a third wave of immigration, beginning in 1979
with the creation of the Orderly Departure Program,
which provided safe and legal exit for Vietnamese seek-
ing to reunite with family members already in America.
Former military officers and soldiers in prison or reed-
ucation camps were allowed to come the United States
with their families, resulting in the immigration of
200,000 individuals by the mid-1990s. The Humanitar-
ian Operation Program of 1989 also permitted more

than 70,000 current and former political prisoners
to immigrate. Finally, the Amerasian Homecoming
Act of 1988 allowed the children of Vietnamese
civilians and American soldiers to immigrate to the
United States. Many of the Amerasian children were
orphans who had lived on the street, received no formal
education, and had been subjected to prejudice and dis-
crimination in Vietnam (Huer et al., 2001).

Reasons for Migration and Associated
Economic Factors
Vietnamese, whether as immigrants or sojourners, have
fled their country to escape war, persecution, or possi-
ble loss of life. Better-educated, first-wave immigrants
from urban areas had professional, technical, or man-
agerial backgrounds. Less-educated, second-wave im-
migrants from more rural areas were fishermen,
farmers, and soldiers and had only minimal exposure
to Western culture. Factors influencing the ability of
displaced Vietnamese to obtain employment included
a higher level of education and the ability to speak
English on arrival. Thus, the second-wave immigrants
were significantly more disadvantaged.

Educational Status and Occupations
Vietnamese place a high value on education and ac-
cord scholars an honored place in society. The teacher
is highly respected as a symbol of learning and culture.
In contrast to American schools’ emphasis on experi-
mentation and critical thinking, Vietnamese schools
emphasize observation, memorization, and repetitive
learning. This style of learning is still predominant in
Vietnam, including the universities with schools of
medicine and nursing. Most Vietnamese men and
women in America are very educationally oriented and
take full advantage of educational opportunities when
possible. Educational level and occupation continue to
vary by the time of arrival in the United States, as de-
scribed earlier in the discussion of the four waves of
immigration.

Communication
Dominant Languages and Dialects
The official language of Vietnam is Vietnamese, with
English increasingly being favored as a second lan-
guage, followed by French and Chinese (CIA World
Factbook, 2011). Ethnic Vietnamese speak a single
distinctive language, with northern, central, and
southern dialects, all of which can be understood by
anyone speaking any of these dialects. The Vietnamese
language resembles Chinese and contains many
borrowed words, but someone speaking one of these
languages cannot necessarily understand the other.
All words in Vietnamese consist of a single syllable,
although two words are commonly joined with a
hyphen to form a new word. Verbs do not change

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People of Vietnamese Heritage 3

forms, articles are not used, nouns do not have plural
endings, and there are no prefixes, suffixes, definitives,
or distinctions among pronouns. Contextually, the
Vietnamese language is musical, flowing, and poly-
tonal, with each tone of a vowel conveying a different
meaning to the word. The language is spoken softly,
and its monosyllabic structure lends itself to rapidity,
but spoken pace varies according to the situation.
Whereas grammar is mostly simple, pronunciation can
be difficult for Westerners, mainly because each vowel
can be spoken in five or six tones that may completely
change the meaning of the word. Vietnamese is
the only language of the Asian mainland that, like
English, is regularly written in the Roman alphabet
since it was introduced by the French in the 17th
century. Although the letters are the same, pronunci-
ation of vowels may vary radically depending on
associated marks indicating tone and accent, and cer-
tain consonant combinations take on unusual sounds.
When speaking Vietnamese, Westerners in particular
will often use “hand signals” to indicate an upward
inflection or a mark that should appear with the letter
being spoken (personal observation, Mattson, 2005,
2007–2009).

Even if someone learns how to pronounce and trans-
late Vietnamese, problems may remain with respect to
intended meaning of various words. One minor but
perennial stumbling point with potential medical con-
notations is that the words for “blue” and “green” are
the same. More important, the word for “yes,” rather
than expressing a positive answer or agreement, may
simply reflect an avoidance of confrontation or a desire
to please the other person. The terms “hot” and “cold,”
rather than expressing physical feelings associated with
fever and chills, may actually relate to other conditions
associated with perceived bodily imbalances. Various
medical problems might be described differently from
what a Westerner might expect; for example, a “weak
heart” may refer to palpitations or dizziness, a “weak
kidney” to sexual dysfunction, a “weak nervous sys-
tem” to headaches, and a “weak stomach or liver” to
indigestion (Muecke, 1983b).

Most Vietnamese refugees, even those who have
been in the United States for many years, do not feel
competent in English. Although many refugees
eventually learn English, their skills may not be ad-
equate in certain situations. The important subtleties
in describing medical conditions and symptoms, or
the more abstract presentation of ideas during psy-
chiatric interviews may be particularly difficult.
Health-care providers may need to watch patients
for behavioral cues, use simple sentences, paraphrase
words with multiple meanings, avoid metaphors and
idiomatic expressions, ask for correction of under-
standing, and explain all points carefully. Approach-
ing Vietnamese patients in a quiet, unhurried manner,
opening discussions with small talk, and directing

the initial conversation to the oldest member of the
group facilitate communication.

Cultural Communication Patterns
Traditional Vietnamese religious beliefs transmitted
through generations produce an attitude toward life
that may be perceived as passive. For example, when-
ever confronted with a direct but delicate question,
many Vietnamese cannot easily give a blunt “no” as
an answer because they feel that such an answer may
create disharmony. Self-control, another traditional
value, encourages keeping to oneself, whereas expres-
sions of disagreement that may irritate or offend
another person are avoided. Individuals may be in
pain, distraught, or unhappy, yet they rarely complain
except perhaps to friends or relatives. Expressing
emotions is considered a weakness and interferes with
self-control. Vietnamese are unaccustomed to dis-
cussing their personal feelings openly with others. In-
stead, at times of distress or loss, they often complain
of physical discomforts such as headaches, backaches,
or insomnia. Vietnamese tend to be very polite and
guarded. Sparing one’s feelings is considered more
important than factual truth.

The strong influence of the Confucian code of
ethics means that proper form and appearance are
important to Vietnamese people and provide the
foundation for nonverbal communication patterns.
For example, the head is a sacred part of the body and
should not be touched. Similarly, the feet are the low-
est part of the body and to place one’s feet on a
desk is considered offensive to a Vietnamese person.
To signal for someone to come by using an upturned
finger is a provocation, usually done to a dog; waving
the hand is considered more proper.

Hugging and kissing are not seen outside the pri-
vacy of the home. Men greet one another with a
handshake but do not shake hands with a woman un-
less she offers her hand first. Women do not usually
shake hands. Two men or two women can walk hand
in hand without implying sexual connotations. How-
ever, for a man to touch a woman in the presence of
others is insulting.

Looking another person directly in the eyes may
be deemed disrespectful. Women may be reluctant to
discuss sex, childbearing, or contraception when men
are present and demonstrate this unwillingness by
giggling, shrugging their shoulders, or averting their
eyes. Negative emotions and expressions may be con-
veyed by silence or a reluctant smile. A smile may ex-
press joy, convey stoicism in the face of difficulty,
indicate an apology for a minor social offense, or be
a response to a scolding to show sincere acknowledg-
ment for the wrongdoing or to convey the absence of
ill feelings. Vietnamese prefer more physical distance
during personal and social relationships than some
other cultures, but extended Vietnamese families of

2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 3

many individuals live comfortably together in close
quarters.

Temporal Relationships
Vietnamese religion and tradition place emphasis on
continuity, cycles, and worship of ancestors. Tradi-
tional Vietnamese may be less concerned about the
precise schedules than are European Americans. To
cope with their changed situation, many Southeast
Asian refugees concentrate on the present and, to
some extent, on the future.

Asians frequently arrive late for appointments.
Noncompliance in keeping appointments may relate
to not understanding oral or written instructions or
to not knowing how to use the telephone. One other
aspect of time involves the concept of age. Vietnamese
people pay much less attention to people’s precise ages
than do Americans. Actual dates of birth may pass
unnoticed, with everyone celebrating their birthdays
together during the Lunar New Year (Tet) in January
or February. In addition, a person’s age is calculated
roughly from the time of conception; most children
are considered to be already a year old at birth and
gain a year each Tet. A child born just before Tet
could be regarded as 2 years old when only a few days
old by American standards. Because the practice of
determining age is so different in Vietnam, many im-
migrants who do not know their exact birth date are
often assigned January 1 for official records.

When a friend is invited on an outing, the bill is paid
for by the person offering the invitation. When giving
gifts, the giver often discounts the item, even though it
may be of great value. The recipient of a gift is ex-
pected to display significant gratitude, which some-
times lasts a lifetime. Some may be reluctant to accept
a gift because of the burden of gratitude. Vietnamese
may refuse a gift on the first offer, even if they intend
to accept it eventually, so as not to appear greedy.

Format for Names
Most Vietnamese names consist of a family name, a
middle name, and a given name of one or two words,
always written in that order. There are relatively few
family names, with Nguyen (pronounced “nwin”) and
Tran accounting for more than half of all Vietnamese
names. Other common family names are Cao, Dinh,
Hoang, Le, Ly, Ngo, Phan, and Pho. Additionally,
there is little diversity in middle names, with Van being
used regularly for men and Thi (pronounced “tee”) for
women. Given names frequently have a direct mean-
ing, such as a season of the year or an object of ad-
miration. Family members often refer to offspring by
a numerical nickname indicating their order of birth.

This practice may increase the difficulty of modern
record-keeping and identification of specific individ-
uals. Therefore, use the family name in combination
with the given name. Indeed, Vietnamese refer to one

another by given name in both formal and informal
situations. For example, a typical woman’s name is
Tran Thi Thu, which is how she would write or give
her name if requested. She would expect to be called
simply Thu or sometimes Chi (sister) Thu by friends
and family. In other situations, she would expect to be
addressed as Cô (Miss) or Ba (Mrs.) Thu. If married
to a man named Nguyen Van Kha, the proper way to
address her would be as Mrs. Kha, but she would
retain her full three-part maiden name for formal pur-
poses. The man would always be known as Kha or
Ong (Mr.) Kha. Some Vietnamese American women
have adopted their husband’s family name. Children
always take the father’s family name.

Family Roles and Organization
Head of Household and Gender Roles
The traditional Vietnamese family is strictly patriar-
chal and is almost always an extended family struc-
ture, with the man having the duty of carrying on the
family name through his progeny. Some families who
are not accustomed to female authority figures may
have difficulty relating to women as professional
health-care providers, although this is changing in
Vietnam. Today there are many physicians, dentists,
and pharmcists who are women, with an increasing
number of men choosing nursing as a career (personal
observation, Mattson, 2007–2009). With the move
into Western society, the father may no longer be the
undisputed head of the household, and the parents’
authority may be undermined. Immigrant Vietnamese
families frequently experience role reversals, with
wives or children adapting more easily than men.

A Vietnamese woman lives with her husband’s
family after marriage but retains her own identity.
Within the traditional family, the division of labor is
gender related: the husband deals with matters outside
the home, and the wife is responsible for the actual
care of the home, and often makes health-care
decisions for the family. While many Vietnamese and
Vietnamese American women work outside the home,
they also continue as the primary caretaker of the
home. Although her role in family affairs increases
with time, a Vietnamese wife is expected to be dutiful
and respectful toward her husband and his parents
throughout the marriage.

Vietnamese refugees of all subgroups have experi-
enced degrees of reversal of the provider and recipient
roles that existed among family members in Vietnam.
“Women’s jobs,” such as hotel maid, sewing machine
operator, and food-service worker, are more readily
available than male-oriented unskilled occupations;
today more men are employed in these jobs. Role re-
versals between parents and children are also common
because children often learn the English language and
American customs more rapidly than their parents

4 Aggregate Data for Cultural-Specific Groups

2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 4

People of Vietnamese Heritage 5

and therefore, may be able to find employment more
quickly. Vietnamese families in the United States
experience a greater tendency toward nuclearization,
growth in spousal interaction and interdependency,
more-egalitarian spousal relations, and shared deci-
sion making than their traditional counterparts.

Prescriptive, Restrictive, and Taboo Behaviors
for Children and Adolescents
Traditionally, children are expected to be obedient and
devoted to their parents, their identity being an exten-
sion of the parents. Children are obliged to do every-
thing possible to please their parents while they are alive
and to worship their memory after death. The eldest
son is usually responsible for rituals honoring the mem-
ory and invoking the blessings of departed ancestors.
This pattern may be ingrained from early childhood.

Vietnamese children are prized and valued because
they carry the family lineage. For the first 2 years, their
mothers primarily care for them; thereafter, their
grandmothers and others take on much of the respon-
sibility. Parents usually do not discipline or place
extensive limits on their children at a young age.
Generally, Vietnamese do not use corporal punish-
ment such as spanking; rather, they speak to the chil-
dren in a quiet, controlled manner.

Young people are expected to continue to respect
their elders and to avoid behavior that might dishonor
the family. As a result of their exposure to Western
cultures, a disproportionate share of young people
have difficulty adapting to this expectation. A conflict
often develops between the traditional notion of filial
piety, with its requisite subordination of self and
unquestioning obedience to parental authority, and
the pressures and needs associated with adaptation to
American life. Ironically, successful relationships with
Americans at school have placed Vietnamese adoles-
cents at risk for conflicts with their parents. Con-
versely, failure to form such relationships with their
American peers has sometimes appeared to be a pre-
cursor of emotional distress. Parents do, however,
show relative approval for adolescent freedom of
choice regarding dating, marriage, and career choices.

The extreme bipolarities of the adaptation of
Vietnamese youth are sometimes overemphasized.
Members of one group, usually the children of the
first-wave refugees, are often portrayed as academic
superstars. At the other end of the social spectrum
are the criminal and gang elements, who often direct
their activities against other Asian immigrants. Most
Vietnamese adolescents, however, fall between these
two extremes and have the same pressures and
concerns as other youths.

Family Goals and Priorities
The traditional Vietnamese family is perhaps the most
basic, enduring, and self-consciously acknowledged

form of national culture among refugees, providing
lifelong protection and guidance to the individual.
The family, usually large, patriarchal, and extended,
includes minor children, married sons, daughters-
in-law, unmarried grown daughters, and grandchil-
dren under the same roof. Other close relatives may be
included within the extended family structure. The
family is explicitly structured with assigned priorities,
identifying parental ties as paramount. A son’s obliga-
tions and duties to his parents may assume a higher
value than those to his wife, children, or siblings. Sibling
relationships are considered permanent. Vietnamese self
is defined more along the lines of family roles and re-
sponsibilities and less along individual lines. These mu-
tual family tasks provide a framework for individual
behavior, promoting a sense of interdependence, belong-
ing, and support. The traditional family has been altered
as a consequence of Western influence, urbanization,
and the war-induced absence of men. Nevertheless,
many Vietnamese continue to uphold this social form
as the preferable basis of social organization in the
United States. As mentioned in the previous section,
exposure of the younger generation to American cul-
ture can become a source of conflict with considerable
family strain as adolescents are influenced by the per-
ceived American values of individuality, independ-
ence, self-assertion, and egalitarian relationships.

Traditionally, older people are honored and have a
key role in transmitting guidelines related to social be-
havior, preparing younger people for handling stressful
life events, and serving as sources of support in coping
with life crises. Older people are usually consulted for
important decisions. Addressing a client in the presence
of an older person, whether they speak English or not,
instead of the elder, may be interpreted as disrespectful
to the family. Homesickness and bewilderment are es-
pecially acute in older refugees when confronted with
the strange Western culture and despair about the future
(Fig. 38-1). Accustomed to considerable respect and es-
teem in their homeland, they may feel increasingly alien-
ated and alone as the younger generations adopt new
values and ignore the counsel and values of the elders.
Living within the family unit facilitates the social adjust-
ment of older refugees into American society.

Traditional Vietnamese are class conscious and
rarely associate with individuals at different levels of
society. Traditional respect is accorded to people in
authoritative positions who are well educated or oth-
erwise successful or who have professional titles. How-
ever, class distinctions are sometimes blurred in the
turmoil of war and resettlement. Two concepts govern
the gain and loss of prestige and power, thereby main-
taining face: mien, based on wealth and power, and
lien, based on demonstration of control over and re-
sponsibility for moral character. For example, to smile
in the face of adversity is to maintain lien and is
considered of great importance.

2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 5

Alternative Lifestyles
The complex extended Vietnamese family in America
is extremely vulnerable to change. Many young peo-
ple, frequently unmarried couples, seek their own liv-
ing accommodations away from the control of older
generations. Unattached male refugees may join
pseudofamilies, households made up of close and dis-
tant relatives and friends who share accommoda-
tions, finances, and companionship. These families
form an important source of social support in the
refugee communities. Because of the high regard
for chastity placed on Vietnamese adolescents, the
number of single-parent households is low, as is the
divorce rate.

Differing sexual orientation is difficult for
Vietnamese to face because being gay or lesbian
brings shame upon the family, causing many gays
and lesbians to remain closeted (Miae, 1999). When
questioning a gay or lesbian person about his or her
sexual activity, an interpreter unknown to the family
is an absolute requirement.

Workforce Issues
Culture in the Workplace
First-wave immigrants adjusted well to the American
workplace, and within a decade, their average income
equaled that of the general U.S. population. Many
later immigrants, who had less education and did not
know English, ended up working in lower-paying jobs.
However, some learned English and opened their own
businesses and prospered.

Traditionally, priority is given to the concerns
of the family rather than to those of the employer.

However, this emphasis is not a detriment to produc-
tivity in work habits, because a good work record
and steady pay bring honor and prosperity to the
family. The Vietnamese are highly adaptable and
adjust their work habits to meet requirements for
successful employment.

Most Vietnamese respect authority figures with im-
pressive titles, achievement, education, and a harmo-
nious work environment. They may be less concerned
about such factors as punctuality, adherence to dead-
lines, and competition. Other traditions include a
willingness to work hard, sacrifice current comforts,
and save for the future to ensure that they assimilate
well into the workforce. Many seek the same material,
financial, and status rewards that beckon native-born
Americans.

Issues Related to Autonomy
Confucianism and its stress on the maintenance of
formal hierarchies within governmental, religious, and
educational institutions; commercial establishments;
and families have heavily influenced the Vietnamese
outlook. This cultural background results in conform-
ity and reluctance to undertake independent action.
At the same time, the cultural outlook of company
and family values superseding personal values creates
a cohesive work group. Moreover, because many
fear losing their job if they speak out about inequities,
they are likely to be taken advantage of by some more-
unscrupulous employers.

Vietnamese quickly learn vocabulary for pragmatic
communication but may have difficulty with complex
verbal skills. Values related to their own culture dis-
courage disclosure of inner thoughts and feelings.
These barriers may adversely affect employment op-
portunities and limit their ability to communicate
needs relative to social, psychological, and economic
matters. Employers may need to allow extra time and
provide visually oriented instructions and programs
that enhance communications to promote increased
harmony in the workplace.

Biocultural Ecology
Skin Color and Other Biological Variations
Vietnamese are members of the Mongolian or Asian
race. Although their skin is often referred to as “yel-
low,” it varies considerably in color, ranging from pale
ivory to dark brown. Mongolian spots, bluish discol-
orations on the lower back of a newborn child, are
normal hyperpigmented areas in many Asians and
dark-skinned races.

To assess for oxygenation and cyanosis in dark-
skinned Vietnamese, the health-care provider must ex-
amine the sclerae, conjunctivae, buccal mucosa,
tongue, lips, nailbeds, palms of the hands, and soles
of the feet. These same areas should be observed for

6 Aggregate Data for Cultural-Specific Groups

Figure 38-1 Elders are honored in traditional Vietnamese
culture, but the effects of American culture on immigrant fami-
lies may sometimes be troubling to older adult Vietnamese
Americans.

2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 6

People of Vietnamese Heritage 7

adverse reactions during blood transfusions, giving
special attention to diaphoresis on the forehead, upper
lip, and palms, which may signify impending shock.

One of the first signs of iron deficiency anemia is
pallor, which varies with skin tones. Dark skin loses
the normal underlying red tones, so that Vietnamese
patients with brown skin will appear yellow-brown.
Petechiae and rashes may be hidden in dark-skinned
individuals as well, but these can be detected by ob-
serving for patches of melanin in the buccal mucosa
and on the conjunctivae. Jaundice can be observed in
dark-skinned Vietnamese as a yellow discoloration of
the conjunctiva. Because many dark-skinned individ-
uals have carotene deposits in the subconjunctival fat
and sclera, the hard palate should also be assessed.

The Vietnamese are usually small in physical stature
and light in build relative to most European Americans.
Adult women average 5 feet tall and weigh 80 to
100 lbs. Men average a few inches taller and weigh
110 to 130 lbs. Although Roberts, Copel, Bhutan, and
Otis (1985) reported no significant difference in birth
weight between refugee babies and those of other par-
ents, Vietnamese children are small by American stan-
dards, not fitting the published growth curves. The
study by Vangen et al. (2002) of the birth weights
for Vietnamese, Pakistani, Norwegian, and African
American babies found that the mean birth weights were
largely unrelated to perinatal mortality, which was low-
est for the Vietnamese (8.2 of 1000; 95 percent confi-
dence interval [CI]: 5.1 to 11.3). They concluded that the
differences in perinatal mortality between ethnic groups
were not explained by differences in mean birth weight.
Paradoxical differences in birth weight–specific mortal-
ity rates could be resolved by adjustment to a relative
scale. Thus, growth charts commonly used in America
cannot provide adequate assessments for evaluating the
physical development of Vietnamese children. Other pa-
rameters such as parental height and weight, apparent
state of health, the energy level of the child, and pro-
gressive development over time need to be considered.

Typical physical features of the Vietnamese include
almond-shaped eyes, sparse body hair, and coarse
head hair. Vietnamese also have dry earwax, which is
gray and brittle. People with dry earwax have few
apocrine glands, especially in the underarm area, and
thus produce less sweat and associated body odor.
Asians generally have larger teeth than European
Americans, creating a normal tendency toward a prog-
nathic profile. In addition, there may be a torus, bony
protuberance, on the midline of the palate or on
the inner side of the mandible near the second premo-
lar. Hjertstedt et al. (2001) found that 23 percent of
Vietnamese subjects in their study had mandibular
tori, 13 percent had palatal tori, and 12 percent had
both mandibular and palatal tori. Mandibular tori
were more common in men, and palatal tori were
more common in women.

Betel nut pigmentation may be found in some Viet-
namese adults, resulting from the practice of chewing
betel leaves (chau). This practice is common among
older women and has a narcotic effect on diseased
gums. Some older women lacquer their teeth, believ-
ing that it strengthens the teeth and symbolizes beauty
and wealth.

Diseases and Health Conditions
Vietnamese women have the highest rate of cervical
cancer of any female population in the United States
that has been surveyed, approximately 43 per 100,000
or six times the national average (Wright, 2000). The
prevalence of the disease is the result of lack of edu-
cation, reluctance to seek early treatment, fear that
nothing can be done, low utilization of annual Pap
smears, and failure to follow up on abnormal Pap
smears. Some evidence also implicates human papil-
lomavirus (HPV), a sexually transmitted etiological
factor, in the pathogenesis of cervical cancer. Cancer
and other problems common to Vietnamese people
may also be associated with the widespread applica-
tion of chemical agents during the Vietnam War.

Vietnamese Americans ages 56 and older are twice
as likely as Caucasian Americans to report needing
mental health care and also less likely to discuss such
issues with a professional. Many of the problems are
believed to be related to the Vietnam War and leaving
the country in 1975. “They already had pre-war
trauma, and they come to the U.S and it’s a new country,
a new language and they have to find jobs. What we
are finding is that 30 years after the war, there are still
people having problems” (Sorkin et al., 2008, p.1).
Mental-health research has indicated that Vietnamese
refugees have disturbingly high rates of depression,
generalized anxiety disorders, and post-traumatic
stress associated with military combat, political im-
prisonment, harrowing events during escapes by sea,
and brutal pirate attacks. Chronic personal and emo-
tional problems often stem from post-traumatic stress
experiences in this population (Hilton et al., 1997).

Of immediate concern to health-care providers
working with Vietnamese refugees is the treatment of
infectious conditions that jeopardize both the refugee
and the resident population. Some refugees suffer
from malaria, parasites, and other problems associ-
ated with the tropics, although Catanzaro and Moser
(1982) reported that the Vietnamese have a lower in-
cidence of intestinal parasites, anemia, and hepatitis
B antigenemia than other refugee groups. However,
69 percent of tuberculin tests return positive in the
Vietnamese refugees, and this high rate of positive re-
sults correlates with their origins from crowded,
poorly ventilated cities. Screening of second-wave
refugees reveals a higher incidence of tuberculosis, in-
testinal parasites, anemia, malaria, and hepatitis B.
Sutter and Haefliger (1990) reported an estimated

2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 7

annual risk of 2.2 percent for developing active tuber-
culosis in Vietnamese people and also noted that the
disease was most likely present before arrival in
refugee camps. Hepatitis B virus is hyperendemic in
Indochina, with most people being infected during
childhood and spreading the infection to others.
Hepatitis B virus vaccination is recommended for all
newborn refugee children.

Other endemic diseases include leprosy (a rate
of about 20 to 30 cases per 1000 population
compared with a U.S. rate of fewer than 0.25 per
1000 population); high levels of parasitism, particu-
larly the intestinal nematodes Ascaris (roundworm)
and Trichuris (whipworm), which are associated with
contaminated or poorly cooked foods, the liver fluke
Clonorchis, which is introduced in raw, pickled, or dried
fish (Dao, Gregory, & McKee, 1984), and Necator
(hookworm); and malaria.

To determine the presence of parasites, health-care
providers must assess for symptoms of anemia, lassi-
tude, failure to thrive, abdominal pain, weight loss,
and skin rashes. In the first two waves of refugees,
major health problems also included skin infections
caused by fungus, impetigo, scabies, and lice (7 to
15 percent); infections of the upper respiratory tract
and otitis media (20 percent); anemia including para-
sitic iron deficiency (16 to 40 percent), with a higher
occurrence in young children; hemoglobin disorders
(30 percent); chronic diseases (10 percent); and mal-
nutrition and poor immunization status (Ross, 1982).

Caution should be used before routinely diagnosing
tuberculosis. Two clinical illnesses that may mimic tu-
berculosis, melioidosis and paragonimiasis, are also
reported among refugees. Additionally, Sutherland,
Avant, Franz, and Monson (1983) reported that
14 percent of the Vietnamese refugees in their Mayo
Clinic study exhibited microcytosis, which can lead to
an incorrect diagnosis of iron deficiency and inappro-
priate treatment with iron. Erythrocytic microcytosis
in Southeast Asians is most likely a reflection of the
presence of thalassemia or of hemoglobin E trait,
conditions that are usually harmless and need no
treatment. These disorders should be suspected in
people with findings consistent with tuberculosis but
with a negative purified protein derivative response
(Ross, 1982).

Screening immigrants for syphilis shows an inci-
dence as low as 1 to 5 percent. Sporadic cases and
limited outbreaks of cholera, measles, diphtheria, epi-
demic conjunctivitis, and typhoid fever fail to show a
notable secondary spread (Ross, 1982). Observations
at the Mayo Clinic reported that refugee populations
are young and generally healthy, despite a prevalence
rate of 82 percent for intestinal parasites (Sutherland
et al., 1983). In addition, moderate to severe dental
problems may occur in newer immigrants, especially
children.

The health-care provider should consider screening
newer refugees and immigrants from Vietnam for nu-
tritional deficits; hepatitis B; tuberculosis; parasites
such as roundworm, hookworm, filaria, flukes, amoe-
bae, and giardia; malaria; HIV; Hansen’s disease; and
post-traumatic stress disorder. Recommended labo-
ratory and other tests for refugees include a nutri-
tional assessment, stool for ova and parasites,
hemoglobin and hematocrit, and a chest radiograph
for tuberculosis.

Variations in Drug Metabolism
Little pertinent drug research exists specifically on the
Vietnamese. Clinical studies comparing other Asians
with European Americans provide some idea of what
might be expected. For example, the Chinese are twice
as sensitive to the effects of propranolol on blood
pressure and heart rate; experience a greater increase
in heart rate from atropine; require lower doses of
benzodiazepines, diazepam, and alprazolam because
of their increased sensitivity to the sedative effects
of these drugs; require lower doses of imipramine,
desipramine, amitriptyline, and clomipramine; and
are less sensitive to cardiovascular and respiratory side
effects of analgesics (e.g., morphine) but are more
sensitive to their gastrointestinal side effects. Asians
require lower doses of neuroleptics (e.g., haloperidol)
(Levy, 1993).

Lin and Shen (1991) expressed concern about the
lack of research on pharmacotherapy specifically re-
lated to major depressive and post-traumatic stress
disorders in Southeast Asian refugees. They suggested
that drug metabolism is comparable with that of other
Asian groups with important common traits such
as genetic, cultural, and environmental influences.
Asian diets, for example, are similar in their higher
carbohydrate-to-protein ratio, which significantly
influences the metabolism of some commonly pre-
scribed drugs. Also, because most Asians come from
areas with similar degrees of socioeconomic develop-
ment, exposure to various enzyme-inducing agents,
such as industrial toxins, is likely to be similar. Con-
versely, the exposure of the refugees to war, trauma,
starvation, and other adverse conditions could have
an effect on the enzyme systems governing psy-
chotropic medications. One precaution involves the
continued extensive use of traditional herbal medi-
cines by the refugees. Some of these herbal drugs have
active pharmacologic properties that may interact with
psychotropic drugs. For example, some may cause
atropine psychosis when ingested concomitantly with
tricyclic antidepressants or low-potency neuroleptics.

Significantly lower dosages of psychotropic med-
ications are prescribed in Asian countries than are
common in Western countries. Low doses of antide-
pressant medications are often effective. Weight stan-
dards for neuroleptic dose ranges are significantly

8 Aggregate Data for Cultural-Specific Groups

2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 8

lower in Asians than among white Americans (Levy,
1993). Because Vietnamese are considerably smaller
than most white Americans, medication dosages may
need to be reduced. Vietnamese generally consider
American medicines more concentrated than Asian
medicines; thus, they may take only half of the dosage
prescribed. In addition, many Asian people are slow
metabolizers of alcohol. Thus, Asians are more
sensitive than European Americans to the adverse
effects of alcohol, as expressed by facial flushing,
palpitations, and tachycardia.

High-Risk Behaviors
Alcohol and tobacco use by Vietnamese in general has
been reported to be relatively low. However, some ado-
lescents have turned to alcohol, often drinking alone.
Yu (1991) reported a substantial increase in smoking
among Asian American women in general; tradition-
ally there have been more men than women smokers.
Jenkins, McPhee, Dordham, and Hung (1992) found
the incidence of smoking among men in California was
higher in Vietnamese than in Chinese or Hispanics.
The prevalence of alcohol consumption is 67 percent
among Vietnamese men and only 18 percent among
women, versus 66 percent and 47 percent, respectively,
in the general population. Binge drinking is reported
by 35 percent of men.

Among women, 89 percent say they had never heard
of the Pap test; after this procedure is explained,
32 percent say they never had one (versus 9 percent of
American women). Vietnamese women living in the
United States have a cervical cancer incidence rate that
is five times that of Caucasian women. Contibuting to
this problem is the low rate of cervical cancer screening
among this high-risk population (Solomon, DeJoice,
Nguyen, Kwon, & Berlin, 2005).Recent U.S. data indi-
cate that women of Vietnamese descent also have
lower levels of Pap testing than Caucasian, Black, and
Latina women. Regular Pap testing was strongly asso-
ciated with having a regular doctor, having a physical
in the last year, previous physician recommenda-
tion for testing, and having asked a physician for test-
ing. However, women whose regular doctor was a
Vietnamese man were no more likely to have recieved
a recent Pap smear than those with no regular doctor.
The authors of the study recommend that intervention
programs should improve patient–provider communi-
cation by encouraging health-care providers (especially
male Vietnamese physicians serving women living in
ethnic enclaves) to recommend Pap testing (Taylor et al.,
2009). Solomon et al. (2005) also found that knowl-
edge about the importance of Pap tests was the most
influential factor in contributing to why Vietnamese
women may not seek a Pap test, and recommended
print materials to include both English and Vietnamese
translations. In addition, 28 percent of women never
had a breast examination and 83 percent never had a

mammogram. Findings from a study of the Cancer
Prevention Institute of California reveal that Asian-
born women in the United States, particularly women
from Vietnam, China, and the Philippines, have a
much higher risk of dying from breast cancer than
U.S.-born Asian Americans. The highest-risk group,
women born in Vietnam, had a four times greater
risk of dying from breast cancer than U.S.-born
Vietnamese (Medical News Today, 2010).

The incidence of lung cancer is 18 percent higher
among Southeast Asian men than among European
American men, most likely associated with smoking
and exposure to environmental pollutants. Among
Asian American men, lung and bronchial cancer are
the leading causes of death (Medical News Today,
2010). Further, the incidence of liver cancer is more
than 12 times higher among Southeast Asian men and
women. The high rate of liver cancer is associated with
the prevalence of hepatitis B (HBV) in Southeast Asian
immigrants. Between 7 and 14 percent of Vietnamese
American men are chronically infected with HBV
(Medical News Today, 2009). Up to 60 percent of liver
cancer from HBV can be prevented by immunization,
but it was found that low socioeconomic status and use
of traditional health care were associated with lower
immunization rates (Medical News Today, 2010).

High rates of gastrointestinal cancer may be due to
asbestos that is used in the process of “polishing” rice
in some parts of the world. Colorectal cancer is the
fourth most common cancer in the United States, and
the third most common among Vietnamese adults in
California. Yet Vietnamese Americans have lower
rates of screening for colorectal cancer compared to
other Asian Americans and Whites (Medical News
Today, 2010). Trichinosis risk is 25 times greater in
Southeast Asian refugees than in the general popula-
tion. This increased risk is related to undercooking
pork and purchasing pigs directly from farms.

Generally, young Asians are less sexually active than
other groups and have a lower risk of AIDS. Similarly,
Vietnamese also have a lower incidence of AIDS than
do Japanese people (Cochran, Mays, & Leung, 1991).

Possibly related to psychological pressures on
refugees is the occurrence of sudden unexplained
death syndrome (SUDS), a phenomenon reported
mainly for the Hmong but also affecting Vietnamese
and other Asian groups. Nearly all deaths involve
physically healthy, young adult men who die at night
or during sleep. The Centers for Disease Control and
Prevention (1990) reported 117 cases from 1981 to
1988 and suggested that a structural abnormality of
the cardiac conduction system and stress may be risk
factors for SUDS. The exact cause of the deaths
remains unknown. These deaths may be a form of
unconscious suicide associated with nightmares
brought on by intensive feelings of depression and
survivor guilt (Tobin & Friedman, 1983).

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Health-Care Practices
The Vietnamese approach to health care is one of am-
bivalence. Many Vietnamese immigrants are accus-
tomed to depending on the family unit and traditional
means of providing for health needs. They may be dis-
trustful of outsiders and Western methods. Most are fa-
miliar with immunizations and diagnostic tests, and they
do want to avoid health problems and are anxious to
follow reasonable procedures. Newly arrived refugees
are less likely to seek Western health care, but once es-
tablished, Vietnamese are the most likely of the South-
east Asians to seek care and to do so earlier (Strand &
Jones, 1983). Most Southeast Asian refugees want to go
to a physician for an illness, but they rarely seek care
when they are asymptomatic (for screeing and preven-
tion services), and few are familiar with the appointment
system. Some regard the most-convenient physician as
the closest one not requiring an appointment and ac-
cepting medical coupons, which usually translates into
a hospital emergency room (Muecke, 1983a).

In contrast, the Vietnamese family may not seek
outside assistance for illness until it has exhausted its
own resources. The family may try various home
remedies, allowing the condition to become serious,
before seeking professional assistance. Once a physi-
cian or nurse has been consulted, the Vietnamese are
usually quite cooperative and respect the wisdom and
experience of health-care professionals. Hospitaliza-
tion is viewed as a last resort and is acceptable only in
case of emergency when everything else has failed.
With respect to mental health, Vietnamese do not eas-
ily trust authority figures, including treatment staff,
because of their refugee experiences.

Nutrition
Meaning of Food
Meals are an important time to the Vietnamese, allow-
ing the entire family to come together and share a
common activity. Preparation is precise and may
occupy much of the day. Celebrations and holidays
involve elaborately prepared meals.

Common Foods and Food Rituals
Because of their size, the normal daily caloric intake
of the Vietnamese is approximately two-thirds that of
average Americans. Rice is the main staple in the diet,
providing up to 80 percent of daily calories. Other
common foods are fish (including shellfish), pork,
chicken, soybean curd (tofu), noodles, various soups,
and green vegetables. Preferred fruits are bananas,
mangoes, papayas, oranges, coconuts, pineapples, and
grapefruits. Soy sauce, garlic, onions, ginger root,
lemon, and chili peppers are used as seasoning.

The Vietnamese eat almost exclusively white or pol-
ished rice, disdaining the more nutritious brown or un-
polished variety. Rice and other foods are commonly

served with nuoc mam, a salty, marinated fish oil
sauce. A meal typically consists of rice, nuoc mam and
a variety of other seasonings, green vegetables, and
sometimes meat cut into slivers. Chicken and duck
eggs may be used. The Vietnamese prefer white bread,
particularly French loaves and rolls, and pastry. A reg-
ular dish is pho, a soup containing rice noodles, thinly
sliced beef or chicken, and scallions.

Other Vietnamese dishes resemble Chinese foods
commonly seen in the United States. Some of these
include com chien (fried rice) and thit bo xau ca chua
(beef fried with tomatoes). Perhaps the favorite of
Americans is cha gio (pronounced “cha-yuh”), a com-
bination of finely chopped vegetables, mushrooms,
meat or bean curd, rolled into delicate rice paper
and deep fried. If fried, it is also called a “spring”
roll, while if left uncooked (the rice paper), it is a
“summer” roll. It is served as part of elaborate meals
or during celebrations; proper preparation may
require many hours.

Vietnamese eat three meals a day: a light breakfast,
a large lunch, and dinner, with optional snacks. Meals
are served communal style, with food being placed in
the center of the table or passed around, with every-
one taking what they wish. If in a restaurant, the var-
ious dishes are often brought out when they are
prepared, not necessarily all at once. Children wait for
their elders to pass each dish. Chopsticks and some-
times spoons are used for eating. Knives are seldom
necessary at the table, because meat and vegetables are
usually cut into small pieces before serving. Stir frying,
steaming, roasting, and boiling are the preferred
methods of cooking. Hot tea is the usual beverage.

Dietary Practices for Health Promotion
A predominant aspect of the traditional Asian system
of health maintenance is the principle of balance be-
tween two opposing natural forces, known as am and
duong in Vietnamese. As with medicines, these forces are
represented by foods that are considered hot (duong) or
cold (am). The terms have nothing to do with tempera-
ture and are only partly associated with seasoning. Rice,
flour, potatoes, most fruits and vegetables, fish, duck,
and other things that grow in water are considered
cold. Most other meats, fish sauce, eggs, spices, peppers,
onions, candies, and sweets are hot. Tea is cold, coffee
is hot, water is cold, and ice is hot.

Illness or trauma may require therapeutic adjust-
ment of hot–cold balance to restore equilibrium. Hot
foods and beverages, used to replace and strengthen
the blood, are preferred after surgery or childbirth.
During illness, certain foods are consumed in greater
quantity, such as a light rice gruel (chao) mixed with
sugar or sweetened condensed milk, and a few pieces
of salty pork cooked with fish sauce. Fresh fruits
and vegetables are usually avoided, being considered
too cold. Water, juices, and other cold drinks are

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restricted. Nutritional counseling should take into
consideration these factors and other aspects of the
usual Vietnamese diet, because advice to simply eat
certain kinds of American foods may be ignored.

Nutritional Deficiencies and Food Limitations
The traditional Vietnamese diet is basically nutritious,
comparing favorably with U.S. federal guidelines for
a diet low in fat and sugar, high in complex carbohy-
drates, and moderate in fiber. However, the prevalence
of anemia in children may be associated with an iron
deficiency (Goldenring, Davis, & McChesney, 1982),
although many pregnant women have thalassemia β
which may be genetically transmitted to their children.
The Vietnamese diet may also be deficient in calcium
and zinc but exceedingly high in sodium, with impli-
cations relevant to hypertension.

Most Vietnamese adults and many children have
lactose intolerance, which may cause problems in
schools, other institutional settings, and adoptive fam-
ilies. Health-care providers may need to encourage
the use of substitute milk products that are based on
soybeans.

Before 1975, immigrants encountered difficulty in
preparing traditional dishes, especially in areas with
no established Vietnamese community. Even then, the
determined housewife could assemble most necessary
ingredients through judicious selections at ethnic
American, Chinese, Korean, and Indian groceries.
Today, nearly all common Vietnamese foods are avail-
able at reasonable cost in the United States, except
perhaps for certain native fruits and vegetables. In ad-
dition, Vietnamese Americans have changed their diet
to a degree, often increasing their fat intake.

Pregnancy and Childbearing
Practices
Fertility Practices and Views Toward Pregnancy
Indochinese women have children over a longer period
of life than European Americans, evidenced by fe-
males aged 40 to 44 having a birth rate nearly 14 times
that of their European American counterparts
(Hopkins & Clarke, 1983). However, in Vietnam,
the birth rate is down to 1.91 children per woman
(CIA World Factbook, 2011). This is not true for
Vietnamese immigrants. They have the highest fertility
rate at 72/1000 births in the previous 12 months
(Office of Minority Health, 2007). It has been sug-
gested that the high fertility rate is an attempt to re-
place children lost during the attempts to leave
Vietnam. Abortions are commonly performed in their
homeland because pregnancy outside of marriage is
considered a disgrace to the family. Contraception
is also not practiced on a regular basis, and abortion
is used as birth control. It is not uncommon for young
women to have several abortions before she is in her

20s. While the period of the New Year (Tet) is re-
garded as a positive time for a marriage, it is not a de-
sirable time to have a child born, so women will often
have abortions if they believe they will deliver during
this time (Mattson, personal communication, 2007).
Fertility practices of the Vietnamese in America in
this regard are relatively unknown

After arriving in the United States, women often
desire information on contraception but are afraid to
ask. The problem stems in part from their cultural
background and emphasis on premarital modesty and
virginity. However, when contraception is addressed
and information made available Vietnamese women
choose some method of contraception. Providers
should avoid forceful family-planning indoctrination
on the first encounter, but such information is usually
well received on subsequent visits.

Prescriptive, Restrictive, and Taboo Practices
in the Childbearing Family
Prescriptive food practices for a healthy pregnancy
include noodles, sweets, sour foods, and fruit but
avoidance of fish, salty foods, and rice. After birth, to
restore equilibrium and provide adequate warmth to
the breast milk, women consume soups with chili pep-
pers, salty fish and meat dishes, and wine steeped with
herbs. In addition to hot (duong) and cold,(am),
foods are classified as tonic and wind. Tonic foods
include animal protein, fat, sugar, and carbohydrates;
they are usually also hot and sweet. Sour and some-
times raw and cold foods are classified as antitonic.
Wind foods, often classified as cold, include leafy
vegetables, fruit, beef, mutton, fowl, fish, and gluti-
nous rice. It is considered critical to increase or de-
crease foods in various categories to restore bodily
balances upset by unusual or stressful conditions such
as pregnancy. Whereas the balance of foods may be
followed, the terminology is not consistently used.

During the first trimester, the expectant mother is
considered to be in a weak, cold, and antitonic state.
Therefore, she should correct the imbalance by eating
hot foods such as ripe mangoes, grapes, ginger, pep-
pers, alcohol, and coffee. To provide energy and food
for the fetus, she is prescribed tonic foods, including a
basic diet of steamed rice and pork. Cold foods, in-
cluding mung beans, green coconut, spinach, and
melon, and antitonic foods, such as vinegar, pineapple,
and lemon, are avoided during the first trimester.

In the second trimester, the pregnant woman is con-
sidered to be in a neutral state. Cold foods are intro-
duced, and the tonic diet is continued.

During the third trimester, when the woman may
feel hot and suffer from indigestion and constipation,
cold foods are prescribed and hot foods are avoided
or strictly limited. Tonic foods, which are believed to
increase birth weight, are restricted to reduce the
chances of a large baby, which would make birthing

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difficult. Wind foods are generally avoided throughout
pregnancy, because they are associated with convul-
sions, allergic reactions, asthma, and other problems.
This regimen may appear more complex and restric-
tive than it actually is in practice. Most women use it
only as a general guide, commonly restricting, rather
than totally abstaining from, the proscribed foods.
A great variety of food, including rice, many kinds
of vegetables and fruits, various seasonings, and
certain meats and fish, is generally permissible
throughout pregnancy.

Intensive prenatal care is not the norm in Southeast
Asia. Many women do not seek medical attention
until the third trimester because of cost, fear, or lack
of perceived need. Vietnamese women who are gener-
ally better educated seek early prenatal care more than
other Southeast Asians (Hopkins & Clarke, 1983). For
obstetric and gynecological matters, Vietnamese
women feel more comfortable with a female physician
or midwife.

Traditionally, Vietnamese women maintain physical
activity to keep the fetus moving and to prevent
edema, miscarriage, or premature delivery. Prolonged
labor may result from idleness, and an undesirable
large baby may result from afternoon napping. Addi-
tional restrictive beliefs include avoiding heavy lifting
and strenuous work; raising the arms above the head,
which pulls on the placenta causing it to break; and
sexual relations late in pregnancy, which may cause
respiratory stress in the infant. In Vietnam, many con-
sider it taboo for pregnant women to attend weddings
or funerals. However, they often look at pictures of
happy families and healthy children, believing that it
helps give birth to healthy babies.

In Vietnam, some rural children are delivered in a
screened-off portion of the home or in a special birth
house by certified midwives; more frequently though,
more are born in hospitals with Western-trained
physicians or midwives in attendance, especially in the
cities and towns, although they may receive their pre-
natal care in the rural clinics. Southeast Asians gener-
ally dislike invasive procedures, such as episiotomies,
cesarean sections, circumcisions, nasal oxygen, and
intravenous fluids. However, unlike some women of
other ethnic groups, Vietnamese women may ask for
anesthesia during labor and delivery and epidurals are
becoming popular if the woman can pay. Otherwise,
once in labor, the Vietnamese woman tries to maintain
self-control and may even smile continuously. Her pe-
riod of labor is usually short, and there may be no
warning of impending delivery. Although a special
bed may be available, the mother may prefer walking
around during labor and squatting during the birth
process. This position is less traumatic than others, for
both mother and baby, and results in fewer and less-
serious lacerations. This is a deviation from normal
birth practices in the United States and may need to

be discussed with the attending physician or midwife
prior to birth.

Because the head is considered sacred, neither that
of the mother nor that of the infant should be
touched or stroked. Removal of vernix from the in-
fant’s head can cause distress. The American practice
of inserting intravenous devices into infants’ scalps
can be particularly stressful to Vietnamese families.
Health-care providers need to stress the importance
and necessity of this invasive procedure and select
other venous routes if possible.

Customary practices include clearing the neonate’s
throat using the finger, cutting the umbilical cord with
a nonmetal instrument, quickly burying the placenta
to protect the infant’s health, and ritually cleaning the
mother in a manner that does not involve actual
bathing with water.

Because body heat is lost during delivery,
Vietnamese women avoid cold foods and beverages
and increase consumption of hot foods to replace and
strengthen their blood. Ice water and other cold
drinks are usually not welcome, thus the usual practice
of offering a newly delivered mother a cold drink
should be replaced with something hot—either water
or tea is usually available. This can accomplish the
nurse’s goal of replacing fluids and maintain the pa-
tient’s cultural heritage. Most raw vegetables, fruits,
and sour items are taken in lesser amounts. Prescrip-
tive foods include steamed rice, fish sauce, pork,
chicken, eggs, soups with chili or black peppers, other
highly seasoned and salty items, wine, and sweets.

Because water is cold, women traditionally do not
fully bathe, shower, or wash their hair for a month
after delivery. Some Vietnamese women have com-
plained that they were adversely affected by showering
shortly after delivery in American hospitals. Others,
however, have welcomed the opportunity to shower
and seem willing to give up other traditional practices.
Postpartum women also avoid drafts and strenuous
activity; wear warm clothing; stay in bed, indoors, or
both for about a month; and avoid sexual intercourse
for months. In the past, postpartum women remained
in a special bed above a slow-burning fire. This prac-
tice still continues with the use of hot-water bottles or
electric blankets.

Other women in the family assume responsibility
for the baby’s care. In Vietnam, husbands would never
be present at their child’s delivery. For Vietnamese in
the United States, this varies and some men do attend
deliveries. The mother’s inactivity and dependence on
others may be incorrectly interpreted by health-care
workers as apathy, depression, or lack of attachment
to the baby. A newborn is often dressed in old clothes;
it is considered taboo to praise the child lest jealous
spirits steal the infant. The mother may be reluctant
to cut the child’s hair or nails for fear that this might
cause illness. The infant is generally maintained on a

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diet of milk for the first year, with the introduction of
rice gruel at around 6 months. There is little formal
toilet training; the child usually learns by imitating
an older child. One can see mothers holding their
naked babies away from them to urinate, and “whis-
pering” in their ears to stimulate a bowel movement.
The child is then cleaned and returned to his or her
usual clothing.

Breastfeeding is customary in Vietnam, but since
resettlement, some variations on this practice have
been instituted. Some Southeast Asian women discard
colostrum and feed the baby rice paste or boiled sugar
water for several days. This does not indicate a deci-
sion against breastfeeding. After the milk comes
in, both mother and baby benefit from the hot foods
consumed by the mother for the first month. Then,
however, a conflict arises: The mother believes that hot
foods benefit her health but that cold foods ensure
healthy breast milk. Having the mother change from
breastfeeding to formula can easily solve this
dilemma; however, it is counterproductive to the med-
ical and nursing community’s efforts to promote
breastfeeding during the baby’s first year. If the
mother cannot afford formula, she may use fresh milk
or rice boiled with water, which may result in anemia
and growth retardation. Some health-care profession-
als, concerned about these developments and their im-
pact on the infant’s health, have recommended
educational programs that might restore conditions
conducive to traditional breastfeeding.

Death Rituals
Death Rituals and Expectations
Vietnamese accept death as a normal part of the life
process. The traditional stoicism of the Vietnamese,
the influence of Buddhism with its emphasis on
cyclic continuity and reincarnation, and the pervad-
ing association of current activities with ancestral
spirits and burial places contribute to attitudes
toward death

Most Vietnamese have an aversion to hospitals and
prefer to die at home. Some believe that a person who
dies outside the home becomes a wandering soul with
no place to rest. Family members think that they can
provide more comfort to the dying person at home.
Sixty percent of women in one survey said that if
someone in their family were dying, they would not
want that person told; 95 percent said that they would
want a priest or minister with them when they died;
and 95 percent indicated a belief in life after death
(Calhoun, 1986). Ancestors are commonly honored
and worshipped and are believed to bestow protection
on the living.

Southeast Asians tend not to want to artificially pro-
long life and suffering, but it may still be difficult for
relatives to consent to terminating active intervention,

which might be viewed as contributing to the death of
an ancestor who would shape the fates of the living
(Muecke, 1983a).

Few Vietnamese families consent to autopsy unless
they know and agree with the reasons for it. Older
Vietnamese, on realizing the inevitability of death,
sometimes purchase coffins in advance, display them
beneath the household altar, and choose burial sites
with a favorable position. Although Vietnamese cus-
tom is associated with proper burial practices and
maintenance of ancestral tombs, cremation is an
acceptable practice to some families.

Responses to Death and Grief
Vietnamese families may wish to gather around the
body of a recently deceased relative and express great
emotion. Traditional mourning practices include wear-
ing white clothes for 14 days, the subsequent wearing
of black armbands by men and white headbands by
women, and the yearly celebration of the anniversary
of a person’s death. Such observances, together with rit-
ual cleaning and worship at ancestral graves, help rein-
force family ties and are deeply woven into Vietnamese
culture. Departure from Vietnam has greatly curtailed
the observance of these practices, leaving a painful void
for many refugees.

Priests and monks should be called only at the re-
quest of the client or family. Clergy visitation is usu-
ally associated with last rites by the Vietnamese,
especially those influenced by Catholicism, and can
actually be upsetting to hospitalized patients. Sending
flowers may be startling, because flowers are usually
reserved for the rites of the dead.

Spirituality
Dominant Religion and Use of Prayer
Although some Vietnamese refugees are Catholic, or
have converted to other branches of Christianity, many
Vietnamese follow Buddhist concepts. Buddhism on
the whole is best understood not as a religion in the
Western sense but more a philosophy of life and
impacts profoundly on the health-care beliefs and
practices of the Vietnamese.

If one lives in adherence to the Buddhist path
one can expect less suffering in future existences. Bud-
dhsim stresses disconnection to the present, especially
materialism and self-aggandizement. Thus pain and
illness are sometime endured and health-seeking
remedies delayed because of this belief in fate. Simi-
larly, preventive health care has little meaning in this
philosophy. Respect for and veneration of ancestors
is associated with Buddhism and Confucianism. The
prospect of burial away from ancestral burial sites is
a source of significant distress to older Vietnamese.
Difficulty visiting burial sites in Vietnam is also
distressful (Rasbridge, 2004).

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Religions practiced by the Vietnamese are Buddhism
(9.3 percent), Catholic, (6.7 percent), Hao Hao (1.5 per-
cent), Cao Dai (1.1 percent), Protestant (0.5 percent),
Muslim (0.1 percent), and none (80.8 percent)
(CIA World Factbook, 2011). There are a number of
other religions, including Taoism and Confucianism,
which are basically offshoots and combinations
of the major faiths. Animism is found mainly among
the highland tribes. Many Vietnamese believe that
deities and spirits control the universe and that the
spirits of dead relatives continue to dwell in the home.

Most Vietnamese who practice a religion are
Buddhists, but some almost never visit temples
or perform rituals. Others, both Buddhist and
Christian, may maintain a religious altar in the
home and conduct regular religious observances.
In cases of severe illness, prayers and offerings may
be made at a temple.

Meaning of Life and Individual Sources
of Strength
Whereas the wish to bring honor and prosperity
to the family remains a dominant force for most
Vietnamese, some find meaning in life from the prac-
tice of Buddhism or other religions. Some are driven
by the desire to learn, to relieve suffering, to produce
beauty, to assist the progress of civilization, and to
gain strength from participating in ethnic community
activities.

A tenet of Buddhism holds that the family unit
is more important than the individual, with less
emphasis on the “self.” Accordingly, health-care
decision making is frequently a family matter. Con-
cordantly, the family is typically involved in treat-
ment. (Bankston & Zhou, 2000). The family is the
fundamental social unit and the primary source of
cohesion and continuity.

Spiritual Beliefs and Health-Care Practices
Vietnamese religious practices are influenced by the
Eastern philosophies of Buddhism, Confucianism,
and Taoism. Central to Buddhism is the concept of
following the correct path of life, thus eliminating
suffering that is caused by desire. Another tenet is
that the world is a cycle of ordeals: to be born, grow
old, fall ill, and die. In addition, people’s present
lives predetermine their own and their dependents’
future lives.

Confucianism stresses harmony through mainte-
nance of the proper order of social hierarchies, ethics,
worship of ancestors, and the virtues of chastity
and faithfulness. Taoism teaches harmony, allowing
events to follow a natural course that one should not
attempt to change. These beliefs have contributed
to an attitude that may be perceived as passive
by Westerners, characterized by maintenance of

self-control, acceptance of one’s destiny, and fatalism
toward illness and death.

Health-Care Practices
Health-Seeking Beliefs and Behaviors
The diagnosis of illness is frequently understood in
three different, although overlapping models. The
first, the least common, could be considered supernat-
ural or spiritual, where illness can be brought on by a
curse or sorcery, or failure to observe a religious ethic
or belief. Traditional medical providers are common,
both in the United States and Vietnam; some are spe-
cialists in the more magico-religious realm, and may
be called upon to exorcise a bad spirit via chanting, a
potion, or consultation from an ancient Chinese text.

The use of amulets and other forms of spiritual pro-
tection is also commonly employed. For example, babies
and children often wear bua, an amulet of cloth con-
taining a Buddhist verse, or that has been blessed by a
monk. It is worn on a string around the wrist or neck.

Vietnamese traditionally do not have a concept of
mental illness as discrete from somatic illness, and
thus rarely utilize Western-based psychological and
psychiatric services. Instead, most mental health issues
such as depression or anxiety fall into this spiritual
health realm and are treated appropriately. Similarly,
somatization is common, and treatments overlap with
Western treatments and metaphysical interventions
described below.

Second, a widespread belief is that the universe is
composed of opposing elements held in balance;
health is a state of balance between these forces, know
as am and duong, based on the more familiar concepts
of yin and yang in China. In health, these concepts are
frequently translated as “hot” and “cold,” although
they do not necessarily refer to temperature. Illness re-
sults when there is an inbalance of the “vital” forces;
the imbalance can be a result of a physiological state,
such as pregnancy or fatigue, or it can be brought on
by extrinsic factores like diet or overexposure to
“wind,” one of the body forces or humors first de-
scribed by Galen. Balance can be restored by a num-
ber of means, including diet changes to compensate
for the exess of “hot” or “cold” Western medicines
and injections, and tradtional medicines, herbs, and
medical practices. Naturalistic explanations for poor
health include eating spoiled food and exposure to in-
clement weather. The natural element known as cao
gio is associated with bad weather Third, most Viet-
namese Americans also recognize the more Western
concept of disease causation such as the germ theory.
There is widespread understanding that disease can
come from contaminants in the environment, even if
full concepts of microbiology or virology are not
grasped. Thus, through decades of French occupation

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and more recently the American influence, even the
most rural Vietnamese has come to know the power
of antibiotics.

When Vietnamese enter the American health-care
setting, they do so frequently with the goal to relieve
symptoms; in general, the patient expects a medicine
to cure the illness immediately. When something is not
prescribed initially, the patient is likely to seek care
elsewhere, either directly from a Vietnamese pharma-
cist or specialized “injectionists.” Newly arrived im-
migrants are used to receiving the medication directly
from the doctor; the concept of a “prescription” writ-
ten on a piece of paper to take to a pharmacy to be
“filled” is foreign to them. They may feel that this
piece of paper contains instructions for the patient,
and not follow through with obtaining the medication.

Vietnamese frequently discontinue medicines after
the symptoms disappear; similarly, if symptoms are
not perceived, there is no illness. Thus, preventive,
long-term medications like antihypertensives must be
prescribed with culturally sensitive education. It is
quite common for Vietnamese patients to amass large
quantities of half-used prescription drugs, even antibi-
otics, many of which are shared with friends and
may be sent back to family in Vietnam. Additionally,
Vietnamese commonly believe that Western pharma-
ceuticals are developed for Americans and Europeans,
and hence dosages are too strong for more slightly built
Vietnamese, resulting in self-adjustment of dosages.

The Vietnamese hold great respect for those with
education, especially physicians. The doctor is consid-
ered the expert on health; diagnosis and treatment
should happen at the first visit, with little examination
or personally invasive laboratory or other diagnostic
tests. Commonly, laboratory procedures involving
the drawing of blood are feared and resisted by
Vietnamese, who believe the blood loss will make
them sicker, and that the body cannot replace what
was lost. Surgery is especially feared for this reason.
Overall, as health is believed to be a function of
balance, surgery would be considered an option of
last resort, as the removal of an organ would alter the
internal balance.

Vietnamese view health and illness from a variety
of different perspectives, sometimes simultaneously. It
is not uncommon for a sick person to interpret their
illness as an interaction of spiritual factors, internal
balance inequities, and even an infective process. They
will thus combine diagnostic and treament elements
from all three models in order to get the maximum
health benefits (Rasbridge, 2004).

The belief that life is predetermined is a deterrent to
seeking health care. For many Vietnamese, diagnostic
tests are baffling, inconvenient, and often unnecessary.
Procedures such as circumcision or tonsillectomy,
which biomedicine considers simple, are generally

unknown to the Vietnamese. Invasive procedures are
frightening. The prospect of surgery can be terrifying.
The fear of mutilation stems from widespread beliefs
among non-Christians that souls are attached to dif-
ferent parts of the body and can leave the body, caus-
ing illness or death. Loss of blood from any route is
feared, and the Vietnamese may refuse to have blood
drawn for laboratory tests. The client may complain,
though not to the health-care worker, of feeling weak
for months. A Vietnamese client in America may feel
that any body tissue or fluid removed cannot be re-
placed, and the body suffers the loss in this life as well
as into the next.

The concept of long-term medication for chronic
illnesses and acceptance of unpleasant side effects and
increased autonomic symptoms, which are standard
components of modern Western medicine, are not
congruent with traditional notions of safe and effec-
tive treatment of illnesses.

Responsibility for Health Care
In Vietnam, the family is the primary provider of
health care, even in hospitals. This practice survives
because of tradition and a shortage of professional
personnel. Their own families attend hospitalized pa-
tients day and night. The importance of involving
family members, including elder family members or
clan leaders, in all major treatment decisions regarding
physical and mental health must be stressed.

Health care in Vietnam is crisis oriented, with
symptom relief as the goal. Vietnamese typically deal
with illness by means of self-care, self-medication, and
the use of herbal medicines. Facsimiles of Western
prescription drugs are sold over the counter through-
out Southeast Asia, which may explain the increasing
resistance of bacteria to several readily available
antibiotics.

Many Vietnamese believe that Western medicine is
very powerful and cures quickly, but few understand
the risks of overdosages or underdosages. Patients
being treated for depression who fail to take their
antidepressants evidence improvement after receiving
instructions for taking their medication. Vietnamese
patients may not follow prescribed schedules of med-
ication for the treatment and prevention of tubercu-
losis. Extensive education, repetition of instructions,
and home visitations are necessary.

Unfortunately, most Vietnamese women who have
abnormal Pap smears fail to return for follow-up care,
thereby contributing to the shockingly high incidence
of cervical cancer in the population (Wright, 2000).
That problem has been associated with lack of organ-
ized language services and, thus, a failure by the
women to comprehend the severity of the situation
and the potential for recovery if regular treatment be-
gins early enough. To increase follow-up visits and

People of Vietnamese Heritage 15

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care, it may be necessary to carefully explain the prob-
lems that may result if they do not follow up after an
abnormal Pap smear. Women should understand that
lack of symptoms or pain may be only temporary and
that experiences of acquaintances may not apply to
them. Persistent reminding, as part of an overall effort
to improve communication and information dissemi-
nation, has been suggested as the best way to encour-
age Vietnamese women to undergo regular cancer
screening and follow-up treatment.

Folk and Traditional Practices
The forces of am (cold) and duong (hot) are pervasive
forces in the practice of traditional Vietnamese
medicine. Am represents factors that are considered
negative, feminine, dark, and empty, whereas duong
represents those that are positive, masculine, light, and
full. These terms are applied to various parts, organs,
and processes of the body. For example, the inside of
the body is am, and the surface is duong. The front
part of the body is am, and the back is duong. The
liver, heart, spleen, lungs, and kidneys are am, and the
gallbladder, stomach, intestines, bladder, and lymph
system are duong. Am stores strength, and care must
be taken not to use it up too quickly. Duong protects
the body from outside forces, and if it is not cared for,
the organs are thrown into disorder. Proper balance
of these two life forces ensures the correct circulation
of blood and good health. If the balance is not proper,
life is short.

Diseases and other debilitating conditions result
from either cold or hot influences. For example, diar-
rhea and some febrile diseases are due to an excess of
cold, whereas pimples and other skin problems result
from an excess of hot. Countermeasures involve using
foods, medications, and treatments that have properties
opposite those of the problem and avoiding foods that
would intensify the problem. Asian herbs are cold, and
Western medicines are hot. A widely held belief among
Vietnamese refugees is that Asian medicine relieves
symptoms of a disease more quickly than Western
medicine but that Western medications can actually
cure the illness. Many prefer Asian methods for chil-
dren. Reliance on traditional folk medicine is declining
in the United States, partly because of the unavailabil-
ity of suitable shamans and traditional herbs.

The following are common treatments practiced
in Vietnam and continued to some degree in the
United States:

Cao gio (or coining) literally meaning “rubbing out
the wind,” is used for treating colds, sore throats,
flu, sinusitis, and similar ailments. An ointment or
hot balm oil is spread across the back, chest, or
shoulders and rubbed with the edge of a coin
(preferably silver) in short, firm strokes. This tech-
nique brings blood under the skin, resulting in

dark ecchymotic stripes, so the offending wind
can escape. Health-care professionals must be
careful not to interpret these ecchymotic areas as
evidence of child abuse. However, dermabrasion
may provide a portal for infection.

Be bao or bat gio, skin pinching, is a treatment for
headache or sore throat. The skin of the affected
area is repeatedly squeezed between the thumb
and the forefinger of both hands, as the hands
converge toward the center of the face. The
objective is to produce ecchymoses or petechiae.

Giac (or cup suctioning) another dermabrasive
procedure, is used to relieve stress, headaches, and
joint and muscle pain. A small cup is heated and
placed on the skin with the open side down. As
the cup cools, it contracts the skin and draws
unwanted hot energy into the cup. This treatment
leaves marks that may appear as large bruises.

Xong(or steaming) relieves motion sickness or
cold-related problems. Herbs or an agent such
as Vicks® VapoRub is put into boiling water, and
the vapor is inhaled. Small containers of aromatic
oils or liniments are sometimes carried and
inhaled directly.

Moxibustion is used to counter conditions associated
with excess cold, including labor and delivery.
Pulverized wormwood or incense is heated and
placed directly on the skin at certain meridians
(Fig. 38-2)

Acupuncture, acupressure, and acumassage relieve
symptomatic stress and pain.

Balms and oils, such as Red Tiger balm, available
in Asian shops, are applied to affected areas for
relief of bone and muscle ailments.

Herbal teas, soups, and other concoctions are taken
for various problems, generally in the sense of
using cold measures to overcome hot illnesses.

Eating organ meats such as liver, kidneys, testes,
brains, and bones of an animal is said to increase
the strength of the corresponding human part.

Two additional practices in Vietnam are consuming
gelatinized tiger bones to gain strength and taking
powdered rhinoceros horn to reduce fever. At least
430 folk medicines used by Vietnamese contain ingre-
dients from endangered, threatened, or protected
species (Gaski & Johnson, 1994).

Barriers to Health Care
Barriers to adequate health care for Vietnamese
people include

1. Subjective beliefs and the cost of health care
2. Lack of access to a primary health-care provider
3. Differences between Western and Asian health-

care practices
4. Caregivers’ judgment of Vietnamese as deviant

and unmotivated because of noncompliance with

16 Aggregate Data for Cultural-Specific Groups

2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 16

medication schedules, diagnostic tests, follow-up
care, and their failure to keep appointments

5. Inability to communicate effectively in the English
language by recent immigrants who lack confi-
dence in their ability to communicate their needs;
failure of providers to communicate adequately or
lack of an interpreter

6. Avoidance of Western providers out of fear that
traditional methods will be criticized

7. Fear of conflicts and ridicule resulting in loss
of face

8. Lack of knowledge of the availability of resources

Additional barriers exist for Vietnamese people
when seeking mental-health care. These include fear
of stigmatization, difficulty locating agencies that can
provide assistance without distorted professional and
cultural communication, and reluctance to express
inner feelings.

Cultural Responses to Health and Illness
Fatalistic attitudes and the belief that problems are
punishment may reduce the degree of complaining
and expression of pain among the Vietnamese, who

view endurance as an indicator of strong character.
One accepts pain as part of life and attempts to main-
tain self-control as a means of relief. A deep cultural
restraint against showing weakness limits the use of
pain medication. However, the sick person is allowed
to depend on family and receives a great deal of
attention and care.

Many Vietnamese believe that mental illness results
from offending a deity and that it brings disgrace to
the family and, therefore, must be concealed. A
shaman may be enlisted to help, and additional ther-
apy is sought only with the greatest discretion and
often after a dangerous delay. Emotional disturbance
is usually attributed to possession by malicious spirits,
the bad luck of familial inheritance, or for Buddhists,
bad karma accumulated by misdeeds in past lives.
The term psychiatrist has no direct translation in
Vietnamese and may be interpreted to mean nerve
physician or specialist who treats crazy people. The
nervous system is sometimes seen as the source
of mental problems—neurosis being thought of as
“weakness of the nerves” and psychosis as “turmoil
of the nerves.”

To overcome these problems, Kinzie and Manson
(1982) and Buchwald and colleagues (1993) developed
a Vietnamese depression scale, which uses terms that
allow an English-speaking practitioner to make a cross-
cultural assessment of the clinical characteristics of de-
pressed Vietnamese patients. Health-care providers
working with Vietnamese patients may find this scale
useful when providing mental-health services.

Physically disabled people are common and readily
seen in Vietnam. Some are veterans or survivors of the
Vietnam War, and others have been affected by con-
genital disabilities (often from environmental toxins)
or birth injuries. To the extent that resources allow,
they are treated well and cared for by their families
and the government. In contrast, a mentally disabled
person may be stigmatized by the family and society
and can jeopardize the ability of relatives to find mar-
riage partners. The mentally disabled are usually har-
bored within their families unless they become
destructive; then, they may be admitted to a hospital.

Blood Transfusions and Organ Donation
Because many Vietnamese believe that the body must
be kept intact even after death, they are averse
to blood transfusions and organ donation. Many
Vietnamese, even those whose families have long been
Christian, may object to removal of body parts or
organ donation. However, some staff in a rural hos-
pital in Vietnam donated blood after learning that the
body replenished its blood supply. The smaller size of
Vietnamese adults makes many of them ineligible to
donate a full unit of blood. Other Vietnamese people,
who may prefer cremation, will donate body parts
under certain circumstances.

People of Vietnamese Heritage 17

Figure 38-2 Moxibustion is used to counter conditions asso-
ciated with excess cold, including labor and delivery. Pulverized
wormwood or incense is heated and placed directly on the
skin at certain meridians. (From Ancient Way Acupuncture and
Herbs. Klamath Falls, Oregon. Retrieved from www.AncientWay.com)

2780_BC_Ch38_001-019 03/07/12 10:07 AM Page 17

Health-Care Providers
Traditional Versus Biomedical Providers
Four kinds of traditional and folk providers exist in
Vietnam. The first group includes Asian physicians
who are learned individuals and employ herbal med-
ication and acupuncture. The second group consists
of more informal folk healers who use special herbs
and diets as cures based on natural or pragmatic ap-
proaches. The secrets of folk medicine are passed
down through the generations. The third group in-
cludes various forms of spiritual healers, some with a
specific religious outlook and others with powers to
drive away malevolent spirits. The fourth group is
made up of magicians or sorcerers who have magical
curative powers but no communication with the spir-
its. Many Vietnamese consult one or more of these
healers in an attempt to find a cure.

Whereas many Vietnamese have great respect for
professional, well-educated people, they may be dis-
trustful of outside authority figures. Most Vietnamese
have come to America to escape oppressive authority.
Refugees generally expect health-care professionals to
be experts. A common suspicion is that divulging
personal information for a medical history could
jeopardize their legal rights. Respect and mistrust are
not mutually exclusive concepts for Vietnamese seek-
ing care from Western providers.

Because of the need to build trust with a Vietnamese
client, it is particularly important to acknowledge and
support traditional belief systems.

Traditional Asian male providers do not usually
touch the bodies of female patients and sometimes use
a doll to point out the nature of a problem. Whereas
most Vietnamese may no longer insist on the use of
this practice, adults, particularly young and unmarried
women, are more comfortable with health-care
providers of the same gender. Pelvic examinations on
unmarried women should not be made on the first
visit or without careful advance explanation and
preparation. When such an examination is necessary,
the woman may want her husband present. If possible,
the practitioner and an interpreter should both be fe-
male. Women may not want to even discuss sexual
problems, reproductive matters, and birth control
techniques until after an initial visit and after confi-
dence has been established in the practitioner.

Status of Health-Care Providers
Because of the shortage of physicians in Vietnam,
medical assistants, nurses, village health-care workers,
self-trained individuals, and injectionists practice
Western medicine. Paralleling these approaches are the
traditional systems of Asian and folk medicine. Tra-
ditional healers often provide the Vietnamese with
necessary social support that may be lacking with

Western providers. However, all are respected and
have high status and may be used concurrently or sep-
arately, according to the illness and varying beliefs of
each individual.

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For case studies, review questions, and additional
information, go to
http://davisplus.fadavis.com

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