Week 4
People of Appalachian Heritage.
People of Arab Heritage.
Please read chapter 8 and 9 of the class textbook and review the attached PowerPoint presentations. Once done answer the following questions;
1. Give an overview of the Inhabited localities and topography of the Appalachian and Arab heritage.
2. Discuss any similarities in the beliefs of the Appalachian and Arab heritages regarding the delivery of healthcare.
3. How the religion or folks beliefs influence the delivery of healthcare in these two heritages.
You must cite or quote at least two evidence-based references (besides the class textbook) no older than 5 years old. Two replies to any or yours peers sustained with the proper reference (s) are required. An example of how to present the first page is attached for your guidance.
A minimum of 600 words excluding the first and references page is required.
Week_____ discussion questions
Name
Florida National University
Nursing Department
BSN Program
NUR 4636
Date
Prof. Eddie Cruz, RN MSN
Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company
Arab American Culture
Larry Purnell, PhD, RN, FAAN
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company
Arab Overview/Heritage
Arabs, coming from 22 countries, are united by a common language, Arabic.
No U.S. census category for Arabs; they are absorbed into the White category.
Most earlier Arab immigrants in the late 1880s to 1913 were Christians, educated, and settled in the Northeastern United States
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company
Arab Overview/Heritage
Post-1965, Arabs in the US were Muslims, highly educated and professional or immigrated for higher education.
Arabism, Muslim, and Islam are intricately interwoven and share basic traditions and beliefs.
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Arab Communication
Arabic is the official language of the Arab world.
English is a common second language among Arabs throughout the world.
Communication is highly contextual.
Conversants stand close and maintain rather intense eye contact.
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Copyright © 2013 F.A. Davis Company
Arab Communication
For traditional Arabs, touch is only accepted between members of the same sex.
Speech is generally loud and expressive with repetition and gesturing.
Privacy is valued so sharing outside the immediately family is not common.
Etiquette requires handshaking upon arrival and departure but only between same sex individuals.
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Copyright © 2013 F.A. Davis Company
Arab Communication
Titles are important and are used in combination with the person’s first name as in Mr. Ali.
Punctuality is not always valued except in cases of professional or business meetings.
Explain the importance of timeliness in health-care appointments.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Family Roles and Organization
Traditional Arab families are highly patrilineal.
In public, a wife’s interactions with her husband is formal and respectful. At home, the woman may have tremendous influence in matters pertaining to the home and children.
Gender roles are clearly defined: men are decision-makers, protectors, and breadwinners.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Family Roles and Organization
The authority structure and division of labor within Arab families are often misinterpreted, fueling common stereotypes of the overtly dominant male and the passive and oppressed woman.
Children are dearly loved, indulged, and included in all family activities.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Family Roles and Organization
Children are dearly loved, indulged, and included in all family activities.
Children are raised not to question elders and to be obedient to older brothers and sisters. Discipline may include physical punishment and shaming.
Adolescents are pressed to succeed academically.
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Arab Family Roles and Organization
• Adolescents are pressed to succeed academically.
Academic failure, sexual activity, illicit drug use, and juvenile delinquency bring shame to the family. For girls in particular, chastity and decency are required.
Family members live nearby and sometimes intermarry with first cousins.
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Arab Family Roles and Organization
Devout Muslim women value modesty.
Many Muslim women view the hijab, “covering the body except for one’s face and hands,” as offering them protection in situations in which the sexes mix. It is a recognized symbol of Muslim identity and good moral character.
Many Americans associate the hijab with oppression rather than protection.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Family Roles and Organization
Sons are held responsible for supporting elderly parents.
Elderly parents are almost always cared for within the home.
Homosexuality is usually highly stigmatized. In some Arab countries, it is considered a crime, and participants may be killed.
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Arab Workforce Issues
Discrimination such as intimidation, being treated suspiciously, and negative comments about their religious practices have been reported as a major source of stress among Arab Americans.
Muslim Arabs who wish to attend Friday prayer services and observe religious holidays may encounter job-related conflicts.
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Arab Workforce Issues
Impassioned communication may incorrectly be assumed that Arabs are argumentative, confrontational, or aggressive.
Criticism is often taken personally as an affront to dignity and family honor.
Whereas such direct praise may be somewhat embarrassing for Americans, Arabs expect and want praise when they feel they have earned it.
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Arab Biocultural Ecology
Most Arabs have dark or olive-colored skin, but some have blonde or auburn hair, blue eyes, and fair complexions.
Infectious diseases such as tuberculosis, malaria, trachoma, typhus, hepatitis, typhoid fever, dysentery, and parasitic infestations are common with newer immigrants.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Biocultural Ecology
Glucose-6-phosphate dehydrogenase deficiency, sickle cell anemia, and the thalassemias are extremely common in the eastern Mediterranean.
High consanguinity rates (roughly 30 percent of marriages in Iraq, Jordan, Kuwait, and Saudi Arabia) occur between first cousins and contribute to the prevalence of genetically determined disorders in Arab countries.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Biocultural Ecology
Some Arabs have difficulty metabolizing debrisoquine, antiarrhythmics, antidepressants, beta blockers, neuroleptics, and opioid agents.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab High-Risk Health Behaviors
Smoking and nonuse of seat belts and helmets are major issues among Arabs in the US.
Some Arab women may be at high risk for domestic violence, especially new immigrants, because of the high rates of stress, poverty, poor spiritual and social support, and isolation from family members.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab High-Risk Health Behaviors
Sedentary lifestyle and high fat intake among Arab Americans place them at higher risk for cardiovascular diseases.
The rates of breast cancer screening, mammography, and cervical Pap smears among Arab Americans are low because of modesty.
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Arab Nutrition
Spices and herbs include cinnamon, allspice, cloves, ginger, cumin, mint, parsley, bay leaves, garlic, and onions.
Skewer cooking and slow simmering are typical modes of preparation. All countries have rice and wheat dishes, stuffed vegetables, nut-filled pastries, and fritters soaked in syrup.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Nutrition
Consumption of blood is forbidden; Muslims are required to cook meats and poultry until well done. Some Muslims refuse to eat meat that is not halal (slaughtered in an Islamic manner).
Muslims are prohibited from eating pork and pork products which includes ingredients mouthwashes, toothpastes, alcohol-based syrups and elixirs, and gelatin coated capsules. However, if no substitutes are available, Muslims are permitted to use these preparations.
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Arab Nutrition
Grains and legumes are often substituted for meats; fresh fruit and juices are especially popular, and olive oil is widely used.
Food is eaten with the right hand because it is regarded as clean.
Eating and drinking at the same time is viewed as unhealthy.
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Arab Nutrition
During Ramadan, the Muslim month of fasting, abstinence from eating, drinking (including water), smoking, and marital intercourse during daylight hours is required.
Although the sick are not required to fast, many pious Muslims insist on fasting while hospitalized.
Lactose intolerance is common among Arab Americans.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Pregnancy and Childbearing Practices
Fertility practices are influenced by traditional Bedouin values, which support tribal dominance and beliefs that “God decides family size.”
Procreation is regarded as the purpose of marriage; high fertility rates are favored.
Sterility in a woman can lead to rejection and divorce.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Pregnancy and Childbearing Practices
Many reversible forms of birth control are undesirable but not forbidden. They should be used when there is a threat to the mother’s life, too frequent childbearing, risk of transmitting a genetic disease, or financial hardship.
Irreversible forms of birth control such as vasectomy and tubal ligation are “absolutely unlawful” as is abortion, except when the mother’s health is compromised by a pregnancy-induced disease or her life is threatened.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Pregnancy and Childbearing Practices
Unwanted pregnancies are dealt with by hoping for a miscarriage, “by an act of God”, or by covertly arranging for an abortion.
The pregnant woman is indulged and her cravings satisfied, lest she develop a birthmark in the shape of the particular food she craves.
Although pregnant women are excused from fasting during Ramadan, some Muslim women may be determined to fast.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Pregnancy and Childbearing Practices
Labor and delivery are women’s affairs.
During labor, women openly express pain through facial expressions, verbalizations, and body movements.
Care for the infant includes wrapping the stomach at birth, or as soon as possible thereafter, to prevent cold or wind from entering the baby’s body.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Pregnancy and Childbearing Practices
The call to prayer is recited in the Muslim newborn’s ear.
Male offspring are preferred.
Male circumcision is almost a universal practice, and for Muslims it is a religious requirement.
Mothers may be reluctant to bathe postpartum because of beliefs that air gets into the mother and causes illness.
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Arab Pregnancy and Childbearing Practices
Many believe washing the breasts “thins the milk.” Breast-feeding is often delayed until the second or third day after birth because of beliefs that the mother requires rest, that nursing at birth causes “colic” pain for the mother, and that “colostrum makes the baby dumb.”
Postpartum care foods, such as lentil soup, are offered to increase milk production.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Death Rituals
Death is accepted as God’s will. Muslim death rituals include turning the patient’s bed to face the holy city of Mecca and reading from the Qur’an, particularly verses stressing hope and acceptance.
After death, the deceased is washed three times by a Muslim of the same sex. The body is then wrapped, preferably in white material, and buried as soon as possible in a brick or cement-lined grave facing Mecca.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Death Rituals
Prayers for the deceased are recited at home, at the mosque, or at the cemetery.
Women do not ordinarily attend the burial unless the deceased is a close relative or husband. Instead, they gather at the deceased’s home and read the Qur’an.
For women, wearing black is considered appropriate for the entire period of mourning.
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Arab Death Rituals
Cremation is not practiced.
Autopsy is generally not approved because of respect for the dead and feelings that the body should not be mutilated.
Islam does allow forensic autopsies and autopsies medical research and instruction.
Organ donation and transplantation as well as administration of blood and blood products are acceptable.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Spirituality
Islam is the official religion of most Arab countries, and in Islam there is no separation of church and state; a certain amount of religious participation is obligatory.
Islam has no priesthood. Islamic scholars or religious sheikhs, the most learned individuals in an Islamic community, assume the role of imam, or “leader of the prayer.” The imam acts as a spiritual counselor.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Spirituality
The 5 major pillars or duties of Islam are
Faith, shown by the proclamation of the Unity of God by saying “There is no God but Allah; Mohammed is the Messenger of Allah.”
• Prayer, facing Mecca, is performed at dawn, noon, midafternoon, sunset, and nightfall.
• Almsgiving to assist the poor and to support religious organizations.
• Fasting fulfills religious obligations, wipes out previous sins, and demonstrates appreciate the hunger of the poor.
• A pilgrimage to Mecca (hadj) once in a lifetime is encouraged if the means are available.
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Arab Spirituality
School and work schedules revolve around Islamic holidays and weekly prayer. Because Muslims gather for communal prayer on Friday afternoons, the work week runs from Saturday through Thursday.
Devout patients may request that their chair or bed be turned to face Mecca and that a basin of water be provided for ritual washing or ablution before praying.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Spirituality
Providing for cleanliness is particularly important because the Muslim’s prayer is not acceptable unless the body, clothing, and place of prayer are clean.
Sometimes illness is considered punishment for one’s sins.
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Arab Health-care Practices
Good health is considered the ability to fulfill one’s roles.
Diseases are attributed to an inadequate diet, shifts of hot and cold, exposure of one’s stomach during sleep, emotional or spiritual distress, and envy or the “evil eye.”
Informed consent, self-care, advance directives, and preventive care are valued.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Health-care Practices
Women are often reluctant to seek care because of cultural emphasis placed on modesty.
Many fear that a diagnosed illness, such as cancer or psychiatric illness, may bring shame and influence their marriageability.
Family members indulge the individual and assume the ill person’s responsibilities.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Health-care Practices
Communicating a grave diagnosis is often viewed as cruel and tactless because it deprives clients of hope.
Most expect physicians to select treatments. The client’s role is to cooperate.
Beautiful women, healthy-looking babies, and the rich are believed to be particularly susceptible to the evil eye. Thus, expressions of congratulations may be interpreted as envy.
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Arab Health-care Practices
Protection from the evil eye is afforded by wearing amulets, such as blue beads, or figures involving the number five; reciting the Qur’an; or invoking the name of Allah.
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Arab Health-care Practices
Mental or emotional illnesses may be attributed to possession by evil jinn.
Islamic medicine is based on the theory of four humors and the spiritual and physical remedies prescribed by the Prophet. Because illness is viewed as an imbalance between the humors—black bile, blood, phlegm, and yellow bile—and the primary attributes of dryness, heat, cold, and moisture, therapy involves treating with the disease’s opposite: thus, a hot disease requires a cold remedy.
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Arab Health-care Practices
Although methods such as cupping, cautery, and phlebotomy may be used, treatment with special prayers or simple foods such as dates, honey, salt, and olive oil is preferred.
Preoperative instructions are thought to cause needless anxiety, hypochondriasis, and complications.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Health-care Practices
The tendency of Arabs to be more expressive with their family and more restrained in the presence of health professionals may lead to conflicting perceptions regarding the adequacy of pain relief.
Mental illness is a major social stigma. Psychiatric symptoms may be denied or attributed to “bad nerves” or evil spirits.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Health-care Practices
When individuals suffering from mental distress seek medical care, they are likely to present with a variety of vague complaints, such as abdominal pain, lassitude, anorexia, and shortness of breath.
Patients often expect and may insist on somatic treatment, at least “vitamins and tonics.”
When mental illness is accepted as a diagnosis, treatment with medications, rather than counseling, is preferred.
Hospitalization is resisted because such placement is viewed as abandonment.
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Arab Health-care Practices
Because of social stigma, the disabled are often kept from public view.
Medical treatments that require surgery, removal of causative agents, or eradication by intravenous treatments are valued more than therapies aimed at health promotion or disease prevention.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Health-care Practitioners
Many Arabs find interacting with a health-care professional of the opposite sex quite embarrassing and stressful.
Discomfort may be expressed by refusal to discuss personal information and by a reluctance to disrobe for physical assessments and hygiene.
Women may refuse to be seen by male health care providers.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Arab Health-care Practitioners
Knowledge held by a doctor is thought to convey authority and power.
Most clients who lack English communication skills prefer an Arabic-speaking physician.
The authority of physicians is seldom challenged or questioned. When treatment is successful, the physician’s skill is recognized; adverse outcomes are attributed to God’s will.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Copyright © 2013 F.A. Davis Company
Appalachians
Larry Purnell, PhD, RN, FAAN
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Overview
Heritage from England, Wales, Scotland, Ireland, France, and Germany
Came to the United States for religious freedom and better economic opportunities
Purposely isolated themselves in the mountains to live and practice their religions as they chose
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Overview Continued
Appalachia includes 410 counties in 13 states and extends from southern New York to northern Mississippi.
Continuous migration from the country to the city and vice versa
High proportion of aging in Appalachia
Farming, mining, textiles, service industries, etc.
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Overview Continued
High poverty and unemployment rates
Originally most educated group in America, now some of the least educated due to isolation
Area still lacks infrastructure
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Communications
Carry over from Elizabethan English
Spellin for spelling
Warsh for wash
Badder for bad
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Ethic of Neutrality
Avoid aggression and assertiveness
Do not interfere with others’ lives
Avoid dominance over others
Avoid arguments and seek agreement
Accept without judging—use few adjectives and adverbs, resulting in less precise description of emotions and thoughts
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Communications
Sensitive about direct questions and personal issues
Sensitive to hints of criticism. A suggestion may be seen as criticism.
Cordiality precedes information sharing so “sit a spell” and chat before doing business, which is necessary for developing trust
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Communication Continued
A few may avoid direct eye contact because it can be perceived as aggression, hostility, or impoliteness
More being than doing oriented, more relaxed culture and being in tune with body rhythms
Be formal with name format until told to do otherwise.
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Communication Continued
Healthcare provider must be flexible and adaptable
Come early or late for an appointment and still expect to be seen
Family lineage is important
Formality with respect—Miz Florence or Mr. John
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Family
Varied decision-making patterns but the more traditional Appalachian family is still primarily patriarchal
Women make decisions about health care and usually carry out the herbal treatments and folk remedies
Women marry at a young age and have larger families than the other white ethnic groups
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Family Continued
Children are accepted regardless of what they do
Hands-on physical punishment is common
Motherhood increases the status of the woman in the eyes of the community
Take great pride in being independent and doing things for oneself
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Family Continued
Family rather than the individual is the treatment unit
Having a job is more important than having a prestigious position
Consistent with the ethic of neutrality, alternative lifestyles are accepted, they are just not talked about
Extended family is the norm
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Biocultural Ecology
High incidence of respiratory conditions due to occupations
Increase of parasitic infections due to lack of modern utilities in some areas
High incidence of cancer, otitis media, anemia, obesity, cardiovascular disease, suicide, accidents, SIDS, and mental illness
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
High-Risk Behaviors
Tobacco is a main farming crop in some areas of Appalachia
Smoke at a young age
Alcohol use at a young age—binge drinking
Believe in the mind, body, spirit connection
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Ten Steps in Seeking Health Care
Use self-care practices learned from mother or grandmother
Call mother or grandmother if available
Then trusted female family member, neighbor, or a nurse
Then go to OTCs they saw on TV
Then use a neighbor’s prescription medicine
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Ten Steps in Seeking Health Care Continued
Pharmacist or nurse for advice
Physician or Advanced Practice Nurse
Then to a specialist
Then to the closest tertiary medical center
DO NOT BE JUDGMENTAL, if you want to keep them in the system
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Nutrition
Food may be synonymous with wealth
Wide variety of meats, do not trim the fat—low-fat wild game is also eaten
Organ meats are common
Bones and bone marrow used for making sauces
Preserve with salt
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Nutrition Continued
Lots of frying (using lard or bacon grease) and pickling
Anytime is the time to celebrate with food, especially in the rural areas
Many teens have particularly poor health
Status symbol to have instant coffee and snack foods for some
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Nutrition Continued
Early introduction of solid foods
May feed babies teaspoons of grease to make them healthy and strong
Diet is frequently deficient in Vitamin A, iron, and calcium
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Childbearing Family
Must eat well to have a healthy baby
Do not reach over your head when pregnant to prevent the cord from wrapping around the neck of the fetus
Being frightened by a snake or eating strawberries or citrus can cause the baby to be marked
Use bands around the belly and asafetida bags
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Death Rituals
Must stay with the dying person
Family should not be left alone
Funerals with personal objects at the viewing and buried in their best clothes
May take the deceased for viewing at home
After the funeral there is more food and singing and for some a “wake” to celebrate life
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Death Rituals Continued
Flowers are more important than donations to charity
Particularly good at working through the grieving process
Funeral directors are commonly used for bereavement
Cremation is acceptable and ashes may be saved or dispersed on the “land”
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Spirituality
Baptist, Pentecostal, Episcopalian, Jehovah’s Witness, Methodist, Presbyterian
Each church adapts to the community
Most are highly religious even though they do not attend church
Common to attend Sunday and other days
Preacher has a calling to “preach”
Ministers are trained
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Spirituality Continued
Meaning in life comes from the family and “living right with God,” which varies by the specific religious sect
Nature is in control—fatalism
Religion and faith is important in a hostile environment
I will be there if the “creek does not rise” or if “God is willing”—fatalism
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Healthcare Practices
Good health is due to God’s Will
Self-reliance fosters self-care practices
Family important for health care
May be very ill before a decision is made to see a professional resulting in a more compromised health condition
Direct approaches are frowned upon
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Healthcare Practices Continued
Herbal medicines, poultices, and teas are common
See Table 8–1 in the textbook; these practices are still alive and well
Folk medicines used in conjunction with biomedical treatments
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Barriers
Fatalism
Self-reliance
Lack of infrastructure
Health profession shortages
Culture of “being”
Poverty and unemployment
Care not acceptable from outsiders
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Responses to Health and Illness
Take care of our own and accept the person as whole individual
Not mentally ill, the person has “bad nerves” or are “odd turned”
Having a disability with aging is natural and inevitable—if you live long enough
Must establish rapport and trust
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Responses to Health and Illness Continued
Pain is something that is to be endured
Some may be stoical
Pain legitimizes not working or fulfilling one’s responsibilities
Withdraw into self when ill
Culture of being works against rehabilitation
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Healthcare Practitioners
Lay and trained nurses and midwives still provide much of the care in some parts of Appalachia
Breckenridge Frontier Nursing Service
Prefer people known to the family and community —the insider versus outsider concept
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Healthcare Practitioners Continued
Culture of “being” says the healthcare provider should not give the perception of being rushed
Physicians may not be trusted due to outsided-ness, not to being foreign
Must ask the clients what they think is wrong
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