Appalachian and Arab Heritage

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People of Appalachian Heritage

Chapter 5

KATHLEEN W. HUTTLINGER and LARRY D. PURNELL

Overview, Inhabited Localities, and Topography

OVERVIEW

Appalachia consists of that large geographic expanse in the eastern United States that is associated with the Appalachian mountain system, a 200,000-square-mile region that extends from the northeastern United States in southern New York to northern Mississippi. It includes all of West Virginia and parts of Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia. This very rural area is characterized by a rolling topography with very rugged ridges and hilltops, some extending over 4000 feet high, with remote valleys between them. The surrounding valleys are often 2000 feet or more in elevation and give one a sense of isolation, peacefulness, and separateness from the lower and more heavily traveled urban areas. This isolation and rough topography have contributed to the development of secluded communities in the hills and natural hollows or narrow valleys where people, over time, have developed a strong sense of independence and family cohesiveness. These same isolated valleys and rugged mountains pre- sent many transportation problems for those who do not have access to cars or trucks. Very limited public trans- portation is available only in the larger urbanized areas.

Even though the Appalachian region includes several large cities, many people live in small settlements and in inaccessible hollows or “hollers” (Huttlinger, Schaller- Ayers, & Lawson, 2004a). The rugged location of many communities in Appalachia results in a population that is

often isolated from the mainstream of health-care ser- vices. In some areas of Appalachia, substandard secondary and tertiary roads, as well as limited public bus, rail, and airport facilities, prevent easy access to the area (Fig. 5–1). Difficulty in accessing the area is partially responsible for continued geographic and sociocultural isolation. The rugged terrain can significantly delay ambulance response time and is a deterrent to people who need health care when their health condition is severe. This is one area in which telehealth innovations can and often do provide needed services.

Many of the approximately 24 million people who live in Appalachia can trace their family roots back 150 or more years, and it is common to find whole communities comprising extended, related families. The cultural her- itage of the region is rich and reflected in their distinctive music, art, and literature. Even though family roots are strong, many of the region’s younger residents have left the area to pursue job opportunities in the larger urban cities of the north. The remaining, older population reflects a group that often has less than a high-school edu- cation, is frequently unemployed, may be on welfare and/or disability, and is regularly uninsured (20.4 per- cent) (Virginia Health Care Foundation, 2001). In fact, of the total current population in Appalachia, 12.4 percent are 65 years or older (Haaga, 2004).

The lack of education has often been associated with nonparticipation in health promotion activities (Graduate Medical Education Consortium [GMEC], 2001). Graduation rates from high school in the year 2000 vary widely from 60.7 to 91.4 percent, with the lowest number of gradu- ates occurring in West Virginia, southwestern Virginia, eastern Kentucky, and northeastern Tennessee (Haaga, 2006).

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HERITAGE AND RESIDENCE

Appalachians generally identify by family name and by their country of origin, such as German, Scotch-Irish, Welsh, French, or British, the primary groups who settled the region between the 17th and the 19th centuries. It is important to remember that migrating into the area does not make one an Appalachian. Historically, the popula- tion has been predominantly white, although many maintain a strong family identity with Native American groups who once populated the area (e.g., Cherokee, Choctaw) (Huttlinger, Schaller-Ayers, Kenney, & Ayers, 2004b).

Appalachians in general cannot be distinguished from other white cultural and ethnic groups by either dress or physical appearance. However, similarities in beliefs and practices, tempered by the primary and secondary charac- teristics of culture (see Chapter 1), give them a unique and rich ethnic identity. Like many disenfranchised groups, the people of Appalachia have been described in stereotypically negative terms (e.g., “poor white trash”) that in no way represent the people or the culture as a whole. They have also been called “mountaineers,” “hill- billies,” “rednecks,” and “Elizabethans.” The media per- petuates these stereotypes with cartoon strips such as “Li’l Abner” and “Snuffy Smith,” television programs such as the Dukes of Hazzard, and stories of the feuding Hatfields and McCoys and the Whites and Garrards. Interestingly, these feuds were among wealthy families over salt deposits and land and families who had high political profiles. Failure of the courts to intervene and a propen- sity of Appalachians to “handle things themselves” per- petuated the longevity of the feuds.

In reality, Appalachians value a deep-seated work ethic, a low cost of living, and a high quality of life. Appalachians see themselves as loyal, caring, family- oriented, religious, hardy, independent, honest, patriotic, and resourceful (Huttlinger et al., 2004a).

Other groups in the region who may identify with Appalachian culture include Native Americans, African Americans, and Melungeons, who are of mixed African American, Native American, Middle Eastern, Mediterranean, and white ethnic descent (Costello, 2000; Kennedy, 1997).

Although Melungeon heritage is often denied, there is, of late, a resurgence of identification of Melungeon ancestry. In fact, annual Melungeon get-togethers are now held once a year in Appalachia (Kennedy, 1997). With the increase in immigration to the United States since the 1970s, the Appalachian region is becoming more ethnically and cultur- ally diverse, and it is now common to observe various south- east Asian, Chinese, and Hispanic groups.

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Approximately 300 years ago, people came to Appalachia to seek religious freedom, land for themselves, and per- sonal control over interactions with the outside world. Over the years, mining and timber resources became depleted, farmland eroded, and jobs became scarce, which resulted in an out-migration of people, especially those of working age, to larger urban areas of the North such as Cincinnati, Cleveland, and Louisville. This migra- tion began after World War II and has remained constant ever since (Obermiller & Brown, 2002). Those who moved to urban areas often felt alone and sometimes became depressed as they were separated from family and friends. Many feared the large cities because of high crime and their unfamiliarity with how to get along in an urban environment. Those who remained in urban settings have become bicultural, adapting to the culture of urban life while retaining, as much as possible, their traditional Appalachian culture.

The limited opportunities for employment in Appalachia often require wage earners to leave their fam- ilies to seek work elsewhere, returning home only to maintain close ties with their kinfolk as resources allow. Their migration pattern is regional, where individuals from one area primarily migrate to the same urban areas as their relatives and friends—a pattern that is common with many migrants. This practice helps decrease the occurrence of depression and feelings of isolation and provides a support network of family and friends so important for members of an Appalachian culture.

Appalachian migration patterns reflect the economic conditions found in the area as well as some of the cul- tural values of home, connection to the land, and impor- tance of the family. Working-age individuals move from Appalachia to make their living but often return to the area to retire. Because of these patterns, Appalachia has one of the highest existing aging populations (Haaga, 2004). The pattern of returning home to retire has given rise to challenges for health-care delivery. In fact, older people were once able to rely on home care services, but severe budget cuts in 1977 left home care health service unreliable and ineffective. Therefore, older people and the chronically ill have to rely on options for short-term and expensive hospital care, nursing homes, or no care at all (Hurley & Turner, 2000).

For generations, the region has been a symbol of poverty in a land of wealth and opportunity. During the 1960s, the Appalachian Regional Commission (ARC) appropriated funds for building roads to attract industry and provided loans for residents to start their own businesses. In many areas of Central Appalachia, the

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FIGURE 5–1 Before the construction of the New River Gorge bridge, many people were isolated from health care. (Courtesy of West Virginia Division of Tourism and Parks.)

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unemployment rate and the number of people living in poverty have remained consistently above the national average, while the per capita income has remained below the national average. Eight of the 13 states in Appalachia have an unemployment rate higher than the national average of 4.8 percent, and the national poverty rate of 12.6 percent is exceeded by 10 of the 13 states in Appalachia. The average per capita income rate in Appalachia is $20,872. Not one Appalachian state achieves the national per capita income of $25,470. Of 410 counties in Appalachia, 77 are considered economi- cally distressed, 81 are at risk, and 222 are transitional (ARC, 2006a). Even though the cost of living in much of the area is lower than that in many other parts of the United States, costs for transportation of food, basic living supplies, and transportation fuels rise, thus creating hard- ships for an area that is already economically stressed (ARC, 2006a).

EDUCATIONAL STATUS AND OCCUPATIONS

Although many of the original immigrants to this area were highly educated when they arrived, limited access to more formal education resulted in the isolation of later generations with fewer educational opportunities. Despite the value placed on education, a disparity in the number and placement of educational facilities exists throughout the region. Access to colleges and universities has improved, but there is still a lack of knowledge about life outside of Appalachia and the educational opportunities available. Examples of universities and colleges in Appalachia include, but are not limited to, West Virginia University, Appalachian State, University of Virginia’s College at Wise, East Tenneesse State, Shawnee State, and the University of North Alabama. A dichotomy between those who are poorly educated and those who are extremely well educated still exists today (Huttlinger et al., 2004a).

Because isolationism results in a cultural lag, IQ scores of children from Appalachia are sometimes lower than those in the populations outside of Appalachia who have access to larger schools and live in urban settings. However, with television and the Internet now available throughout the area, this cultural lag has been slowly improving. In fact, U.S. Representatives from many of the districts that lie in Appalachia made it a priority to have broadband and Internet connections made accessible. Factors such as improved mobility, access to better schools with qualified teachers, increased employment opportunities in some regions, and greater use of technol- ogy are responsible for improving socioeconomic condi- tions and better performance on standard IQ tests (ARC, 2006a).

Although a value is placed on education, many see education beyond high school as not as important as earning a living to help support the family. Many Appalachian parents, and especially those who belong to more conservative and secular religious sects, do not want their children influenced by mainstream middle-class American behaviors and actions. However, fewer children drop out of school today than in previous decades. One interesting fact is that several states in Appalachia have

laws that grant permanent driving privileges only upon completion of high school, which has lowered dropout rates significantly.

Parents who value higher education encourage their children to seek quality education at the best institutions possible. Despite this value, the graduation rate from col- lege has remained at 36 percent, compared with 45 per- cent for non-Appalachian counterparts (ARC, 2006a). Unfortunately, the highly educated, including health- care workers, who return to the area are often unable to secure financially lucrative employment.

Because educational levels of individuals within the Appalachian regions vary, it is essential for health-care providers to assess the health literacy and basic under- standing of health and disease of individuals when pro- viding any kind of intervention. Educational materials and explanations must be presented at literacy levels that are consistent with clients’ understanding. If materials are presented at a level that is not understandable to clients, providers may be seen as being “stuck-up,” “putting on airs,” or “not understanding them and their ways” (Huttlinger et al., 2004b).

PEOPLE OF APPALACHIAN HERITAGE • 97

V I G N E T T E 5 . 1

The Carter Family Fold lies deep in Appalachia at the base of Clinch Mountain in the Maces Springs or Poor Valley Community of southwestern Virginia. The Carter Family Fold is the home of the musical Carter family who provided the country with the rich legendary “Carter” family, a museum, a church, a cemetery, and a music center where lively concerts featuring local, national, and international musicians are fea- tured. The concerts are family centered and, in keeping with a traditional style, feature only acoustic instruments (no electric instruments allowed!). Seating is in a barnlike structure with tiered platforms with seats made from discarded buses, cars, and tractors. The hospitality is contagious and as welcoming as the bluegrass and country musical tradition of the Appalachian culture. The “fold” includes the home sites of the family. Outsiders, young and old, are encouraged to dance, sing, and celebrate the rich musical heritage of the area.

Go to the Carter Family Fold website at http://www. carterfamilyfold.org/

1. What is the Center’s objective? 2. For what are Maybelle, Sara, and A. P. Carter given his-

torical credit? 3. How do the Fold and Center contribute to Appalachian

culture?

Communication DOMINANT LANGUAGE AND DIALECTS

The dominant language of the Appalachian region is English, with many words derived from 16th-century Saxon and Gaelic. Because the Appalachian dialect tends to be very concrete, continued exposure is necessary to avoid misunderstandings. Negative interpretations of Appalachian behaviors by non-Appalachian health-care

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workers can be detrimental to positive and facilitative working relationships.

Some of the more isolated groups in Appalachia speak an Elizabethan English, which has its own distinct vocab- ulary and syntax and can cause communication difficul- ties for those who are not familiar with it. Some examples of variations in pronunciation for words are allus for “always” and fit for “fight.” Word meanings that may be different include poke or sack for “paper bag” and sass for “vegetables.” The Appalachian region is also noted for its use of strong preterits such as clum for “climbed,” drug for “dragged,” and swelled for “swollen.” Plural forms of monosyllabic words are formed like Chaucerian English, which adds es to the word, for example: “post” becomes postes, “beast” becomes beastes, “nest” becomes nestes, and “ghost” becomes ghostes. Many people, especially in the nonacademic environment, drop the g on words end- ing in ing. For example, “writing” becomes writin’, “read- ing” becomes readin’, and “spelling” becomes spellin’. In addition, vowels may be pronounced with a diphthong that can cause difficulty to one unfamiliar with this dialect; hence, poosh for “push,” boosh for “bush,” warsh for “wash,” hiegen for “hygiene,” deef for “deaf,” welks for “welts,” whar for “where,” hit for “it,” hurd for “heard,” and your’n for “your.” However, when the word is written, the meaning is apparent. Comparatives and superlatives are formed by adding a final er or est, making the word “bad” become badder and “preaching” become preach- in’est (Wilson, 1989).

If health-care workers are unfamiliar with the exact meaning of a word, it is best to ask clients to explain. Otherwise, miscommunication can occur and will proba- bly result in incorrect diagnoses and/or other poor health outcomes. The health-care worker may want to ask the person to write the words (if the person has writing skills) to help prevent errors in communication and to improve outcomes and following directions with health prescrip- tions and treatments.

CULTURAL COMMUNICATION PATTERNS

Appalachians practice the ethic of neutrality, which helps shape communication styles, their worldview, and other aspects of the Appalachian culture. Four dominant themes affect communication patterns in the Appalachian culture: (1) avoiding aggression and assertiveness, (2) not interfering with others’ lives unless asked to do so, (3) avoiding dominance over others, and (4) avoiding arguments and seeking agreement (Smith & Tessaro, 2005).

Appalachians often tend to accept others and do not want to judge others. This value is reflected in written and oral communications in which fewer adjectives and adverbs are used. Thus, many Appalachians may be less precise in describing their emotions, may be more con- crete in conversations, and will answer questions in a more direct manner. Accordingly, the health-care worker may need to use more open-ended questions when obtaining health information and eliciting opinions and beliefs about health-care practices. Otherwise, Appalachian clients are likely to give a yes or no answer without expanding or clarifying their answers.

In general, Appalachians are a very private people who do not want to offend others, nor do they easily trust or share their thoughts and feelings with outsiders. They are more likely to say what they think the listener wants to hear rather than what the listener needs to hear. In addi- tion, because of past, and often unfavorable, experiences with large mining and timber companies, many Ap- palachians dislike authority figures and institutions that attempt to control their behavior. Individualism and self- reliant behavior are idealized; personalism and individu- alism are admired; and people are accepted on the basis of their personal achievements, qualities, and family lin- eage.

Appalachians’ perceptions of themselves, their com- munity, and their families influence many aspects of their communication styles. Families are more than genetic relationships and are described as including brothers, sis- ters, aunts, uncles, parents, grandparents, cousins, in- laws, and out-laws (those related by marriage). This per- ception of family and community transcends the concept of self as “I.” The use of the pronoun “we” throughout speech patterns recognizes the concept of self. Thus, “we can make it,” “we will survive,” “we will be there” may refer to only the person speaking.

An example of a typical interaction in an Appalachian community may be illustrated by this statement from a key informant in the Counts and Boyle (1987) Genesis Project, which took place from 1985 to 1994. Miss Ruth, a 94-year-old native Appalachian, was interviewed in the house in which she was born. In fact, she had her appen- dix removed in the living room of this same house by a traveling nurse. After returning from a trip to Africa (she had a doctorate and liked to travel, but always returned home), Miss Ruth described the concept of “neighboring” as a double-edged sword. The positive side is that when you are sick, everyone comes around to take care of you; however, on the negative side, when you try to do some- thing quietly, everyone knows about it.

Appalachians may be sensitive to direct questions about personal issues. Sensitive topics are best ap- proached with indirect questions and suggestions and any critical innuendo. Appalachians are taught to deny anger and not complain. Information should be gathered in the context of broader relationships with respect for the ethic of equality, which implies more horizontal than hierarchical relationships, allowing cordiality to precede information sharing. Starting with sensitive issues may invite ineffectiveness; thus, the health-care worker may need to “sit a spell” and “chat” before getting down to the business of collecting health information. To establish trust, the health-care worker must show interest in the community, the client’s family, and other personal mat- ters, drop hints instead of give orders, and solicit the client’s opinions and advice. These actions increase the client’s self-worth and self-esteem and helps to establish the trust needed for an effective working relationship.

Traditional Appalachians value personal physical space, so they are more likely to stand at a distance when talking with people in both social and health-care situations. This physical distancing has its origins in religious persecution endured by this group in their history and has been per- petuated by a social isolationism that has encouraged

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family members to become the main social contact (Coyne, Demian-Popescu, & Friend, 2006). Therefore, many people may perceive direct eye contact, especially from strangers, as an aggressive or hostile act. Staring is considered bad manners.

To communicate effectively with Appalachian clients, nonverbal behavior must be assessed within the contex- tual framework of the culture. Many Appalachians are comfortable with silence, and when talking with health- care providers who are outsiders, they are likely to speak without emotion, facial expression, or gestures and avoid telling unpleasant news to avoid hurting someone’s feel- ings. Health-care providers who are unfamiliar with the culture may interpret these nonverbal communication patterns as not caring. Within this context, the health- care provider needs to allow sufficient time to develop rapport by dropping hints instead of giving orders (Coyne et al., 2006).

the emphasis on illness prevention in our current society is still relatively new for many Appalachians (GMEC, 2001). For those living in poverty and isolation, the trend is to “live for today” and to rely on more traditional approaches for those things that cannot be controlled. This worldview is common with present-oriented soci- eties, in which some higher power is in charge of life and its outcomes, but it is a deterrent to preventive health ser- vices. With a fatalistic view in which individuals have lit- tle or no control over nature and the time of death is “pre- determined by God,” one frequently hears expressions such as “I’ll be there, God willing and if the crick [creek] don’t rise.” As communication systems such as televi- sions, satellite dishes, and the Internet become more commonplace, temporal relationships are becoming more future-oriented.

For the traditional Appalachian, life is unhurried and body rhythms, not the clock, control activities. One may come early or late for an appointment and still expect to be seen. If individuals are not seen because they are late for an appointment and are asked to reschedule, they are likely to not return because they may feel rejected. Many Appalachians are hesitant to make appointments because “somethin’ better might come up.”

Appalachians who live outside the area usually talk about, and sometimes even dwell upon, “home” in a nos- talgic way. To some, this might seem like a glorification of a past temporal orientation. However, these authors believe that it is nostalgia for “the way things used to be” as, in reality, most people do not want to return to the harshness of the life experienced by past generations.

FORMAT FOR NAMES

Although the format for names in Appalachia follows the standard given name plus family name, individuals address nonfamily members by their last name. A com- mon practice that denotes neighborliness with respect is to call a person by his or her first name with the title Mr. or Miss (pronounced “miz” similar to “Ms.,” when refer- ring to women, whether single or married); for example, Miss Lillian or Mr. Bill. Miss Lillian may or may not be married. There is also a need to provide a link with both families of origin. Many times Appalachians refer to a married woman as “she was [born] a . . . ,” thus linking the families and enhancing the feeling of continuity.

To communicate effectively with traditional Ap- palachians, health-care workers must not ignore speech patterns; they must clarify any differences in word mean- ings, translate medical terminology into everyday lan- guage using concrete terms, explain not only what is to be done but also why, and ask clients to repeat or demon- strate instructions to ensure understanding. Adopting an attitude of respect and flexibility demonstrates interest and helps bridge barriers imposed by health-care workers’ personal ideologies and cultural values. Throughout his- tory, Appalachians have enjoyed storytelling, a practice that still continues; accordingly, some individuals may respond better to verbal instructions and education, with reinforcement from videos rather than printed communi- cations.

PEOPLE OF APPALACHIAN HERITAGE • 99

V I G N E T T E 5 . 2

Dr. Smythe has just finished his residency training and has moved to a small town in Appalachia to serve out his com- mitment of government service as payment for medical school. He is married and has three school-aged children. He is opening a general medical practice with another physician who has lived in the area for 30 years and is getting ready to retire. The community in which he will live is approximately 150 miles from any large metropolitan area. Although shop- ping areas are limited, the community does support several schools, churches, and community centers. In fact, the com- munity boasts the prowess of their “boys” and “girls” basket- ball teams who generally finish high in the state rankings each year. Most of the families who live here can trace their her- itage back 200 or more years. Once Dr. Smythe has moved in, he sends his children out of the area to boarding schools, and he and his wife travel to the larger city to attend church on Sundays. His wife is seldom observed shopping in local stores. He prefers to spend his “off-time” playing golf with fel- low physicians from larger, neighboring communities and has, so far, not engaged in community service activities.

1. How do you think the community will respond to Dr. Smythe and his family? How might the local people perceive him?

2. What do you think Dr. Smythe and his family will need to do to be accepted into the community?

3. Identify potential communication problems that might arise in the clinical setting between Dr. Smythe and his patients.

TEMPORAL RELATIONSHIPS

The traditional Appalachian culture is “being”-oriented (i.e., living for today) as compared with “doing”-oriented (i.e., planning for the future). A being orientation not only opposes progress but also may mean ignoring expert advice and “accepting one’s lot in life.” With the poten- tial for economic and cultural lag, other problems may be more pressing, and “just getting by” may be the most important activity. Health-care workers must realize that

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Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

In previous decades, gender roles for Appalachian men and women were more clearly defined. Men were sup- posed to do physical work, to support the family finan- cially, and to provide transportation. Women took care of the house and assumed responsibility for child rearing. Self-made individuals and families, those who carried out their own subsistence and depended little on outsiders, were idealized.

The traditional Appalachian household continues to be patriarchal, although many families are becoming more egalitarian in their beliefs and practices. This is espe- cially true if the woman makes more money than the man. Women are generally the providers of emotional strength, with older women having a lot of clout in health-care matters. Older women are usually responsi- ble for preparing herbal remedies and folk medicines and are sought out by family members and neighbors for these preparations. Older women have a higher status in the community than older men, who in turn have a higher status than younger women. With the advent of better access to education and improved transportation throughout the Appalachian region, more women are working outside the home, thus creating an environment in which gender roles are becoming more egalitarian.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

Children are important to the Appalachian culture (Coyne et al., 2006). Large families are common and chil- dren are usually accepted regardless of whether the par- ents are married. Parents may impose strict social confor- mity for family members in fear of community censure and their own parental feelings of inferiority. Permissive behavior at home is unacceptable, and hands-on physical punishment, to a degree that some perceive as abuse, is common. For Appalachian children who have problems with school performance, the most effective approach to increase performance is to provide individualized atten- tion rather than group support or attention, an approach that is congruent with the ethic of neutrality. To be effec- tive in changing negative behavior, it is necessary to emphasize positive points.

As children progress into their teens, mischievous behavior is accepted but not condoned. Continuing for- mal education may not be stressed because many teens are expected to get a job to help support the family. Children are seen as being important, and to many, hav- ing a child, even at an early age (less than 18 years), means fulfillment. Motherhood increases the woman’s status in the church and the community. In previous gen- erations, it was not uncommon for teenagers to marry by the age of 15, and some as early as 13. Children, single or married, may return to their parents’ home, where they are readily accepted, whenever the need arises.

Teens in Appalachia are often in a cultural dilemma upon exposure to other lifestyles outside the home and

family. Health-care workers can assist adolescents and family members in working through these cultural differ- ences by helping them resolve personal conflicts. One way is to promote a positive self-awareness that conveys a respect for their culture, by discussing personal parenting practices, and by providing information about health promotion and wellness; disease, illness, and injury pre- vention; and health restoration and maintenance in a culturally congruent way.

FAMILY GOALS AND PRIORITIES

Appalachian families take great pride in being indepen- dent and doing things for themselves. Even though eco- nomics may permit paying others to do some tasks, great pride is taken in being able to do for oneself. This is an area in which one of the authors can still strongly relate to Appalachian roots. Even though reaching a financial position at which he can pay someone to do chores on home and farm, he continues to take pride in doing them for himself. For many, family priorities include men get- ting a job and making a living and, for women, bearing children. Traditionally, nuclear and extended families are important in the Appalachian culture, so family members frequently live in close proximity. Relatives are sought for advice on child rearing and most other aspects of daily living.

Elders are respected and honored in the Appalachian family. Grandparents frequently care for grandchildren, especially if both parents work. This form of child care is readily accepted and is an expectation in large extended families. Elders usually live close to or with their children when they are no longer able to care for themselves. The physical structure of the home is designed to assist aging parents. Many adult children do not consider nursing home placement because it is the equivalent of a death sentence. Migration of children out of the home area may force many older people to relocate outside their home area to be with their children. A dilemma occurs because they have an equally strong Appalachian value of attach- ment to place and family. As a compromise, some practice “snow birding”—leaving their home in the winter and moving in with their children, then returning to their home in the summer. It is not unusual for adult children to drive 3 to 5 hours on days off work to spend time with and help maintain their aging parents at their homes in Appalachia.

One’s obligation to extended family outweighs the obligations to school or work. The nuclear family feels a personal responsibility for nieces and nephews and read- ily takes in relatives when the need arises. This extended family is important regardless of the socioeconomic level. Upon migration to urban areas, the nuclear family becomes dominant because the extended family is usu- ally left behind in Appalachia. This strong sense of family, in which the family distrusts outsiders and values privacy, can be a deterrent to getting involved in community activities or joining self-help group activities.

The Appalachian family network can be a rich resource for the health-care worker when health teaching and assistance with personalized care are needed. For pro- grams with Appalachians to be effective, support must

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begin with the family, specifically the grandmothers, and immediate neighborhood activities. The health-care worker must respect each person as an individual and be nonbureaucratic in nature. The family, rather than the individual, must be considered as the basic treatment unit.

Social status is gained from having the respect of family and friends. Formal education and position do not gain one respect. Respect has to be earned by proving that one is a good person and “living right.” Living right is based on the ethic of neutrality and on being a good “Christian per- son.” Having a job, regardless of what the work might be, is as important as having a prestigious position. Families are very proud of their family members and let the entire community know about their accomplishments. In some instances, migration to the city may result in mixed views toward one’s status. Monetary gain does not necessarily improve one’s status in the family and community. Rather, skills and character traits that allow one to achieve finan- cial comfort are given high status.

ALTERNATIVE LIFESTYLES

Alternative lifestyles including single and divorced par- ents are usually readily accepted in the Appalachian cul- ture. Same-sex couples and families living together are accepted, but rarely discussed. Such acceptance is congru- ent with the ethic of neutrality, the Appalachian need for privacy, not interfering with other’s lives unless asked to do so, avoiding arguments, and seeking agreement, even though agreement may be implied rather than spoken.

Workforce Issues CULTURE IN THE WORKPLACE

As many Appalachians value family above all else, report- ing to work may become less of a priority when a family member is ill or other family obligations are pressing. When family illnesses occur, many Appalachian individu- als willingly quit their jobs to care for family members. For some, the preferred work pattern is to work for an extended period of time, take some time off, and then return to work. Although work patterns may change, a deep-seated work ethic exists. Liberal leave policies for funerals and family emergencies are seen as a necessary part of work environment.

Because personal space is important, many Ap- palachians use a greater distance when communicating in the workplace. Close, face-to-face encounters, hugs, and the like are rarely seen. A harmonious environment that fosters cooperation and agreement in decision making is valued and desired. Health-care workers who come from outside the area may have some difficulty establishing rap- port in the workplace if they lack an understanding and appreciation for Appalachian workplace etiquette.

Appalachian individuals usually wish to maintain independent lifestyles and often frown upon or not engage in the latest fads of the larger, macroculture. Although most people want progress, they also wish to remain isolated from the mainstream. Thus, more tradi-

tional Appalachians may be slower to assimilate the val- ues of middle-class society into their daily work habits.

ISSUES RELATED TO AUTONOMY

In general, a lack of leadership is not uncommon because ascribed status is more important than achieved status and because there is an attempt to keep hierarchal rela- tionships to a minimum (Coyne et al., 2006). The Appalachian ethic of neutrality and the values of individ- ualism and nonassertiveness, with a strong people orien- tation, may pose a dichotomous perception at work for outsiders who may not be familiar with the Appalachian way of life. However, when conflicts occur, mutual col- laboration for seeking agreement is consistent with the ethic of neutrality. Because many Appalachians align themselves more closely with horizontal rather than hier- archical relationships, they are sometimes reluctant to take on management roles. When they do accept man- agement roles, they take great pride in their work and in the organization as a whole.

Most middle-class Americans gain self-actualization through work and personal involvement with doing. Appalachians seek fulfillment through kinship and neigh- borhood activities of being. To foster positive and mutu- ally satisfying working relationships, organizations should capitalize on individual strengths such as independence, sensitivity, and loyalty, which are recognized values in the Appalachian culture. Many Appalachians prefer to work at their own pace, devising their own work rules and methods for getting the job done. Some local factories, mines, lumber, and health-care facilities that hire man- agers and administrators from outside the region often provide educational seminars about the Appalachians’ worldview, work culture, and way of life in order to foster cultural sensitivity and a general understanding of the people with whom they work.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Since its first settlement, the Appalachian region has had a predominantly white population with little variation over time. Some individuals can trace their heritage to a mix- ture of white ancestry along with Cherokee, Apalachee, Choctaw, and other indigenous tribes of the region. A few blacks, a distinct minority of 3.2 percent, may identify themselves as Appalachian, and intermarriage with Native Americans and white settlers was not uncommon (ARC, 2006a). The influence of Native Americans and blacks can be seen in skin color along with pronounced epicanthic eye folds, high cheekbones characteristic for Native American ancestory, and darker skin tone and black, curly hair that is a characteristic in black people.

DISEASES AND HEALTH CONDITIONS

Those Appalachians who have migrated and live in the urban centers of the north are often exposed to poor

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housing conditions that include inadequate sewage and plumbing systems, lack of refrigeration, and various envi- ronmental problems stemming from industrial pollution (Obermiller & Brown, 2002). Even those who have remained and live in Appalachia are often exposed to sub- standard housing where there is a lack of safe potable water and sewage disposal (GMEC, 2000).

Although national safety programs implemented by the Occupational Safety and Health Administration have been implemented throughout Appalachia, many people are still exposed to the harmful by-products of the pre- dominant occupations in the region—farming, textile manufacturing, mining, furniture making, and timber- ing (ARC, 2006a). Occupational hazards include respira- tory diseases such as black lung, brown lung, emphy- sema, and tuberculosis. The incidence of other health conditions including hypochromic anemia, otitis media, cardiovascular diseases, female obesity, non–insulin- dependent diabetes mellitus, and parasitic infections is greater than the national norm (GMEC, 2001; Huttlinger et al., 2004a). White Appalachian residents may have a 20 percent greater chance of dying from heart disease between the ages of 35 and 64 than other white Americans. This rate may be due to limited access to healthy foods, a general lack and use of recreational facilities, and a lack of access to medical care (GMEC, 2001; Centers for Disease Control and Prevention [CDC], 2001). Appalachia is one of the areas in the United States with the highest rate of disability (Hurley & Turner, 2000).

Children are at greater risk for sudden infant death syndrome, congenital malformations, and infections. The infant mortality rate throughout the Appalachian region varies greatly, with an overall rate of 7.7 per 100 live births, which is lower than the national average of 7.9. However, the states of Alabama, Mississippi, and North Carolina have an infant mortality rate that exceeds the national rate (ARC, 2006a). Only 70 percent of children are immunized, compared with 90 percent for the nation as a whole. Childhood injuries due to burns, trauma, poi- soning, child neglect, and abuse are also higher than the national average (Voices of Appalachia, 2001).

Cancer, suicide, and accident rates in some parts of Appalachia are significantly greater than the national average. The higher rate of cancer in Appalachia prompted the National Cancer Institute in 1999 to create the Appalachian Leadership Initiative on Cancer (ALIC) to help communities challenge cancer at the grassroots level. Through ALIC, significant progress has been made on screening for cervical and breast cancer among low- income older women (CDC, 2004).

Educational information presented in a nonjudgmen- tal manner can have a significant impact on the health of Appalachian clients. Clients generally prefer verbal rather than printed material to obtain health-related informa- tion. In fact, an effective success strategy used by ALIC is storytelling, a strong tradition in Appalachia and one in which people can relate. Thus, the presentation of health and educational material needs to include the entire fam- ily and be linked with improvement in function in order to be taken seriously.

VARIATIONS IN DRUG METABOLISM

Current medical and research literature reports no studies specific to the pharmacodynamics of drug interactions among Appalachians. Given the diverse gene pool of many residents, the health-care worker needs to observe each individual for adverse drug interactions.

High-Risk Behaviors Compared with non-Appalachians, Appalachians seem to be less concerned about their overall health and risks associated with smoking (Huttlinger et al., 2004a, 2004b). Their use of smokeless tobacco is the highest in the coun- try, and deaths from tobacco-related uses are the highest in the nation (CDC, 2004). Underage use of tobacco and alcohol is widespread among teens.

The Appalachian definition of health encompasses three levels: body, mind, and spirit. This definition pre- cludes viewing disease as a problem unless it interferes with one’s functioning. Consequently, many conditions are denied or ignored until they progress to the point of decreasing function. (Nutrition practices are covered more extensively later in the chapter.)

OxyContin has become one of the most widely abused drugs in America. Dubbed “Hillbilly heroin,” it has become the drug of choice for narcotic abusers in Appalachia. Although chronic pain sufferers are finding it increasingly difficult to obtain, elaborate OxyContin underground transportation systems have developed to sustain a lucrative drug trafficking business throughout many mountain communities (Hays, 2004; Lubell, 2006). There has been a tremendous response from lawmakers and law enforcement agencies throughout the region to curb the trafficking of OxyContin. The result is that many physicians have become increasingly unwilling to pro- vide the drug, even to the cancer patients and chronic pain sufferers who need it (Lubell, 2006). One woman with cancer relates how she searched 7 months before she found a specialist near Cincinnati who would prescribe OxyContin for her (Hays, 2004).

Several states have tightened the control of Oxy- Contin. At least nine have limited Medicaid patients’ ac- cess to the drug. Virginia adopted a resolution to study the use and abuse of OxyContin, whereas Kentucky has legislation pending that would restrict distribution of the drug. In Virginia, police have provided fingerprint kits to pharmacies for customers wanting OxyContin (ARC, 2006b; Lubell, 2006).

Another high-risk behavior involves the proliferation of methamphetamine laboratories throughout Appalachia. The seclusion of mountain hollows and the number of remote and available barns and sheds have contributed to the rise in methamphetamine production. This highly addictive drug is made using common ingredients such as over-the-counter (OTC) cold medications, acetone, and rock salt. Setting up a laboratory doesn’t require a lot of room. Unfortunately, ingredients and recipes aren’t hard to find. It is cooked up in homemade laboratories using items such as paint thinner, camping fuel, starter fluid,

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gasoline additives, mason jars, and coffee filters (U.S. Drug Enforcement Agency [DEA], 2006a).

Marijuana abuse and trafficking is a serious problem throughout the region and especially in the more remote areas. Tennessee is a major supplier of domestically grown marijuana. In fact, the DEA (2006b) reported that Tennessee, along with West Virginia and Kentucky, pro- duces the majority of the U.S.’s supply of domestic mari- juana. Prosecution of marijuana growers in the state has been extremely difficult owing to a lack of intelligence and because many of the domestic marijuana sites detected are so small that even if the owner/grower were identified, the U.S. Attorney would be reluctant to prose- cute (DEA, 2006b).

HEALTH-CARE PRACTICES

A 10-step pattern of health-seeking behaviors has been identified among Appalachians.

1. At the onset of symptoms, Appalachians typi- cally implement self-care practices that are usu- ally learned from mothers.

2. When the symptoms persist, they call their mother, if she is available.

3. If the mother is unavailable, they call the female in their kin network who is perceived as knowledgeable regarding health. If a nurse is available, they may seek the nurse’s advice.

4. If relief is not achieved, they use OTC medicine they have seen advertised on television for symptoms that most closely match their own.

5. If that is ineffective, they use some of “Mable’s medicine” (she lives down the road, had similar symptoms, and did not finish her medicine).

6. Next, they ask the local pharmacist for a rec- ommendation; this usually marks the first encounter with a professional health provider. (Of course, they usually do not tell the pharma- cist that they tried Mable’s medicine.) The pharmacist may strongly suggest that they see a health-care provider; however, on their insis- tence, the pharmacist may recommend another OTC medication.

7. When no relief is achieved, they seek a local health-care provider or utilize local emergency- and urgent-care centers.

8. If the condition does not resolve itself, the local health-care provider refers them to a specialist in the area or to a larger urban area (e.g., Lexington, Cincinnati).

9. The specialist treats the condition to the best of her or his ability.

10. If unsuccessful, the specialist refers him or her to the closest tertiary medical center.

These 10 steps may not always follow the sequence pre- sented here; some steps may be skipped, and not all steps are always completed. Moreover, the time frame around these 10 steps may be several years. Often by the time typi-

cal Appalachians are referred for definitive treatment, com- pensatory reserves have been depleted and they die at large medical centers. The story is then passed on in the “holler”: “So-and-So went to [Hospital X] and died.” This pattern leads to a significant mistrust of large medical centers and continued reluctance to use these facilities effectively.

Health-care workers can have a significant impact on improving a client’s health-seeking behaviors by providing information early in this pattern. Nurses especially can help to reverse this pattern because they are viewed as knowl- edgeable, nonjudgmental, and respectful of Appalachian lifestyles.

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V I G N E T T E 5 . 3

A public health nurse is traveling to a remote area of Appalachia on a follow-up visit to check on a baby born 2 weeks ago at home with the assistance of a granny midwife. The granny midwife left a written description of the uncom- plicated, term birth for the nurse so the nurse is making a ser- vice visit to talk with the new mother about well-baby care, immunization schedules, and nutrition and to answer any questions that the mother, aged 17, might have about the care of her new infant. Travel to the home is along unpaved and winding roads with no signage. Upon reaching her destina- tion, the nurse notes that the family is living in a clearing in a mobile home. There is no sign of electricity, but she sees a gasoline-powered generator on one side of the dwelling and hears the sounds of a stream nearby. Three shedlike buildings are within 150 feet of the home. She tries to call into the pub- lic health department to tell them that she has arrived at her destination, as per protocol, but there is no reception for her cell phone. As she exits her car, she notes that one of the buildings has a small greenhouse behind it and another has a “chemical”-smelling smoke coming from a chimney. Several cooking pans, milk cartons, kerosene cans, and other debris are piled outside of the building with the smoke.

1. Given the location and description of this home, what activity do you believe might be taking place?

2. Discuss courses of action the nurse should take. 3. Should the nurse continue with her original assign-

ment? Why? Why not?

Nutrition MEANING OF FOOD

As with most ethnic and cultural groups, food has meaning beyond providing nutritional sustenance. To many Appalachians, wealth means having plenty of food for fam- ily, friends, and social gatherings. One should drink plenty of fluids and eat plenty to have a strong body. A strong body is a healthy body. Food and the sharing of food has broad social implications. Applalachians love to get together with family members, friends, and neighbors for meals. Weekend meals at a family member’s home are common and serve as a mechanism to share information, community events and happenings, and gossip. Church suppers are also common- place, with members contributing favorite dishes.

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COMMON FOODS AND FOOD RITUALS

Many Appalachians, and especially those living in the more remote areas, include wild game in their diet. Muskrat, groundhog, rabbit, squirrel, duck, turkey, and venison commonly supplement “store-bought” meats. Wild game traditionally has a lower fat content than meat raised for commercial purposes. However, consistent with tradi- tional practices from previous decades, most parts of both wild and domesticated animals are eaten. High-cholesterol organ meats such as tongue, liver, heart, lungs (called lights), and brains are considered delicacies. Bone marrow is used to make sauces, and stomach, intestines (chitlins or chitterlings), pigs’ feet, tail, and ribs are also commonly eaten. Low-fat game meat is usually breaded and fried with lard or animal fat, negating the overall gains from these low-fat meat sources. Most diets include sweet prepackaged drinks, Kool-Aid with added sugar, very sweet iced tea, and soda.

Food preparation practices may increase dietary risk factors for cardiac disease because many recipes contain lard and meats are preserved with salt. Other common foods in particular regions of Appalachia that may be unfamiliar to non-native Appalachians are sweet potato pie; molasses candy; apple beer; gooseberry pie; pumpkin cake; and pickled beans, fruit, corn, beets, and cabbage, all of which are high in sodium. Frying foods with bacon grease or lard was once a common practice, but recent publicity on the dangers of lard have initiated a cut-back in its use in cooking (Huttlinger et al., 2004a). Fried green tomatoes, biscuits, and thick gravies are favorites.

Appalachians celebrate Thanksgiving, Christmas, other national and religious holidays, and many other occa- sions with food. In rural areas, people celebrate with food when game and livestock are slaughtered because this is usually an extended-family or community affair. The value of self-reliance is enhanced during the “cannin’” season when foodstuffs are preserved. Canning becomes a social or family occasion and is an excellent avenue for health teaching if the health-care provider is willing to participate and learn. Additional celebrations with food occur during times of death and grieving, when friends and participants bring dishes specifically prepared for the occasion.

DIETARY PRACTICES FOR HEALTH PROMOTION

Many Appalachians believe that good nutrition has an effect on one’s health. In one study with rural Ap- palachians, young mothers were asked what it meant to eat well for good health. They referred to “taking fluids” and “eating right,” but they were unable to describe healthy eating patterns any further (Gainor, Fitch, & Pollard, 2006). Because of health intervention programs, publicity though television, magazines, newspapers, and the internet, residents of most Appalachian communities are aware of “good foods” and “bad foods” in terms of general health. However, a lack of money and having a meager budget including Food Stamps may limit choices.

Many believe that the sooner a baby can take food other than milk, the healthier it will be. At one time, babies from the first month were fed grease, sugar, and

coffee to promote hardiness, but the practice seems to have fallen by the wayside with the younger generations of mothers. One author fondly remembers being fed tea- spoons of bacon grease as a child to be sure to growing up strong and healthy. Another example is a family who saved the skin from fried chicken for the author to eat to increase his body fat, because they believed that he was too thin. The Women, Infants, and Children program, commonly known as WIC, has done much to change some of these practices. Health-care workers have a rich opportunity to provide education in healthy eating prac- tices. Factual information that describes health risks with early feeding of solid foods may help prevent later nutri- tional allergies in children.

An example of how a community intervention can work is illustrated by the decrease in the incidence of hypertension in one community. A local health-care worker participated in the cannin’ of beans and showed the residents that the beans would remain crisp with a “tige (a pinch) of vinegar” rather than a “pile of salt.” It is essential for health-care workers to assess specific food practices and food preparation practices in order to pro- vide effective dietary counseling for health promotion and wellness. Health-care workers in clinics and school settings have an excellent opportunity to have a positive impact on the nutritional status of individuals and fami- lies. School breakfast and lunch programs, Meals on Wheels, and church-sponsored meal plans are some of the ways in which health-care workers can encourage and support families to attain better nutrition practices.

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

A common practice for rural and urban Appalachian chil- dren is to replace meals with snacks. The most common snacks are candy, salty foods, desserts, and carbonated beverages. Many adolescents skip breakfast and lunch entirely, preferring to eat snack foods. This pattern of snacking can result in deficiencies in vitamin A, iron, and calcium.

No specific food limitations or enzyme deficiencies exist among Appalachians. With subsistence farming and commercial farms from nearby areas, all foods for a healthy diet are readily available during the growing sea- son. Even though the climate is ideal for growing a large variety of vegetables, broccoli, cauliflower, or asparagus are rarely seen as vegetables of choice in the mountainous regions of Appalachia.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

Birth outcomes among some regions of Appalachia are poorer than among middle-class white groups in rural, suburban, and urban populations. In one study compar- ing birth outcomes among rural, rural-adjacent, and urban women, rural women had the worst birth outcomes

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overall; rural-adjacent women had the best birth out- comes of the three groups, yet were the youngest, least educated, least likely to be married, and least likely to be privately insured (Gainor et al., 2006). Contraceptive practices of Appalachians follow the general pattern of the U.S. population. Methods include birth control pills, condoms, and tubal ligation; abortion is an individual choice. A popular belief among many is that taking laxa- tives facilitates an abortion. As a group, a disproportion- ate number of teenage pregnancies occur at a younger age compared with non-Appalachians.

Fertility practices and sexual activity, both sensitive topics for many teenagers, are areas in which outsiders unknown to the family may be more effective than health-care practitioners who are known to the family. To be effective, counseling by the health-care provider must be accomplished within the cultural belief patterns of this group and must be approached in a nonhierarchical manner, preferably with a health-care provider of the same gender.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Although the literature reports no specific research or studies related to prescriptive, restrictive, or taboo prac- tices during pregnancy, the following are some of the cur- rent beliefs:

• Pregnant women subscribe to the belief that to have a healthy baby they need to eat well and take care of themselves.

• Boys are carried higher and the mother’s belly appears pointy, whereas girls are carried low.

• The expectant mother should not have her pic- ture taken because it can cause a stillbirth.

• Reaching over one’s head can cause the cord to strangle the baby.

• Wearing an opal ring during pregnancy may harm the baby.

• Being frightened by a snake or eating strawberries or citrus fruit can cause birthmarks.

• If the mother experiences a tragedy, a congenital anomaly may occur.

• If the mother craves a particular food during her pregnancy, then she should eat that food or the baby will have a birthmark resembling the craved food.

Childbearing is a family affair. The birthing mother is expected to accept childbirth as a short, intense, natural process that will bring her closer to the earth and must be endured (Gainor et al., 2006).

The literature reports no specific studies on beliefs related to postpartum practices. When a new baby is born, relatives and extended family members gather to assist the new mother with household chores until she is able to complete them herself. Some newborns wear a band around the abdomen to prevent umbilical hernias and an asafetida bag around the neck to prevent or ward off contagious disease. The health-care professional pro-

viding pregnancy counseling to the Appalachian family needs to demonstrate an openness to discuss cultural differences.

Death Rituals DEATH RITUALS AND EXPECTATIONS

When a death is expected, family and friends may stay through the night and prepare food for the event. Because death is such an important occasion in Appalachia, many employers give workers 3 days of funeral leave for deaths of extended family members. After a death, extended family and friends may spend the night with the deceased’s immediate family to prevent loneliness.

Deaths in Ohio, Michigan, and other adjoining states are frequently published in Appalachian newspapers with a notice that the individual will be returned to their mountain home for burial. Funeral services serve an important social function and are usually simple. This is a time when extended family and friends come together for services that can last for 3 hours or longer. The length of time for a service varies according to the age of the deceased. The service for an older person may be longer than that for a younger person. The body is displayed for hours, either in the home or at the church, so that all those who wish to view the body can do so. At the end of the service, all who wish to can view the body again, with the closest relative being the last. Many Appalachian fam- ilies go to funeral homes that specialize in personal ser- vices to the Appalachian culture. Urban Appalachian areas have funeral homes that specialize in long-distance transport for burial and have become familiar with Appalachian customs to meet culturally specific require- ments.

The deceased is usually buried in her or his best clothes. Some individuals have a custom-made set of clothes in which to be buried and may even design their own funeral services long before their death. A common practice is to bury the deceased with personal possessions. At the funeral home, the person’s favorite chair, a picture of the deceased, or other personal items may be displayed. Flowers are more important than donations to a charity. Cremation is an acceptable practice, and disposition of the ashes is a personal decision. After the funeral services are completed, elaborate meals are served either in the home or at the church. Services are accompanied by singing before, during, and after the service. Cemeteries through- out Appalachia show frequent visitations and give a sense of place and relationship to the land. Plots are carefully tended with displays of flowers, wreaths, and flags. Other beliefs regarding burial practices include placing grave- yards on hillsides for fear that graves may be flooded out in low-lying areas. If the body is exhumed and reburied, it is believed that the person may not go to heaven.

RESPONSES TO DEATH AND GRIEF

Clergy help families through the grieving process by pro- viding counseling and support to family members. Family members, fellow church members, friends, and community

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leaders often assist the bereaved. Typically, family mem- bers get together and reminisce about their deceased loved one. Friends and neighbors bring food for about a week and share memories of the “one who passed on.”

Spirituality DOMINANT RELIGION AND USE OF PRAYER

The original inhabitants of Appalachia were mostly Protestant and Episcopalian. In the early settlement years, as central organization of churches was difficult to retain, people individualized their chosen church structure. Today, the predominant religions in the Appalachian region are Baptist, Methodist, Presbyterian, Holiness, Pentecostal, and Episcopalian. For most Appalachians, the church is the center for social and community activi- ties. Some of the more religiously devout pray daily whether or not they formally attend church. Very often, religious beliefs are of a spiritual nature and not tied to the tenets of any singular faith and reflect the harmony of the mountains and being at one with life.

In addition to Protestant and Episcopalians, there are congregations of Roman Catholics and Jehovah’s Wit- nesses as well as other groups who, although they call themselves Baptists, are not associated with the national church organization. These Baptist “sects” are quite diverse and have important central beliefs, including the belief in autonomy at the local level. As a result, many divisions have occurred within and among churches to accommodate more personal beliefs and philosophies. Regardless of the denomination, most churches in the region stress fundamentalism in religious practices and use the King James Version of the Bible.

Many small churches have lay preachers instead of trained ministers, and there is a belief that to be a preacher, a person must have a divine calling. Thus, a minister may or may not be ordained. Many of the Baptist faiths believe that baptism must be done in a river, pond, or lake so that the body can be submerged. Another prac- tice, feet washing, is believed to demonstrate humility and occurs when men wash men’s feet and women wash women’s feet. Many of the more fundamentalist churches segregate women and children from men in the seating arrangement within the church—men and older boys sit on one side, and women and children sit on the opposite side. In some churches, men sit on the right side of the church to represent the “right hand of God,” while women sit on the left (Huttlinger, personal communica- tion, 2006).

Some denominations believe in divine healing, and the region is full of examples to testify to its effective- ness. Two or more weekly services are common, and revival meetings are customary. Revivals tend to be lively, allowing individuals to shout out when the spirit moves them. Some denominations speak in tongues and believe in visions. Stringed music is played in some churches.

Some freewill churches, for example, the Holiness Church, preach against attending movies, ball games, and social functions where dancing occurs. Other sects believe

in handling poisonous snakes. Although the practice is rare, it is believed that the snake will not bite those who have faith. A few people do get bitten by snakes, and their usual course of action is to heal themselves rather than to go to a hospital even though deaths occur each year fol- lowing snake-handling rituals.

Another practice, the ingestion of strychnine in small doses during religious services, is believed to increase sen- sory stimuli. Needless to say, this practice can precipitate convulsions if ingested in large enough amounts. Fire- handling is still practiced by some groups, again with the belief that the hot coals will not burn those who have faith.

Prayer for many Appalachians is a primary source of strength. Prayer is personally designed around specific church and religious beliefs and practices, which vary widely throughout the region and between and among churches of similar faith.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

Meaning in life comes from the family and “living right,” which is defined by each person and usually means living right with God and in the beliefs of a chosen church. Religion tends to be less focused on institutional rituals and ceremonies and consists more of personalized beliefs in God, Christ, and church. Because life in the moun- tainous regions can often be harsh, religious beliefs and faith make life worth living in a grim situation. The church provides a way of coping with the hurts, pains, and disappointments of a sometimes hostile environ- ment and becomes a source for celebration and a social outlet.

Common themes that give Appalachians strength are family, traditionalism, personalism, self-reliance, religios- ity, a worldview of being, and not having undue concern about things that one cannot control, such as nature and the future. Appalachians believe that rewards come in another life, in which God repays one for kind deeds done on earth.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Within the context of fatalism comes the belief that what happens to the individual is largely a result of God’s will. Many Appalachians may not seek health care until symptoms of illness are well advanced. This practice is described more thoroughly under “High-Risk Behaviors,” earlier in this chapter. Forming partnerships between health-care workers and faith-related organizations for health promotion and illness and disease prevention has strong potential for improving the health status of Appalachians. Health-care workers who are aware of clients’ religious practices and spirituality needs are in a better position to promote culturally competent health care and to incorporate nonharmful practices into clients’ care plans. Practitioners must indicate an appreciation and respect for the dignity and spiritual beliefs of Appalachians without expressing negative comments about differing religious beliefs and practices.

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Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

Beliefs that influence health-care practices for many Appalachians are derived from concepts such as family, fatalism, traditionalism, self-reliance, individualism, and the ethic of neutrality. Even though many Appalachians believe that health is God’s will, the concept of self- reliance can foster good health practices through self- care. Many may not see formal biomedical health-care practitioners until self-medicating and folk remedies have been exhausted. At one time, Appalachians, compared with non-Appalachians, were less likely to use the emer- gency room or to have private physicians, but the trend has since changed and emergency rooms and urgent-care centers are communly used (GMEC, 2000; Obermiller & Brown, 2002).

Health information on the Appalachian client should be gathered in the context of broader family relationships and cordiality that precedes information sharing, as the family rather than the individual is the basic unit for treatment. Because direct approaches are frowned upon, health-care workers need to learn to approach sensitive topics, such as contraception and alcohol and drug use, indirectly. Many Appalachians expect the health-care worker to establish an advocacy role and to understand and accept their cultural differences; thus, it is best to involve professionals from the same backgrounds, if they are available.

Huttlinger et al. (2004a) surveyed a large sample of Appalachians from southwestern Virginia and northeast- ern Tennessee to determine access to health care. They also addressed factors related to “good health.” Over 75 percent stated that their health was “God’s will,” and over half stated that their families, church, and community played a vital role in their overall health and well-being.

RESPONSIBILITY FOR HEALTH CARE

When entering the biomedical health-care arena, Ap- palachians might feel powerless to control their own health. They often abdicate responsibility for their own care and expect that the health-care worker will com- pletely take over their care. Many have high expectations for their health-care worker and provider, with an unreal- istic dependence on the system and an abandonment of more self-reliance activities (Coyne et al., 2006).

One major health concern for many Appalachians is the state of the blood, which is described as being thick or thin, good or bad, and high or low; these conditions can be regulated through diet (Huttlinger, personal communi- cation, 2006; Obermiller & Brown, 2002). Venereal dis- ease and Rh-negative blood fall into the category of bad blood. Sour foods can also cause bad blood. Appalachian men, in general, report a greater number of backaches, with women reporting a greater number of headaches, than the rest of society (Coyne et al., 2006).

Self-care is a primary focus of health. Self-care is pri- marily perceived as an individual responsibility, and care is focused within the family rather than within the com-

munity. Because many Appalachians value the ability to respond to, and cope with, events of daily life, home remedies, treatments, and active consultation with family members are sought before seeking outside help (Huttlinger et al., 2004a). Good health is feeling well and being able to meet one’s obligations. Care within the medical system is used when the condition is perceived as serious, does not respond to self-care, or has a high potential for death. Furthermore, because self-reliance activities and nature predominate over people, many believe that it is best to let nature heal. Health-care work- ers need to keep this in mind when giving explanations and instructions to make them more acceptable to clients and their families.

When older Appalachians go to a physician or another health-care provider, they usually expect immediate help. Physicians who dispense medications in their offices are seen as helpful; providing presciptions may be interpreted as rejection. The average Appalachian client does not understand the restrictions and limitations that are placed on physicians and nurse practitioners with respect to dispensing “sample” medications.

Health-care workers can assist Appalachian clients by reinforcing their preferred coping methods and strategies when they are ill. The five most frequently used coping methods are helping, thinking positively, worrying about the problem, trying to find out more about the problem, and trying to handle things one step at a time. Coping strategies include talking the problem over with friends, praying, thinking about the good things in life, trying to handle things one step at a time, and trying to see the good side of the situation (Hunsucker, Flannery, & Frank, 2000). When establishing rapport, a health-care worker can go a long way in achieving trust by using churches, grange halls, and other community places (e.g., libraries, schools) as meeting places for the entire family to work with Appalachian families at the community level.

FOLK AND TRADITIONAL PRACTICES

A strong belief in folk medicine is a traditional part of the Appalachian culture. Using herbal medicines, poultices, and teas is common practice among individuals of all socioeconomic levels. Table 5–1 presents a reference guide for the health-care practitioner with the major ingredi- ents and conditions for which the folk treatments are used. These treatments can be adjusted to accommodate prescription therapies or education regarding folk treat- ments. Information in this table has been derived from the Foxfire series, the authors’ backgrounds and experi- ences, and health-care workers who practice in the area. Note that specific amounts are not given, and in many cases, the amounts vary from person to person, according to the geographic region and local family practices. Local names are given rather than scientific names because this is how the residents identify them. Many folk and tradi- tional practices were learned from the Cherokee and Apalachee Indians living in the region and have been passed down from generation to generation. Although many of these home remedies are not harmful, some may have a deleterious effect when used to the exclusion of, or in combination with, prescription medications. This

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T A B L E 5.1 Health Conditions and Appalachian Folk Medicine Practices

Health Condition Folk Medicine Practices

Arthritis Make tea from boiling the roots of ginseng. Drink the tea or rub it on the arthritic joint. Mix roots of ginseng and goldenseal in liquor and drink it. Ginseng is used heavily by many

Koreans and was exported to Korea in the 18th and 19th centuries. Eat large amounts of raw fruits and vegetables. Carry a buckeye around in a pocket. Drink tea from the stems of the barbell plant. Drink a mixture of honey, vinegar, and moonshine (or other liquor). Drink tea made from alfalfa seeds or leaves. Drink tea made from rhubarb and whiskey. Place a magnet over the joint to draw the arthritis out of the joint.

Asthma Drink tea from the bark of wild yellow plum trees, mullein leaves, and alum. Take every 12 hr. Combine gin and heartwood of a pine tree. Take twice a day. Suck salty water up the nose. Smoke or sniff rabbit tobacco. Swallow a handful of spiderwebs. Smoke strong tobacco until choking occurs. Drink a mixture of honey, lemon juice, and whiskey. Inhale smoke from ginseng leaves.

Bedbugs/chiggers Apply kerosene liberally to all parts of the body. Caution: Kerosene can cause significant irritation to sensitive skin, especially when exposed to sunlight.

Bleeding Place a spiderweb across the wound. This is also used in rural Scotland. Put kerosene oil on the cut. Place soot from the fireplace into a cut. Be sure to wash out the soot after bleeding is stopped

or the area will scar. Apply a mixture of honey and turpentine on the bleeding wound. Apply a mixture of soot and lard on the wound. Place a cigarette paper over the wound. Put pine resin over the cut. Place kerosene oil on the wound. Caution: If used in large doses, kerosene will burn the skin.

Blood builders Drink tea from the bark of a wild cherry tree. Combine cherry bark, yellowroot, and whiskey. Take twice each day. Eat fried pokeweed leaves.

Blood purifiers Drink tea from burdock root. Drink tea from spice wood.

Blood tonic Take a teaspoon of honey and a tiny amount of sulfur. Take a teaspoon of molasses and a tiny amount of sulfur. Drink tea made from bloodroot. Soak nails in a can of water until they become rusty. Drink the rusty water.

Boils or sores Apply a poultice of walnut leaves or the green hulls with salt. Apply a poultice of the houseleek plant. Apply a poultice of rotten apples. Apply a poultice of beeswax, mutton tallow, sweet oil, oil of amber, oil of spike, and resin. Apply a poultice of kerosene, turpentine, Vaseline, and lye soap. Apply a poultice of heart leaves, lard, and turpentine. Apply a poultice of bread and milk. Apply a poultice of slippery elm and pork fat. Apply a poultice of flaxseed meal. Apply a poultice of beef tallow, brown sugar, salt, and turpentine.

Burns Apply a poultice of baking soda and water. Place castor oil on the burn. Apply a poultice of egg white and castor oil. Place a potato on the burn. Wrap the burn in a gauze and keep moist with salt water. Place linseed oil on the burn.

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T A B L E 5.1 Health Conditions and Appalachian Folk Medicine Practices (Continued)

Health Condition Folk Medicine Practices

Apply a poultice of lard and flour. Put axle grease on the burn. This is also a practice with some Germans in Minnesota.

Chapped hands and lips Apply lard, grease, or tallow from pork or mutton. Chest congestion Apply a poultice of kerosene, turpentine, and lard to the chest. Make sure the poultice is not

applied directly to the chest but rather on top of a cloth. Apply mutton tallow directly to the chest. Apply a warm poultice of onions and grease. Rub pine tar on the chest. Chew leaves and stems of peppermint. Drink a combination of ginger and sugar in hot water. Make a mixture of rock candy and whiskey. Take several teaspoons several times each day. Drink tea made from ginger, honey, and whiskey. Drink tea made from pine needles. Put goose grease on the chest. Drink red pepper tea. Eat roasted onions. Drink brine from pickles or kraut. Make tea from boneset, rosemary, and goldenrod. Make tea from butterfly weed.

Colic Make tea from calamus root and catnip. (Calamus is a suspected carcinogen.) Tie an asafetida bag around the neck. Drink baking soda and water. Chew and swallow the juice of camel root. Massage stomach with warm castor oil. Drink ginseng tea.

Constipation Take two tablespoons of turpentine. Combine castor oil and mayapple roots. Take castor oil or Epsom salts.

Croup Have child wear a bib containing pine pitch and tallow. Apply cloth to the chest saturated with groundhog fat, turpentine, and lamp oil. Drink juice from a roasted onion. Apply a poultice of mutton tallow and beeswax to the back. Eat a spoonful of sugar with a drop of turpentine. Eat honey with lemon or vinegar. Eat onion juice and honey.

Diarrhea Drink tea from the ladyslipper plant. Place soot in a glass of water, let the soot settle to the bottom of the glass, and drink the water. Drink tea made from blackberry roots. Drink tea from red oak bark. Drink blackberry or strawberry juice. Drink tea made from strawberry or blackberry leaves. Drink tea made out of willow leaves. Drink the juice from the bark of a white oak or a persimmon tree.

Earache Place lukewarm salt water in the ear. Put castor oil or sweet oil in the ear. Put sewing machine oil in the ear. Place a few drops of urine in the ear. Place cabbage juice in the ear. Blow smoke from tobacco in the ear. Place a Vicks-soaked cotton ball in the ear.

Eye ailments Place a few drops of castor oil in the eye. Drop warm salty water in the eye. Drink tea made from rabbit tobacco or snakeroot.

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Fever Drink tea made from butterfly weed, wild horsemint, or feverweed. Mash garlic bulbs and place in a bag tied around the pulse points. Drink water from wild ginger.

Headache Drink tea made of ladyslipper plants. Tie warm fried potatoes around the head. Take Epsom salts. Tie ginseng roots around the head. Place crushed onions on the head. Rub camphor and whiskey on the head.

Heart trouble Drink tea made from heartleaf leaves or bleeding heart. Eat garlic.

High blood pressure (not to Drink sarsaparilla tea. be mistaken for high blood) Drink a half cup of vinegar.

Kidney trouble Drink tea made from peach leaves or mullein roots. Drink tea made from corn silk or arbutus leaves.

Liver trouble Drink tea made from lion’s tongue leaves. Drink tea made from the roots of the spinet plant.

Poison ivy Urinate on the affected area. Take a bath in salt water and then apply Vaseline. Wash the area with bleach. Wash the area with the juice of the milkweed plant. Apply a poultice of gunpowder and buttermilk. Apply baking soda to wet skin.

Sore throat Gargle with sap from a red oak tree. Eat honey and molasses. Eat honey and onions. Drink honey and whiskey. Tie a poultice of lard of cream with turpentine and Vicks to the neck. Apply a poultice of cottonseed to the throat. Swab the throat with turpentine.

T A B L E 5.1 Health Conditions and Appalachian Folk Medicine Practices (Continued)

Health Condition Folk Medicine Practices

should be evident from the 10-step pattern health-seeking behaviors among Appalachians presented in the section on health-care practices.

Because ingredients in some of these herbal medicines can have serious side effects, especially if taken in large quantities, health-care providers must become familiar with folk medicines used by Appalachians as part of client assessments. Health-care workers must ascertain whether individuals intend to use folk medicines simultaneously with prescription medications and treatment regimens so that these remedies can be incorporated into the plan of care and that dialogue can be undertaken to prevent adverse effects. Health-care workers who integrate folk medicine into allopathic prescriptions have a greater chance of improving clients’ compliance with health pre- scriptions and interventions. Health-care workers must remember that today’s scientific medicine may be tradi- tional or folk medicine to the next generation.

BARRIERS TO HEALTH CARE

Barriers to health care for Appalachians are numerous and center on accessibility, affordability, adaptability, accept-

ability, appropriateness, and awareness. Bureaucratic, writ- ten forms foster fear and suspicion of health-care workers, which can lead to confusion, distrust, and negative stereotyping by both parties. Some individuals fear “being cut on” or “going under the knife” and feel that a hospi- tal is a place where you go to give birth or die.

As noted earlier, the rugged terrain and distance to health-care facilities and service is a deterrent to accessing services. Even though ARC has sponsored road-building campaigns in the mountainous regions of Appalachia since 1965, transportation problems continue to exist in parts of the region (see Fig. 5–1). The high rate of unem- ployment in Appalachia means that many people cannot afford basic health care. A disproportionate number of Appalachians, especially those who are self-employed, unemployed, or underemployed, do not have health insurance. For some who do not believe in owing money, seeing a health-care provider may be postponed until the condition is severe or until they have the money. If ser- vices can be offered on a sliding scale, more people may be willing to access them.

Health-care facilities are closing in some areas of Ap- palachia. Most often, the closings are related to decreasing

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availability of health-care workers and the ability to pay competitive salaries, especially for registered nurses (Huttlinger, personal communication, 2006). These changes have resulted in the relocation of highly educated and trained professionals of all professions.

Recent studies have demonstrated that there is not a lack of primary-care providers in Appalachia (Huttlinger et al., 2004a). The shortage of primary-care providers resulted in a large portion of health-care being provided by nurses, which continues today in some areas. There is, however, an acute shortage of specialty providers in respi- ratory and pulmonary diseases, oncology, dental services, and ophthalmology. Those physicians who settle in the region quickly learn that flexible fee schedules, patience, and hands-on treatment approaches work best. Referral to “specialty” care in the larger urban centers must be made with consideration of travel and other expenses. For example, a referral to a pulmonologist in Charlottesville, Virginia, for a person who lives in Wise might require a 3- day trip: 1 full 8-hour day of travel each way, with the expense of gasoline, a relative taking off work to drive the person, and 2 nights in a motel. For some, this is an expense that simply cannot be incurred.

Preventive health services have not been stressed in the past and are not perceived as important by many (GMEC, 2001). Even when services are available, people may feel they are not delivered in an appropriate manner. Outsider health-care workers may be seen as disrespectful of Appalachian ways and self-care practices, and clients may see the health-care workers advice as criticism. If the health-care worker uses language that the patient does not understand, the health-care worker may be perceived as “stuck up.” Many Appalachians do not like the imper- sonal care delivered in large clinics and, therefore, shop around and ask friends and family for suggestions for a private health-care provider. “Sittin’ for a spell and enga- gin’ in small talk” with the patient before an examination or treatment will help ensure return visits for follow-up care.

When health-care facilities have limited hours or are not adaptable, patients may not return for scheduled appointments. For example, a mother may bring her child in for an immunization. If the mother has a health problem and perhaps needs a Pap smear, she may be will- ing to have the test performed while having the child examined. However, if she is given an appointment to return at a later date, she may not keep the appointment because it is too far to travel for a problem she sees as nonurgent. If services are not available during evening hours, people may be afraid of taking time off during reg- ular work hours for fear of losing their job.

CULTURAL RESPONSES TO HEALTH AND ILLNESSES

Appalachians take care of their own and accept a person as a “whole individual.” Thus, those with mental impair- ments or physical handicaps are generally accepted into their communities and not turned away. The mentally handicapped are not crazy but are seen as having “bad nerves,” “quite turned,” or “odd turned.” Appalachians may label certain behaviors as “lazy,” “mean,” “immoral,” “criminal,” or “psychic” and recommend punishment by

either the social group or the legal system or tolerance of these behaviors (Obermiller & Brown, 2002).

Traditional Appalachians believe that disability is a natural and inevitable part of the aging process. Their cul- ture of being discourages the use of rehabilitation as an option. To establish trust and rapport when working with Appalachian clients with chronic diseases, health-care workers must avoid assumptions regarding health beliefs and provide health maintenance interventions within the scope of cultural customs and beliefs.

Individual responses to pain cannot be classified among Appalachians. The Appalachian background is too varied, and no studies regarding cultural beliefs about pain could be found in the literature. For many Ap- palachians, pain is something that is to be endured and accepted stoically. However, when a person becomes ill or has pain, personal space collapses inward, and the person expects to be waited on and to be cared for by others. A belief among many is that if one places a knife or axe under the bed or mattress of a person in pain, the knife will help cut the pain. This practice occurs with child- bearing and other conditions that cause pain. The authors are aware of an Appalachian woman who requested to have a knife or axe placed under the bed or mattress post- operatively to help cut (or decrease) the pain associated with surgery. One of the authors offered a small pock- etknife or butter knife to place under the bed. Both were unacceptable as the pocketknife was too small and the butter knife was too dull to be of use. A sharp meat- cutting knife from the kitchen was deemed appropriate because it was both large enough and sharp enough to help cut the pain.

BLOOD TRANSFUSIONS AND ORGAN DONATION

Appalachians generally do not have any specific rules or taboos about receiving blood, donating organs, or under- going organ transplantation. These decisions are largely one’s own, but advice is usually sought from family and friends.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

For decades, both lay and trained nurses have provided sig- nificant health-care services, including obstetrics. Grannies midwives and more formally trained midwives have pro- vided obstetric services throughout the history of Ap- palachia. Although many practitioners and herbalists are older women, men may also become healers. Grannies and herb doctors are trusted and known to the individual and the community for giving more personalized care.

The entire Appalachian area has a shortage of health personnel even though recent years have evidenced a good supply of primary-care providers, thanks to govern- ment incentives for medical school loans. As a result and as mentioned before, nurses have delivered the bulk of health care to some areas of Appalachia (Huttlinger et al., 2004a, 2004b).

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The Frontier Nursing Service, started by Mary Brecken- ridge, is one of the oldest and most well-known nurse-run clinics in the United States and is a notable example of nurses taking the initiative to provide health care in Appalachia. It was started in one of the most rural areas of Appalachia in response to a lack of physicians and the high birth and child mortality rates in the area (Dawley, 2003; Jesse & Blue, 2004). Many Appalachians prefer to go to insider health-care professionals, especially in the more rural areas, because the system of payment for services is accepted on a sliding scale, and in some communities, even an exchange of goods for health services exists. One nurse-practitioner in private practice states that the only time she locks her car is when the zucchini are “in.” If she does not, when she gets in her car after a clinic session, she has no room to drive because of all the “presents” of the large vegetable.

Locally respected Appalachians are engaged to facili- tate acceptance of outside programs and of the staff who participate at the grassroots level in planning and initiat- ing programs. For Appalachian clients to become more accepting of biomedical care, it is important for health- care providers to approach individuals in an unhurried manner consistent with their relaxed lifestyle, to engage clients in decision making and care planning, and to use locally trained support staff whenever possible.

STATUS OF HEALTH-CARE PROVIDERS

Most herbal and folk practitioners are highly respected for their treatments, mostly because they are well known to their people and trusted by those who need health care. Physicians and other health-care professionals are fre- quently seen as outsiders to the Appalachian population and are, therefore, mistrusted. This initial mistrust is rooted in outsider behaviors that exploited the Appalachian peo- ple and took their land for timbering and coal mining in earlier generations. Trust for an outsider is gained slowly. Once the person gets to know and trust the health-care provider, the provider is given much respect. Trust and respect for health-care providers depend more on personal characteristics and personal behavior than on knowledge.

In terms of provider care, Appalachians seem to prefer home-based nurses, health-care workers, and social work- ers. To obtain full cooperation, the health-care provider needs to ask clients what they consider to be the problem before devising a plan of care. If the provider begins with an immediate diagnosis without considering the patient’s explanation, there is a good chance that the provider’s treatment or recommendation will be ignored. Lastly, it is important to decrease language barriers by decoding the jargon of the health-care environment.

REFERENCES Appalachian Regional Commission (ARC). (2006a). Available at http://www.

arc.gov Contains various articles on economics, populations statistics, health-care delivery, education, and general life in Appalachia.

Appalachian Regional Commission (ARC). (2006b). Twenty-six communi- ties awarded seed grants to battle substance abuse in Appalachia. News Brief. http://arc.gov Viewed 01/03/07.

Centers for Disease Control and Prevention (CDC). (2001). http:// www.cdc.gov

Centers for Disease Control and Prevention (CDC). (2004). CDC report shows cancer death rates in Applachia higher than national. https://www.scienceblog.com/community

Costello, C. (2000, May 30). Beneath myth, Melungeons find roots of oppres- sion: Appalachian descendants embrace heritage. The Washington Post, p. A4.

Counts, M. M., & Boyle, J. S. (1987). Nursing, health, and policy within a community context. Advances in Nursing Science, 9(3), 12–23.

Coyne, C., Demian-Popescu, C., & Friend, D. (2006). Social and cultural factors influencing health in southern West Virginia: A qualitative study. Preventing Chronic Disease, 3(4), A. 124.

Dawley, K. (2003). Origins of nurse-midwifery in the United States and its expansion in the 1940s. Journal of Midwifery and Womens’ Health, 48(2), 86–95.

Gainor, R., Fitch, C., & Pollard, C. (2006). Maternal diabetes and perinatal outcomes in West Virginia Medicaid enrollees. West Virginia Medical Journal, 102(1), 314–316.

Graduate Medical Education Consortium (GMEC). (2001, August). Report to the board. Wise, VA: Graduate Medical Education Consortium.

Haaga, J. (2004). The aging of Appalachia: Demographic and socioeco- nomic change in Appalachia. Washington, DC: Appalachian Regional Commission.

Haaga, J. (2006). Educational attainment in Appalachia: Regional and national trrends. Washington, DC: Appalachian Regional Commission. http://www.arc.gov/index

Hays, J. (2004). A profile of oxycontin addiction. Journal of Addictive Disorders, 23(4), 1–9.

Hunsucker, S., Flannery, J., & Frank, D. (2000). Coping strategies of rural families of critically ill patients. Journal of the American Academy of Nurse Practitioners, 12(4), 123–127.

Hurley, J., & Turner, H. S. (2000). Development of a health service at a rural community college in Appalachia. Journal of American College Health, 48(4), 181–189.

Huttlinger, K., Schaller-Ayers, J., & Lawson, T. (2004a). Health care in Appalachia: A population-based approach. Public Health Nursing, 21(2), 103–110.

Huttlinger, K., Schaller-Ayers, J., Kenny, B., & Ayers, J. (2004b). Rural, com- munity health nursing, research and collaboration. Online Journal of Rural Nursing and Health Care, 4(1), www.rno.org

Jesse, D., & Blue, C. (2004). Mary Breckinridge meets Healthy People 2010: A teaching strategy for visioning and building healthy communities. Journal of Midwifery & Womens’ Health, 49(2), 126–131.

Kennedy, N. (1997). Melungeons. Macon, GA: Mercer University Press. Lubell, J. (2006). Virginia doctors report controlled substances. Program

targets substances with high potential for abuse. Modern Healthcare, 36(26), 32.

Obermiller, P., & Brown, M. (2002, February). Appalachian health status in greater Cincinnati: A research overview. Urban Council Working Paper No. 18. Cincinnati, OH: Urban Appalachian Council.

Smith, S., & Tessaro, I. (2005). Cultural perspectives on diabetes in an Appalachian population. American Journal of Health Behavior, 29(4), 291–301.

U.S. Drug Enforcement Agency (DEA). (2006a, September 9). DEA briefs and backgound drugs and drug abuse, drug descriptions. News Release. Washington, DC: Drug Enforcement Agency.

U.S. Drug Enforcement Agency (DEA). (2006b, November 29). National methamphetamine awareness day events represent largest single-day education effort in the dangers of methamphetamine. News Release. Washington, DC: Drug Enforcement Agency.

Virginia Health Care Foundation. (2001). Results of Virginia’s 2001 health access survey. Joint Commission on Health Care. Richmond, VA: Virginia Health Care Foundation.

Voices of Appalachia Health Start Project. (2001). Whitley County Public Health Department. Available at http://www.wcphd.com.

Wilson, C. M. (1989). Elizabethan America. In W. K. Neil (Ed.), Appalachian images in folk and popular cultures (pp. 205–216). London: UMI Press.

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

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113

People of Arab Heritage

Chapter 6

ANAHID DERVARTANIAN KULWICKI

Overview, Inhabited Localities, and Topography

OVERVIEW

Arabs trace their ancestry and traditions to the nomadic desert tribes of the Arabian Peninsula. They share a com- mon language, Arabic, and most are united by Islam, a major world religion that originated in 7th-century Arabia. Despite these common bonds, even Arab residents of a sin- gle Arab country are characterized by diversity in thoughts, attitudes, and behaviors. Indeed, a poor tradition-bound farmer from rural Yemen may appear to have little in com- mon with an educated professional from cosmopolitan Beirut. Additional factors such as refugee status, time since arrival, ethnic identity, disparity between cultures, eco- nomic status, employment status, social support, and English language skills influence the immigration experi- ence and the Arab’s adjustment to life in America.

The September 11, 2001, al Qaeda terrorist attack on the United States has increased negative comments about Arabs by some people. Health-care providers need to understand that few Arab Americans support the terrorist attacks, and they must not pigeonhole people by their cultural background.

The diversity among Arabs makes presenting a repre- sentative account of Arab Americans a formidable task because of the primary and secondary characteristics of culture (see Chapter 1) and the limited research literature on Arabs in the Americas. The earliest Arab immigrants arrived as part of the great wave of immigrants at the end of the 19th century and the beginning of the 20th century.

They were predominantly Christians from the region that is present-day Lebanon and Syria, and like most newcom- ers of the period, they valued assimilation and were rather easily absorbed into mainstream U.S. society. Arab Americans tend to disappear in national studies because they are counted as white in census data rather than as a separate ethnic group. Therefore, to portray Arab Americans as fully as possible, including the large num- bers of new arrivals since 1965, literature that describes Arabs is used to supplement research completed by groups studying Arab Americans residing in Michigan and the San Francisco Bay area of California. An underly- ing assumption is that the attitudes and behaviors of first- generation immigrants are similar in some aspects to those of their counterparts in the Arab world.

Islamic doctrines and practices are included because most post-1965 Arab American immigrants are Muslims. Religion, whether official Islam, Christianity, or a local folk variant, is an integral part of everyday Arab life. Historically, Christians, Muslims, and Jews share a common religious background, and the three prophets are descendants from the same father, Abraham. Moses, the messenger of Judaism, and Jesus, the messenger of Christianity, are believed to be descendants of Isaac; whereas, Mohammed, the messenger of Islam, is believed to be a descendant of Abraham’s eldest son, Ishmael. Moreover, because Arabism and Islam are so intrinsically interwoven and because Islam has some elements of Christianity, Arabs, whether Christian or Muslim, share some basic traditions and beliefs. Consequently, knowledge of religion is critical to understanding the Arab American client’s cultural frame of reference and for providing care that considers specific reli- gious beliefs and practices of devout Arab Muslim clients.

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HERITAGE AND RESIDENCE

Arab Americans are defined as immigrants from the 22 Arab countries of North Africa and Southwest Asia: Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, and Yemen. The Arab American Institute (2007) estimates 3.5 million Arab Americans live in the United States, with approximately 94 percent living in urban settings. The largest concentrations are in Los Angeles County, California; Wayne County, Michigan; and Kings, New York. However, Zogby International (2007) estimates the number of Arab American as three times greater than estimates from the Arab American Institute.

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

First-wave immigrants came to the United States between 1887 and 1913 seeking economic opportunity and per- haps the financial means to return home and buy land or set up shop in their ancestral villages. Most first-wave Arab Americans worked in unskilled jobs, were male and illiterate (44 percent), and were from mountain or rural areas (Naff, 1980). Today, 39 percent of Arab Americans are from Lebanon, and 12 percent come from Syria (Arab American Institute, 2007).

Second-wave immigrants entered the United States after World War II; the numbers increased dramatically after the Palestinian-Israeli conflict erupted and the passage of the Immigration Act of 1965 (Naff, 1980). Unlike the more economically motivated Lebanese-Syrian Christians, most second-wave immigrants are refugees from nations beset by war and political instability— chiefly, occupied Palestine, Jordan, Iraq, Yemen, Lebanon, and Syria. Included in this group are a large number of professionals and individuals seeking educational degrees who have subsequently remained in the United States. Of the current Arab American population, 57 percent are male, 25 percent are age 18 years or younger, and 9 per- cent are age 65 years or older; their median age is 33 years (Arab American Institute, 2007).

EDUCATIONAL STATUS AND OCCUPATIONS

Because Arabs favor professional occupations, education, as a prerequisite to white-collar work, is valued. Not surprisingly, both U.S.- and foreign-born Arab Americans are more educated than the average American. Over 84 percent of Arab Americans have a high school education, compared with all Americans at 81 percent, and 41 per- cent have a college education, compared with 24 percent of the total population (U.S. Bureau of the Census, 2005).

In comparison with Americans, Arab Americans are more likely to be self-employed and much more likely to be in managerial and professional specialty occupations (U.S. Bureau of the Census, 2005). Nearly 42 percent are employed in managerial and professional positions, 32 percent in sales, and 11.7 percent in retail trade. Few Arab Americans are employed in farming, forestry, fish- ing, precision production, crafts, or work as operators and

fabricators (U.S. Bureau of the Census, 2005). Arab American households in the United States have a mean annual income of $47,000, compared with $42,000 for all households (Arab American Institute, 2007).

Communication DOMINANT LANGUAGE AND DIALECTS

Arabic is the official language of the Arab world. Modern or classical Arabic is a universal form of Arabic used for all writing and formal situations ranging from radio news- casts to lectures. Dialectal or colloquial Arabic, of which each community has a variety, is used for everyday spo- ken communication. Arabs often mix Modern Standard Arabic and colloquial Arabic according to the complexity of the subject and the formality of the occasion. The pres- ence of numerous dialects with differences in accent, inflection, and vocabulary may create difficulties in com- munication between Arab immigrants from Syria and Lebanon and Arab immigrants from Iraq and Yemen.

The Arab person’s speech is likely to be characterized by repetition and gesturing, particularly when involved in serious discussions. Arabs may be loud and expressive when involved in serious discussions to stress their com- mitment and their sincerity in the subject matter. Observers witnessing such impassioned communication may assume that Arabs are argumentative, confronta- tional, or aggressive.

English is a common second language in Egypt, Jordan, Lebanon, Yemen, Bahrain, and Kuwait. In contrast, liter- acy rates among adults in the Arab world vary from 44 per- cent in Yemen to 88 percent in Lebanon and Jordan. Literacy rates among women also vary, ranging from 23.7 percent in Yemen to 84 percent in Lebanon, where women often earn university degrees (Arab human develop- ment report, 2000). More than half (65 percent) speak a lan- guage other than English at home, although 44 percent report a good command of the English language (U.S. Bureau of the Census, 2005). Despite this, ample evidence indicates that language and communication pose formi- dable problems in American health-care settings. For example, Kulwicki and Miller (1999) reported that 66 per- cent of respondents using a community-based health clinic spoke Arabic at home and only 30.2 percent spoke both English and Arabic. Even English-speaking Arab Americans report difficulty in expressing their needs and understanding health-care providers.

Health-care providers have cited numerous interper- sonal and communication problems, including erroneous assessments of patient complaints, delayed or failed appointments, reluctance to disclose personal and family health information, and in some cases, noncompliance with medical treatments (Kulwicki, 1996; Kulwicki, Miller, & Schim, 2000), and a tendency to exaggerate when describing complaints (Sullivan, 1993).

CULTURAL COMMUNICATION PATTERNS

Arab communication has been described as highly nuanced, with more communication contained in the

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context of the situation than in the actual words spoken. Arabs value privacy and resist disclosure of personal infor- mation to strangers, especially when it relates to familial disease conditions. Conversely, among friends and rela- tives, Arabs express feelings freely. These patterns of com- munication become more comprehensible when inter- preted within the Arab cultural frame of reference. Many personal needs may be anticipated without the individual having to verbalize them because of close family relation- ships. The family may rely more on unspoken expecta- tions and nonverbal cues than overt verbal exchange.

Arabs need to develop personal relationships with a health-care provider before sharing personal information. Because meaning may be attached to both compliments and indifference, manner and tone are as important as what is said. Arabs are sensitive to the courtesy and respect they are accorded, and good manners are impor- tant in evaluating a person’s character. Therefore, greet- ings, inquiries about well-being, pleasantries, and a cup of tea or coffee precede business. Conversants stand close to one another, maintain steady eye contact, and touch (only between members of the same sex) the other’s hand or shoulder. Sitting and standing properly is critical; to do otherwise is taken as a lack of respect. Within the context of personal relationships, verbal agreements are consid- ered more important than written contracts. Keeping promises is considered a matter of honor.

Substantial efforts are directed at maintaining pleasant relationships and preserving dignity and honor. Hostility in response to perceived wrongdoing is warded off by an attitude of maalesh, “never mind, it doesn’t matter.” Individuals are protected from bad news for as long as possible and are then informed as gently as possible. When disputes arise, Arabs hint at their disagreement or simply fail to follow through. Alternatively, an intermedi- ary, someone with influence, may be used to intervene in disputes or present requests to the person in charge. Mediation saves face if a conflict is not settled in one’s favor and reassures the petitioner that maximum influ- ence has been employed (Nydell, 1987).

Guidelines for communicating with Arab Americans include

1. Employ an approach that combines expertise with warmth. Minimize status differences, as Arab Americans report feeling uncomfortable and self-conscious in the presence of authority figures. Pay special attention to the person’s feel- ings. Arab Americans perceive themselves as sen- sitive, with the potential for being easily hurt, belittled, and slighted (Reizian & Meleis, 1987).

2. Take time to get acquainted before delving into business. If sincere interest in the person’s home country and adjustment to American life is expressed, he or she is likely to enjoy relating such information, much of which is essential to assessing risk for traumatic immigration experi- ence (see Barriers to Health Care, later in this chapter) and understanding the person’s cultural frame of reference. Sharing a cup of tea does much to give an initial visit a positive beginning (Kulwicki, 1996).

3. Nurses may need to clarify role responsibilities regarding history taking, performing physical examinations, and providing health information for newer immigrants. Although recent Arab American immigrants may now recognize the higher status of nurses in the United States, they are still accustomed to nurses’ functioning as medical assistants and housekeepers (see Status of Health-Care Providers, later in this chapter).

4. Perform a comprehensive assessment. Explain the relationship of the information needed for physical complaints.

5. Interpret family members’ communication pat- terns within a cultural context. Recognize that a spokesperson may answer questions directed to the client, and that the family members may edit some information that they feel is inappropriate (Kulwicki, 1996). Family members can also be expected to act as the client’s advocates; they may attempt to resolve problems by taking appeals “to the top” or by seeking the help of an influential intermediary.

6. Convey hope and optimism. The concept of “false hope” is not meaningful to Arabs because they regard God’s power to cure as infinite. The amount and type of information given should be carefully considered.

7. Be mindful of the patient’s modesty and dignity. Islamic teachings forbid unnecessary touch (including shaking hands) between unrelated adults of opposite sexes (al-Shahri, 2002). Observation of this teaching is expressed most commonly by female patients with male health- care professionals, and may cause the patient to be shy or hesitant in allowing the professional to do physical assessments. Health-care providers must make concerted efforts to understand the patient’s feelings and to take them into consider- ation.

TEMPORAL RELATIONSHIPS

First-generation Arab immigrants may believe in predesti- nation; that is, God has predetermined the events of one’s life. Accordingly, individuals should work hard to make the best of life while acknowledging that God has ulti- mate control over all that happens. Consequently, plans and intentions are qualified with the phrase inshallah, “if God wills,” and blessings and misfortunes are attrib- uted to God rather than to the actions of individuals.

Throughout the Arab world, there is nonchalance about punctuality except in cases of business or profes- sional meetings; otherwise, the pace of life is more leisurely than in the West. Social events and appoint- ments tend not to have a fixed beginning or end. Although certain individuals may arrive on time for appointments, the tendency is to be somewhat late. However, for most Arab Americans who belong to profes- sional occupations or who are in the business field, punc- tuality and respecting deadlines and appointments are considered important (Kulwicki, 2001).

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FORMAT FOR NAMES

Etiquette requires shaking hands on arrival and depar- ture. However, when an Arab man is introduced to an Arab woman, the man waits for the woman to extend her hand. Devout Muslim men may not shake hands with women.

Titles are important and are used in combination with the person’s first name (e.g., Mr. Khalil or Dr. Ali). Some may prefer to be addressed as mother (Um) or father (Abu) of the eldest son (e.g., Abu Khalil, “father of Khalil”).

Family Roles and Organization

power and status in advancing years, particularly when they have adult children. The bond between mothers and sons is typically strong, and most men make every effort to obey their mother’s wishes, and even her whims (Nydell, 1987).

Gender roles are clearly defined and regarded as a com- plementary division of labor. Men are breadwinners, pro- tectors, and decision makers, whereas women are respon- sible for the care and education of children and for maintenance of a successful marriage by tending to their husbands’ needs.

Although women in more urbanized Arab countries such as Lebanon, Syria, Jordan, and Egypt often have pro- fessional careers, with some women advocating for women’s liberation, the family and marriage remain pri- mary commitments for the majority. Most educated women still consider caring for their children as their pri- mary role after marriage. Arab women value modesty, especially among devout Muslim Arabs—modesty is expressed with their attire. For example, many Muslim women view the hijab, “covering the body except for one’s face and hands,” as offering them protection in sit- uations in which the sexes mix, because it is a recognized symbol of Muslim identity and good moral character.

Ironically, many Americans associate the hijab with oppression rather than protection. Similarly, the author- ity structure and division of labor within Arab families are often misinterpreted, fueling common stereotypes of the overtly dominant Arab male and the passive and oppressed Arab woman. Thus, by extension, conservative Arab Americans perceive the stereotypical understanding of the submissive role of women as a criticism to the Arab culture and family values (Kulwicki, 2000).

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

In the traditional Arab family, the roles of the father and mother as they relate to the children are quite distinct. Typically, the father is the disciplinarian, whereas the mother is an ally and mediator, an unfailing source of love and kindness. Although some fathers feel that it is advantageous to maintain a degree of fear, family rela- tionships are usually characterized by affection and senti- mentality. Children are dearly loved, indulged, and included in all family activities.

Among Arabs, raising children so they reflect well on the family is an extremely important responsibility. A child’s character and successes (or failures) in life are attributed to upbringing and parental influence. Because of the emphasis on familialism rather than individualism within the Arab culture, conformity to adult rules is favored. Correspondingly, child-rearing methods are ori- ented toward accommodation and cooperation. Family reputation is important; children are expected to behave in an honorable manner and not bring shame to the fam- ily. Child-rearing patterns also include great respect toward parents and elders. Children are raised to not question elders and to be obedient to older brothers and sisters (Kulwicki, 1996). Methods of discipline include physical punishment and shaming. Children are made to feel ashamed because others have seen them misbehave,

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V I G N E T T E 6 . 1

Mrs. Nasser arrived at the urgent-care center with her 16- year-old daughter, who had been experiencing burning upon urination, itching around her genital area, and a high fever. Mrs. Nasser appeared very anxious, explaining to the nurse that her daughter had never had these symptoms before. The nurse tried to calm Mrs. Nasser and asked that her daughter, Samia, get undressed in preparation for a physical examina- tion. Mrs. Nasser appeared concerned and requested that the nurse inform the doctor that she will not allow the doctor to perform a vaginal examination on her daughter.

The nurse explained to Mrs. Nasser that it will be neces- sary for the doctor to examine Samia so that she can deter- mine the cause of Samia’s discomfort. Mrs. Nasser became extremely agitated and explained to the nurse that in her cul- ture, young girls are not allowed to have vaginal examination for fear that their virginity will be compromised. Mrs. Nasser insisted that she would not allow her daughter to be exam- ined by the female doctor on duty. Mrs. Nasser requested that the nurse ask the doctor to write a prescription for her daugh- ter’s infection, or else she would leave the clinic immediately.

1. How should the nurse respond to Mrs. Nasser’s request? Explain your rationale.

2. Identify culturally congruent strategies that may be most effective in addressing the needs of Mrs. Nasser.

3. How might the nurse ensure that Mrs. Nasser’s con- cerns are addressed appropriately and that Samia has received the appropriate care?

HEAD OF HOUSEHOLD AND GENDER ROLES

Arab Muslim families are characterized by a strong patri- lineal tradition (Aswad, 1999). Women are subordinate to men, and young people are subordinate to older people. Consequently, within his immediate family, the man is the head of the family and his influence is overt. In pub- lic, a wife’s interactions with her husband are formal and respectful. However, behind the scenes, she typically wields tremendous influence, particularly in matters per- taining to the home and children. A wife may sometimes be required to hide her power from her husband and chil- dren to preserve the husband’s view of himself as head of the family.

Within the larger extended family, the older male fig- ure assumes the role of decision maker. Women attain

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rather than to experience guilt arising from self-criticism and inward regret.

Whereas adolescence in the West is centered on acquir- ing a personal identity and completing the separation process from family, Arab adolescents are expected to remain enmeshed in the family system. Family interests and opinions often influence career and marriage deci- sions. Arab adolescents are pressed to succeed academi- cally, in part because of the connections between profes- sional careers and social status. Conversely, behaviors that would bring family dishonor, such as academic fail- ure, sexual activity, illicit drug use, and juvenile delin- quency, are avoided. For girls in particular, chastity and decency are required. Adolescence in North America may provide more opportunities for academic success and more freedom in making career choices than can be accessed by their counterparts in the Arab countries. Cultural conflicts between American values and Arab val- ues often cause significant conflicts for Arab American families. Arab American parents cite a variety of concerns related to conflicting values regarding dating, after-school activities, drinking, and drug use (Zogby, 2002).

FAMILY GOALS AND PRIORITIES

The family is the central socioeconomic unit in Arab soci- ety. Family members cooperate to secure livelihood, rear children, and maintain standing and influence within the community. Family members live nearby, sometimes intermarry (first cousins), and expect a great deal from one another regardless of practicality or ability to help. Loyalty to one’s family takes precedence over personal needs. Maintenance of family honor is paramount.

Within the hierarchical family structure, older family members are accorded great respect. Children, sons in particular, are held responsible for supporting elderly par- ents. Therefore, regardless of the sacrifices involved, the elderly parents are almost always cared for within the home, typically until death.

Responsibility for family members rests with the older men of the family. In the absence of the father, brothers are responsible for unmarried sisters. In the event of a hus- band’s death, his family provides for his widow and chil- dren. In general, family leaders are expected to use influ- ence and render special services and favors to kinsmen.

Although educational accomplishments (doctoral de- grees), certain occupations (medicine, engineering, law), and acquired wealth contribute to social status, family origin is the primary determinant. Certain character traits such as piety, generosity, hospitality, and good manners may also enhance social standing.

ALTERNATIVE LIFESTYLES

Most adults marry. Although the Islamic right to marry up to four wives is sometimes exercised, particularly if the first wife is chronically ill or infertile, most marriages are monogamous and for life. Recent studies have reported that 2 to 5 percent of Arab Muslim marriages are polygamous (Kulwicki, 2000). Whereas homosexuality occurs in all cul- tures to some extent, it is stigmatized among Arab cultures. In some Arab countries, it is considered a crime; fearing

family disgrace and ostracism, gays and lesbians remain closeted (Global Gayz, 2006). However, in recent years, Arab American gays and lesbians have been active in gay and lesbian organizations, and some have been outspoken and publicly active in raising community awareness about gay and lesbian rights in Arab American communities.

Workforce Issues CULTURE IN THE WORKPLACE

Cultural differences that may have an impact on work life include beliefs regarding family, gender roles, one’s ability to control life events, maintaining pleasant personal rela- tionships, guarding dignity and honor, and the impor- tance placed on maintaining one’s reputation. Arabs and Americans may also differ in attitudes toward time, instructional methods, patterns of thinking, and the amount of emphasis placed on objectivity. However, because many second-wave professionals were educated in the United States, and thereby socialized to some extent, differences are probably more characteristic of less-educated, first-generation Arab Americans.

Stress is a common denominator in recent studies of first-generation immigrants. Sources of stress include sep- aration from family members, difficulty adjusting to American life, marital tension, and intergenerational con- flict, specifically coping with adolescents socialized in American values through school activities (Seikaly, 1999). Issues related to discrimination have been reported as a major source of stress among Arab Americans in their work environment. In a recent study exploring the per- ceptions and experiences of Arab American nurses in the aftermath of 9/11, the majority of nurses did not experi- ence major episodes of discrimination at work such as ter- mination and physical assaults; however, some did expe- rience other types of discrimination such as intimidation, being treated suspiciously, negative comments about their religious practices, and patient refusal to be treated by them (Kulwicki & Khalifa, 2007). Arab Americans are keenly aware of the misperceptions Americans hold about Arabs, such as notions that Arabs are inferior, backward, sinister, and violent. In addition, the American public’s ignorance of mainstream Islam and the stereotyping of Muslims as fanatics, extremist, and confrontational bur- den Arab American Muslims.

Muslim Arab Americans face a variety of challenges as they practice their faith in a secular American society. For example, Islamic and American civil law differ on matters such as marriage, divorce, banking, and inheritance. Individuals who wish to attend Friday prayer services and observe religious holidays frequently encounter job- related conflicts. Children are often torn between fulfill- ing Islamic obligations regarding prayer, dietary restric- tions, and dress and hiding their religious identity in order to fit into the American public school culture.

ISSUES RELATED TO AUTONOMY

Whereas American workplaces tend to be dominated by deadlines, profit margins, and maintaining one’s

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competitive edge, a more relaxed, cordial, and relation- ship-oriented atmosphere prevails in the Arab world. Friendship and business are mixed over cups of sweet tea to the extent that it is unclear where socializing ends and work begins. Managers promote optimal performance by using personal influence and persuasion, and perfor- mance evaluations are based on personality and social behavior as well as job skills.

Significant differences also exist in workplace norms. In the United States, position is usually earned, laws are applied equally, work takes precedence over family, hon- esty is an absolute value, facts and logic prevail, and direct and critical appraisal is regarded as valuable feedback. In the Arab world, position is often attained through one’s family and connections, rules are bent, family obligations take precedence over the demands of the job, subjective perceptions often dictate actions, and criticism is often taken personally as an affront to dignity and family honor (Nydell, 1987). In Arab offices, supervisors and managers are expected to praise their employees to assure them that their work is noticed and appreciated. Whereas such direct praise may be somewhat embarrassing for Americans, Arabs expect and want praise when they feel they have earned it (Nydell, 1987).

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Although Arabs are uniformly perceived as swarthy, and whereas many do, in fact, have dark or olive skin, they may also have blonde or auburn hair, blue eyes, and fair com- plexions. Because color changes are more difficult to assess in dark-skinned people, pallor and cyanosis are best detected by examination of the oral mucosa and conjunctiva.

DISEASES AND HEALTH CONDITIONS

The major public health concerns in the Arab world include trauma related to motor vehicle accidents, maternal- child health, and control of communicable diseases. The incidence of infectious diseases such as tuberculosis, malaria, trachoma, typhus, hepatitis, typhoid fever, dysentery, and parasitic infestations varies between urban and rural areas and from country to country. For example, disease risks are relatively low in modern urban centers of the Arab world, but are quite high in the countryside where animals such as goats and sheep virtually share liv- ing quarters, open toilets are commonplace, and running water is not available. Schistosomiasis (also called bil- harzia), infecting about one-fifth of Egyptians, has been called Egypt’s number-one health problem. Its prevalence is related to an entrenched social habit of using the Nile River for washing, drinking, and urinating. Similarly, out- breaks of cholera and meningitis are continuous concerns in Saudi Arabia during the Muslim pilgrimage season. In Jordan, where contagious diseases have declined sharply, emphasis has shifted to preventing accidental death and controlling noncommunicable diseases such as cancer and heart disease. Correspondingly, seatbelt use, smoking

habits, and pesticide residues in locally grown produce are major issues. Campaigns directed at improving chil- dren’s health include hepatitis B vaccinations and dental health programs.

Glucose-6-phosphate dehydrogenase (G-6-PD) defi- ciency, sickle cell anemia, and the thalassemias are extremely common in the eastern Mediterranean region, probably because carriers enjoy an increased resistance to malaria (Hamamy & Alwan, 1994). High consanguinity rates—roughly 30 percent of marriages in Iraq, Jordan, Kuwait, and Saudi Arabia are between first cousins—and the trend of bearing children up to menopause also con- tribute to the prevalence of genetically determined disor- ders in Arab countries (Hamamy & Alwan, 1994).

With modernization and increased life expectancy, multifactorial disorders—hypertension, diabetes, and coronary heart disease—have also emerged as major prob- lems in eastern Mediterranean countries (Kulwicki, 2001). In many countries, cardiovascular disease is a major cause of death. In Lebanon, the increased frequency of familial hypercholesterolemia is a contributing factor. Individuals of Arabic ancestry are also more likely to inherit familial Mediterranean fever, a disorder characterized by recurrent episodes of fever, peritonitis, or pleurisies, either alone or in some combination.

The extent to which these conditions affect the health of Arab Americans is limited. However, a Wayne County Health Department (1994) project, a telephone survey including Arabs residing in the Detroit, Michigan, area, identified cardiovascular disease as one of two specific risks, based on the high prevalence of cigarette smoking, high-cholesterol diets, obesity, and sedentary lifestyles. Although the prevalence of hypertension was lower in the Arab community than in the rest of Wayne County, Arab respondents were less likely to report having their blood pressure checked. In fact, lower rates for appropri- ate testing and screening, such as cholesterol testing, cholorectal cancer screening, and uterine cancer screen- ing, were considered a major risk for this group of Arab Americans. In recent years, the rate of mammography has increased dramatically. The Institute of Medicine’s report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002) indicated that death rates for Arab females, compared with those of other white groups, was higher from heart disease and cancer but lower from strokes. However, the death rate for Arab males from coronary heart disease is higher when com- pared with that of white males. Lung and colorectal can- cer are the two leading causes of death among Arab Americans. For Arab American men, lung cancer is the leading cause of death, and breast cancer is the leading cause of death in Arab American women (Schwartz, Darwish-Yassine, & Wing, 2005).

The rate of infant mortality in the Arab world is very high, ranging from 24 per 1000 births in Syria to 108 per 1000 births in Iraq. In Bahrain, the infant mortality is low: 8.5 per 1000 births (World Health Organization [WHO], 2006). Although overall infant mortality rates for Arab Americans are the same as for white infants, figures for Michigan show a lower infant mortality rate for Arab Americans (6.2 per 1000 births) than for white infants (7.8 per 1000).

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VARIATIONS IN DRUG METABOLISM

Information describing drug disposition and sensitivity in Arabs is limited. Between 1 and 1.4 percent of Arabs are known to have difficulty metabolizing debrisoquine and substances that are metabolized similarly: antiarrhyth- mics, antidepressants, beta-blockers, neuroleptics, and opioid agents. Consequently, a small number of Arab Americans may experience elevated blood levels and adverse effects when customary dosages of antidepres- sants are prescribed. Conversely, typical codeine dosages may prove inadequate because some individuals cannot metabolize codeine to morphine to promote an optimal analgesic effect (Levy, 1993).

High-Risk Behaviors Despite Islamic beliefs discouraging tobacco use, smoking remains deeply ingrained in Arab culture. For many Arabs, offering cigarettes is a sign of hospitality. Consistent with their cultural heritage, Arab Americans are characterized by higher smoking rates and lower quit- ting rates than European Americans (Darwish-Yassine & Wang, 2005; Rice & Kulwicki, 1992).

According to the 2001–2002 Special Cancer Behavioral Risk Factor Survey, Arab Americans who are 50 years and older have the highest smoking rates compared with other populations in Michigan. Smoking rates for Arab women in the same age group are considerably lower (39.9 versus 10.9 percent) (Michigan Department of Community Health and Michigan Department of Public Health Institute, 2003). Preliminary research results related to tobacco use among Arab Americans suggests that the rates of tobacco smoking among Arab American youth are considerably lower than those among non-Arab youth in Michigan, with only 16 percent of Arab youths smoking versus 34 percent of non-Arabs (Templin, Rice, Gadelrab, Weglicki, Hammad, & Kulwicki, 2003).

Limited information is available on alcohol use among Arab Americans. However, Islamic prohibitions do appear to influence patterns of alcohol consumption and atti- tudes toward drug use (Wayne County Health Depart- ment, 1994). Ninety percent of the Arab respondents in the survey reported that they abstain from drinking alco- hol. None reported heavy drinking, with a limited num- ber reporting binge drinking (2.2 percent) and driving under the influence of alcohol (1.4 percent). All respon- dents believed that occasional use of cocaine entails “great” risk, with most saying the same about occasional use of marijuana.

The actual risk for, and incidence of, HIV infection and AIDS in Arab countries and among Arab Americans is low. However, an increase in the rate of infection has been noticed among many Arab countries and among Arab Americans (Centers for Disease Contral and Prevention [CDC], 2006). The reported number of individuals having AIDS in the Arab countries varies and may not be an accu- rate reflection of the real incidence owing to restrictions placed on HIV/AIDS research by some Arab countries. The largest number of AIDS cases is seen in Djibouti (214); the lowest numbers of individuals reported as having AIDS

are found in Palestine (1), Kuwait (11), Syria (18), Lebanon (24), Yemen (45), and Egypt (63) (WHO, 2004).

Despite the reported low rate of HIV/AIDS among Arab Americans, 4 percent of the Arab American respondents surveyed by Kulwicki and Cass (1994) reported that they were at high risk for AIDS. In addition, the sample demonstrated less knowledge of primary routes of trans- mission and more misconceptions regarding unlikely modes of transmission than other populations surveyed.

Cultural norms of modesty for Arab women are also a significant risk related to reproductive health among Arab Americans. For example, the rate of breast cancer screen- ing among Arab women was 50.8 percent, compared with 71.2 percent for other women in Michigan. The rate of cervical Pap smears was 59.9 percent, and the rate of mammogram screenings was 51.2 percent (Kulwicki, 2000). Arab American women, especially new immi- grants, may be at a higher risk for domestic violence because of the higher rates of stress, poverty, poor spiri- tual and social support, and isolation from family mem- bers owing to immigration (Kulwicki, 2001).

Sedentary lifestyle and high fat intake among Arab Americans place them at higher risk for cardiovascular diseases. For instance, 43 percent of the participants sur- veyed by Wayne County Health Department indicated that they had been told that their cholesterol level was high (Office of Minority Health [OMH], 2001). Studies in Arab countries and in Michigan have also reported higher rates of cardiovascular disease and diabetes among Arabs and Arab Americans.

Many Arab Americans are refugees fleeing war and political and religious conflicts, placing them at greater risk for psychological distress, depression, and other psy- chiatric illnesses (Hikmet, Hakim-Larson, Farrag, & Jamil, 2002; Kinzie, Boehnlein, Riley, & Sparr, 2002). Psycho- logical distress was also documented among immigrants who themselves were not victims of war and conflict but who worried over family members that were in areas of conflict. Studies conducted with Iraqi refugees and vic- tims of torture in the United States identified higher prevalence of post-traumatic stress disorder and depres- sion (Kinzie et al., 2002).

HEALTH-CARE PRACTICES

According to the Wayne County Health Department (1994), Arab Americans’ risk in terms of safety is mixed. Factors enhancing safety include low rates of gun owner- ship and high recognition of the risks associated with having guns in the house. Conversely, lower rates of fire escape planning and seatbelt usage for adults and older children (car seats are generally used for younger chil- dren), as well as higher rates of physical assaults, threaten their safety.

In most health areas surveyed in Michigan, education and income were important determinants of risk for peo- ple of Arab descent. Socioeconomic status was also a strong indicator in accessing health-care services. The Wayne County Health Department (1994) indicated that 37.2 percent of the adult Arab respondents were not cov- ered by health insurance. Use of health-care services for prenatal care was, however, higher among Arab American

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females than other ethnic groups in Michigan (Michigan Department of Public Health, 1995). Physical or mental disability among Arab Americans in Michigan was almost equal to that of white Americans.

Nutrition MEANING OF FOOD

Sharing meals with family and friends is a favorite pas- time. Offering food is also a way of expressing love and friendship, hospitality, and generosity. For the Arab woman, whose primary role is caring for her husband and children, the preparation and presentation of an elabo- rate midday meal is taken as an indication of her love and caring. Similarly, in entertaining friends, the types and quantity of food served, often several entrees, is a measure of one’s hospitality and esteem for one’s guests. Honor and reputation are based on the manner in which guests are received. In return, family members and guests express appreciation by eating heartily.

COMMON FOODS AND FOOD RITUALS

Although cooking and national dishes vary from country to country and seasoning from family to family, Arabic cooking shares many general characteristics. Familiar spices and herbs such as cinnamon, allspice, cloves, gin- ger, cumin, mint, parsley, bay leaves, garlic, and onions are used frequently. Skewer cooking and slow simmering are typical modes of preparation. All countries have rice and wheat dishes, stuffed vegetables, nut-filled pastries, and fritters soaked in syrup. Dishes are garnished with raisins, pine nuts, pistachios, and almonds.

Favorite fruits and vegetables include dates, figs, apri- cots, guavas, mangos, melons, papayas, bananas, citrus fruits, carrots, tomatoes, cucumbers, parsley, mint, spin- ach, and grape leaves. Lamb and chicken are the most popular meats. Muslims are prohibited from eating pork and pork products (e.g., lard). For Arab Christians, pork is not prohibited; however, pork consumption by Arab Christians is low. Similarly, because the consumption of blood is forbidden, Muslims are required to cook meats and poultry until well done. Bread accompanies every meal and is viewed as a gift from God. In many respects, the tra- ditional Arab diet is representative of the U.S. Department of Agriculture’s food pyramid. Bread is a mainstay, grains and legumes are often substituted for meats, fresh fruit and juices are especially popular, and olive oil is widely used. In addition, because foods are prepared “from scratch,” con- sumption of preservatives and additives is limited.

Lunch is the main meal in Arab households. Encour- aging guests to eat is the host’s duty. Guests often begin with a ritual refusal and then succumb to the host’s insis- tence. Food is eaten with the right hand because it is regarded as clean. Beverages may not be served until after the meal because some Arabs consider it unhealthy to eat and drink at the same time. Similar concerns may exist regarding mixing hot and cold foods.

Health-care providers should also understand Ramadan, the Muslim month of fasting. The fast, which is meant to

remind Muslims of their dependence on God and the poor who experience involuntary fasting, involves absti- nence from eating, drinking (including water), smoking, and marital intercourse during daylight hours. Although the sick are not required to fast, many pious Muslims insist on fasting while hospitalized, necessitating adjust- ments in meal times and medications, including medica- tions given by nonoral routes. In outpatient settings, health-care providers need to be alert to potential “non- compliance.” Patients may omit or adjust the timing of medications. Of particular concern are medications requiring constant blood levels, adequate hydration, or both (e.g., antibiotics that may crystallize in the kidneys). Health-care providers may need to provide appointment times after sunset during Ramadan for individuals requir- ing injections (e.g., allergy shots).

DIETARY PRACTICES FOR HEALTH PROMOTION

Arabs associate good health with eating properly, con- suming nutritious foods, and fasting to cure disease. For some, concerns about amounts and balance among food types (hot, cold, dry, moist) may be traced to the Prophet Mohammed, who taught that “the stomach is the house of every disease, and abstinence is the head of every rem- edy” (Al-Akili, 1993, p. 7). Within this framework, illness is related to excessive eating, eating before a previously eaten meal is digested, eating nutritionally deficient food, mixing opposing types of foods, and consuming elabo- rately prepared foods. Conversely, abstinence allows the body to expel disease.

The condition of the alimentary tract has priority over all other body systems in the Arab perception of health (Meleis, 2005). Gastrointestinal complaints are often the reason Arab Americans seek care (Meleis, 2005). Obesity is a problem for second-generation Arab American women and children, most of whom report eating American snacks that are high in fat and calories. Most women try to lose weight by reducing caloric intake (Wayne County Health Department, 1994).

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

In Arab countries, diet is influenced by income, govern- ment subsidies for certain foods (e.g., bread, sugar, oil), and seasonal availability. Arab Americans most at risk for nutritional deficiencies include newly arrived immigrants from Yemen and Iraq (Ahmad, 2004) and Arab American households below the poverty level. Lactose intolerance sometimes occurs in this population. However, the prac- tice of eating yogurt and cheese, rather than drinking milk, probably limits symptoms in sensitive people.

Many of the most common foods are available in American markets. Some Muslims may refuse to eat meat that is not halal, “slaughtered in an Islamic manner.” Halal meat can be obtained in Arabic grocery stores and through Islamic centers or mosques.

Islamic prohibitions against the consumption of alco- hol and pork have implications for American health-care providers. Conscientious Muslims are often wary of

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eating outside the home and may ask many questions about ingredients used in meal preparation: Are the beans vegetarian? Was wine used in the meat sauce or lard in the pastry crust? Muslims are equally concerned about the ingredients and origins of mouthwashes, toothpastes, and medicines (e.g., alcohol-based syrups and elixirs), as well as insulins and capsules (gelatin coating) derived from pigs. However, if no substitutes are available, Muslims are per- mitted to use these preparations.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

Fertility rates in the countries from which most Arab Americans emigrate range from 1.9 in Tunisia and 2.2 in Lebanon to 5.9 in Yemen (UNICEF, 2005). Fertility prac- tices of Arabs are influenced by traditional Bedouin values supporting tribal dominance, popular beliefs that “God decides family size,” and “God provides,” and Islamic rul- ings regarding birth control, treatment of infertility, and abortion.

High fertility rates are favored. Procreation is regarded as the purpose of marriage and the means of enhancing family strength. Accordingly, Islamic jurists have ruled that the use of “reversible” forms of birth control is “undesirable but not forbidden.” These should be employed only in certain situations, listed in decreasing order of legitimacy, such as threat to the mother’s life, too frequent childbearing, risk of transmitting genetic dis- ease, and financial hardship. Moreover, irreversible forms of birth control such as vasectomy and tubal ligation are haram, “absolutely unlawful.” Muslims regard abortion as haram except when the mother’s health is compro- mised by pregnancy-induced disease or her life is threat- ened (Ebrahim, 1989). Therefore, unwanted pregnancies are dealt with by hoping one miscarries “by an act of God” or by covertly arranging for an abortion. Recently, great decline in fertility rates has occurred in Arab coun- tries and among Arab Americans. According to Michigan’s birth registration data, fertility rates among Arab Americans are highest (approximately 4) when com- pared with those of the total population (OMH, 2001).

Among Jordanian husbands, religion and the fatalistic belief that “God decides family size” were most often given as reasons why contraceptives were not used. Contraceptives were used by 27 percent of the husbands, typically urbanites of high socioeconomic status. Although the intrauterine device (IUD) and the pill were most widely favored, 4.9 percent of females used steriliza- tion despite religious prohibitions (Hashemite Kingdom of Jordan, 1985). A survey of a random sample of 295 Arab American women in Michigan indicated that 29.1 percent of the surveyed women did not use any birth control methods because of their desire to have children, 4.3 percent did not use any form of contraceptives because of their husband’s disapproval, and 6 percent did not use contraceptive methods because of religious reasons. The use of birth control pills was the highest

(33.2 percent) among the users of contraceptive methods, followed by tubal ligation (12.9 percent) and IUD (10.7 percent) (Kulwicki, 2000).

Indeed, among Arab women, in particular, fertility may be more of a concern than contraception because sterility in a woman could lead to rejection and divorce. Islam condones treatment for infertility, as Allah pro- vides progeny as well as a cure for every disease. However, approved methods for treating infertility are limited to artificial insemination using the husband’s sperm and in vitro fertilization involving the fertilization of the wife’s ovum by the husband’s sperm.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Because of the emphasis on fertility and the bearing of sons, pregnancy traditionally occurred at a younger age and the fertility rate among Arab women was higher in the Arab world. However, as the educational and eco- nomic conditions for Arab women have improved both in the Arab world and in the United States, fertility pat- terns have also changed accordingly.

The pregnant woman is indulged and her cravings sat- isfied, lest she develop a birthmark in the shape of the particular food she craves. Because of the preference for male offspring, the sex of the child can be a stressor for mothers without sons. Friends and family often note how the mother is “carrying” the baby as an indicator of the baby’s sex (i.e., high for a girl and low for a boy). Although pregnant women are excused from fasting dur- ing Ramadan, some Muslim women may be determined to fast and thus suffer potential consequences for glucose metabolism and hydration.

Labor and delivery are women’s affairs. In Arab coun- tries, home delivery, with the assistance of dayahs (“midwives”) or neighbors was common because of lim- ited access to hospitals, “shyness,” and financial con- straints. However, recently, the practice of home delivery has decreased dramatically in Arab countries, and hospi- tal deliveries have become common. During labor, women openly express pain through facial expressions, verbalizations, and body movements. Nurses and medical staff may mistakenly diagnose Arab women as needing medical intervention and administer pain medications more liberally to alleviate the pain.

Care for the infant includes wrapping the stomach at birth, or as soon thereafter as possible, to prevent cold or wind from entering the baby’s body (Luna, 1994). The call to prayer is recited in the Muslim newborn’s ear. Male cir- cumcision is almost a universal practice, and for Muslims, it is a religious requirement.

Folk beliefs influence bathing and breastfeeding. Arab mothers may be reluctant to bathe postpartum because of beliefs that air gets into the mother and causes illness (Luna, 1994) and washing the breasts “thins the milk” (Cline, Abuirmeileh, & Roberts, 1986).

Breastfeeding is often delayed until the 2nd or 3rd day after birth because of beliefs that the mother requires rest, that nursing at birth causes “colic” pain for the mother, and that “colostrum makes the baby dumb” (Cline et al., 1986). Postpartum care also includes special foods such as

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lentil soup to increase milk production and tea to flush and cleanse the body.

Statistics describing the pregnancy and birth experiences of Michigan mothers, including 2755 Arab Americans, depict the experiences of Arab American mothers and infants as fairly comparable with their white counterparts with regard to adequacy of prenatal care, maternal com- plications, infant mortality, and birth complications. In addition, fewer Arab American mothers smoke, drink alcohol, or gain too little weight (Kulwicki, Smiley, & Devine, 2007).

Although these statewide statistics are quite favorable, it is important to mention that earlier studies revealed an alarming rate of infant mortality among Arab American mothers in Dearborn, Michigan, a particularly disadvan- taged community of new immigrants with high rates of unemployment. Factors contributing to poor pregnancy outcomes include poverty; lower levels of education; inability to communicate in English; personal, family, and cultural stressors; cigarette smoking; and early or closely spaced pregnancies. Fear of being ridiculed by American health-care providers and a limited number of bilingual providers limit access to health-care information.

Death Rituals DEATH RITUALS AND EXPECTATIONS

Although Arabs insist on maintaining hope regardless of prognosis, death is accepted as God’s will. According to Muslim beliefs, death is foreordained and worldly life is but a preparation for eternal life. Hence, from the Qur’an, Surrah III, v. 185:

Every soul will taste of death. And ye will be paid on the Day of Resurrection only that which ye have fairly earned. Whoso is removed from the Fire and is made to enter Paradise, he indeed is triumphant. The life of this world is but comfort of illusion (Pickthall, 1977, p. 70).

Muslim death rituals include turning the patient’s bed to face the holy city of Mecca and reading from the Qur’an, particularly verses stressing hope and acceptance. After death, the deceased is washed three times by a Muslim of the same sex. The body is then wrapped, preferably in white material, and buried as soon as possi- ble in a brick- or cement-lined grave facing Mecca. Prayers for the deceased are recited at home, at the mosque, or at the cemetery. Women do not ordinarily attend the burial unless the deceased is a close relative or husband. Instead, they gather at the deceased’s home and read the Qur’an. Cremation is not practiced.

Family members do not generally approve of autopsy because of respect for the dead and feelings that the body should not be mutilated. Islam allows forensic autopsy and autopsy for the sake of medical research and instruction.

Death rituals for Arab Christians are similar to Christian practices in the rest of the world. Arab American Christians may have a Bible next to the patient, expect a visit from the priest, and expect medical means to prolong life if possible. Organ donations and autopsies are acceptable. Wearing black during the mourning

period is also common. For both Christians and Muslims, patients, especially children, are not told about terminal illness. The family spokesperson is usually the person who should be informed about death. The spokesperson will then communicate news to family members.

RESPONSES TO DEATH AND GRIEF

Mourning periods and practices may vary among Muslims and Christians emigrating from different Arab countries. Extended mourning periods may be practiced if the deceased is a young man, a woman, or a child. However, in some cases, Muslims may perceive extended periods of mourning as defiance of the will of God. Family members are asked to endure with patience and good faith in Allah what befalls them, including death. Whereas friends and relatives are to restrict mourning to 3 days, a wife may mourn for 4 months, and in some spe- cial cases, mourning can extend to 1 year. Although weep- ing is allowed, beating the cheeks or tearing garments is prohibited. For women, wearing black is considered appropriate for the entire period of mourning.

Spirituality RELIGIOUS PRACTICES AND USE OF PRAYER

Not all Arab Americans are Muslims. Prominent Christian groups include the Copts in Egypt, the Chaldeans in Iraq, and the Maronites in Lebanon (Kulwicki & Kridli, 2001). Despite their distinctive practices and liturgies, Christians and Muslims share certain beliefs because of Islam’s origin in Judaism and Christianity. Muslims and Christians believe in the same God and many of the same prophets, the Day of Judgment, Satan, heaven, hell, and an afterlife. One major difference is that Islam has no priesthood. Islamic scholars or religious sheikhs, the most learned individuals in an Islamic community, assume the role of imam, or “leader of the prayer.” The imam also performs marriage ceremonies and funeral prayers and acts as a spiritual counselor or reference on Islamic teachings. Obtaining the opinion of the local imam may be a help- ful intervention for Arab American Muslims struggling with health-care decisions.

As with any religion, observance of religious practices varies among Muslims; some nominally practice their religion whereas others are devout. However, because Islam is the state religion of most Arab countries, and in Islam, there is no separation of church and state, a certain degree of religious participation is obligatory.

To illustrate, consider a few examples of Islam’s impact on Jordanian life. Because of Islamic law, abortion is investigated as a crime, and foster parenting is encour- aged, whereas adoption is forbidden. The infertility treat- ments available are those approved by Islamic jurists. Shariah, Islamic law courts, rule on matters such as mar- riage, divorce, guardianship, and inheritance. Public schools have classes on Islam and prayer rooms. School and work schedules revolve around Islamic holidays and the weekly prayer. During Ramadan, restaurants remain closed during daylight hours and workdays are shortened

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to facilitate fasting. Because Muslims gather for commu- nal prayer on Friday afternoons, the workweek runs from Saturday through Thursday. Finally, because of Islamic tradition that adherents of other monotheistic religions be accorded tolerance and protection, Jordan’s Christians have separate religious courts and schools, and non- Muslims attending public schools are not required to par- ticipate in religious activities.

For Arab American Christians, church is an important part of everyday life. Most celebrate Catholic and Orthodox Christian holidays with fasting and ceremonial church services. They may display or wear Christian sym- bols such as a cross or a picture of the Virgin Mary.

devout patient may request that her or his chair or bed be turned to face Mecca and that a basin of water be pro- vided for ritual washing or ablution before praying. Providing for cleanliness is particularly important because the Muslim’s prayer is not acceptable unless the body, clothing, and place of prayer are clean.

Islamic teachings urge Muslims to eat wholesome food; abstain from pork, alcohol, and illicit drugs; prac- tice moderation in all activities; be conscious of hygiene; and face adversity with faith in Allah’s mercy and com- passion, hope, and acceptance. Muslims are also advised to care for the needs of the community by visiting and assisting the sick and providing for needy Muslims.

Sometimes, illness is considered punishment for one’s sins. Correspondingly, by providing cures, Allah manifests mercy and compassion and supplies a vehicle for repen- tance and gratitude (Al-Akili, 1993). Some emphasize that sickness should not be viewed as punishment, but as a trial or ordeal that brings about expiation of sins and that may strengthen character (Ebrahim, 1989). Common responses to illness include patience and endurance of suffering because it has a purpose known only to Allah, unfailing hope that even “irreversible” conditions might be cured “if it be Allah’s will,” and acceptance of one’s fate. Suffering by some devout Muslims may be viewed as a means for greater reward in the afterlife (Lovering, 2006). Because of the belief in the sanctity of life, euthanasia and assisted suicide are forbidden (Lawrence, & Rozmus, 2001).

Spiritual beliefs and health-care practices for Arab American Christians are similar to those of Orthodox or Catholics. Caring for the body and burial practices are similar. A priest is always expected to visit the patient; if the patient is Catholic, a priest administers the sacrament of the sick.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

Good health is seen as the ability to fulfill one’s roles. Diseases are attributed to a variety of factors such as inad- equate diet, hot and cold shifts, exposure of one’s stom- ach during sleep, emotional or spiritual distress, and envy or the evil eye. Arabs are expected to express and acknowledge their ailments when ill. Muslims often men- tion that the Prophet urged physicians to perform research and the ill to seek treatment because “Allah has not created a disease without providing a cure for it,” except for the problem of old age (Ebrahim, 1989, p. 5).

Despite beliefs that one should care for health and seek treatment when ill, Arab women are often reluctant to seek care. Because of the cultural emphasis placed on modesty, some women express shyness about disrobing for examination. Similarly, some families object to female family members being examined by male physicians. Because of the fear that a diagnosed illness, such as cancer or psychiatric illness, may bring shame and influence the marriageability of the woman and her female relatives, delays in seeking medical care may be common.

Evidence also suggests that the cultural preference for male offspring influences the health care that low-income

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V I G N E T T E 6 . 2

Bilal, the terminally ill son of Mr. and Mrs. Khoury, has been on an inpatient unit for 3 weeks. Mrs. Khoury had been extremely critical of the nurses and the care they have been giving her son. Bilal has died. Upon being informed of their son’s death, Mrs. Khoury appeared shocked and started sobbing loudly. The nurse tried to comfort her without success. Mrs. Khoury blamed herself for not bringing their son to the hospital sooner. Mr. Knoury appeared upset about the death but still tried to comfort his wife, also without success. He seemed reserved, and despite all efforts to calm his wife, she continued crying and beating on her chest. Patients from nearby rooms gathered in the hallway and inquired about the incident.

1. Based on your readings about the Arab culture, what measures should the nurse have taken prior to inform- ing Mr. and Mrs. Khoury about their son’s death?

2. Explain Mrs. Khoury’s behavior, the critical behavior of the nurses, and the care they provided her son.

3. What is the role of Mr. Khoury in caring for his wife? How can a nurse ensure that Mr. Khoury’s emotional needs are being met?

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

For Muslims, adherents of the world’s second largest reli- gion, Islam means “submission to Allah.” Life centers on worshipping Allah and preparing for one’s afterlife by ful- filling religious duties as described in the Qur’an and the hadith. The five major pillars, or duties, of Islam are (1) declaration of faith, (2) prayer five times daily, (3) alms- giving, (4) fasting during Ramadan, and (5) completion of a pilgrimage to Mecca.

Despite the dominance of familialism in Arab life, reli- gious faith is often regarded as more important. Whether Muslim or Christian, Arabs identify strongly with their respective religious groups, and religious affiliation is as much a part of their identity as family name. God and his power are acknowledged in everyday life.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Many Muslims believe in combining spiritual medicine, performance of daily prayers, and reading or listening to the Qur’an with conventional medical treatment. The

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parents provide for female children. In poor communities in Jordan, boys were better nourished, more likely to be immunized, and more apt to receive prompt medical attention for illnesses (West, 1987). Delay in seeking treat- ment was noted by a local health-care provider who diag- nosed “failure to thrive” in a young Iraqi female infant when her refugee parents sought medical attention for a feverish male sibling.

Whereas Arab Americans readily seek care for actual symptoms, preventive care is not generally sought (Kulwicki, 1996; Kulwicki et al., 2000). Similarly, pedi- atric clinics are used primarily for illness and injury rather than for well-child visits (Lipson, Reizian, & Meleis, 1987). Laffrey, Meleis, Lipson, Solomon, and Omidian (1989) attributed these patterns to Arabs’ pre- sent orientation and reluctance to plan and to the mean- ing Arab Americans attach to preventive care. Whereas American health-care providers focus on screening and managing risks and complications, Arab Americans value information that aids in coping with stress, illness, or treatment protocols. Arab Americans’ failure to use pre- ventive care services may be related to other factors such as insurance coverage, the availability of female physi- cians who accept Medicaid patients, and the novelty of the concept of preventive care for immigrants from developing countries.

RESPONSIBILITY FOR HEALTH CARE

Dichotomous views regarding individual responsibility and one’s control over life’s events often cause misunder- standing between Arab Americans and health-care providers (Abu Gharbieh, 1993). For example, individual- ism and an activist approach to life are the underpinnings of the American health-care system. Accordingly, prac- tices such as informed consent, self-care, advance direc- tives, risk management, and preventive care are valued. Patients are expected to use information seeking and problem solving in preference to faith in God, patience, and acceptance of one’s fate as primary coping mecha- nisms. Similarly, American health-care providers expect that the patient’s hope be “realistic” in accordance with medical science.

However, in Arab culture, quite the opposite values— familialism and fatalism—influence health care and responses to illness. For Arabs, the family is the context within which health care is delivered (Lipson et al., 1987). Rather than engage in self-care and decision making, clients often allow family members to oversee care. Family members indulge the individual and assume the ill person’s responsibilities. Although the patient may seem overly dependent and the family overly protective by American standards, family mem- bers’ vigilance and “demanding behavior” should be interpreted as a measure of concern. For Muslims, care is a religious obligation associated with individual and collective meanings of honor (Luna, 1994). Individuals are seen as expressing care through the performance of gender-specific role responsibilities, as delineated in the Qur’an.

Although most American health-care professionals consider full disclosure an ethical obligation, most Arab

physicians do not believe that it is necessary for a client to know a serious diagnosis or full details of a surgical proce- dure. In fact, communicating a grave diagnosis is often viewed as cruel and tactless because it deprives clients of hope. Similarly, preoperative instructions are believed to cause needless anxiety, hypochondriasis, and complica- tions. Apart from the educated, most clients are not inter- ested in actively participating in decision making (Abu Gharbieh, 1993). Most Arabs expect physicians, because of their expertise, to select treatments. The client’s role is to cooperate. The authority of physicians is seldom challenged or questioned. When treatment is suc- cessful, the physician’s skill is recognized; adverse out- comes are attributed to God’s will unless there is evidence of blatant malpractice (Sullivan, 1993).

Not all Arabs may be familiar with the American con- cept of health insurance. Traditionally, the family unit, through its communal resources, provides insurance. Certain Arab countries, such as Saudi Arabia and Kuwait, provide free medical care, whereas in other countries, many citizens are government employees and are entitled to low-cost care in government-sector facilities. Private physicians and hospitals are preferred because of the belief that the private sector offers the best care.

Because many medications requiring a prescription in the United States are available over the counter in Arab countries, Arabs are accustomed to seeking medical advice from pharmacists. In comparison with other Americans in Wayne County, Arab Americans were less likely to take prescription medications, but when they did, they were more likely to use medications as directed (Wayne County Health Department, 1994).

FOLK PRACTICES

Although Islam disapproves of superstition, witchcraft, and magic, concerns about the powers of jealous people, the evil eye, and certain supernatural agents such as the devil and jinn are part of the folk beliefs. Those who envy the wealth, success, or beauty of others are believed to cause adversity by a gaze, which brings misfortune to the victim. Beautiful women, healthy-looking babies, and the rich are believed to be particularly susceptible to the evil eye, and expressions of congratulations may be inter- preted as envy. Protection from the evil eye is afforded by wearing amulets, such as blue beads or figures involving the number 5, reciting the Qur’an, or invoking the name of Allah (Kulwicki, 1996). Barren women, the poor, and the unfortunate are usually suspects for casting the evil eye.

Mental or emotional illnesses may be attributed to pos- session by evil jinn. Some believe that insanity, or jinaan (“possessed by the jinn”), may also be caused by the evil wishes of jealous individuals.

Traditional Islamic medicine is based on the theory of four humors and the spiritual and physical remedies pre- scribed by the Prophet. Because illness is viewed as an imbalance between the humors—black bile, blood, phlegm, and yellow bile—and the primary attributes of dryness, heat, cold, and moisture, therapy involves treating with the disease’s opposite: hot disease, cold remedy. Although methods such as cupping, cautery, and phlebotomy may be

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employed, treating with special prayers or simple foods such as dates, honey, salt, and olive oil is preferred (Al- Akili, 1993). Yemeni or Saudi Arabian patients may apply heat (cupping, moxibustion) or use cautery in combina- tion with modern medical technology.

BARRIERS TO HEALTH CARE

Newly arrived and unskilled refugees from poorer parts of the Arab world are at particular risk for both increased exposure to ill health and inadequate access to health care. Factors such as refugee status, recency of arrival, dif- ferences in cultural values and norms, inability to pay for health-care services, and inability to speak English add to the stresses of immigration (Kulwicki, 2000; Kulwicki et al., 2000), affecting both health status and responses to health problems. Moreover, these immigrants are less likely to receive adequate health care because of cultural and language barriers, lack of transportation, limited health insurance, poverty, a lack of awareness of existing services, and poor coordination of services (Kulwicki, 1996, 2000).

Although a lack of insurance coverage affects a signifi- cant number of Wayne County Health Department respondents (Wayne County Health Department, 1994), other studies suggest that Arab Americans regard other barriers and services as more significant. For instance, lan- guage and communication remain serious barriers for recent Arab American immigrants (Kulwicki, 2000). Transportation to health-care facilities and culturally competent service providers also adds to the problems of accessing health-care services.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

Arabs regard pain as unpleasant and something to be con- trolled (Reizian & Meleis, 1986). Because of their confi- dence in medical science, Arabs anticipate immediate postoperative relief from their symptoms. This expecta- tion, in combination with a belief in conserving energy for recovery, often contributes to a reluctance to comply with typical postoperative routines such as frequent ambulation. Although expressive, emotional, and vocal responses to pain are usually reserved for the immediate family, under certain circumstances, such as childbirth and illnesses accompanied by spasms, Arabs express pain more freely (Reizian & Meleis, 1986). The tendency of Arabs to be more expressive with their family and more restrained in the presence of health professionals may lead to conflicting perceptions regarding the adequacy of pain relief. Whereas the nurse may assess pain relief as adequate, family members may demand that their rela- tive receive additional analgesia.

The attitude that mental illness is a major social stigma is particularly pervasive. Psychiatric symptoms may be denied, attributed to “bad nerves” (Hattar-Pollara, Meleis, & Nagib, 2001) or evil spirits (Kulwicki, 1996). Underrecognition of signs and symptoms may occur because of the somatic orientation of Arab patients and physicians, patients’ tolerance of emotional suffering, and relatives’ tolerance of behavioral disturbances (El-Islam, 1994). Indeed, home management with stan- dard but crucial adjustments within the family may abort or control symptoms until remission occurs. For example, female family members manage postpartum depression by assuming care of the newborn and/or by telling the mother she needs more help or more rest. Islamic legal prohibitions further confound attempts to estimate the incidence of problems such as alcoholism and suicide, resulting in underreporting of these conditions because of a potential for severe social stigma.

When individuals suffering from mental distress seek medical care, they are likely to present with a variety of vague complaints, such as abdominal pain, lassitude, anorexia, and shortness of breath. Patients often expect and may insist on somatic treatment, at least “vitamins and tonics” (El-Islam, 1994). When mental illness is accepted as a diagnosis, treatment by medications rather than by counseling is preferred. Hospitalization is resisted because such placement is viewed as abandonment (Budman, Lipson, & Meleis, 1992). Although Arab Americans report family and marital stress as well as vari- ous mental health symptoms, they often seek family counseling or social services rather than a psychiatrist (Aswad & Gray, 1996).

Yousef (1993) described the Arab public’s attitude toward the disabled as generally negative, with low expec- tations for education and rehabilitation. Yousef also related misconceptions about mental retardation to the dearth of Arab literature about disability and the public’s lack of experience with the disabled. Because of social stigma, the disabled are often kept from public view. Similarly, although there is a trend toward educating some children with mild mental retardation in regular schools, special education programs are generally institutionally based.

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V I G N E T T E 6 . 3

Amal is a 22-year-old pregnant woman who has just immi- grated from Lebanon. She is 6 months’ pregnant and has not seen a doctor because she does not have health insurance. She is visiting the health department for the first time, hoping to be seen by a doctor and enroll in the Women, Infants, and Children (WIC) program. She, her husband, and her 4-year- old son fled Lebanon 1 year ago owing to the political unrest in their home country. Amal is hesitant to fill out the necessary paperwork or answer questions about her residency status for fear of being deported. She states that her son constantly coughs and has breathing problems, especially when her hus- band smokes. Her husband works in a local restaurant as a dishwasher but was recently laid off because of his frequent abscences from work owing to his constant coughing and breathing difficulties. Amal does not smoke, but her husband has smoked two packs a day since he was 18 years old. Amal speaks only limited English.

1. What additional information is needed to complete an assessment for Amal and her family? Given Amal’s lim- ited English proficiency, how would you obtain the necessary information?

2. Explain the cultural barriers Amal is experiencing in accessing prenatal care.

3. What type of intervention can the nurse provide to Amal regarding her husband’s smoking?

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Reiter, Mar’i, and Rosenberg (1986) found that parents who were most intimately involved with the develop- mentally disabled held rather positive attitudes. More tol- erant views were expressed among Israeli Arab parents, Muslims, the less educated, and residents of smaller vil- lages than among Christians, the educated, and residents of larger villages with mixed populations. Reiter et al. (1986) linked the less positive attitudes of the latter groups to the process of modernization, which affects a drive toward status and a weakening of family structures and traditions. Traditions include regarding the handi- capped as coming from God, accepting the disabled per- son’s dependency, and providing care within the home.

Dependency is accepted. Family members assume the ill person’s responsibilities. The ill person is cared for and indulged. From an American frame of reference, the patient may seem overly dependent and the family overly protective.

BLOOD TRANSFUSIONS AND ORGAN DONATION

Although blood transfusions and organ transplants are widely accepted, organ donation is a controversial issue among Arabs and Arab Americans. Practices of organ donation may vary among Arab Muslims and non- Muslims based on their religious beliefs about death and dying, reincarnation, or their personal feelings about helping others by donating their organs to others or for scientific purposes (Kulwicki, 2001). Health-care profes- sionals should be sensitive to personal, family, or religious practices toward organ donation among Arab Americans and should not make any assumptions about organ dona- tion unless family members are asked.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

Although Arab Americans combine traditional and bio- medical care practices, they are very cognizant of the effec- tive medical treatments in the West and consider them- selves privileged to be able to use the American health-care system, which would not have been accessible to them in their country of origin (Kulwicki, 1996). Because of their profound respect for medicine, Arab Americans seek treat- ments for physical disorders or ailments. Medical treat- ments that require surgery, removal of causative agents, or eradicating by intravenous treatments are valued more than therapies aimed at health promotion or disease pre- vention. Although most Arab Americans have high regard for medicine related to physical disorders, many do not have the same respect or trust for mental or psychological treatment. A pervasive feeling among many Arab Americans is that psychiatric services or therapies related to mental disorders are not effective and are required only for individuals who have severe mental disorders or who are considered “crazy.” Psychiatric services are, therefore, underutilized among Arab Americans despite greater need for such services among distressed immigrant populations.

Gender and, to a lesser extent, age are considerations in matching Arab patients and health-care providers. In Arab societies, unrelated males and females are not accus- tomed to interacting. Shyness in women is appreciated, and Muslim men may ignore women out of politeness. Health-care settings, client units, and sometimes waiting rooms are segregated by sex. Male nurses never care for female patients.

Given this background, many Arab Americans may find interacting with a health-care professional of the opposite sex quite embarrassing and stressful. Discomfort may be expressed by refusal to discuss personal informa- tion and a reluctance to disrobe for physical assessments and hygiene. Arab American women may refuse to be seen by male American health-care providers, excluding or denying men the opportunity to interact or appropri- ately diagnose health conditions for high-risk Arab American females.

STATUS OF HEALTH-CARE PROVIDERS

Arab Americans have great respect for science and medi- cine. Most Arab Americans are aware of the historical con- tributions of Arabs in the field of medicine and are proud of their accomplishments. Knowledge held by a doctor is believed to convey authority and power. When ill, most Arab American clients who lack English communication skills prefer to see Arabic-speaking doctors because of their feelings of cultural and linguistic affinity toward Arab American doctors. Many Arabic-speaking clients also feel that Arab American doctors understand them better, and they feel more at ease speaking with someone from their own culture. However, clients who are able to com- municate in English do not usually show preferences for seeing Arab doctors rather than American doctors. In some cases, these clients prefer to be seen by American doctors because they view American doctors as more pro- fessional and more respectful to clients than their Arab American counterparts.

Although medicine is perhaps the most respected pro- fession in Arab society, nursing is viewed as a menial pro- fession that conflicts with societal norms proscribing cer- tain female behavior. In this conservative culture, in which contact between unrelated males and females is often discouraged, nursing is considered particularly undesirable as an occupation because it requires close contact between the sexes and work during evening and night hours (Abu Gharbieh, 1993). American nurses are regarded more favorably because of their education, expertise, and performance of roles ascribed solely to Arab physicians (e.g., performing physical examinations). However, younger immigrants, and especially immigrants who come from Lebanon, Iraq, and Jordan, have more favorable perceptions about nursing as a profession than the older generation of Arab American immigrants (Kulwicki & Kridli, 2001).

Perhaps because Arab physicians tend to be older males and Arab nurses are typically young females, the status and roles of physicians and nurses mirror the hier- archical family structure of Arab society. Physicians require that nurses “know their place” and leave the inter- pretation of data, decision making, and disclosure of

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