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People of French Canadian Heritage

Chapter 11

GINETTE COUTU-WAKULCZYK, DENISE MOREAU, and DIANE ALAIN

Overview, Inhabited Localities, and Topography

OVERVIEW

Canada, with over 3,800,000 square miles, is larger than the entire United States but has only one-ninth the popu- lation. The population is 32,270,507, of which one-quar- ter have French as their mother tongue and 3 million speak French as a second language (Statistics Canada, 2006). Canada is surrounded by three oceans; the land mass covers six time zones and has fertile agricultural land, vast tundra, dense forests, and mountain ranges. The country is rich in minerals, coal, oil, and gas.

Canada, a member of the Commonwealth of Nations and of the G8, is a federation of 10 provinces, the Northwest and Yukon Territories, and the Nunavut. The Constitution Act of 1981 transferred the Parliament from Britain to Canada; the Canadian constitution is now entirely in the hands of the Canadians. People in each province elect their own premier and provincial legislative government. Even though the Queen of England is also the Queen of Canada, represented by the Governor General, a lieutenant governor is symbolically appointed by the fed- eral government in every province. The 10 provinces in descending order of population are Ontario, Québec, British Columbia, Alberta, Manitoba, Saskatchewan, Nova Scotia, New Brunswick, Newfoundland, and Prince Edward Island; the Yukon Territories and Northwest Territories, which have been subdivided to form the Nunavut.

Based on the 2001 census, Canada’s largest cities are Toronto (5,304,100), Montréal (3,635,700), Vancouver (2,208,300), and Ottawa Gatineau (1,148,800), the national

capital region (Statistics Canada, 2006). Although more than 9 million people report being able to converse in French (Office of the Commissionor of Official Languages, 2006), the Francophone (French-speaking) population remains stable with over 6.6 million, the vast majority of them living in the province of Québec (Statistics Canada, 2002). The presence of the French in North America, begin- ning in Acadia, has celebrated its 400th-anniversary (1604–2004). Since the early 1980s, Canada has relied on immigration for its demographic growth, with an average of 230,000 newcomers per annum. Since the beginning of the 21st century, the majority come from Asia and Africa (Statistics Canada, 2006).

Before the latter half of the 18th century, most French people immigrating to Canada were Catholics, whereas French Protestants tended to come directly to the United States. After the French Revolution, an increased number of Catholics sought shelter in the United States. The bulk of those coming via Canada settled in the New England states and later dispersed throughout the United States. Peaks of emigration occurred from the Acadian deporta- tion (1755), from the latter part of the 19th century, and just prior to the Great Depression. Most of this latter migration was directly related to economic opportunities and was part of an apparently contagious groundswell of immigration to the United States from Europe via Canada. As of 2000, it was estimated that more than 2.2 million people of French Canadian descent resided in the United States. Nowadays, French-speaking Canadians, unlike those of the 19th century living in the United States, may have been raised within the French culture but descended from a variety of ethnicities. Because French Canadian cultural characteristics vary according to the primary and secondary characteristics of

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culture (see Chapter 1), assessments must be carefully completed to avoid generalizations based on language and physical or racial traits. In addition, the Multi- culturalism Canada Act of 1988 provided guidelines for implementing policies regarding multicultural diversity.

HERITAGE AND RESIDENCE

Before the 1960s, people with French as their mother tongue were identified as French Canadians, referring to France as their country of origin. The ancestors of most French Canadians were the French “colons” who estab- lished themselves in the St. Lawrence Valley during the 17th and 18th centuries. They brought with them their native language and culture, their customs, songs, stories, and games, which have been enriched over the centuries by contact with indigenous peoples and other immigrant cultures to the region: the Basques, the Scots, and the Irish. The Métis, descendants of Native Americans and Europeans, are mainly, though not entirely, French- speaking. Some regard the Métis as a historically and cul- turally distinct people in their own right. Another major portion of Canada’s French-speaking population are the Acadians. They are the descendants of the early French colonists, mainly people from west-central France, who settled in the Maritime region of modern-day Nova Scotia and New Brunswick.

Today, the French-speaking population of Canada is far from homogeneous. In many homes, English and French may be used equally. Canadians whose first lan- guage is French are called Francophones, a designation that broadly encompasses the multiethnic and cultural mosaic of the Canadian population. More recently, Francophones from former colonies under French rule such as Carribeans, Lebanon, Vietnam, Africa, and a smaller number from Eastern Europe (Madibbo & Labrie, 2005) have added to the French population of Canada. Moreover, during the last 20–30 years, many families in Québec have adopted young children mostly from Africa, China, Latin America, and the Middle East. This practice has contributed to the development of an ethnic mosaic within the younger adult population. Although most French-speaking Canadians live in the province of Québec, the French language is used daily for communi- cation within families and communities from coast to coast and as far north as the Yukon. The number increases yearly with the population seeking work in the western provinces.

New France (Nouvelle France) was the name given to Canada when it was first settled in the 17th century, a period in which Portugal, Spain, Holland, France, and England all vied for territory. Although religious influ- ences played a part in colonial policies, it was the mer- cantile system that stimulated exploration of the North American wilderness and the development of trading companies. One of the first permanent colonies in Canada was Québec City. Soon after settling there in 1608, French explorers and traders moved up the St. Lawrence River, established a settlement at Ville-Marie (Montréal) in 1642, explored the Great Lakes (from which the St. Lawrence flows), opened fur-trading centers, and con-

verted the natives to Christianity. In 1718, the French set- tled at the opposite end of the continent, in New Orleans. In 1750, approximately 80,000 French colonials lived within the vast area between the mouths of the St. Lawrence and Mississippi rivers. The French influence is still visible in large parts of Canada and in cities such as St. Louis and New Orleans in the United States.

Around 1603, other groups of settlers established themselves in Acadia, north of what Giovanni da Verrazano, in 1534, referred to as Arcadia (note the r). This region is known today as Delaware, Maryland, and Virginia. After a devastating experience during the winter of 1604 to 1605, the settlers moved to the Bay of Fundy and founded Port-Royal, which was to become the first coastal settlement and capital of Acadia. By the middle of the 1700s, Acadians were caught in the crossfire of the imperial rivalries of England, France, and inhabitants of the American colonies, finally being absorbed into the British Empire.

With the Treaty of Utrecht in 1713, England secured Newfoundland, Acadia (renamed Nova Scotia), and the extensive region drained by the rivers flowing into the Hudson Bay. As a result of the Treaty of Paris in 1763, France relinquished all its North American possessions east of the Mississippi River to England. Spain ceded Florida to England in exchange for the French territories west of the Mississippi River. Thus, as a geographic area, New France became only a memory. Yet, the French cul- ture, language, and religious institutions remain as an everlasting tribute to the past. The heritage and early French architecture is well preserved through concen- trated efforts and pride in restoration. Publication of information about monuments, houses, churches, and ramparts around Québec City keep the public informed about the area’s rich French heritage.

As a result of unresolved controversy over several highly contentious oaths of allegiance to the English between 1755 and 1762, a massive deportation occurred, referred to as le grand dérangement. French-speaking Catholic Acadians were removed from their homes in Nova Scotia and New Brunswick. Some fled to Québec, others took refuge in the woods, and many died. Still others dispersed to the south: Massachusetts, New York, Pennsylvania, Maryland, Virginia, the Carolinas, Georgia, and Louisiana (Cajun). In 1774, some exiled Acadians returned to the Maritimes and attempted to re-create their lives. Unable to secure their former lands because of British occupation, they directed their energies to settling new areas and gradually explored new activities such as fishing and forestry. Today, 90 per- cent of the Acadians reside in northern and eastern New Brunswick, southern Nova Scotia, the Acadian region of Cape Breton, and the Evangeline region of Prince Edward Island (Beaudin & Leclerc, 1995).

Throughout Canada, important regional differences exist among the French-speaking population. Outside Québec, the French-speaking population within each province or territory has its own association, which is orga- nized nationally under the Fédération des Communautés Francophones et Acadiennes du Canada (FCFA). An impor- tant consideration when health-care providers assess a family’s cultural background is the number of mixed mar- riages leading to the adoption of English as the language

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spoken in the home and by the majority. French-speaking Canada has become an increasingly diverse society com- posed of various ethnocultural groups with more than 100 different languages as mother tongue. In 2001, 5,335,000 (1 in 6) allophones (mother tongue other than French or English) immigrated to Canada, up 12.5 percent over 1996, which is three times that of population growth (4.0 per- cent) (Statistics Canada, 2006). Very much like the situa- tion in the U.S., interethnic marriage patterns have dra- matically changed from “. . . a multiethnic society . . . into multiethnic individuals” (Huntington, 2004, p. 299). For example, in Toronto, the Francophones of European descent (de souche) are becoming the minority among the Francophones of different ethnic groups (Statistics Canada, 2002).

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Economic reasons, including the desire to cultivate the land and exploit fisheries, were the most frequent moti- vations for French Canadian settlers in the 17th century. Most of these settlers originated from the French regions of Normandy, Perche, and Poitou, and some came from Aunis, Brittany, Ile de France, and Saintonge. During the 17th century in France, many nobles lost their fortune because of changes in France’s feudal system and wars; thus, colonization of New France offered possibilities for regaining their prestige and land for their vassals. The richness and the quality of pelts available in the New World promoted fur trading with the Native Americans and attracted merchants and their employees. In addi- tion, missionaries and religious orders were among the earlier settlers. The latter half of the 20th century saw a wide range of reasons for migration including wars, humanitarianism, and appeal for a better life, which is called economic immigration. Today, French-speaking Canadians are represented in all trades and professions.

EDUCATIONAL STATUS AND OCCUPATIONS

Although the overall official literacy rate in Canada approaches 99 percent, the functional literacy rate is lower, and the educational levels of French Canadians rep- resent a broad spectrum, depending on age group and geo- graphic location. Among the older population, illiteracy reaches as high as 50 percent in some regions (Citizenship and Immigration Canada, 2005). In the 2001 national census, despite important progress in accessibility to post- secondary education in the French language, the univer- sity education level for Francophones remains below the national average. For example, for Francophones living outside Québec, the rate has increased to 19.6 percent, which is still lower than the national Canadian rate of 22.3 percent (Citizenship and Immigration Canada, 2005).

More recently, educational opportunities at all levels have become available in the French language in Ontario. Nevertheless, the lack of professionals prepared for the delivery of health services in French, as prescribed by the 1989 Ontario Government Law #8, jeopardizes the devel- opment of a full network of services in some rural regions.

In order to provide opportunities for the training of health professionals in the French language, the Consortium National de Formation en Santé (CNFS, 2001) has put in place mechanisms and organizations in all provinces and Territories outside Québec.

At the beginning of colonization, major occupations such as agriculture, fur trading, and fisheries were impor- tant for survival. In the latter part of the 19th century, French-speaking Canadians joined the developing indus- trial labor force. Factories, mining, forestry, and fisheries took advantage of the numerous hands available among the fertile Canadian families of French ancestry. Despite language barriers, this was a time when the borders of Québec did not stop young families from moving across Canada for work. Throughout Canada, even in the Yukon, the origins of early French-speaking Canadian settlements can be traced to these years. Today, French-speaking Canadians are represented in all trades and professions. However, the older population may have a different life his- tory, depending on their region of origin: Gaspésie, Abitibi, Beauce, Acadia, or the cities of Montréal and Québec.

Communication DOMINANT LANGUAGE AND DIALECTS

Canada has two official languages, French and English. Regional differences exist in accent, vocabulary, and degree of anglicization. However, French Canadians do not have difficulty understanding one another because the original French spoken in Canada includes some old 17th-century French words and expressions that are no longer used in France. Oral communication, in particular, has undergone assimilation. Indian words have been added and English words are incorporated into a syntax and grammar that is essentially French, resulting in a dialect, joual in Québec and Chiac in New Brunswick, which is spoken primarily by lower socioeconomic and undereducated groups. Age and location in Canada fre- quently determine language use and ability.

A population trend analysis in 1983 showed that despite the improved legal status of Francophones in Ontario, urbanization and economic pressures were contributing to a decline in French-speaking Ontarians. This decrease is more noticeable in southern Ontario, with a lesser decline in the northern and eastern counties bordering Québec. As a result of urbanization, the distribution of Francophones in Ontario has become fragmented, although regional cohesion of French-speaking Ontario has remained strongly supported by active networks at the local and provincial levels. Adding to this reality, the 2001 census demonstrated that low birth rate, mixed marriage with bilingualism, and an increase in mean age of Francophones contributed to the fragilized use of French in Canada. For example, in 2001, there were more allophones (732,200 had neither French nor English as mother tongue) in Québec than anglophones (591,400). In Canada, although a little less than a quarter (22.9 percent) reported French as the spoken language in their daily activities, 43.4 percent declared being bilingual (French-English) compared with 9 percent of Anglophones (Statistics Canada, 2002).

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Since 1969, the Official Languages Act of New Brunswick guaranteed the availability of government ser- vices and education in French and English at all educa- tional levels. Although the Act has increased the political and social utility of French, it has not reversed the Acadians’ use of English or the decline in the proportion of Francophones in the province. In an effort to prevent linguistic assimilation, a new policy for language teaching is used in the French schools of heavily Anglicized regions. English as a second language is taught only beginning in grade 5, whereas in Québec since 2000, teaching the second language begins in grade 1. In all provinces except New Brunswick, where the French are the minority, a disproportionate number of young French Canadians are assimilated into the majority English- speaking society. In contrast, on Prince Edward Island, the struggle to obtain education in French remains an ongoing issue.

A recent report prepared by the Official Language Community Development Bureau on behalf of the Consultative Committee for French-Speaking Minority Communities (CCFSMC) states that services in the user’s language have benefits that extend far beyond simple respect for the user’s culture (Public Works and Government Services Canada, 2001). These services are indispensable for improving the health status of individ- uals and for community empowerment in matters of health. Studies have shown that the health status of minority Francophones is generally poorer than that of their fellow citizens in any given province. In fact, between 50 and 55 percent of French-speaking minority communities often have little or no access to health ser- vices in their mother tongue. Of foremost importance, one of the recommendations is to increase the number of French-speaking health professionals who practice in minority communities and to support the establishment of a pan-Canadian Francophone consortium for the train- ing of French-speaking health professionals and the addi- tion of a school of nursing at Collège Universitaire de St- Boniface in Winnipeg, Manitoba.

The law protecting the French language in Québec may have created another problem for its population. While promoting a false sense of security by maintaining the dominance of the French language, a large portion of Québec’s French-speaking population lacks sufficient knowledge of the English language to access the workforce outside their province and may have difficulty in higher- education programs in which readings are mostly in English.

From a health perspective, cultural heritage remains pre- sent long after words of the French language have been for- gotten. Maintaining the use of French depends mostly on the strength of the local French community. As for other culturally diverse clients, health-care providers must respect the client’s preference in choice of language by seeking interpreters when possible; gearing health teaching to the educational level of the client; and supplementing written directions with verbal instructions, demonstrations, and pictures. In the 2001 census, over 100 different languages as mother tongue were identified, although reporting at the same time that French was the primary language; thus, health teaching represents quite a challenge.

CULTURAL COMMUNICATION PATTERNS

Conversation is very important to French people. Among French Canadians, a conversation may be conducted with high voice crescendos, which do not necessarily mean anger or violence. Volume can increase with the importance and the emotional charge invested in the content of the message. Nonverbal communication pat- terns for French Canadians resemble those of their Latin and Mediterranean ancestors, which encourage sharing thoughts and feelings. Acadians are more reserved, qui- eter, shy, even self-effacing, and are less likely to share their thoughts and feelings than people from Québec. The use of hand gestures for emphasis when speaking is common. Facial expressions for men and women of all ages are a part of communication, often replacing words. Health-care providers working with French-speaking Canadians need to be attentive to nonverbal and paraver- bal communication. These observations provide much of the information on affect, emotion, and mutual under- standing between health-care providers and clients.

Spatial distancing for French-speaking Canadians dif- fers among family members, close friends, and the public. When in the intimacy zone, people may touch frequently and converse in close physical space; however, they tend to avoid physical contact in public. When greeting another person, men usually shake hands, which is rec- ommended for health-care providers. Close female friends and family members may greet each other with an embrace. However, in public and more formal situations such as the health-care environment, this is not a recom- mended practice. Eye contact is an important way for the health practitioner to acknowledge whether the person has understood or is following what is being said. Today, with the many ethnic and cultural groups, this behavior is not always possible. For example, for a student from the Haitian culture, it would be a lack of respect to make eye- to-eye contact with the professor. Hence, training these students to make eye contact with patients may be quite a challenge. Conversely, health professionals should be aware of the wide range of behaviors attached to commu- nication in French among different ethnic cultural groups.

Before radio and television reached the Port au Port Peninsula of Newfoundland, there was a public tradition of storytelling. Narrators were invited to a home where sev- eral families had gathered, and an entire evening of story- telling took place. These public performances were time- consuming, followed stylistic conventions and formulas, and made dramatic use of gesturing. Since the 1960s, pri- vate storytelling has substantially replaced the public tradi- tion. Stories are told within the confines of a single family or small group and usually last less than an hour, about the length of a television episode. Narrators no longer use styl- istic devices, literary formulas, or dramatic gesturing.

TEMPORAL RELATIONSHIPS

For the French Canadian people, relationships take a long time to develop, but once in place, the relationship becomes very important and enduring. Langelier (1996) stated that once one enters the inner sanctum of close friendship, commitment and responsibility ensue.

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French-speaking Canadians from Québec have a past, pre- sent, and future orientation in their worldview. Balancing the three dimensions depends on traditionalism, genera- tion, religiosity, and urbanization (Pronovost, 1989). More traditional people, and many from rural backgrounds, attach primary importance to living in the present and accepting day-to-day occurrences in a context of fatalism. Many older people, with a strong religious background, maintain a future worldview, regarding life after death, and a past orientation, celebrating death anniversaries of family members and other events. However, many of the younger generation reject past traditions and attempt to maintain a balance by enjoying the present, working, and planning for their future.

FORMAT FOR NAMES

Traditionally, until the late 1970s, women and children took the father’s surname. Today, under Québec law, a woman keeps her maiden name throughout her lifetime, although in other parts of Canada, this practice is decided between the spouses. This situation has created tension and self-identity difficulties for some older people. As for children, a Québécois family of two spouses and two chil- dren may well include four different surname combina- tions: One child may have the father’s surname or the mother’s surname alone or a hyphenated or nonhyphen- ated surname composed of those of the father and mother. For a second child, the surnames are the same, but in reverse order. The decision for using surnames rests entirely with the parents and must appear on the birth certificate. Today, very few parents adhere to the official use of multiple surnames for children. Women married for several years before the new law often added their maiden name hyphenated with that of their husbands.

Many French-speaking Canadians have dropped the custom of naming the oldest son after the father or the grandfather. Also declining is the custom of adding Joseph to male infants’ and Mary to female infants’ names. Until the early 1980s, the custom was to use only one name without initials, except on legal documents, which used all three or four names as they appeared on the birth certificate. Another recent change is using names other than those of saints. All of these factors should alert the health-care practitioner to the potential for confusion in the name format for client cultural identification. When in doubt, the health-care provider should ask the patient her or his legal name for record-keeping.

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

Traditionally, in French-speaking Canadian families, the man was seen as the moral authority and responsible for material well-being, such as economic provider and pur- veyor of affection and security. The woman served as the family mediator and social director, as well as being responsible for household activities, child care, and health care (Langelier, 1996). The profound social changes encountered after the “Quiet Revolution” of the late 1960s

and early 1970s brought important modifications in edu- cation and industrialization and increased the role of women in economic activity. Better education for young women, along with the feminist movement, brought forth a desire and opportunities for women to have a career and a family of their own. Furthermore, even without a formal career education, women took the work market path mainly because it was no longer possible to live on one salary. These changes resulted in a new dynamic of family roles and organization that affected every member of the family, be it nuclear or extended. This model shaped fam- ily life dynamics and gave birth to a lexicon like “the superwomen or super mom,” referring to mothers having two days’ work, one outside and one inside the home, and men started to learn about “shared inside home chores.” Women not only became producers of domestic goods in the household but also became productive outside the home environment.

Using the husband’s income as an index for comparing the family communication and relative independence on marital adjustment among 180 French-speaking couples, Aube and Linden (1991) found that the degree of marital discord was similar across different socioeconomic levels. However, quality of communication accounted for 16 percent of the variance in marital satisfaction among men, and only 13 percent of the variance among women. By the end of the 1980s, marriages changed fundamen- tally, moving toward equality of husbands and wives, but not necessarily of children and parents. From a socioan- thropological perspective, a national survey with 5614 females and 10,965 males demonstrated income differ- ences between genders. Inequality, attributable to career interruptions by women, was estimated along with the importance of factors such as education, occupation, socioeconomic status, and number of hours worked per year. The income difference by gender among native and linguistic minorities in Canada showed that the inequal- ity between sexes was smaller among French-speaking Canadians than among other groups (Goyder, 1981).

According to Langelier (1996), French Canadians have always attributed great value to family relationships and obligations; however, Wu and Baer (1996) found that Francophones were less committed than Anglophones to traditional values concerning marriage and relationships. Those results are consistent with Fong and Guilia’s (1990) study showing that French Canadians had more permissive attitudes than English Canadians with respect to marriage, sexual activity, and nonmarried parenthood. Conversely, French Canadians are more traditional than English Canadians when it comes to rating the impor- tance of having children. In addition, Catholicism was positively related to attitudes toward childbearing and differences in these attitudes among French and English Canadians. Recent studies provide clear evidence of a pro- found transformation in attitudes toward family-related behaviors and gender roles in much of the Western world since the mid-1970s: increased acceptance of divorce, nonmarital cohabitation, unmarried parenthood, perma- nent nonmarriage, and voluntary childlessness. Norms for gender roles are also changing, with shifts toward gen- der egalitarianism with respect to the appropriate roles of women and men in the family and workplace.

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PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

The greatest source of pride for French Canadian families is to see their children well established with a good edu- cation. On this issue, most of the present political elite, educated at religious colleges, share the values and beliefs of their religious professors, not the prescribed behavior for their offspring.

FAMILY GOALS AND PRIORITIES

Traditional French Canadian intergenerational relation- ships are rapidly disappearing (Fig. 11–1). Urbanization, particularly without adequate social security measures, results in social dislocation of the young and old. Strategies for maintaining cohesion among the genera- tions are required to avoid intergenerational conflict related to competition for scarce resources when survival challenges are real. In Canada, many of the social policies are under provincial jurisdiction. Today, French Canadian families follow the same pattern of declining birth rates as other Canadians. Québec has done the most in formulating a family policy and stimulating a widespread popular debate on the issue. Family policy, when geared toward pro- tecting and fostering a particular type of family, contributes to the detriment of other types of families and becomes a prescribed structure for acceptance. For example, because children who were born out-of-wedlock were being penal- ized on the basis of their parents’ relationship, the legal cat- egory of illegitimacy has been abolished in most Canadian provinces. The French Canadian family is more nuclear and autonomous than its counterpart in France.

Starting in 1997, Québec initiated a family policy aimed at promoting family life and increasing the birth rate. Among the most meaningful policies are the monthly allocations granted to each child at birth, for pregnant mothers or for mothers during the breastfeeding period, the right to reprieve from potentially harmful work conditions for the mother and child, parental leave up to 52 weeks for the mother or the father divided between them should they wish to do so, and subsidized

day-care centers at a cost of $7.00 a day per child to be paid by parents (Gouvernement du Québec, 2006).

French-speaking Canadian family membership is known for its closeness, and some families are a “closed” family sys- tem. Urbanization and smaller families, along with the “Quiet Revolution” in Québec, have encouraged people to open their borders and expand their circle to include others by broadening their family perspective. Nevertheless, within the microcosm of the French Canadian population, the physical and social quality of the microenvironment is more essential to health and survival than wealth and a physical connection (Evans & Stoddart, 1994). House, Landis, and Umberson (1988) reported widespread and strong correlations between mortality and social support networks—friends and family keep French Canadians alive! The sheer number of contacts one has is protective, regard- less of the nature of the interaction (Evans, 1994).

Lambert, Brown, Curtis, and Kay (1986), using the 1984 national election study of 3377 Québec inhabitants, explored cognitive differences from a class perspective. English-speaking and French-speaking residents of Québec were surveyed regarding their perceptions of social class, the importance of using characteristics to describe people from diverse social classes, and differentiation of the most important characteristics of social class. Approximately 45 percent stated that the idea of social class had no meaning to them or that they were unsure of its meaning, with English-speaking Canadians being more likely to give this response. Generally, people who said they understood the concept believed that social classes differed materially, whereas those who did not understand the concept pre- ferred to evaluate people on individual characteristics. French-speaking respondents defined social class in the materialistic sense of income and wealth, whereas English- speaking Canadians emphasized individuals in terms of character and ambition and used ascriptive criteria such as country of origin, birth, or ancestry.

ALTERNATIVE LIFESTYLES

Traditionally, the Catholic Church dictated the parameters of sexual behavior, with a high priority placed on marriage and the begetting and raising of children. In the years before 1960 abstinence from premarital sex was encour- aged, and a sexual double-standard existed, whereas the 1970s and 1980s witnessed a liberalization of sexual norms and the establishment of more egalitarian relation- ships between young men and women. At present, there is a growing trend for couples to live together without mar- rying. Many young couples answer that they cannot financially afford to get married. Yet, many of these same couples insist on having their children baptized and raise them according to Catholic Church principles.

Hobart (1992) studied sexual behaviors and attitudes toward sex, sexually transmitted diseases, and HIV/AIDS among 1775 Anglophone and 493 Francophone Canadian postsecondary students, surveying their expectations about condom use with different sexual partners. Results imply that women’s patterns of sexual behaviors were more predictive than men’s, but the relationships among variables were neither consistent nor strong. A shift toward greater sexual permissiveness and recognition of

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female sexuality is apparent. The percentage of sexually active adolescents has increased, from less than 50 percent in the early 1980s to 76 percent in the mid-1990s, with an average age at the time of the first sexual relations of approximately 16 years (Samson, Otis, & Levy, 1996).

An Internet search on gays and lesbians in Canada resulted in numerous Websites devoted to alternative lifestyles. Some Websites were hosted by universities, whereas others were hosted by gay and lesbian organiza- tions (see, e.g., http://www.er.uqam.ca, http://www.clga.ca and http://www.teleport.com). In 1996, the Canadian government extended health, relocation, and other job benefits to same-sex partners of federal employees. During the same year, the Ontario Court of Appeals ruled that same-sex couples must be treated as common-law couples under the Family Leave Act. In 1999, a poll conducted by the Canadian federal government revealed that 53 percent of the Canadian public, across provincial and demo- graphic lines, supported gay people’s freedom to marry (International Recognition of Same-Sex Relationships, 2002). Canada is one of the few countries in the world where same-sex marriage is legalized.

Workforce Issues

V I G N E T T E 1 1 . 1

Michel and Marie Tremblay have moved to the Boston area where they have both found work as aeronautical engineers. Because their life is now more stable with long-term con- tracts, they decided it was time to have children. Marie is pregnant. Michel is from the Lac St-Jean area of Canada, and Marie was born and raised in Montréal. They located a med- ical clinic and a physician for health care and the delivery of their baby-to-be. They consider language skills in French as excellent and that they can converse adequately in English for everyday conversations.

1. Do you think their English communication skills will be adequate for meeting their health-care needs? Why? Why not?

2. Name three genetically transmitted diseases for which the Tremblay baby may be at risk.

3. Identify strategies to help the Tremblay family meet their health-care needs in a new culture.

4. Compare the reason the Tremblay family has moved to Boston with the reasons the French immigrated in the 19th century.

CULTURE IN THE WORKPLACE

Among Canadians, workforce issues often correspond to educational background. In this respect, one must not forget the effects of the Durham Report and Law #17, which eliminated public schools’ rights to teach in the French language, with the consequence of a high level of illiteracy among French Canadians. This situation was finally reversed with full rights to education in the French language in 1982, based on the Canadian Charter of Rights, article 23 (Denault & Cardinal, 1999). Hence, the

overall educational level of French-speaking Canadians is lower than that of their English-speaking counterparts.

Using the Canadian version of the International Literacy Measure, which has a 5-point scale on which “1” is the lowest level and “5” refers to a university level, a survey on 23,000 Canadians provided data on compre- hension competency for continued text, schematic text, numeracy, and problem solving. In four provinces (New Brunswick, Québec, Ontario, and Manitoba), the propor- tion of Francophones aged 16 years and older who obtained a score of 3 or lower was higher than the pro- portion of Anglophones. A level 3 in comprehension of text equates with understanding, for example, what is written on the label of a medicine bottle (when, how, and numbers of days). The level 3 is considered a basic requirement for active participation in civic life and vot- ing. Of Francophones living outside of the province of Québec, 69 percent chose to be evaluated in the English language (35 percent in New Brunswick; 64 percent in Ontario, and 84 percent in Manitoba). The mean score obtained by those tested in English was higher in text comprehension than their counterparts who chose the French test. However, these differences could be attribut- able to the educational level, based on the fact that when controlled for educational level, there are no differences between Francophones and Anglophones (National Adult Literary Base, 2005). This information may be useful to health-care professionals when providing written infor- mation and prevention education to clients and families.

In addition, the proportion of part-time and casual workers among French-speaking Canadians is higher, especially in Québec hospitals. Labor unions support part- time and casual work as being shared work. However, many male workers are beginning to resent this approach, calling it “shared poverty.” This situation resulted in less interest for the younger generation to enter the profes- sion and, combined with 27,000 nurses who emigrated to the United States in the 1990s, resulted in a significant shortage of health-care practitioners (Canadian Nurses Foundation, 2006).

Hofstede (as cited in Punnett, 1991) examined the preferred leadership styles of 113 Anglophone and 77 Francophone managers in Ottawa from the perspective of language and cultural values. The two groups were similar in their preferred style of leadership, but differed signifi- cantly in terms of individualism. Differences between this group and an earlier Canadian sample suggest that organi- zational influences may have more impact on expressed cultural values than do language differences. To a large extent, outside the province of Québec, French-speaking Canadians’ patterns of acculturation are intermeshed with educational and work opportunities. From an educational perspective, in the 1970s, a vast movement for French- immersion classes across Canada started changing the views of the younger generation. Also, the long battle for the administrative French school board system has reduced the acculturation process in many areas of Canada without stopping it. The availability of French language higher education outside Québec completes the realm of factors necessary to reverse acculturation and assure health services for French-speaking Canadians wherever they live.

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In 1987, Ontario adopted legislation requiring equity in public services and recognized the necessity of look- ing closely into the principles of equality and equiva- lence. The designation of a certain number of positions identified as Francophone may have opened the door to a new phenomenon, that of ghettos (Denault & Cardinal, 1999). Most of these Francophone positions were cre- ated within the areas of essential population services and in the senior positions in the public services. Another aspect of the Francophone positions turns out to be more task elasticity and work overload in the sense that the regular job must be completed in addition to the translation of whatever material is to be produced for the service to be delivered.

ISSUES RELATED TO AUTONOMY

Baccalaureate level education, bilingualism, multicultural- ism, and a focus on open-mindedness are the dominant themes in the Canadian workplace. Entry to practice requires a baccalaureate basic training since the early 2000s in the majority of provinces, excluding Québec province. Moreover, in the province of Québec, average yearly salaries may have a difference of nearly $19,000 lower than those paid in Ontario. Another exception relates to the Québec province’s position with French as the official language in the workplace. Very few employers outside Québec need to identify English and French as official language; hence, geo- graphic and regional aggregates of people living in specific areas shape the language of services offered.

Nurses’ roles and activities remain consistent across Canada; however, changes in the mode of care and the language used in delivering services are apparent. Opportunities for Francophone nurses to function suc- cessfully outside Québec are limited if they have not mas- tered the English language. Frustration occurs among Francophone nurses when the time and effort put into mastering and delivering services in both official lan- guages are not recognized. In addition, the number of Francophone nurses academically prepared to serve in decision-making positions is limited outside the province of Québec. This hinders the type and mode of services offered when decisions become public health policies. Today, with the CNFS contribution and the advancement of distance teaching, the training of health-care profes- sionals in the French language is possible at every level from baccalaureate to doctorate not only in Québec but also all over Canada. Nevertheless, The University of Montréal Faculty of Nursing, founded in 1962, remains the only Francophone international university to offer programs in French from baccalaureate to doctorate. In terms of the number of Francophone students, that Faculty is the most important in Québec and in Canada.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Canadians of French descent are white or Caucasian; however, Francophones, as a linguistic group, represent a

mosaic of ethnocultural characteristics, including racial differences prompted by acculturation, adoption, and the children of mixed marriages. However, remember that one may change many things in life but one cannot change the biological grandparents (Huntington, 2004). Thus, individuals must be assessed individually for bio- logical risks according to their racial and cultural heritage.

DISEASES AND HEALTH CONDITIONS

Given the limited population density, multiculturalism, and regionalism factors affecting Canadian society, spe- cific risk factors for Canadians of French ancestry are the same as those for other minority groups. The primary causes of death among the Québec population are, in order of prevalence, cancer with an increase of lung cancer in women and cardiovascular diseases. In Québec between 2001 and 2005, death and injuries from road accidents increased by 17 percent. Newborn deaths attributed to the respiratory distress syndrome and neonate septicemia have also increased in Québec (Institut National de Santé Publique [INSPQ], 2006). In Ontario, according to Niday Perinatal Database and Southwest Data Warehouse in 2003, independently of language or culture, 1 in 12 babies are born before term (PPPESO, 2005).

Emard, Drouin, Thouez, & Ghardirian (2001) reported a higher level of prostate cancer among the Francophone population of Québec. Genetic susceptibility to breast cancer in French Canadians has been reported by Krajinovic et al. (2001), who associated the increase with the role of carcinogen-metabolizing enzymes and gene- environment interactions. In addition, Godar (1998) identified major influencing factors of risks for familial and sporadic ovarian cancer among French Canadians, including a family history of breast or ovarian cancer, beginning use of oral contraceptives at a late age, and last childbirth at a late age.

In addition, the suicide rate in Québec is higher than in any other province. On an average, nearly every day four Québecers take their lives, in particularly men between 30 and 49 years of age. Suicide occurs more often in rural areas than in urban areas. From an international perspective, few countries surpass the Québec mortality rate by suicide (INSPQ, 2006). Eighty percent of all sui- cides reported in 1991 involved men. The male-to-female ratio for suicide risk was 3.8:1 in both males and females; the greatest risk increase between 1960 and 1991 occurred in the 15- to 19-year age group, with a 4.5-fold increase for males and a 3-fold increase for females (Canadian Task Force on Preventive Care, 2003). The high rate of suicide and suicidal ideation, particularly among adolescent and young adult males, is one aspect of mental health that health-care practitioners have yet to address adequately.

Today’s French Canadian population suffers from the same endemic conditions and sensitivities to environmen- tal diseases as the Canadian population as a whole. The harsh topography and low winter temperatures are respon- sible for 19 percent of the population’s osteoarthritic disor- ders, and the prevalence of multiple sclerosis is one of the highest in the world (Société Canadienne de la Sclérose en Plaques, 2005). Allergies related to urban air pollution, smog, and poor air circulation in public buildings affect

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13 percent of the population (Pampalon et al., 1990). Distinctive features of idiopathic inflammatory myopathies in French Canadians were also reported by Uthman, Vazquez-Abad, and Sénécal (1996). Pausova et al. (2000) found an association in pedigrees of French Canadian ori- gin. The tumor necrosis factor-! (TNF-!) gene locus con- tributes to obesity and obesity-related hypertension, and gender modifies the effect of the regional distribution of body fat.

A number of hereditary and genetic diseases more common among Québécois can be traced to early colonists. The regions of Charlevoix et du Saguenay Lac St-Jean are among the most affected in Québec and in Canada, with genetic and hereditary diseases such as spas- tic ataxia Charlevoix-Saguenay type, cystic fibrosis, tyrosi- naemia, cytochrome lipase deficiency (COX), to name but a few. Familial chylomicronemia resulting from the lipoprotein lipase (LPL) deficiency, hyperlipoproteinemia type I, is an autosomal recessive disorder with a preva- lence of 1 in 1 million individuals (Brunzell, 1989). Through genealogical research, this hereditary disorder has been traced to migrants from the Perche region of France (DeBraekeleer & Dao, 1994). The distribution of LPL deficiency among French Canadians of Québec reflects the highest frequency worldwide (Ma et al., 1991). Within the French Canadian population of Québec, its prevalence is especially high in the eastern part of the province (Gagné, Brun, Moorjani, & Lupien, 1989). Two separate mutations in the LPL gene introduced by French immigrants in the 17th century have been identified. Although the birthplaces of the obligate carriers were scattered throughout the province, three geographic clus- ters were identified: the Trois-Rivières-Mauricie region, the Saguenay-Lac-St.-Jean-Charlevoix region, and Beauce region (Dionne, Gagné, Julien, Murthy, et al., 1993). The carrier rate of LPL deficiency is estimated to be 1 in 139 individuals in the province as a whole, but 1 in 85 indi- viduals in eastern Québec, with a peak of 1 in 47 individ- uals in Saguenay-Lac-St.-Jean (Dionne et al., 1993). With the discovery of a mutation in the human LPL gene, sci- entists have identified the most common cause of familial chylomicronemia in the French Canadian population (Ma et al., 1991). Furthermore, a single mutation of the fumarylacetoacetate hydrolase gene can lead to heredi- tary tyrosinemia type I (Grompe, St-Louis, Demers, Al- Dhalimy, Leclerc, & Tanguay, 1994).

Familial hypercholesterolemia (FH), leading to coronary thrombosis, supports the French origin of the French Canadian deletion. One century after settlement in North America, the founders originating from Perche had a large number of descendants. Among the 50 or more fertile cou- ples, 14 came from Perche (Charbonneau, Desjardins, Guillemette, Landry, Légaré, & Nault, 1987). However, it is suggested that the high frequency of this mutation among French Canadian clients with hypercholesterolemia is due to a founder effect rather than to a high frequency within the population (Fumeron et al., 1992). FH is one of the most common autosomal codominant diseases. The frequency of FH among French Canadians in northern Québec is higher than in most other populations (1 in 154 versus 1 in 500) owing to the high prevalence of a few recurrent mutations in the LDL receptor gene (Levy et al., 1997).

A provincewide, long-term longitudinal study on all newborns identified a rare genetic disease among French Canadians. Profiles of phenylketonuria (PKU) in Québec populations show evidence of stratification and novel mutations (Rozen, Mascisch, Lambert, Lamframboise, & Scriver, 1994). To date, five mutations account for almost 90 percent of PKU diagnoses among French Canadians from eastern Québec (National PKU Index, 1992). Time and space clusters of the PKU mutation can be traced to France (Lyonnet et al., 1992). Studies by Vohl et al. (2000) and St.-Pierre et al. (2001) on genetic mutations in the population of French Canadian origin are currently being conducted.

In addition, an increased incidence of cystic fibrosis occurs among French-speaking Canadians (Rozen et al., 1992). Muscular dystrophy, with a worldwide frequency of 1 in 25,000 individuals, occurs in 1 in 154 French Canadians of the Saguenay region (DeBraekeleer, 1991). Health-care providers working with this specialized popu- lation of Québecers must screen for these genetic diseases and provide genetic counseling for high-risk clients who express an interest.

VARIATIONS IN DRUG METABOLISM

Research supporting differences in drug metabolism related to race and ethnicity is beginning to identify genetic mutations among descendants of French Canadian settlers from specific areas of France. Although these find- ings may produce data related to drug metabolism, thus far, little has been published. Risk factors affecting French- speaking Canadians tend to be related to type of work, geographic region, communication, education, and age groups.

High-Risk Behaviors Special attention must be given to older Francophones living outside Québec. Abuse of alcohol, tobacco, and psychotropic drugs are major health problems among Francophone Québecers. In Québec, the number who use tobacco has been decreasing, down to 24 percent instead of 35 percent in 1995 (INSPQ, 2006). A study with high school students reported that tobacco smoking decreased to 19 percent; yet, marijuana smoking increased to 39 percent (Gouvernement du Québec, 2006).

The French population has a long-standing apprecia- tion of alcohol, with wine being their beverage of choice, dating to the early 17th century. Both French and French Canadians continue to view drinking favorably. Disapproval of women drinking heavily is evident. Francophone youth start drinking at younger ages than do Anglophone youths (DeWit & Beneteau, 1998). Alcohol consumption has increased since the early 1990s, particularly among men, and drinking and driving among young men has reached a summit despite the legal implications (INSPQ, 2006). However, drug use is not associated with personal- ity factors or depression when measured by Rotter’s Internal-External Locus of Control Scale Depression Inventory. Tobacco and alcohol use is highest among French-speaking males and is associated with masculine

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sex roles, higher self-esteem, and an external locus of con- trol. Nonmedical drug use, primarily marijuana and hashish, most frequently involved men and was related to an internal locus of control.

HEALTH-CARE PRACTICES

The aging Francophone population across the country has increased, passing from 11.2 percent in 1996 to 12.5 per- cent in 2001 (Statistics Canada, 2006). Beliefs about meth- ods for improving one’s health are seen as influential fac- tors in health-seeking behaviors. The rate of individuals who do not exercise on a regular basis has increased from 35 percent in 1995 to 26 percent in 2003 despite numer- ous educational campaign in favor of exercise (INSPQ, 2006). In 2004, half of the population of children aged 4 to 18 years and nearly 60 percent of the adults aged 19 years and older ate at least five portions of fruits or vegeta- bles daily (INSPQ, 2006). According to Wharry (1997), Québécois probably give tobacco its strongest bulwark in the country; in health communication, one has to tailor the message. A communication method that works among the English-speaking populations does not mean it will auto- matically work among the French. Yet very little has been developed specifically for the French community.

Feather and Green’s (1993) study on health behaviors found that good health practices were more prevalent among Canadian men under the age of 25 years and over the age of 65 than among men in their middle adult years. In contrast to men, the prevalence of good health practices among Canadian women increases until the age of 65 and then decreases. In addition, these practices were positively correlated with levels of education in both sexes, adequate income for women, and managerial or professional occupations for men.

Responses of French-speaking Canadians throughout Canada correlated more with the province in which they lived than with the selected cultural group. This correla- tion could be due to the method of data collection, which is less accurate with a small response rate. The higher pro- portion of respondents from Québec and New Brunswick may have skewed the statistical outcome. Overall, age was a factor associated with beliefs about one’s ability to achieve an improved health status. Results imply that older people focus more on personal well-being than on health practices.

Nutrition MEANING OF FOOD

For French Canadians, food is associated with hospitality and warmth. Food is part of all meetings and celebrations. The strong influence of nutritional status on health prompted the inclusion of questions on nutritional behaviors and diet changes in the 1990 health promotion survey to identify data among high-risk groups. In this survey, body mass index was used to calculate the ratio of weight relative to height and determine the potential for health risk. Age, gender, and education, rather than cul- ture, were identified as positive influences on the practice of reading labels for nutritional value of food. Regardless

of the reason, this practice demonstrates the importance individuals attribute to food in relation to health.

COMMON FOODS AND FOOD RITUALS

Common vegetables enjoyed by French Canadians include potatoes, turnips, carrots, asparagus, cabbage, let- tuce, cucumbers, and tomatoes. Apart from citrus fruits, all other edible fruits, particularly apples and berries grown in gardens or in the wild, are prepared and pre- served by French Canadians for the winter. Meat choices are mainly beef, pork, and poultry. Lately, however, lamb has gained popularity. Christmas and seasonal festivities call for the tourtières and ragoût de boulettes to go with the turkey. Ham is usually the Easter main dish, along with maple sugar pastery of all kinds. Until the late 1960s, fish was often perceived as a Friday food. However, for the younger generation, this belief is no longer practiced. Increased immigration and fast-food availability have influenced food choices and customs to the point of transforming French Canadians’ customs and food prac- tices, with a new phenomenon as poutine, fries topped with cheese curds and covered with gravy.

In Acadia, owing to the proximity of the coastal areas, fresh fish and seafood are part of the diet. Common foods include fricot (stew made with a special spice called sum- mer savory). Traditional foods such as poutine réfrapées (balls of dough made from grated potatoes) and réfrapure (grated potato) are not part of the regular diet, but are still enjoyed during special events. The equivalent to the French Canadian pea soup is named fayots soup in Acadia.

DIETARY PRACTICES FOR HEALTH PROMOTION

Most men and women report reading nutritional labels on food packages. This behavior is a good predictor of diet changes during the preceding year. As a whole, more Québecers than other Canadians report eating breakfast. Only 10 percent of the French-speaking Canadians report skipping breakfast, which is significantly lower than among respondents from the rest of Canada (Craig, 1993). A similar study conducted with children in grades 1 to 3 yielded similar results in the northern part of Ontario (McIntyre & Doyle, 1992).

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

In an industrialized country like Canada, six times as many women as men are underweight, yet half as many women as men rated themselves as underweight (Craig, 1993). However, 33 to 50 percent of all Canadians are try- ing to lose weight. The 1990 health promotion study demonstrates that being overweight is inversely propor- tional to education and income for both men and women. For men, there was no association between being underweight and education and income, whereas for women, with the exception of the very poor, a positive correlation existed between being underweight and increased income (Craig, 1993). Nevertheless, recent stud- ies tend to show that French Canadians do not escape the overall trend toward being overweight.

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Pregnancy and Childbearing Practices

V I G N E T T E 1 1 . 2

Mrs. Gagné, age 38 years, is of French Canadian heritage. She arrives at the physician’s office with complaints of vaginal bleeding and acute unilateral (right side) pain radiating to her shoulder. She has missed her last two last menses and believes she is pregnant for the third time. Her two previous pregnancies ended with spontaneous abortions. The physi- cian diagnosed a right ectopic pregnancy, for which she undergoes a salpingectomy. During surgery, she lost a signifi- cant amount of blood for which the surgeon wanted to do a blood transfusion. Mrs. Gagné refuses the blood transfusion based on her religious beliefs. The surgeon has ordered treat- ment with methotrexate, requiring daily follow-up. Because, Mrs. Gagné lives in a rural area, daily follow-up is not an option.

1. Identify culturally congruent counseling strategies to help Mrs. Gagné and her husband work through the grieving process on losing a third baby.

2. Identify possible reasons for the spontaneous abortions. 3. What services would you recommend to assure that

Mrs. Gagné can get daily follow-up care? 4. With a high value placed on family and children in

French Canadian families, do you think Mr. and Mrs. Gagné would benefit from long-term counseling?

5. How would you foresee their long-term marital rela- tionship if they remain childless?

FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

Until the middle of the 20th century, French Canadians maintained high fertility rates, which is uncommon for a population living in an industrialized country. This phe- nomenon, called the revenge of the cradles, has never been explained. Classic interpretations based on the economy, religion, or education do not hold up to scientific exami- nation (Fournier, 1989). The historical co-occurrence of the power of the Church and high birth rates do not prove a causal link. Instead, the “overfertility” of French Canadians appears to be a response to socialization that is distinguished by the prevalence of extended family ties (Fournier, 1989). However, Ansen (2000) found that as education increases, fertility rate within the Francophone group decreases, whereas the contrary is observed within the English group, meaning that as education level increases, so does the fertility rate. For many years, French Canadian fertility practices have been closely tied to the Catholic religion. Before the 1960s, the only acceptable birth control method was abstinence, resulting in a high fecundity rate. From 1851 until the 1960s, Québec fami- lies had a mean of 6.84 children per family. The number of children per family started to decline from 3.1 in 1965 to 1.5 in 1990 (Henripin & Martin, 1991), with a current record of 1.2 children per family (Statistics Canada, 2001).

Effective contraception and family planning methods such as the pill, intrauterine devices, and tubal ligation have become available to all women. The pill remains the pri- mary reversible method for birth control (Health and Welfare Canada, 1989). Nowadays contraceptive methods are strongly encouraged. Adolescents by the age of 14 years are legally allowed to obtain a contraception prescription from a physician without a parent’s approval. In addition, the “morning-after pill” is available to adolescents in drug stores without a prescription. On the basis of relative fre- quency, tubal ligation and vasectomy follow the pill as non- reversible methods of fertility control. Diaphragms, foams, and creams are not commonly used for birth control, par- tially because perceptions imply that women are not sup- posed to, or do not like to, touch their genitals. The beliefs that condoms reduce the level of sexual feeling during inter- course or that contraception is not a man’s responsibility are inversely proportional to the age of men. Many French- speaking Canadians believe that abortion is morally wrong, but it is legally available. The number of annual abortions by language or cultural subdivision is unavailable. Finally, new reproductive technologies are available but are used by a small number of French-speaking Canadians, more because of scarcity than cultural denial or restriction.

Although pregnancy is considered a normal life event, fear of labor and delivery prevails. This learned fear is transmitted to women from childhood and is often rein- forced by the health-care system. Midwives have officially been accepted by the government, but the use of mid- wives and maternity centers (maisons des naissances) is far from being the custom. More women are talking about the desire to deliver at home, but the actual use of a mid- wife throughout labor and delivery at home is quite low. Obstetricians still provide 84 percent of women’s health care, family physicians 11 percent; only 4 percent of women’s health care is provided by midwives (PPPESO, 2005).

From another perspective, in Canada, age of childbear- ing has changed with the times. In 1991, women over 30 years of age gave birth to 34 percent of newborns, whereas 10 years later, the rate increased to 41.9 percent, and in Ontario in 2003, the proportion was as high as 55 percent (PPPESO, 2005). Analgesic use and/or local anesthesia such as an epidural for delivery remain high and the rate of cesearian sections has increased to 1 in 4 newborns, for a proportion of 25 percent of total births and 30.3 percent of those in university facilities (PPPESO, 2005). The data do not differ much from those in Québec for cesearian sections over the last 10 years.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

From a clinical perspective, prenatal medical visits are recommended once a month until the end of the seventh month, twice during the eighth month, and weekly during the last month. Since the mid-1970s, prenatal classes are well attended by both the mother and the father-to-be. These classes are generally free of charge and focus on information regarding health and hygiene during preg- nancy and on preparation and exercises for labor and delivery.

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Alcohol and tobacco use is discouraged for the duration of pregnancy and the breastfeeding period. Intercourse restrictions are not commonly applied during pregnancy unless required for medical reasons. Since the 1970s, fathers have been encouraged to be present in the delivery room. They are invited to assume an active role by assist- ing the mother and the physician, receiving the baby, and cutting the cord. Most Canadian women still deliver in a dorsal position, even though lying on the back has been shown to be antiphysiological. However, with the advent of birthing rooms, more women are delivering their babies in half-sitting or side-lying positions.

Few French Canadians practice natural childbirth. Although the number of women who are cared for by a widwife is still low, the number is increasing because mid- wifes have access to hospitals and, in many places, they are part of the health-care team. During hospitalization, room- ing-in of the mother and child is a relatively new practice. Many hospitals have made cohabitation a generalized practice, unless the child or mother requires special treat- ments. Breastfeeding has regained importance after years of bottlefeeding. The mother’s general hesitation to breast- feed relates to not having sufficient milk, experiencing sore nipples, losing breast firmness, and muscle wasting after the breastfeeding period. In practice, once the mother has made a decision regarding breastfeeding, the father’s sup- port and encouragement are key for a successful outcome.

Differences exist between English-speaking and French- speaking women with respect to breast-feeding. During the Health Survey of 1990, 44 percent of Canadian mothers reported breastfeeding their last child. Of these, 48 percent were Anglophones and 26 percent were Francophones. Craig (1993) found significant regional differences regarding breastfeeding practices. Approximately one-quarter of women from the Maritimes, one-third from Québec, and one-half from Ontario and the western provinces breastfeed their babies. Maternity and paternity leaves are available with pay for a period ranging from 6 to 20 weeks, which may extend up to 12 months without pay. In practice, however, fathers often take only a few days to a few weeks of leave to help the mother care for the new baby and other children.

Some taboo practices related to pregnancy have per- sisted throughout the years. Although the movement used in washing a floor resembles that of an exercise aimed at strengthening the perineal muscles, this activity in the past was associated with the onset of labor and early or preterm deliveries. Another belief, which is shared by some nurses, is that the full moon plays a role in the onset of labor once the full-term period has been reached. This belief applies to pregnant women who are 2 weeks preterm or postterm. A much less common belief is that pregnant women who experience hyperglycemia give birth to boys and that lack of salt signifies the birth of girls.

Death Rituals

V I G N E T T E 1 1 . 3

Mr. Bouchard, a widowed Catholic age 70 years, has been on oxygen with chronic obstructive pulmonary disease

(COPD) for the last 10 years. A heavy smoker and worker in the mines of Northern Ontario, he has been a socially active individual for many years. He is now confined to his home. His children come to visit as much as they can. His wife cared after him for years, but she now suffers with severe arthritis and has difficulty caring for herself. Their quality of life has greatly diminished.

This morning Mr. Bouchard is giving a press conference to announce his desire to end his life by suicide. He does not want to live another day in this condition. There is no cure for COPD, and living between bed, kitchen, living room, and washroom brings no satisfaction. Even the small- est daily functional activity demands more energy than he has to spare, leaving him continuously overtired. He wishes by this press conference to urge the government to advance the debate on death with dignity, assisted suicide, and euthanasia.

1. How would you assist Mr. Bouchard to identify a source of hope in his life?

2. Discuss the role of spirituality in this family. 3. Discuss Mr. Bouchard’s viewpoint on death, end of life,

and end-of-life care within the French Canadian culture. 4. Explore culturally appropriate rituals related to death

and dying for Mr. and Mrs. Bouchard. 5. To which high-risk health situations are French

Canadians most often exposed, and how have they affected this family?

DEATH RITUALS AND EXPECTATIONS

French Canadians do not differ from Canadians of other European origins on issues related to death and death rit- uals. Expectations are closely related to Christian religious practices, in particular, those of the Roman Catholic Church, of which most French Canadians in or before the first half of the 20th century were members. Whether one is an active church-goer or not, religious funerals are the norm. Values and beliefs related to life after death, the soul, and God vary dramatically across the age span among French Canadians and, even more so, among Francophones. Thus, it is essential to assess each family individually when it comes to death rituals and expecta- tions. For many years, cremation was seen by the Catholic Church as a ritual left for specific circumstances. Currently, the Catholic Church advocates cremation as an acceptable practice.

RESPONSES TO DEATH AND GRIEF

During the second half of the 20th century, long grief and mourning rituals imposed by social norms were adapted to modern lifestyles. Traditional responses to death and mourning periods were influenced by the place women hold in the workforce, the age of the deceased, and other circumstances. Currently, the expression of grief among French Canadians is similar to the stages described by Kübler-Ross (1977). Supports for those who have lost a family member include openly acknowledging the fam- ily’s right to express grief, being physically present, mak- ing referrals to appropriate religious leaders, and encour- aging interpersonal relationships.

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Spirituality DOMINANT RELIGION AND USE OF PRAYER

Whereas most French Canadians identify themselves as Roman Catholic and are baptized at birth, they may or may not remain active church members. A growing number of births are registered through civil channels rather than through the traditional Catholic registry and baptism. Despite the sharp decline in actively practicing Catholics, most people from all socioeconomic levels turn to their church for important life events such as marriage and funerals. In some cases, even in a civil ceremony involving previously divorced spouses, the couple may ask a priest to say mass and bless the union. The Catholic Church does not allow a religious remarriage and exchange of solemn vows for divorcees, unless the previous or first marriage has been annulled and judged void by Church’s sanction. The abolition of the religious school boards all over Québec will most likely increase nonreligious practices.

Religious holidays honored as civic holidays are New Year’s Day, Good Friday, Easter Sunday, and Easter Monday, July 1st (Confederation Day), and Christmas. In the province of Québec, St. John the Baptist Day (June 24) is a civic holiday, and in most Acadian institutions, the national Acadian holiday Feast of the Assumption is cele- brated on August 15. All Saints Day (November 1) and the Epiphany (January 6) were dropped as civic holidays in the 1970s.

Older adults are more inclined to use prayers for find- ing strength and adapting to difficult physical, psycholog- ical, and social health problems. In times of illness and tragedy, French-speaking Canadians use prayer to help recovery. Many of the younger generation are not strongly influenced by religious values, beliefs, and faith practices. The younger generations turn toward spitiruality rather than religion. Many French Acadians still request the sacrament of the sick and a visit from the priest.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

Traditional French Canadians, who view themselves as the core (gyron) of the family and who believe that the well-being of their children is more precious than their own life, have faded proportionally with the prevalence of divorce. For hard-working men and women of previous generations, leisure activity was a trivial expression. The little time that could be spared on holidays was dedicated to visiting distant relatives.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Although modern health promotion theories suggest that spiritual needs are a critical factor in comprehensive client care, this aspect of family needs has received little attention among French-speaking Canadians. Many health-care providers still equate spirituality with reli- gion, which is often reflected in the patient’s history at the time of admission. Renewed interest in spirituality across Canada is being recognized as a source of physical

and psychological health (Simard, 2006). Koenig (2000) discussed spirituality, religion, and medicine with appli- cations to clinical social services.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

In the 19th and early 20th centuries, sick people did not readily enter hospitals because mortality rates were high and care was often inhumane. Before the Confederation, resources and preventive health care rested in the hands of religious sisterhoods, United Empire Loyalists, church groups, and local authorities (Allemag, 1995). As pioneers in health services, the Gray Nuns visited the sick and opened hospitals such as Bytown in Ontario in 1845 and St. Boniface in Manitoba in 1847. In 1860, they extended their services to an Indian settlement 400 miles north of Saskatoon, and in 1867, to Fort Providence on Great Slave Lake.

St. Amant and Vuong (1994) surveyed 57 older former psychiatric clients from 14 organizations in New Brunswick on the relationship between cultural affilia- tion, gender, and satisfaction with health-care services. The findings revealed that women’s mental health was more fragile than men’s. A positive correlation and higher satisfaction with services was found among those with longer institutionalization. The authors concluded that Francophones in New Brunswick rely more on an infor- mal family support network, whereas Anglophones rely more on professional services.

Results of a 1990 Canadian health survey show that res- idents of British Colombia and Ontario reported the most favorable assessments of their health, with almost 3 out of 10 reporting excellent health. Lower levels of health were reported in eastern Canada, where 1 in 5 Nova Scotians reported excellent health. Canadians from New Brunswick, followed by those from Québec, were more likely to report fair or poor health, with only 17 percent and 16 percent, respectively, reporting excellent health (Stephens & Fowler Graham, 1993). Good health has been consistantly related to education and income, occupation, or both. However, lifestyle showed an inconsistent relationship with income. Among younger adults and older men, social class had lit- tle effect on income, whereas among women, the effect of income dominated over social class. Rather than attempt- ing to identify risk factors for specific diseases, it may be more meaningful to identify those factors that affect gen- eral susceptibility to risk factors.

RESPONSIBILITY FOR HEALTH CARE

Canada’s government-administered health system ensures free, universal health coverage at any point of entry into the system. However, many people in the upper socioeconomic classes call on their family physi- cians instead of the local community service centers. Among the lower socioeconomic classes of Québec and the Maritimes, many do not seek health care until their health becomes a crisis situation.

Evans and Stoddart’s (1994) White Paper, “Producing health, consuming health care,” proposed that the

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determinants of health status are lifestyle, environment, human biology, and health-care organizations. According to this paper, lifestyle and, to a lesser extent, living envi- ronments are chosen by the individual. Corin (1994) offered a matrix of stressors for identifying high-risk behaviors within a perspective that avoids victim blam- ing. Lifestyle behaviors are readily perceived as being under the control of the individual. The broad set of rela- tionships encompassed under the label of “stress” and predictive factors against stress have demonstrated the importance of social relationships for preventing disease and mortality (Sapolsky, 1990).

In 1980, New Brunswick set up a novel program at the Extra-Mural Hospital to provide acute and chronic home- care services to a largely rural province with a small pop- ulation density and limited financial resources. Because the willingness of clients and family members to partici- pate actively in a plan of care is critical to the success of community-based services, the Extra-Mural Hospital pro- gram strongly encouraged self-care with family involve- ment. Unlike other community initiatives in Canada, such as the Ontario home-care program, the Extra-Mural Hospital does not restrict services within specific bound- aries, and offers a comprehensive, provincewide delivery system via a single-agency approach (Cormier-Daigle, Baker, Arseneault, & MacDonald, 1995).

Hagan, O’Neill, and Dallaire (1995) raised the associa- tion between health promotion and community health nursing with conceptual and practical issues. In Québec, the infrastructure for public health is different from that in other provinces. The community service centers, or CLSCs, emerged from the Castonguay-Nepveu reform of health and welfare services in the early 1970s. The mis- sion of the Fédération des CLSCs du Québec is to provide health and social services for primary and secondary pre- vention and rehabilitation. In a survey of health educa- tion roles and activities of 631 nurses, Hagan (1991) found that 89 percent of nurses had a humanistic vision of health education. This vision was defined as “teaching and establishing a helping relationship aimed at facilitat- ing individuals’ choices of strategies for improving or maintaining their global health” (p. 278).

French-speaking Canadians have joined the current trend toward over-the-counter drug use. However, from the health survey of 1990, their use of analgesics and tran- quilizers shows strong provincial differences (Adlaf, 1993). As compared with the national average for the use of nar- cotic analgesics (11 percent), Québec residents’ use is only 5 percent. Residents of Québec (67 percent) are less likely to use aspirin than the average Canadian (76 percent). However, the use of tranquilizers among Québecers is slightly higher than the Canadian average (8 percent ver- sus 5 percent). Drug use followed a pattern similar to that found in the healthy lifestyle practice. Despite the move toward healthy lifestyles, older French Canadian adults have not changed dramatically in comparison with younger age groups. In addition, in the 1990 health survey, the leisure time physical activity (LTPA) index reported a positive relation between adoption of healthy lifestyles and socioeconomic status, although not a smooth, linear one. In particular, the daily LTPA index decreased with increasing education.

FOLK AND TRADITIONAL PRACTICES

Saillant (1992) analyzed the importance, characteristics, and mechanics of women’s knowledge of folk medicine in Québec Francophone families at the beginning of the 20th century. This anthropological study focused on domestic activities. The ethnographic data were drawn from 4000 medical receipts dealing with the knowledge of women in folk-healing practices in Québec and abroad to enhance the understanding of the roles played by women in rural society folk-healing tradition. The numerous con- nections between the culinary and the therapeutic realms of activities bring one to rethink the link between nutri- tion and health practiced in the early years of the colony.

BARRIERS TO HEALTH CARE

Language differences may have an important impact on the patient, providers, and administrative interactions and may become a barrier to continuity of care. However, language may also be a proxy for issues that can affect access to care. Language is closely related to culture, and language differ- ences may signal variations in values about behaviors or use of health care. Current views toward multiculturalism include removing barriers so that all citizens have equal access and opportunities and cultural diversity needs are to be considered in decision-making and resource allocation. For many older French Canadian adults raised outside the province of Québec, French was the language used in daily living within their cultural environment, except for educa- tional services. In their childhood, they attended English- speaking schools because the public school system was all that was available outside Québec. This situation and other issues present challenges in organizing transcultural health- care delivery. When the spoken language is French, and reading skills (or what is left of them) are often English, ade- quate communication is limited and complex. Thus, the health-care team may need to supplement written messages and instructions with verbal instructions to ensure under- standing. Recruitment teams visiting France in early 2000 did not provide expected results. Once in Québec, the Franchophone nurses did not have similar training or the cultural language background (Old French used by the peo- ple) to communicate and deliver care to older people in nursing homes where they were expected to work.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

Choinière and Melzack (1987), using the McGill Pain Questionnaire and a visual-analog intensity scale, assessed acute and chronic pain differences between 68 French-speaking and English-speaking people with hemo- philia. The results showed a similarity in the sensory, affective, and evaluative properties between the two types of pain. French-speaking subjects rated their acute pain as more intense than chronic pain and more affectively laden than the English-speaking group. From a different perspective, Rukholm, Bailey, and Coutu-Wakulczyk (1991), studying French and English cultural differences in family needs and anxiety in an intensive care unit (ICU), found that English-speaking subjects rated their distress at seeing a relative in pain more highly than

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French-speaking subjects. Though puzzling, this finding deserves attention and additional research to better understand and plan health-care interventions and to assist family members involved with ICU services.

Adam (1989), as part of a broader package of health promotion, developed, implemented, and evaluated a 15- hour community program for French-speaking women living in minority situations, many of whom were socially and economically disadvantaged. The program was designed to increase the participants’ ability to take charge of their lives and better manage their physical and mental health. After presenting the program to 29 groups, evaluations showed that women generally reported satis- faction as the program progressed. Most subjects were sat- isfied with their broader understanding of stress and relaxation techniques for controlling daily stress.

The deinstitutionalized physically and mentally dis- abled are protected from discrimination and abuse by fed- eral and provincial laws in Canada. Physically disabled people, regardless of their ethnicity, benefit from equal- opportunity regulations. Throughout Canada, official general acceptance and increased awareness have led to the physical adaptation of the environment to facilitate access for the disabled. However, the homeless mentally disabled raise different concerns in regard to the cost of maintaining this segment of the population in the com- munity and the lack of adequate organized services.

Saillant (1990) studied the sick role among a French Canadian sample from a clinical anthropological perspec- tive exploring the relationship between discourse, knowl- edge, and the experience of cancer within the life story of a patient suffering from cancer. The underlying theoreti- cal model drew on a cultural hermeneutic approach. The client’s discourse was analyzed for cognitive and symbolic models used to understand the experience of cancer. The results of this study highlighted the gap between the client’s actual medical knowledge and the health profes- sional’s perception of the client’s experiences and dis- course about cancer (Saillant, 1990).

BLOOD TRANSFUSIONS AND ORGAN DONATION

As a cultural group, French Canadians have no official proscriptions against receiving blood or blood products. Those who are members of a religious group that pro- hibits the acceptance of a blood transfusion are rare in Canada. Organ donation and transplantation are rela- tively new treatments in Canada. The decision to donate or receive an organ is an individual decision without cul- tural influence for French Canadians.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

French Canadians have discarded the idea that one goes to the hospital to die. With a publicly administered health-care system in place since the 1960s, the popula- tion has benefited from increased accessibility to health

care. However, financing this “welfare state” (état provi- dence) has imposed a tremendous burden on taxpayers. Although the overall impact on health-care services is minimal, alternative therapies are gaining popularity, which may reflect disillusionment with the biomedical model in Québec.

Men have been members of the nursing profession since the early 1970s. Although male nurses receive the same training as female nurses, they still account for less than 10 percent of professional nurses in Canada. Whereas bedside nursing is gaining in popularity for men, most still hold administrative or teaching positions.

STATUS OF HEALTH-CARE PROVIDERS

In Canada as a whole, health-care practitioners cover a broad realm of specialties and disciplines, each working within an interdisciplinary and intersectorial approach to well-being. However, the system is not ideal, and tension occurs within and among disciplines. Health-care providers hold a favorable status in the eyes of French Canadians, especially among older people. The prevalence study in three home-care community agencies in southern Ontario has demonstrated the implications for cultural sensitivity training (Majumdar, Browne, & Roberts, 1995). To enhance staff knowledge and skills, in spite of their general assimilation, remnants of French cultural heritage must be recognized as both contributing to behavior and influencing the course of clinical intervention.

At the beginning of the 20th century, parents and grandparents were pragmatic and practical people, shar- ing views about God’s power over everyday life. For exam- ple, a mother would pray to have at least a priest and a nun among her children, and a physician or a nurse was next in her wish to God. Today, folk and traditional prac- titioners are almost nonexistent. The current universal health insurance system makes the folk practitioners less appealing. Professionals throughout Canada are vigilant in trying to avoid exploitation by traditional and folk healers, who are viewed as practicing outside the law.

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Vohl, M. C., Lepage, P., Gaudet, D., Brewe, C. G., Betard, C., Perron, P., Houde, G., Cellier, C., Faith, J. M., Despres, J. P., Morgan, K., & Hudson, T. J. (2000). Molecular scanning of the human PPAR-_ gene: Association of the L162V mutation with hyperapobetalipoproteine- mia. Journal of Lipid Research, 41(6), 945–952.

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

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People of German Heritage

Chapter 12

JESSICA A. STECKLER

Overview, Inhabited Localities, and Topography OVERVIEW

Germans are reserved, formal people who appreciate a sense of order in their lives. Their love of music and cele- brations has permanently influenced many of the world’s cultures. The Christmas tree (Weihnachtsbaum) with its brightly decorated ornaments, a universal symbol of the holiday season, is a German creation. Gingerbread houses (Lebkuchen), Christmas carols (Weihnachtslieder) and cards, the “Easter hare,” (Osterhase), hot cross buns, valen- tines (Freundschaftskarten), Groundhog Day, chain letters (Briefe zum Himmel), the tooth fairy, and Kaffeeklatsch or “gossip sessions” have their origins in German culture.

There are 60 million Germans in the United States and 2.7 million in Canada (Wikipedia, 2006a). Ethnic groups of European origin are usually categorized as “white” on applications, in surveys, and in research studies, so there is little culturally specific information available about them. This is unfortunate, because differences in world- view, cultural beliefs, and health-care practices among white ethnic groups hold important implications for health-care providers.

The Federal Republic of Germany (Bundesrepublik Deutschland), comprising 16 states, boasts beautiful land- scapes, high and low mountain ranges, sandy lowlands, rolling hills, lakelands, and ocean borders. Situated in the heart of Europe, Germany is a link between the East and the West and between Scandinavia and the Mediterranean. Germany has the largest economy in Europe, has the third largest economy in the world, and is the leading per-capita export nation in the world (World

Factbook, 2006). With a population of over 82 million, it is one of the most densely populated countries in Europe. Germany is a member of the United Nations and NATO and is a founding member of the European Union. Most of Germany is located in the temperate zone, with tem- peratures ranging from 27°F in the mountains to 68°F in the valleys of the south. Temperatures are comparable with the climate in the northwest portion of the United States. The Upper Rhine has a mild climate; Upper Bavaria has warm Alpine winds from the south; and the Harz Mountains have cold winds, cool summers, and heavy winter snows.

HERITAGE AND RESIDENCE

In the 18th century, the New World colonies from New England to the deep South grew and flourished. Even though the colonial settlers shared an Old World heritage, they were a diverse people. German settlers, along with other immigrants from Britain, France, Scotland, and Ireland, shared a love of family and land; a love that would eventually bond them to one another to form a nation of Americans. The earliest German immigrants to the United States settled in the colonies along the east- ern seaboard, including William Penn’s colony in Pennsylvania. Religious tolerance and equitable land dis- tribution contributed to the success of these Pennsylvania settlements. Mennonites, Dunkers, Amish, and Moravians from Germany made up the new Pennsylvania communi- ties. The area in which they settled, known as Pennsylvania Dutch Country, was actually mislabeled by English neigh- bors who thought the word deutsch, meaning “German,” stood for “Dutch.” One hundred thousand strong, these Pennsylvania Germans were the main carriers of German culture to the mid-Atlantic area (Domer, 1994).

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Other religious social idealists from Germany soon flowed into the colonies. Among them were the Harmonists, who broke from the German Lutheran Church under the leadership of George Rapp (Boorstin, 1987). The Harmonists built Harmony, Pennsylvania; Harmony, Indiana; and Economy (Ambridge), Pennsylvania. The Harmonists were followed by other German sects: the Zoars, who settled in Ohio, and the Inspirationists, who originally settled in western New York and later moved west to Iowa by divine command.

The second wave of German immigrants arrived in the United States between 1840 and 1860. They were fleeing political persecution, starvation, and poverty in their homeland and settled on the western frontier (Weaver, 1979). This group of influential Germans was less inter- ested in taking root in the United States than in establish- ing a German culture. These new immigrants kept the German language in their schools, published newspapers in German, joined their own singing societies and orches- tras, and married only other Germans.

The 1930s and 1940s saw a third wave of German immigration. Artists, architects, social scientists, physi- cists, and mathematicians came to this country to escape the Nazi Holocaust. These new arrivals were highly edu- cated and at the height of their careers. After witnessing the horrors of the Holocaust, they had no desire to trans- plant Old World institutions or to establish new European-style homelands (Boorstin, 1987). These third- wave immigrants became rapidly acculturated into American life and greatly enriched American culture in the fields of music, psychology, science, and mathemat- ics. Among this prominent group were Albert Einstein and Hannah Arendt, an author and political scientist.

Historians have helped to further our understanding of the diffusion of German immigrants into the American heartland by tracing the existence of the “two-door house.” These German-built houses, which architecturally copied their European counterparts, have two front doors. With their movement across the United States, two-door houses appeared in Pennsylvania, Maryland, West Virginia, the Blue Ridge Mountains, Ohio, Indiana, Illinois, Missouri, Iowa, Kansas, Nebraska, Michigan, and Texas (Domer, 1994).

Germans continue to embrace the United States as their own. The desire to become American has been nur- tured by the presence of American troops in Germany, and many Germans have entered the United States as spouses of military personnel. For others, business ven- tures and the promise of career opportunities brought them to this country. Today, about one-fourth of all American citizens can trace their ancestry to German roots. Germans are the dominant ancestral group in St. Louis, Missouri; Milwaukee, Wisconsin; Chicago, Illinois; Cincinnati, Ohio; Buffalo and New York City in New York; and Baltimore, Maryland.

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Germans have been very much a part of important events shaping U.S. socioeconomic history. They have been par- ticipants, observers, and victims in the Revolutionary

War, the Civil War, the influenza epidemic, the Great Depression, both World Wars, the Vietnam War, the Persian Gulf War, and the current global recession. The reasons for their immigration to the United States vary according to historical antecedents and are, therefore, dis- cussed under Heritage and Residence.

EDUCATIONAL STATUS AND OCCUPATIONS

Germans have a deep respect for education. In Germany, credibility, social status, and level of employment are based on educational achievement. In other words, Germans are very class conscious. Germans take pride in their school system, particularly in their craftsmanship and technology. Unlike in the United States, education is free at all levels, except kindergarten, which is optional, but entrance to university education is difficult and accomplished only by passing the Abitur examination. Literacy rates of Germany (99 percent) and the United States (98 percent) are comparable (CIA, 2007).

According to S. Maubach (personal communication, December 28, 2006), German children can begin kinder- garten at age 3. This is comparable with our preschool. At age 6, they enter grade school, which includes grades 1 to 4. At grade 5, they begin one of three tracks of education: Hauptschule, which is special education and the most basic educational path; Realschule, which is general edu- cation; or Gynasium, which is like U.S. college preparatory courses. German students graduate at grade 10 and can then enter into vocational education, which prepares them for a trade or for working in business, or continue college preparation. Those students wishing to go to the universities must pass the Abitur test, which is both verbal and written.

Germans who immigrated to the United States in the 19th century influenced American preschool and higher- educational systems. The Johns Hopkins University in Baltimore, Maryland, was founded on the model of Humboldt University in Berlin, Germany (McKinnon, 1993). During this same period, many American histori- ans and political scientists attended German universities, returning with their doctoral degrees, and were instru- mental in developing prototypes for American graduate education. Many of the influences of the 19th-century German immigrants on the educational system remain visible today.

By the mid-19th century, Turnvereins were taking root in Midwestern German American communities. These political and gymnastic organizations believed in a sound mind and body and provided opportunities to grow both physically and intellectually (Acton, 1994). In this same era, schools—many of which were parochial schools— were established in which only German was spoken. German Catholics also established parochial schools in this era, but unlike the Lutherans, their ethnic identity was not tied to the church (Coburn, 1992).

German immigrants were viewed as an internal threat in the United States during World War II and faced tur- bulent times. A growing anti-immigrant sentiment lead- ing to calls for immigration restriction intensified the political climate. Some German immigrants’ desire to maintain an identity apart from the American culture was

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expressed through the founding of the National German American Alliance. Many German Americans changed their names, made apologies, and displayed their loyalties in an effort to attenuate suspicions, embarrassments, and persecutions.

Today, German American families continue to value education. Most German Americans have a high school education at minimum. Twenty-four percent have attained post–high school education. However, in the age group 65 and older, 43 percent have less than a high school education (Rowland, 1992); no current informa- tion on educational levels of German Americans could be found. Vocational or university education is being sought more frequently by recent high school graduates attempt- ing to prepare themselves for a highly competitive work environment and by adults who are pursuing second and third careers. By German standards, success means being employed, and education is seen as the way to achieve this success (McKinnon, 1993).

The earliest German immigrants were primarily farm- ers. Tobacco, wheat, rice, cotton, corn, and sugar were among the most widely grown crops. Plantations grew from Virginia to the colonies in the South as a result of these prosperous ventures. Planting and harvesting crops required many workers with strong backs, and because not all Germans could pay for their passage to the New World, many worked as indentured servants. They suf- fered many hardships and worked long hours at the mercy of their owners. Family members were commonly separated from one another; children were very often sold to pay the debt of their parents.

Between the Revolutionary War and the Civil War, many religious sects, including the Shakers, Harmonists, Zoars, and Inspirationists, founded hundreds of inten- tional communities (Boorstin, 1987). Known historically as the Utopians, they farmed the land; spun flax, cotton, and wool into beautiful textiles; and manufactured fine clocks and furniture. Unlike those who immigrated to the United States before the Revolutionary War, the Utopians formed caring and supportive communities instead of liv- ing in isolation from others. They worked happily for the settlement, built simple, strong dwellings, planted boun- tiful gardens, and established strong trade routes to the American West (Boorstin, 1987).

In the post–Civil War era, Germans who came to the United States often “chain-migrated” to the western fron- tier. Families and friends would leave one area to join family, friends, and neighbors in another place. These groups became farmers, miners, millers, construction workers, shopkeepers, blacksmiths, and locksmiths. Many were artists and craftworkers who created pottery, leather goods, soap, candles, and musical instruments (e.g., the dulcimer). These Germans established outstanding brew- eries, beer gardens (biergarten) and pubs (kneipen) every- where they settled. They also brought many trades to the United States: butchering, coppering, tailoring, and cabi- netmaking. Whereas they dominated the trades, German immigrants were found less frequently in professional and management positions (Schied, 1993).

In the early decades of the 20th century, the Nazi Holocaust drove many German immigrants from their home country. Many who came in the 1930s and 1940s

continued their gifted work in the United States. Germans continue to establish their homes in the United States. Newly arriving immigrants are highly educated and voca- tionally well trained. German workers are among the most skilled in the world. Germany and the United States have similar industries in manufacturing, construction, and service.

Communication DOMINANT LANGUAGE AND DIALECTS

German, the official language of the Federal Republic of Germany, is spoken in Germany; Austria; and Liechtenstein; large parts of Switzerland and South Tirol; and small parts of Belgium, France, and Luxembourg. German is the native language of over 100 million peo- ple, and many literary works have been translated into German (Kappler & Grevel, 1993). Within Germany, there are many dialects. Individuals’ home regions can be easily identified through their speech, and citizens from neighboring regions may have difficulty understanding one another because of the differences in regional jargon and accents.

In addition to the German language, German children learn English at grade 5; and at grade 7, learn a third lan- guage of their choice. At grade 9, Advanced English or, perhaps, a fourth language can be chosen (S. Maubach, personal communication, December 28, 2006).

English is the dominant language of German Americans. Germans who originally emigrated from Germany learned American English at work, in school, and through socializa- tion. Their children grew up speaking English in public schools and German at home. Parents encouraged their children to learn English only (Wikipedia, 2006a).

Currently, U.S. school children are learning English, and in some schools, Spanish is taught in the grade school. Russian, French, and Advanced Spanish can be chosen in high school, but the opportunity to learn German may not appear until college.

According to the 2000 census, 1.4 million people over age 5 years speak German in the United States. This does not include the number who speak German dialects like Hutterite German, Texas German, Pennsylvania Dutch, and Pautdietsch (Wikipedia, 2006b).

Today, there is a growing awareness of endangered lan- guages. This is true about the dialects of German Americans. A language becomes endangered when there are so few speakers that it may no longer be used often enough and could be lost forever. For example, Texas German, a dialect found in the Texas hill country, is nearly extinct. This resulted from a change in school law mandating the use of English in all schools during World War I (Wikipedia, 2006b). In German American homes where the German language is expected to be spoken and children are faced with speaking English in the schools, intergenerational conflicts result. Parents do not speak English and the children prefer to speak English.

Americans and Germans have some similar patterns of speech behavior. German is a low-contextual language, with a greater emphasis on verbal than nonverbal

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communication, showing a high degree of social approval to people whose verbal behavior in expressing ideas and feelings is precise, explicit, straightforward, and direct.

Ten percent of more than 47 million German Americans, the largest self-described ethnic population in the United States, can speak German (Wikipedia, 2006b). Individuals in some German American communities mix English and German creatively when expressing humor. In Dubois County, a German American community in Indiana, linguistic competence is measured by a person’s ability to switch between German and English to reflect bicultural roots and traditions (Salmons, 1988).

CULTURAL COMMUNICATION PATTERNS

People of German ancestry enjoy discussing topics of interest after dinner. These conversations, sometimes debates, cover a range of issues from politics, religion, food, and work experiences to life in general. Jokes, funny stories, or anecdotes about family members are inter- spersed within the discussion.

Germans carry on their conversations at three levels. The first, Gespräch, is used for casual conversation; the second, Besprechung, is conversation carried on in a work setting between employees and supervisors about performance; and the third, Diskutieren, is the com- mon form of social discourse used in discussions about various issues (S. Maubach, personal communication, January 11, 2007). Most Americans are often ill prepared to enter the debate on philosophical and political issues that are addressed at this level and are thus placed at a disadvantage. This cultural barrier can prevent Germans from developing deeper relationships with outside groups.

Feelings among Germans and German Americans are considered private and are often difficult to share. Sharing one’s feelings with others often creates a sense of vulner- ability or is looked on as evidence of weakness. The act of expressing fear, concern, happiness, or sorrow allows oth- ers a view of the personal and private self, creating a sense of discomfort and uneasiness. Therefore, philosophical discussions, hopes, and dreams are shared only with fam- ily members and close friends. Emotions are intensely experienced but are not always expressed among family or friends. “Being in control” includes harnessing one’s emotions and not revealing them to others.

Newer-generation German Americans, influenced by the cultural values of the United States, are more overt in sharing their thoughts, ideas, and feelings with others. They have joined in the American belief that direct con- frontation and open dialogue can be productive. In spite of this general pattern of acculturation, pockets of Germans in the United States continue to be reserved when sharing their private affairs, thoughts, and con- cerns, including their health concerns, with strangers. Their reluctance for socializing may make them appear unfriendly; yet, under their stern exterior, they want to be liked.

Good manners are very important to Germans. A dis- play of politeness and courtesy is viewed as a sign of

respect. Social distance, eye contact, touch, and facial expression define boundaries. Failure to adhere to these protocols is considered rude by Germans and may alien- ate people who are unaware of them. When some people think of the handshake in the context of the German cul- ture, they conjure visions of comics imitating this German greeting—the quick stooping of the shoulders and the clicking of the heels (Friday, 1989). The hand- shake, still a structured phenomenon in Germany (with- out the clicking!), has been acculturated into a more casual form by German Americans and is a common method of greeting for both men and women, but the practice is to always shake hands with women first. When families and friends gather, handshaking is practiced along with pats on the arms or back.

Practices associated with personal touch and displays of affection, such as hugging and kissing, vary among German families. In families in which the father plays a dominant role, little touching occurs between the father and the children. This relationship, however, may become more demonstrative as parents and children age. Affection between a mother and her children is more evi- dent. In other German families, there is outward expres- sion of love from both parents, grandparents, and extended family members; hugs and kisses are expected and often demanded as a “reaffirmation of love.”

Whereas close friends are often extended warmth through handshakes, brief embraces, and sometimes kisses, strangers are kept at arm’s length and greeted for- mally. As the author recalls from childhood, strangers, particularly those who were not German, were looked on with suspicion, even though some of these “strangers” were in-laws. Generally, Germans are careful not to touch people who are not family or close friends.

The distancing used by Germans to position them- selves in relation to others is greater than the distancing used by some other cultural groups in the United States. More acculturated German Americans may control their space in a manner similar to that of other Americans. In health-care situations, providers frequently enter their clients’ personal space. German Americans understand the need for this intrusion and voluntarily participate in such encounters while preserving their dignity and privacy.

Germans place a high value on their privacy. Germans may live side by side in a neighborhood and never develop a close friendship. A German neighbor would not be expected to borrow a cup of sugar from another neigh- bor—doing so would be an admission that she or he failed to adequately stock the pantry. Germans would never consider dropping in on another German neighbor because this behavior is incongruent with their sense of order. Much preparation is completed to ready the house for guests. When invited into the home of a German, the guest may be surprised to find that the distance between pieces of furniture is not conducive to conversation. “German space is sacred” (Hall & Hall, 1990, p. 38). In addition to spacing furniture, Germans use doors to pro- tect their privacy. A closed door requires a knock and an invitation to enter regardless of whether the door is encountered in the home, business, or hospital. A closed

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door secures a sense of privacy and safety for Germans. Germans guard their privacy, which includes receiving phone calls at home. It is best to wait for an invitation or ask permission before contacting a new German acquain- tance at home.

Germans maintain eye contact during conversation, but staring at strangers is considered rude. Even looking into a room from the outside is considered a visual intru- sion; the interior of a room should not be entered without permission (Hall & Hall, 1990).

Smiling is reserved for friends and family. Because smiling does not occur during introductions, Germans are often considered unfriendly. Work is considered seri- ous business; thus, Germans smile very little at work. Dealing with illness is also considered serious business, calling for “correct responses” (i.e., reserved, direct, and unsmiling).

Several unacceptable expressions of nonverbal behav- ior for Germans include chewing gum in public, cleaning one’s fingernails in public, talking with one’s hands in the pockets, placing one’s feet and legs on furniture, pointing the index finger to one’s own head (an insult), and public displays of affection. Younger, more nontraditional German American youths may not adhere to these per- ceptions. Americans cross their fingers for luck, whereas Germans squeeze the thumb between index and middle fingers. However, allowing the thumb to protrude more than its tip length is an offensive gesture (CultureGram, 1994).

TEMPORAL RELATIONSHIPS

Germans use time to buy the future and pay for the past. Their focus on the present is to ensure the future. The past, however, is equally important, and Germans begin their discussion with background information, which always includes history. Americans generally do not understand the German peoples’ need to lay a proper foundation for discussion. Conversely, Germans develop a deep understanding of their historical heritage through an intense analysis of past events. Friday (1989) explained this contradiction as the result of a difference in educational emphasis in German and American schools.

Germans pride themselves on their punctuality. Being on time is an obsession. People who expect to be late for appointments should call and explain. If this is not done, the German sense of order is disturbed. Work is com- pleted by setting and meeting deadlines. “Keeping to the schedule” is extremely important. There is a sense of impatience and often intolerance in the German American who encounters a situation in which someone else is not performing on schedule. This impatience can be stirred to anger in the work setting, in the supermarket, on the highway, in the hospital, or in the health-care provider’s office. In the mind of a German, who is always on time, there are rarely good excuses for tardiness, delays, or incompetence that disturb the “schedule” of events. Within this cultural continuum model, Western Europeans and North Americans attend to details in a lin-

ear, orderly manner measuring days, hours, and seconds. Time has value for both groups, often equated with money.

FORMAT FOR NAMES

Traditionally, Germans keep social relations on a formal basis. Even neighbors of long-standing acquaintance are addressed as Herr (Mr.), Frau (Mrs.), or Fräulein (Miss) and their last name. Those in authority, older people, or sub- ordinates are always formally addressed. Only family members and close friends address each other by their first names. Many German Americans born in the 1930s and 1940s continue to be formal in their social and busi- ness interactions. If this consideration is not returned, or if someone presumptuously calls them by their first name, it may be considered a sign of disrespect or poor upbringing. “The taboo against first-naming should not be dismissed as an empty convention” (Hall & Hall, 1990, p. 48). Hall and Hall (1990) describe an old custom, Brüderschaft-trinken, in which “two friends formalize their shift to the more intimate form of address. They hook arms and each sips from a glass. Then they shake hands and announce their first names” (p. 49).

Germans combine a person’s professional title with Herr, Frau, Fräulein, or other titles and their last name. For example, a director of a business is addressed as Frau or Fräulein Direktorin. The title is often used without the name. A physician may be addressed simply as Doktor. Younger generations or more acculturated Germans may be less formal in their interactions. Because of cultural blending, health-care professionals will find that German Americans vary widely in their observance of these rules of etiquette. Therefore, these professionals should ask their clients how they would like to be addressed. This approach lessens the possibility of the provider uninten- tionally offending the client.

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

Traditional German families view the father as the head of the household. In the United States, the husband and wife are more likely to make decisions mutually and share household duties. Stay-at-home dads are uncom- mon in Germany (S. Maubach, personal communication, December 28, 2006). Often, when illness, dependence, and disability interfere and prevent family members from carrying out their roles, others assume decision-making responsibilities either temporarily or permanently.

In Germany, where emphasis is on Ordnung (order), and Gemeinschaft (community), older people are not expected to be self-reliant. Health and social programs for older people are considered part of the institutional approach of European programs. Because of the compre- hensiveness of these benefits, there is less financial reliance on the family. One home may remain in the same family for generations. Often, more than one generation

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live under the same roof. Older family members who live with their children are included in family celebrations as well as in the daily routine of the families. As they become unable to perform their roles and duties, other family members assume their responsibilities.

Older people within German American families are sought for their advice and counsel, although the advice may not always be followed. They are admired for main- taining their level of independence and their continued contributions to society. Many live alone or with aging spouses. Helping older parents or grandparents to remain in their own home is important to German American families. By providing a helping hand with home mainte- nance, shopping, and finances, the family is able to safe- guard and prolong a state of independence, even when living hundreds of miles away. For those who grow dependent, moving in with children or residing in a retirement nursing home is a viable choice for German American families.

The differences in the family role for older people in Germany and in the United States may be due to the far- reaching mobility of the American population that does not exist in Germany, where families generally live in close proximity. When Americans moved to the western frontier, they were required to adopt attitudes that included a degree of individualism, self-reliance, and ini- tiative not demanded in a more geographically stable and settled society in which families had support because they were geographically close. The emphasis on these traits, as well as the concept of “America, land of unlim- ited opportunity,” has made life in the United States difficult.

The Older Americans Act, Medicare, and Medicaid leg- islation, which are considered residual approaches for meeting one’s social needs, support the context of the German belief in self-reliance and the supportive role of the family. Such residual approaches are offered when the normal channels such as family, marketplace, and church are not sufficient for meeting needs. Strong advocacy groups such as the American Association of Retired Persons and the National Council of Senior Citizens, which have mobilized older Americans as a self-interest group, also support this idea of self-reliance (Gelfand, 1988).

In the United States, 31 percent of older people live alone, whereas in Germany, 16 percent live alone. The significant proportion of older women living alone in both countries can be attributed to the heavy loss of life among German men in World War II. Although families may live close to one another, a significant portion of the older population (24 percent) reports feeling lonely (Rowland, 1992). With both spouses working to maintain economic security, many people have less time available to interact socially with older family members living on their own. An interesting fact is that the Germans love their dogs, and in Germany, it is acceptable to take the family dog everywhere—restaurants, visiting, and the hospital. As is well known, animals, except for seeing-eye dogs, are restricted in most public places in the United States. Other pets found in the households includes cats, rabbits, birds, hedgehogs, and of course, horses (S. Maubach, per- sonal communication, December 28, 2006).

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

Prescriptive behaviors for children include using good table manners, being polite, doing what they are told, respecting their elders, sharing, paying attention in school, and doing their chores. Additional behaviors include keeping one’s nose clean, eating all food that is placed on their plates, looking at a person who is talking, and sitting up straight. Prescriptive behaviors for adoles- cents include staying away from bad influences, obeying the rules of the home, sitting “like a lady,” and wearing a robe over pajamas. Restrictive and taboo behaviors for children include talking back to adults, talking to strangers, touching another person’s possessions, and get- ting into trouble. Restrictive and taboo behaviors for ado- lescents include smoking, using drugs, chewing gum in public, having guests when parents are not at home, going without a slip (girls), and having run-ins with the law.

Germany has regulations about noise levels in public areas such as athletic fields where people gather to watch soccer games, tennis, and riding events. These regulations are enforced for both children and adults. On occasion, schools in highly populated areas apply similar restric- tions for playground activities (S. Maubach, personal communication, January 11, 2007).

FAMILY GOALS AND PRIORITIES

In Germany, history, family, and lifelong friendships are highly valued. Concern for one’s reputation is a strong value. One’s family reputation is considered part of a per- son’s identity and serves to preserve one’s social position (good and bad). The author recalls her mother admonish- ing her about the proper behavior for a young woman.

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V I G N E T T E 1 2 . 1

Mrs. Mary Hoffman, a 75-year-old widow and high school graduate, lives in south-central Pennsylvania. Born and raised in York County, Mrs. Hoffman married and had three children. Since her husband died 8 years ago, she has continued to live independently in her own home. Her financial support is from Social Security and from her husband’s government pension. Her days are spent crocheting, walking, and watching home- shopping channels and favorite soap operas. She is an excel- lent cook and prepares many dishes in the Pennsylvania Dutch style.

Her children help her remain in her home by providing assistance with grocery shopping, transportation, and home maintenance. Although she has concerns about her health, she does not always share these with her children. Mrs. Hoffman talks daily with friends in the neighborhood. Occasionally, they share lunch or just visit in each other’s homes.

1. Describe Mrs. Hoffman’s status and role within her family.

2. What positive socioeconomic factors have helped secure independent living for Mrs. Hoffman?

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She always pointed out: “You never know whom you will run into.” This admonition meant that you might meet someone, at any time and without your being aware, who could draw conclusions from your behavior that might tarnish the family’s reputation.

homosexuals experienced in Nazi Germany. In addition, religious education plays an important role in anchoring family conceptions and leads to denial of homosexual feelings. When health-care providers encounter gays and lesbians who need religious support, a referral to one of the gay and lesbian religious groups may be helpful (see Chapter 2).

Workforce Issues CULTURE IN THE WORKPLACE

Germans are among the most skilled and educated work- ers in the world. Much of Germany’s success is due to advanced technologies, and it is a leading nation in Nobel Prizes for physiology or medicine. Some of its most important contributions are in rocketry, material science, and chemical products (Solar Navigator, 2006). German workers are educated to meet the needs of a highly indus- trialized country. The atmosphere of German business is very formal.

Several considerations must be remembered when working with Germans and some German Americans. First, it is important to be on time for work and business appointments and to complete work assignments on time. Second, business communication should remain formal: shaking hands daily, using the person’s title with the last name, keeping niceties to a minimum, and avoid- ing the adjustment of office furniture during meetings. Employees are not addressed by their first names. Third, one should respect privacy by not entering rooms with a closed door before knocking and being invited inside. Fourth, dress, opinions, and activities should be conserv- ative. Finally, learning to speak German is important if an employee is living in Germany and working for a German company (Hall & Hall, 1990).

The current trend toward a global economy has encouraged many American companies to establish sites in Germany and many German corporations to have sub- sidiaries in the United States as well as other places throughout the world. Many German managers are trans- ferred to the United States by their companies and easily enter and adapt to the American business climate. Others trained in the health professions, the physical sciences and education, and technologies join the ranks of practic- ing professionals in the United States.

In the workplace, American values and beliefs often oppose German traditions. Friday (1989), in exploring the problems of transcultural adaptation for American and West German managers, noted “that the management style of German and American managers within the same multinational corporation is more likely to be influenced by their nationality than by the corporation culture” (p. 436). Although Friday’s work was done outside the health-care industry, some of his findings have implica- tions for relationships across a broad range of work set- tings, including health-care services. For one, German and American managers hold different perceptions of their relationship with their employer. Germans see themselves as part of the corporate family, whereas many Americans do not identify with their corporation.

PEOPLE OF GERMAN HERITAGE • 219

V I G N E T T E 1 2 . 2

Henry Wolfgang, a 33-year-old father and husband, was transferred by his company in Germany to their subsidiary in Michigan. Henry’s wife and two children, 6-year-old Harry and 8-year-old Lilli, recently joined him. With the help of an English tutor, the Wolfgang children attend a public school close to their home.

Six weeks after the family’s arrival in the States, Mr. and Mrs. Wolfgang received a call from the school principal ask- ing for a parent teacher conference about their two children. During the conference, Harry’s and Lilli’s teachers expressed their concerns about the level of socialization and activity they observed in the children. They explained that the chil- dren are always seen sitting together, talking softly, and not participating in playground activities.

The teachers offer the help of the school district’s psychol- ogist to help the children adapt to their new school environ- ment. Mr. and Mrs. Wolfgang are shocked and indignant.

1. What explanation, from the parents, about German culture would help the teachers better understand the behavior of the Wolfgang children?

2. Do you think the children need a mental health coun- selor? Why? Why not?

ALTERNATIVE LIFESTYLES

Pregnancy outside marriage results in disapproval, which can be overt or subtle. Because German families are con- cerned about their reputations in the community, the presence of an unwed mother taints their reputation and may result in the family being ostracized. If marriage fol- lows the pregnancy, less sanctioning occurs, but the fact that pregnancy existed before marriage creates a stigma for the woman, and sometimes the child, that may last for the rest of their lives. The family members rarely for- get this embarrassment, although it may never be dis- cussed openly.

Today, acculturation and realignment of the moral rules of society, in which one out of four children is born out of wedlock, have lessened the seriousness of teenage pregnancy. These changes, together with the availability of more options for pregnant teenagers and greater social acceptance for unwed mothers than existed in the 1970s, have not lessened the shock for parents.

When couples delay having children, families may pres- sure the couple about producing children. Understanding a couple’s decision not to have children is often difficult for German American families, and it may never be accepted.

Many middle-aged gay and lesbian German Americans may fear exposure because of the extreme discrimination

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Germans anticipate lifelong employment with the same company, whereas Americans may move to other compa- nies should a good opportunity arise. Another difference is that American managers expend much energy to be liked, whereas Germans prefer being credible in their positions to being liked. To satisfy their need to be liked, American managers encourage informality in the work- place, such as by addressing peers, subordinates, or supe- riors by their first names; by asking personal questions; and by believing in equality and making themselves at home in each others’ offices. For the German manager, credentials and education confirm their credibility and lead to power.

ISSUES RELATED TO AUTONOMY

Germans and German Americans expect to receive respect for their work and for their ability to make deci- sions about their work. They find a hovering supervisor annoying and demeaning. Balancing control and free- dom in the workplace is necessary to foster productivity in German and German American workers (Hall & Hall, 1990). American and German managers use different styles of assertiveness. Whereas Americans case their approach within the idea of equality or “fair play,” Germans, who have no translation for “fair play,” are assertive by putting other people in their place. As in all languages, nuances and jargon can frustrate the individual whose second language comes only from the textbook and who does not understand idioms and colloquial expres- sions. The Germans’ use of two distinctive manners of com- munication—Gesprach, casual talking, and Besprechung, the workplace discussion about performance—continues into the workplace.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Germans range from tall, blond, and blue-eyed to short, stocky, dark-haired, and brown-eyed. Because many Germans have fair complexions, skin color changes and disease manifestations can be easily observed. For those with fair skin, prolonged exposure to the sun increases the risk for skin cancer.

DISEASES AND HEALTH CONDITIONS

Because Germany is highly industrialized, Germans suffer from many of the same life-threatening diseases that afflict groups from other highly industrialized countries. Leading causes of death for German Americans follow the patterns of the dominant American society and include heart disease, cancer, cerebrovascular disease, and acci- dents. Because of the poor management of industrial con- taminants, people in the Eastern regions often suffer from pollution-related illnesses (CultureGram, 1994). When assessing recent German immigrants, it is helpful for health-care providers to know where in Germany the client resided before entering the United States.

HIV/AIDS are also present in Germany. Germany offers guidance and care to those who are infected as well as a comprehensive prevention program for its citizens (Kappler & Grevel, 1993). Because prostitution is legal in Germany, frequent health checks are required for those in this profession.

In 1998, research localized the genetic cause for a syn- drome of symptoms for a new form of myotonic muscu- lar dystrophy. A second study conducted in Minnesota, Texas, and Germany identified the same causative muta- tion (Mackle, 2001). This new form of the disease, called DM2, appears to be most common in Americans of German descent (Mackle, 2001).

Another genetic disease, hereditary hemochromatosis, is also found in German Americans. Hemochromatosis, a toxic level of iron accumulation, can cause diabetes, chronic fatigue, liver disease, impotence, and even heart attacks. The disorder is due to a mutation in the HFE gene located on chromosome 6. German Americans can avoid, prevent, and treat these maladies with genetic testing and early diagnosis. Hemochromatosis is treatable through bloodletting. The person can expect a normal life expectancy with aggressive treatment. Diagnosis can be established through a blood test known as an iron profile.

Sarcoidosis, a disorder found mostly in women between the ages of 20 and 40, occurs in all races, but peo- ple of German descent are at a higher risk (Gottfried, 2001). Sarcoidosis causes persistent cough or no symp- toms. The cause is unknown, but doctors speculate that it involves an adverse reaction of the immune system; the diagnosis is often missed.

Dupuytren’s disease, a slowly progressive disorder, is a deformity of the hand in which the fingers are contracted toward the palm. This often results in a functional disabil- ity. Dupuytren’s disease is frequently found in people of German descent. Affecting mostly older males, the disease causes the synthesis of excessive amounts of collagen. The excess collagen is deposited in a ropelike fashion from the palm into the fingers, permanently fixing the fingers in a state of flexion. The current treatment is surgical, but recent medical experimentation with injectable collagenase shows promise (Biospecifics Technologies, 1998).

Although the cause is uncertain, Peyronie’s disease is often found in people with Dupuytren’s disease (National Kidney and Urology Diseases Information Clearinghouse, 1995). A benign plaque forms within the erectile tissue of the penis, which causes it to bend, resulting in reduced flexibility and causing pain during erection. This can pro- hibit sexual intercourse. The disease occurs mostly in middle-age men and often in men who are related, sug- gesting that genetic factors may increase the likelihood of developing this disease. Some researchers have theorized that Peyronie’s disease may be an autoimmune disorder. A surgical approach to treatment has had some success. Candidates for surgery are men with curvature so severe that it prevents sexual intercourse.

Lowenfels and Velema (1992) examined the incidence of cholelithiasis in people from Denmark, Germany, India, Italy, Norway, and England. Although the study revealed prevalence rates from each of these centers, Norway ranked first and Germany second for the overall incidence of gallbladder disease. Although the study

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addresses populations in Germany, the results may be applicable to Germans in other parts of the world.

A cohort study of white men of Norwegian, Swedish, and German ancestry conducted between 1966 and 1986 revealed an increased risk of stomach cancer among for- eign-born and first-generation German Americans living in the north-central states (Kneller et al., 1991). This study suggests an interrelationship among ethnic, geo- graphic, and dietary factors as the cause. High concentra- tions of immigrants from northern Europe, which includes the high-cancer-risk countries of Germany and Scandinavia, settled in the north-central region of the United States. Low educational attainment, employment in laboring and semiskilled occupations, and ingestion of salted fish (at least once a month), bacon, milk, cooked cereal, and apples increased the risk factors for the for- eign-born and first-generation individuals. These findings support the theory of ethnic risk. Subjects who smoked 30 or more cigarettes per day exhibited a fivefold risk for the development of stomach cancer. In addition, those who smoked a pipe and chewed smokeless tobacco had an increased risk for stomach cancer (Kneller et al., 1991).

According to Zielenski et al. (1993), an increased inci- dence of cystic fibrosis (CF) is found among Hutterite German–speaking communal farmers living on the Great Plains of North America. Mutations in the Hutterite popula- tion, a genetic isolate with an average inbreeding coefficient of about 0.05, exhibit an increased prevalence of CF carriers. Maternal-child health professionals providing care to this ethnic group can assist clients by encouraging genetic coun- seling to ensure early diagnosis of CF in their infants.

Hemophilia, a genetic bleeding disease found in Germany and in the United States, can be traced from Queen Victoria of England, who through a gene mutation, passed hemophilia to her son and through her daughters (Kilcoyne, 2004). The disease was then spread into Europe through the royal families including the House of Hohenzollern. The House of Hohenzollern comprised kings and emperors of Prussia, Germany, and Romania. World War I lead to the German Revolution and the House of Hohenzollern abdicated, ending the monarchy. Historians believe that the source of hemophilia in the United States is a woman in Plymouth, New Hampshire, most likely English. There are currently over 20,000 people in the United States with hemophilia, accounting for over 75 percent of all cases of hemophilia (Kilcoyne, 2004). As in the United States around 1993, those with hemophilia in Germany were contaminated with the AIDS virus through the administration of blood products and anti- clotting factors. Health-care providers may want to be mindful of the German history of hemophilia and the AIDS issues while diagnosing bleeding issues in newly arrived German immigrants.

S. Maubach (personal communication, December 28, 2006) described the back pain experienced by school chil- dren who must carry their books everywhere during school sessions. No lockers are provided in the school building, so all supplies including books are carried all day long. Only public transportation is available to trans- port children to school, and children must carry their books and personal belongings with them. Again, during medical examinations of newly arrived immigrant chil-

dren complaining of back pain, the health-care provider should question whether this situation existed in their former school.

VARIATIONS IN DRUG METABOLISM

Few research studies have been completed on variations in drug metabolism and interactions specific to people of German ancestry. Aggregate data on white populations report that there are no slow metabolizers of alcohol in this population (Levy, 1993). One study reported that 5 percent of Germans are poor metabolizers of debriso- quine (Levy, 1993), and therefore, this group may need lower dosages of propranolol to control blood pressure.

High-Risk Health Behaviors Germans are known for their breweries and their Gasthäuser, or “restaurant that serves spirits.” Beer is also served at the pubs (kneipen). In Germany, drinking beer is a way of life. German youth can legally drink beer at 16 and drive at 18 years of age. Beer is served with meals, whereas water is rarely consumed. Sparkling mineral water (mineralwasser) is commonly served if water is requested by a patron. Even lactating mothers are encour- aged to drink malt beverages to increase breast milk pro- duction. This long-standing tradition of beer consump- tion is not without its abuses.

HEALTH-CARE PRACTICES

Germans, whether born in Germany or in the United States, share a love of nature. They enjoy the great out- doors. Fresh air and exercise are highly valued. Hiking, walking, swimming, skiing, cycling, soccer, horseback rid- ing, and playing tennis are just a few of the activities enjoyed by people of German ancestry. Walking is a way of life. Sports are played for exercise and the pleasure of participating in group activities. Water sports are very popular and are encouraged among older people, disabled people, mothers, and small children. Because many German Americans are joiners, health club memberships appeal to German Americans.

Ruhezeit, or quiet time, is nearly sacred in Germany. This time-honored tradition occurs between 1 p.m. and 3 p.m. Monday through Saturday and all day Sunday. During this time, older Germans take naps and older retired German Americans may follow this ritual as well. Stores in Germany close over this time period. Neighbors and friends are expected not to create noise, telephone, or interrupt in any other manner. This quiet time is often followed by Kaffe and Kuchen, coffee and cake time, around 4 p.m. (German Connection, 2006).

Nutrition MEANING OF FOOD

Food is a symbol of celebration for Germans and is often equated with love. Food and food rituals are powerful identification symbols for ethnic groups. The diet of

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immigrants is modified by the availability of foods and their financial status. The desire to maintain ethnic food habits has prompted children and grandchildren of immigrants to retain their ethnic heritage.

COMMON FOODS AND FOOD RITUALS

Traditional methods of food preparation with high-fat ingredients add to nutritional risks for many German Americans. Real cream and butter are used in German cooking. Gravies and sauces that are high in fat content, as well as fried foods, rich pastries, sausages, and boiled eggs, are only a few of the culinary favorites. Germans have traditional ways to prepare their favorite foods. Meats, turkey, chicken, pork, and fish are stewed, roasted, or marinated and are often served with gravies. Vegetables (fresh is preferred) are often served in a butter sauce. Foods are also fried in butter, bacon fat, lard, or mar- garine. Bratwurst (currywurst) served with curry ketchup and pommes frites (French-fried potatoes) with mayon- naise are found at the top of the list in Germany.

One-pot meals such as string beans and potatoes, snipply cabbage and potatoes, chicken pot pie, pork and sauer- kraut, stews, and soups are served as family meals. Casseroles are also popular. Foods prepared with vinegar and sugar as flavorings are also favorites. Potato salad, cucumber salad, coleslaw, chow, pickled eggs, pickled cucumbers, cauliflower, tongue, and herring are common examples of favored foods prepared with these flavorings. Sour cream, mayonnaise, and mustards are used fre- quently in food preparation.

The nutritional habits of some Germans may be a sig- nificant health risk factor. Food is an integral part of a German’s life. Food is served at celebrations and during visits and is taken on trips. The German infatuation with food can lead to overeating, which results in obesity. Children are rewarded for good behavior with food. Those who are ill receive Jell-O, egg custards, ginger ale, or tomato soup (not creamed) to settle their stomachs. Sending food with loved ones who will be away from the family for a time is quite common: Homemade cakes, cookies, and jams are a few of the offerings.

Nothing pleases German cooks more than witnessing people with hearty appetites at the table. Generous amounts of food are prepared, and second helpings are encouraged. Burping, with an apology, to honor the good food is acceptable at the German table (S. Maubach, per- sonal communication, 2006). In choosing foods for German Americans, the health-care provider should con- sider cutting portion size, overcoming harmful food ritu- als, and reducing fat intake.

Some German American food practices reflect accultura- tion. For example, rice pudding enjoyed by many German Americans is originally a European American dish. However, unlike European Americans who serve rice pudding as a common dessert dish, German Americans reserve it for spe- cial occasions such as weddings. Celebration versions of rice pudding often contain dried fruit, such as raisins or currants, rum for flavoring, or a meringue topping.

Corn, frequently served as a vegetable in North America, is not eaten in Germany, where it is considered food for farm animals. Visitors from Germany are often

startled when corn is served to them, but once they taste it, they are easily converted. Many early German immi- grants turned to farming to conquer starvation, raising grains (including corn), fruits, and vegetables that were popular in North America. Foods associated with special events such as weddings, holidays, and religious occa- sions are the last to yield to acculturation. German cooks produce their best culinary efforts for holidays. Weeks of baking and preparation often precede the actual holi- days. Selection of foods for the meal, proper preserva- tion, and artistic presentation of tasty dishes are attended with care.

Table 12–1 lists common foods in the German American diet, based on the author’s experience, personal interviews, the literature, and a marketing analysis conducted at a meeting of a local DANK (Deutsch Amerikanischer National Kongress [German American National Congress]) for a new food chain planning an international market concept.

DIETARY PRACTICES FOR HEALTH PROMOTION

Because of apartment living in Germany, many Germans love to garden. They bring this love to the United States. Gardening provides the fresh vegetables that Germans enjoy. What is not eaten is canned, pickled, dried, or frozen for future use. Having a full larder is very impor- tant to Germans and German Americans.

A few foods are used to prevent or treat illnesses. Prune juice is given to relieve constipation. A special soup from fresh tomato juice is used to treat a migraine headache. Ginger ale or lemon-lime soda relieves indigestion and settles an upset stomach. After gastrointestinal illnesses, a recuperative diet is administered to the sick family mem- ber, beginning with sips of ginger ale over ice. If this is retained, hot tea and toast are offered. The last step is cod- dled eggs, a variation of scrambled eggs prepared with margarine and a little milk. If these foods are tolerated, the sick person returns to the normal diet. Garlic and onions are eaten daily to prevent heart disease.

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

The literature does not report any enzyme deficiencies or food intolerances specifically related to Germans. However, those of lower socioeconomic status may lack the financial ability to purchase foods essential for a nutritious diet.

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V I G N E T T E 1 2 . 3

Hyde Pfiefer, a retired 70-year-old German American, has lived in the United States for the last 50 years. A widower of 5 years, Mr. Pfiefer prepares his own meals following his wife’s recipes from the old country. Nine months ago, Mr. Pfiefer was told that his cholesterol is elevated and he was instructed about a low-fat diet. His most recent test results show his val- ues to be unchanged.

1. Discuss the meaning of food in the German culture. 2. Using the predominant health beliefs of people of

German ancestry, how might you help Mr. Pfiefer reduce his cholesterol level?

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Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

In her book, Life at Four Corners, Coburn (1992) captured a bit of the history of maternal-child health in Block Corners, Kansas, a German Lutheran settlement of the mid-19th century. She provided a glimpse into the daily life of a woman in the Midwest: “A woman’s role within the family centered on supporting the farm economy, childbearing, child rearing, and providing continuous services to feed, clothe, and nurture all family members” (p. 88).

Coburn’s research showed that large families were com- mon in Block Corners. Farms needed a labor force and a large family often addressed that need. First-generation Block Corners women had at least seven or eight children. Babies were born every 2 years; miscarriages and stillbirths

were common. Accidents and disease claimed the lives of many children. An average of 6.5 children was born to second-generation women, but only 2.5 children were born to third-generation women. This drop in birth rate of the third generation is attributed to assimilation.

Bearing large numbers of children, coupled with the hard life of supporting a farm economy and continuously providing food, clothes, and nurturing, caused physical strain on women, which often limited their longevity. In spite of these hardships, birth control was not sanctioned by the church until the 1930s and was not openly dis- cussed. Educational information was passed verbally from one woman to another. Although it was known that breastfeeding decreased the likelihood of pregnancy, little else about pregnancy prevention was known.

Large families are rare in Germany. Most couples have only two children. This may be a result of limited living space; most Germans rent apartments rather than own homes. The German government recognizes the impor- tance of family and provides child-rearing allowances and

PEOPLE OF GERMAN HERITAGE • 223

Fish Anchovy paste Carp (karpfen) Dover sole Pickled herring Roe Rollmops Smoked cisco

Fruits Apfel (apple) Dried apples Dried pears Madelkerr (fruits) Nüsse (nuts) Prunes

Meats and Fowl Bacon Beef Bratwurst Chicken Duck Frankfurter Game bird Gänseleberwurst (goose liver) Goose Knockwurst Liver dumplings Mettwurst Mutton Pork Salami

T A B L E 12.1 Common Foods in the German American Diet

Beverages Coffee (with sugar and cream) Herbal teas Kümmel (caraway seed) Light and dark beers Schnapps Steinhager (juniper beverage) White wine

Breads, Noodles, and Dumplings Rolls Dumplings Knöpfle Potato dumplings Pretzels Pumpernickel Ribbles Spätzle

Cheese Camembert Limburger

Desserts Baumkuchen (tree trunk cake) Kranz (almond and hazelnut cake) Lebkuchen (honey cakes) Lübecker marzipan Pfannkuchen Pfefferkuchen (gingerbread) Rice pudding Springerle (cookies) Stollen Strudel

Saage (veal) Tongue Veal Venison Vonname (smoked pork chop) Weissbratwurster Wild boar

Preserves Apple butter Crabapple jelly

Vegetables Beets Cabbage Carrots Celery roots Mushrooms Onions Potatoes Sauerkraut White asparagus White radishes

Miscellaneous Caraway seeds Castor sugar (pearl sugar) Cilantro Honey Juniper berries Molasses Paprika Vanilla beans

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work leaves. The state pays a monthly allotment for each child up to 18 months of age and allows a child-rearing leave of 3 years for each child. Employers cannot sever parents from their employment, and leave time counts toward their pension. These benefits also apply to the care of sick family members (Helmert, Beck, Marstedt, Muller, Muller, & Hebel, 1997; Kappler & Grevel, 1993). Family leave legislation in the United States is more restrictive. Although maternity or paternity leave may be available after childbirth, it is often provided without pay and for a shorter duration.

A variety of birth control practices and interventions for improving fertility among Germans are readily available. On the one hand, the German respect for authority and love for scientific facts and data encourage the use of meth- ods to control, as well as to enhance, fertility practices. On the other hand, the use of medication or devices might be viewed as interrupting the natural progression of things. “These approaches may be contradictory to the German love and appreciation of the world of nature” (Cathy Seibold, personal communication, March 25, 1995).

For German Catholics, the influence of religious beliefs on birth control matters should not be overlooked. Heterologous artificial insemination, use of contraceptive pills, and unnatural contraception are forbidden. In addi- tion, therapeutic or direct abortion is forbidden as the unjust taking of innocent life. Teachings of Protestant sects on fertility control vary from no official position to forbidding the behavior (see the discussion under Spirituality).

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Germans share some of the prescriptive, restrictive, and taboo practices of other cultures concerning pregnancy. Some examples of prescriptive practices include getting plenty of exercise and increasing the quantity of food to provide for the fetus. Some restrictive practices include not stretching and not raising the arms above the head to minimize the risk of the cord wrapping around the baby’s neck.

Predicting the sex of the child was, and may still be, an important practice. For example, if the child is carried low, it is a girl; if the child is carried high, it is a boy. If the mother is “all out in the front,” it is a girl; and if the mother is broad in the back, it is a boy.

A review of the literature and personal interviews did not reveal any prescriptive, restrictive, or taboo practices related to the birthing process. Birthing rooms that allow fathers and other family members to be present are popu- lar among German Americans. In Germany, midwives commonly deliver babies (H. Morton, personal communi- cation, February 1995).

The author’s grandmother, who assisted with many home deliveries in the 1930s and 1940s, related one belief concerning the delivery of an infant. A child born with the membrane (the amniotic sac, also known as a veil) over its head is believed to be a special child, a belief shared by many cultures.

Prescriptive practices for the postpartum period include getting plenty of exercise and getting fresh air for the

baby; if the mother is breastfeeding, she should eat foods that enhance the production of breast milk. Many believe that a new baby will soon arrive in the household that is visited first by a newborn. The author’s mother often said, “Come visit us, but go somewhere else first.”

Death Rituals DEATH RITUALS AND EXPECTATIONS

Germans and German Americans traditionally observe a 3-day period of mourning activities after the death of a family member. The body of the deceased is prepared and “laid out” in the home, where support from family and friends is readily available. Neighbors come to do the chores and to sit with the family of the deceased until the burial. A short service is held in the home before the body is taken to the church, where family and friends can attend a funeral service. After the church services, the body is taken to the cemetery for burial. After a short graveside service, the minister invites everyone at the graveside service to the home of the deceased for food.

As embalming practices emerged at the turn of the 20th century and funeral homes became more popular, particularly in the urban areas, this tradition changed. Today, German Americans usually have a family funeral director. The family may go to the funeral home together to select a coffin. Following the directions of loved ones about what should be done after their death is very important. Careful selection of the clothes to be worn by the deceased and the flowers that represent the immedi- ate family is equally important. These selections are based on their knowledge of the deceased’s way of life and on preserving the family’s reputation and good name. Even in death rituals, Germans are quick to judge the quality of attention given to these details. The author can recall her family’s suspicion about the possibility that a certain fam- ily in the community took shortcuts to decrease the cost spent on the funeral process. The insinuation was that the family pocketed the money instead of honoring the fam- ily member.

RESPONSES TO DEATH AND GRIEF

The viewing provides an opportunity for family, friends, and acquaintances to view the body, offer their condo- lences, and extend their offers of assistance should the family need help in the future. Crying in public is per- missible in the author’s family, but in some German American families, the display of grief is done privately. A tradition of wearing black or dark clothing when attend- ing a viewing or a funeral may be expected of both family and friends. Another expectation is that the bereaved family limits socialization activities for the following sev- eral months.

The traditions that surround the provision of food for the mourners have changed over the years. From the 1940s through the early 1960s, women in the neighbor- hood prepared the food and served it as people arrived at the home following the burial. More recently, families have become the primary providers of food and may hire

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caterers to prepare food or use a restaurant as is done in Germany, where homes are too small to accommodate large groups of people.

For Germans and German Americans, death is seen as part of the life cycle, a natural conclusion to life. Individuals who embrace a set of religious beliefs may look forward to a life after death, often a better life. Death is a transition to life with God. Because illness is some- times perceived as a punishment, the length and intensity of the dying process may be seen as a result of the quality of the life led by the person.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

Martin Luther launched the Reformation in the early 16th century. Ninety percent of the population has some religious affiliation. Protestants and Catholics share equal portions of the population (33 percent). Other reli- gions of German Americans include Judaism (the third largest population of Jews in Western Europe), Islam, and Buddhism (Solar Navigator, 2006). Similar to the United States, Germany has no state church; church and state remain separate. Religion is seen as a personal mat- ter for German Americans, but those with an active interest in religion often discuss their beliefs with others (CultureGram, 1994).

A provision made by the Basic Law of Germany guar- antees that “freedom of faith and conscience as well as freedom of creed, religious or other beliefs, shall be invio- lable. The undisturbed practice of religion shall be guar- anteed” (Kappler & Grevel, 1993). Although there is no state church in Germany, churches, as independent pub- lic corporations, have a partnership relationship with the state. They can claim state grants, which in turn, support schools and kindergartens. Churches can levy taxes on their membership, but the taxes are collected by the state. German churches also serve a charitable and social pur- pose by running nursing homes, retirement centers, hos- pitals, schools, training centers, and consultation and car- ing services.

Table 12–2 reflects the formal positions or the relation- ships between spiritual beliefs and health practices of sev- eral Protestant religions and the Roman Catholic Church. The Jewish, Mennonite, Muslim, and Greek Orthodox faiths are addressed in other chapters. Health-care providers must recognize that individuals’ decisions may vary from the formal position of their religious groups. Therefore, the table serves only as a guide, not as an exclusive basis for decision-making in health care.

Most German religious philosophies do not divorce physical health from the actions of God. Many hold the view that God works through health-care providers as well as through the resources of medicine. Prayer is used to ask for healing, for effectiveness of treatments, for strength to deal with the symptoms of the illness, and for acceptance of the outcome of the course of the illness. Prayers are often recited at the sick bed, with all who are present joining hands, bowing their heads, and receiving the blessing from the clergy.

Reading the Bible is also an important spiritual activ- ity. Most German and German Americans have a family Bible, which is passed down through the generations. It serves as spiritual comfort and as a reservoir of family his- torical data such as the dates of births, marriages, and deaths.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

Individual sources of strength for most Germans and German Americans are their beliefs in God and in nature. Although they may not attend church on a regular basis, a Germans’ faith is deep. Family and other loved ones are also sources of support in difficult times. Home, family, friends, work, church, and education provide meaning in life for individuals of German heritage. Family loyalty, duty, and honor to the family are strong values.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Teachings of the churches joined by German people pro- vide direction and counsel on many health-care issues. Many of these churches have taken a formal position on abortion, artificial insemination, and prolongation of life. The church prescribes when individual choice is impor- tant in deciding on accepting or refusing treatments and provides advice when seeking spiritual counseling.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

Germans receive regular medical and dental checkups, immunizations, and routine screening because most of the population is covered by statutory health insurance. Germany has one of the slowest-growing economies in Europe. Supporting the East German modernization, high unemployment, and a growing aging population since the mid-1990s has stressed the economy. In addition, Germany has faced health-care reform, embracing an approach that mirrors the U.S.’s HMOs with protest from the German physicians, similar to the reactions of physicians in the United States. The health-care systems are sharing more similarities than in the past. Germans are facing challenges of access experienced in the United States.

RESPONSIBILITY FOR HEALTH CARE

Although health care in Germany is considered “the indi- vidual’s own responsibility, it is also a concern of the soci- ety as a whole” (Kappler & Grevel, 1993, p. 353). The average life expectancy in Germany is 75.81 years for men and 81.96 years for women versus 74.8 years for men and 80.1 years for women in the United States. Germany’s infant mortality rate of 7 per 1000 infants is comparable with the U.S.’s infant mortality rate of 8 per 1000 (Arias, 2003).

Women in the family often administer remedies and treatments. In traditional families, the mother usually

PEOPLE OF GERMAN HERITAGE • 225

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T A

B L

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226

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, Ju

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to s

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to s

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ir ec

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ic e

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es sa

w it

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ce s

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m o

th er

’s

p h

ys ic

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.g .,

r em

o va

l to

e n

su re

h ys

ic ia

(e .g

., r

ap e

m o

th er

li fe

o r

ac ce

p te

d o

f u

te ri

n e

h ea

lt h

o f

an d

p as

to r

o r

in ce

st )

in c

as e

ca n

ce r)

m o

th er

en co

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o f

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e o

r in

ce st

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o rt

io n

o n

ef t

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h ib

it ed

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p o

se d

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p o

se d

Sa m

e as

ee m

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p o

si ti

o n

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p o

se d

N o

p o

si ti

o n

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p o

se d

d em

an d

in d

iv id

u al

o ve

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ifi ab

ch o

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b y

ci rc

u m

- st

an ce

s (e

.g ., r

ap e

o r

in ce

st )

227

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sees that children receive checkups, immunizations, and vitamins. German Americans use a variety of over-the- counter drugs. C. M. Weicksel (personal communication, February 1995) summed up the practice as “people tend to self-medicate with over-the-counter drugs until these medications are ineffective, then they go to the doctor.” The use of over-the-counter drugs may stem from the belief that individuals are responsible for their own health and from the beliefs and traditions about the treat- ment of sickness learned within the family system. In Germany, however, over-the-counter drugs can be pur- chased only from a pharmacy, which increases the cost to the consumer. Therefore, over-the-counter drugs are not as accessible to Germans as they are to German Americans. Today, prescription drugs are more complex, and numer- ous over-the-counter medications have become more accessible to German Americans. The two, used in combi- nation, may lead to dangerous drug interactions for those who practice self-medication. Thus, health-care providers need to ascertain if over-the-counter and folk remedies are being used to determine whether there are contraindica- tions with prescription medications.

FOLK AND TRADITIONAL PRACTICES

Among the early German immigrants, women practiced folk medicine, which often included singing and the lay- ing on of hands. Families passed this knowledge on from mother to daughter. Common natural folk medicines included roots, herbs, soups, poultices, and medicinal agents such as camphor, peppermint, and spirits of ammo- nia. The author’s mother and grandmother had an arsenal of remedies that were a combination of folk and over-the- counter preparations to treat a variety of ills. A list of these remedies and their uses can be found in Table 12–3.

Magicoreligious folk medicine includes “powwowing,” use of special words, and the wearing of charms. Some stories told by the author’s mother referred to the pow- wow sessions she attended as a child to cure her frequent ear infections and her inability to gain weight. She attempted to cure a plantar’s wart by rubbing it with a sliced onion and burying the onion where water flowed. The expectation was that as the onion deteriorated, so would the wart. When this failed, an appointment with the podiatrist soon followed. Another belief is that carry- ing a buckeye guarantees health. Some individuals have a strong belief that being hexed brings bad luck, which can manifest itself as illness. The extent to which today’s German American population continues to follow these practices is unknown.

BARRIERS TO HEALTH CARE

Germans have varying degress of access to health care (S. Maubach, personal communication, 2006). Because this is also true in the United States, newer immigrants may experience economic difficulties in securing care or in purchasing health-care insurance. Access to care is also limited for those who live in rural areas. Although efforts are being made to reduce these barriers, economic and geographic barriers to health care continue to exist for a large number of German Americans.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

When asked to describe a German’s response to pain, the word most often used is “stoic.” Even when Germans are experiencing pain, they may continue to carry out their family and work roles. Research reveals that older German Americans are less likely to complain, more accurate in their description of pain, and more likely to follow the physician’s advice (Wright, Saleebey, Watts, & Lecca, 1983). Although results of studies that examine ethnicity and pain remain problematic, one significant finding does exist: Regardless of the degree of acculturation, indi- vidual expressions of pain may follow those of the more traditional members of the culture. Thus, health-care pro- fessionals may not be able to identify verbal or nonverbal clues among Germans. Careful interviewing and astute observation must be used to accurately assess the level of pain experienced by Germans.

Although both Germany and the United States provide care for the mentally ill, mental illness may continue to be viewed as a flaw and is perhaps not as acceptable to German Americans as it is for some other cultures. If this is accurate, members of this group may be slow to seek help because of the lack of acceptance as well as the stigma attached to needing help. German people’s discomfort

228 • CHAPTER 12

T A B L E 12.3 German Folk Remedies for Various Afflictions

Affliction Remedy

Abrasions, burns Vaseline Boils Black salve Bumps and burns Butter Cleaning cuts Hydrogen peroxide

and abrasions Colds Vicks as chest rub or placed in a

vaporizer Colds Camphorated oil (chest rub; soft cloth

covered with oil is placed over chest and neck area)

Colic in infants Catnip and fennel (diluted in water and flavored with a little sugar)

Constipation Castor oil Cuts Mercurochrome Diaper rash Cornstarch Diarrhea Paregoric in water Earache Warm oil Headaches Warm oil Menstrual cramps Hot tea Muscle aches Alcohol with wintergreen Muscle stiffness Hot or cold compresses Nervousness Spirits of ammonia in water Sunburn Noxzema Teething in infants Whiskey in water (rubbed on infant’s

gums) To enhance health Cod liver oil Toothache Oil of cloves Upset stomach Hot tea with peppermint oil

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with expressing personal feelings to strangers may impede the counseling process and influence the counsel- ing methods used. The German need to discuss the past without expressing their feelings should be recognized within the counseling process.

Even though the mentally ill have been assimilated into American culture, many may remain stigmatized in the German American culture. Since the passage of the Americans with Disabilities Act, more people are aware of the needs of the physically disabled, including accultur- ated German Americans. Physical disabilities caused by injury are more acceptable to German Americans than those caused by genetic problems. The latter brings feel- ings of guilt and a sense of responsibility.

Returning people to the highest level of health possible appeals to the German nature. The European American culture believes in helping people, including older peo- ple, to recover their health. Rehabilitation has become an integral part of patient care in both Germany and the United States, and rehabilitation facilities abound in both countries. In Germany, rehabilitation is also a vital com- ponent of care in psychiatric facilities (Wuerth, 1993). For Germans, the rapid return to their roles in society is para- mount, and rehabilitation represents the transition to these roles.

Once others become aware of illness, sick individuals are excused from their responsibilities. Even through German Americans are allowed to assume the sick role, some individuals may have difficulty doing so. The sto- icism of some may delay their seeking medical care and allow the problem to become more severe or chronic. This may result in the need for more complex treatments for relief of symptoms. As individuals recover, they are expected to relinquish the sick role and resume their nor- mal responsibilities. It is important to note that it is the physician in Germany who determines whether a person can attend work. The physician determines the length of absence from work, and the employer must provide employees with their salaries. There is no accruing of sick time as we do in the United States (S. Maubach, personal communication, December 28, 2006).

BLOOD TRANSFUSIONS AND ORGAN DONATION

German Americans identify blood transfusions, organ donation, and organ transplants as acceptable medical interventions. Many religions followed by German Americans provide guidance on each of these issues. See Table 12–2 for a more complete description of these beliefs and practices.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

In Germany, folk medicine and midwifery are highly revered. Midwifery is a “family-based tradition” (Coburn, 1992, p. 93), with skills passed from mother or close female relatives to daughters. Through interviews with

the residents of Block Corners, Kansas, Coburn was able to describe the work of a local midwife, Grandma Block. In addition to her midwifery, she passed along folk reme- dies for a variety of illnesses. The local physicians respected Grandma Block. She knew when their skills and knowledge were needed, and if she called them, they knew to come immediately (Coburn, 1992). Adolescent girls were pressed into service when illness and childbirth occurred. Older or widowed women also provided help in preparing food, cleaning house, and nursing the sick in families of both relatives and nonrelatives. Currently, in Germany, medical-care regulations deem that a physi- cian must have a midwife (Hebamme) present during a birth. However, a physician does not have to be present if the midwife is doing the delivery (Wikipedia, 2006c). This is opposite of the practice in the United States, where a physician must be present if the birth is complicated. In Germany, alternative medicine such as acupuncture and homeopathy is used also during childbirth to control pain.

The use of certified nurse-midwives is currently grow- ing in the United States. Choosing a nurse-midwife over an obstetrician is a personal, not a cultural, decision for German Americans. German Americans accept the care of health-care practitioners of the opposite gender. However, this is probably due to cultural indoctrination rather than an ethnic mandate.

STATUS OF HEALTH-CARE PROVIDERS

Health-care providers hold a relatively high status among Germans. This admiration stems from the German love of education and respect for authority. German Americans appreciate the status symbols of money, power, and insti- tutional affiliations held by these professionals. German families are proud to have a health-care professional in their midst, and it is common for family members to seek counsel from them. Because Germans may find asking for help difficult, they may feel more comfortable confiding in a family member.

Health-care providers’ strange language, unusual prac- tices, and “secret” body of knowledge often create barriers to forming relationships with clients. Because of their indoctrination into the culture of the health professions, health-care providers can become short-sighted and fail to meet the personal needs of German clients. To deliver culturally conscious health care, providers must under- stand their own ethnic and professional culture as well as the ethnic cultures of their clients.

Today, the entry of more women into nontraditional work roles in health care has forced changes in the health-care environment in the United States. The same may not be true in Germany, where hospital libraries are reserved for doctors and patients only and are closed to nurses (Wuerth, 1993).

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

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