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

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Chapter 37

People of Turkish Heritage Marshelle Thobaben And Sema Kuguoglu

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

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

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

The first historical reference to the Turks appears in Chinese records dating back around 200 BC, which refer to tribes called the Hsiung-nu (an early form of the Western term Hun).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

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

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

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

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

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

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

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

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

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

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

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

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

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

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People of Turkish Heritage 3

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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People of Turkish Heritage 5

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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