People of Egyptian Heritage. People of Filipino Heritage. 700 WORDS MINIMUM

oda1113

EgiptianandFilipinoHeritage.Book.pdf

Home >Nursing homework help >People of Egyptian Heritage. People of Filipino Heritage. 700 WORDS MINIMUM

157

People of Egyptian Heritage

Chapter 9

AFAF IBRAHIM MELEIS and MAHMOUD HANAFI MELEIS

Overview, Inhabited Localities, and Topography

OVERVIEW

Egypt, the country of origin of Egyptian Americans, has a landmass of 386,900 square miles (about 11⁄2 times the size of Texas) and a population of over 78 million people, giv- ing it a population density of 177 per square mile. More than 95 percent of the land is barren desert, resulting in 90 percent of the population’s living on 3 percent of the total land area, in the Nile Valley and Delta (CIA, 2007). The Nile has been and still is significant in shaping life and living patterns in Egypt. The average annual rate of popu- lation increase is 1.75 percent, with a birth rate of 22.94 per 1000 and an infant mortality rate of 31.3 per 1000 (CIA, 2007). The capital, Cairo, has over 11 million peo- ple, followed in population by Alexandria with 3.5 million people. The population of Egypt continues to grow by about 1.4 million per year (Zohry & Harrell-Bond, 2003).

Egypt is bordered by Libya on the west, Sudan on the south, the Mediterranean Sea on the north, and the Red Sea and Israel on the east. The eastern region, across the Suez Canal, is Sinai. Egypt’s climate is hot and dry most of the year. The average daily temperature on the Mediterranean coast is 68!F with a maximum of 88!F, and in Aswan, average temperatures are 80!F but can reach 120°F with little or no humidity. The Mediterranean region receives most of the country’s annual rainfall (7.5 in.). The northern summers are balmy with moderate temperatures and 80 percent humidity. Between March and April, khamsi winds blow in from the Western Desert at up to 93 miles per hour. Except for a few hills outside Cairo, Egypt has a flat terrain on both sides of the south-

ern Nile valley and the Sinai Peninsula. The Nile River, a main artery for Egypt and an orientation point for its ter- rain, runs through the center of the country from south to north to the Mediterranean Sea. The Nile—considered to be Egypt’s lifeline—provides water and supports agri- culture.

Egypt is considered by many politicians, historians, and social scientists to be part of 22 Arabic-speaking countries in North Africa. Egyptians are among the 255 million Arab people of the world, as well as part of the 1 billion persons who are Muslim. Others write about Egypt as a Middle Eastern country and count its popula- tion as Middle Eastern. A review of scholarly literature about Egyptian Americans is embedded in writing that aggregates them with Arab Americans, African Americans, and Middle Eastern Americans, as well as separates them out as Egyptian Americans. Scholarly literature about Egyptians in the United States is limited; therefore, the reader will find citations that reflect a broader geographic territory, which in turn reflects how Egyptians are often connected to or embedded in many Arab, Middle Eastern, African, and Muslim cultures.

This chapter is also based on the authors’ own experi- ences. Both authors are Egyptian Americans who came to the United States in the early 1960s and observed many Egyptian Americans as they defined themselves within the multiple identities generated by the different group- ings, such as generation and length of time away from the country of origin. Both authors have been insiders as well as outsiders to Middle Eastern communities in the United States and globally. They have participated in different community celebrations, experienced immigrants’ grief over the impending or actual death of a family member, provided social and emotional support during times of crisis, and counseled many immigrants. One of the

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 157 Aptara Inc.

authors has been professionally involved with health care for this population for over 30 years as part of a project that was designed to provide health-care services to Middle Eastern immigrants in California. Therefore, data in this chaper are from our lived experiences in the two worlds Egyptian Americans claim as their own—Egypt and the United States.

Arab Americans are estimated to number 3 million (Salari, 2002), although census data estimate that popula- tion at only 1.1 million (U.S. Bureau of Census, 2002). The variation is an artifact of census survey problems. Among these estimates is around 1 million Arab Americans who reside in the United States as permanent residents, citi- zens, or residents in the process of becoming permanent residents. Egyptians reside in most states in the United States; 66 percent of Arab Americans are concentrated in 16 states (Zogby, 2001). Heavily populated states are New Jersey, California, Michigan, Illinois, and New York. Egyptian Americans’ religious affiliations resemble those of others from the rest of the Arab countries. The majority are Christians, and among the Christians are Orthodox (Greek and Copts), Catholics, and Protestants. Egyptian American Muslims who are Sunni are increasing in num- bers and represent the fastest growing religious group among Egyptian immigrants (Salari, 2002). Ninety percent of Egyptians are Muslims, and the overwhelming majority of these are Sunni Muslims.

Egyptian Americans are diverse in other ways. They come from urban and rural communities, upper and lower Egypt, and diverse educational backgrounds, and they possess a wide range of cultural characteristics influ- enced by colonialization, occupations, and a variety of immigration experiences that shaped their responses. However, only the most common patterns of responses and experiences of Egyptian Americans with regard to heath and illness are presented in this chapter. Diversity among Egyptians is not well depicted, and this descrip- tion does not represent a universal profile either. By defin- ing the similarities among Egyptian Americans, we hope to stimulate interest in more systematic scholarhip about this unique community and their lifestyles, health, and health-care practices.

HERITAGE AND RESIDENCE

In spite of the many attributions of geographic belonging to Egypt, the Egyptian people have a strong sense of iden- tity with their country and demonstrate pride in coming from such an old civilization. Egyptian history is inextri- cably connected to the Nile River and dates back to about 4000 B.C., when the kingdoms of upper and lower Egypt were united by King Menes, who presented himself as a god. The ancient Egyptians were the first to believe in life after death, mummify bodies, and build elaborate tombs to preserve and protect these bodies for the afterlife. Egyptians also developed the plow, a system of writing, and medical skills such as surgical operations.

The Arab conquest of Egypt around A.D. 641, which spread the Islamic and Arabic culture among the Egyptians, has lasted to this day. The minority (Christian) Copts, who preserved the African-Asiatic language of ancient Egypt, now use the Arabic language and have

been assimilated into the Arabic culture. The Ottoman Turks invaded Egypt in 1517, adding it to their vast empire. While living under Turkish rule, Egypt enjoyed religious and cultural stability because the Turks shared the Islamic and Arabic cultures. In the last 2 centuries, Egypt experienced invasions by the French, followed by the British in 1882, who remained in the country until 1954. In 1952, an Egyptian army group led by Lieutenant Colonel Gamal Abdel Nasser took control of the govern- ment and removed King Farouk from power. Since then, Egypt has been an independent state called the Arab Republic of Egypt (CIA, 2007).

An influential part of modern Egyptian history is the Arab-Israeli conflict. The conflict between Egypt, as part of the Arab League, and Israel ended in 1979 when the two countries signed the Camp David Accords. Anwar Sadat was the president of Egypt at the time. Egypt con- tinues to be involved in diplomatic efforts to arrive at peace between Israel and its neighboring Arab countries. This long history and the diversity of populations have influenced the value systems, beliefs, and explanatory frameworks Egyptians use in their daily lives and have contributed to the diverse thinking processes they use to resolve issues and conflict.

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Many Egyptians immigrated to the United States in an attempt to escape economic stagnation during President Nasser’s regime and his failed economic policies that nationalized all privately owned companies and enter- prises. The United States offered educational opportuni- ties, career options, and economic incentives that rewarded hard-working individuals. After the 1952 mili- tary revolution, Egyptians immigrated in three main waves. The first wave, in the 1950s, consisted of graduate students who came to the United States to obtain advanced degrees. After the defeat of the Egyptian army by the Israelis in 1967, many of these students, believing the totalitarian military regime of Egypt did not offer hope for economic recovery, changed their status to immigrant. For most, this ensured a promising future for their children, even though they would have been assured decent posi- tions in Egypt because of their American education.

The second wave of immigration resulted from the heightened mass dissatisfaction, hopelessness, and anger toward the government of the educated and professional community after the 1967 war. A lenient government pol- icy made it easy and safe for anyone who wanted to leave the country, resulting in the largest exodus from Egypt in modern history. Included in this wave were many Coptic and other Egyptian Christians (Shaw, 2000).

The third wave, in the 1980s and beyond, had many more risk takers. They came to seek better lives and forsake the security of government jobs for unknown adventures. They sought new opportunities such as cab driving and working at food outlets in large cities (Meleis, 2002). It is important to note here that the terrorist attacks in New York, Pennsylvania, and Washington, DC, and the tragic consequences of September 11, 2001, have rendered many newly immigrated Egyptian Americans vulnerable to

158 • CHAPTER 9

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 158 Aptara Inc.

profiling and stereotyping in their newly adopted country, the United States of America. Therefore, a newly acquired sense of stigma tends to influence their patterns of responses in ways that were not manifested previously. Long-term effects of this situation on their patterns of behaviors have yet to be studied and understood.

EDUCATIONAL STATUS AND OCCUPATIONS

Most of the first-wave Egyptian immigrants were highly educated individuals with graduate and postgraduate degrees earned in the United States. Members of this group were able to obtain teaching and research positions in universities or work in industries. Some joined compa- nies or started their own businesses in the high-technology industries.

Egyptians in the second and third waves were more diverse in their educational backgrounds, although most of them were college graduates. Second-wave immigrants worked as engineers, physicians, dentists, accountants, and technicians; however, some with college degrees ini- tially accepted employment as gas station attendants, cab drivers, security guards, and other blue collar positions to ensure employment. After improving their language skills and obtaining degrees from American universities, many obtained professional positions. A small minority never achieved an occupational status equivalent to their origi- nal training. Many from this group returned to their home country or plan for such a return.

Communication DOMINANT LANGUAGE AND DIALECTS

The dominant language of Egyptians is Arabic, a Semitic language understood by all Arab nationals, who hear it in popular Egyptian movies, songs, and television programs. The written Arabic language is the same in all Arab coun- tries, but spoken Arabic is dialectal and does not necessar- ily follow proper Arabic grammar. A number of Arabic dialects are spoken in Egypt. The Saiidis (Egyptians south of Cairo) have a different dialect from the northerners. The Nubians (who live around and south of Aswan) have another unique dialect, as do the Bedouins, who live in the desert. Despite these different dialects and their distinct vocabularies, neither Egyptians nor Egyptian Americans have any noticeable communication barriers among themselves.

For Egyptian immigrants in the United States, English is the language of communication in business and con- tact with American society. Within their own gatherings, they speak a mixture of Arabic and English, switch with great ease from one language to another, and sometimes speak a mixture of Arabic, English, and French. Egyptian social gatherings usually involve large numbers of people, with multiple conversations occurring simultaneously. When they are discussing subjects such as politics or reli- gious issues, the level of excitement heightens and the tone of the speech is sharpened, so an outside observer may mistakenly characterize the exchanges as chaotic or angry.

CULTURAL COMMUNICATION PATTERNS

V I G N E T T E 9 . 1

Rania Selim is a 37-year-old Egyptian American teacher who is married to 45-year-old engineer Abdel Samih Adeeb, who works for a moderate-sized construction company. They have one daughter, Salwa, who is 8 years old. Mrs. Selim went to her gynecologist on a routine visit, and her doctor discovered a lump in her breast. This led to a diagnosis of inflammatory carcinoma.

1. Identify cultural beliefs and values that may frame the assessment and intervention plan for this family.

2. What problems should the health-care provider antici- pate related to communication between family mem- bers about the diagnosis?

3. Identify three problems and three strengths during the process of decision making and care.

4. What culturally congruent strategies should be used to support family decision making for the different treat- ment options?

5. Name two interventions that are immediately needed.

Several values govern interaction patterns among Egyptians. The first is respect (ihteram), which is expected when speaking with those who are older and those in higher social positions. Respect is demonstrated in the Arabic language by differentiation in the words used to address those who are equal in age or position and those who are older in age or higher in position (see Format for Names). A second important value, politeness (adab) is related to what is appropriate, expected, and socially sanctioned. Truth and reality may be sacrificed for what is appropriate and polite. Politeness results in a preference for more indirect modes of communication. Sharing neg- ative news directly or asking for things directly is not polite. Therefore, a poor prognosis of an illness is not immediately shared; calamities should be slowly and deliberately introduced and shared in stages. It is more appropriate and expected that such news will be shared first with other family members who will provide a buffer that helps those coping with and responding to such news.

Significant value is related to the status of insiders and outsiders, the private and public spheres. Private spheres are reserved for immediate family, some members of the extended family, and friends who are elevated to the sta- tus of family. The public sphere includes acquaintances, public officials, and the rest of the world. Those who occupy a public sphere may get completely different com- munications and versions of the same events or incidents.

Because Egyptian Americans tend to be externally dri- ven, they are concerned about what others think of their behaviors, which are considered a direct reflection on their entire family. Therefore, parents tend to be overzeal- ous and anxious about the good or bad behaviors of chil- dren and adult sons and daughters. These behaviors reflect a measure of how well or how badly parents have raised their children.

PEOPLE OF EGYPTIAN HERITAGE • 159

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 159 Aptara Inc.

Egyptian Americans tend to be in touch with their inner feelings and are highly expressive of them; how- ever, this expression is governed by external orientation, spontaneity, and the differences between private and public spheres. Egyptians in America tend to share prob- lems and the most minute details about their lives with their trusted circle of insiders. However, because they are externally oriented, they tend to look outside for expla- nations of their feelings, rather than to focus on their own actions. Egyptians tend to be comfortable and gener- ous in sharing ideas and giving advice to others who might be family members or friends. This behavior stems from close family ties and trust that ensures the family will always be there to provide help. Advice is offered (even when not requested), out of love, care, and a sense of loyalty to friends or relatives. They do not shy away from becoming involved in the problems, trials, and tribulations of those in their private sphere. The extent and depth of involvement is less for those in the public sphere. Although these behavior patterns are a part of the lifestyle of first-generation immigrants, second-genera- tion immigrants may not necessarily maintain them.

Egyptian Americans’ nonverbal communication pat- terns are expressive. Because their personal space bound- aries tend to be small, they stand and sit very close to each other. In spite of their preference for closeness, women and men use personal space boundaries differ- ently during interactions. Women tend to keep male friends as far away as male strangers. Egyptian Americans speak with expressive words and facial expressions, ges- ticulating with hands and using body movements. They communicate with their entire body as much as with ver- bal language. Their facial expressions are mirrors of their internal processes and reflections of their inner evalua- tions of their situations. They tend to touch each other frequently and easily, and touch is both reflexive and deliberative. For example, they tend to touch others while speaking to solicit attention, concentration, and empha- sis. To demonstrate trust, increase trust, or emphasize a point, they tend to touch each other on the hands, arms, legs, and shoulders. Men, whether strangers or acquain- tances, touch each other. Similarly, it is acceptable for women to touch. Family members and friends of the same gender always hug and kiss on both cheeks. Friends of different sexes normally shake hands. However, tradi- tionally, it is unacceptable for women and men to touch each other. Touch between the sexes is accepted in private and only between husbands and wives, parents and chil- dren, and adult brothers and sisters. Levels of religiosity govern the protocols about touching between males and females. The more religious the individuals, the more pro- hibitions about touching between males and females.

Devout Muslim men and women do not touch each other; even a handshake is not practiced. In these situa- tions, a head nod substitutes for a physical greeting. Among devout Muslims, only mahrams, those individuals who are not permitted to marry (e.g., sisters and brothers), are permitted to greet each other with hugs. Among Christians and Westernized Egyptians and Egyptian Americans, greetings usually include formal courteous hugs and kisses on the cheeks. In Egypt, it is very common to see Egyptian men or women walking in public places

holding hands or embracing each other. In the United States, Egyptians are more self-conscious about touching members of the same sex, touching non-Egyptians only on the arm or shoulder as an expression of caring, assuring them that one is a friend. Some Westerners may be uncomfortable with these gestures.

Egyptians have their own nonverbal facial expressions. A momentary wide-eyed gaze to a child means “stop it now.” A wink to an adult means “watch what you are say- ing” or “change the subject because you are treading on dangerous ground.” Dissatisfaction is demonstrated by intentionally looking through the person or by avoiding eye contact. Egyptians think of those who do not main- tain eye contact or have shifty eye contact as people who should not be trusted. Because Egyptians tend to stand in close proximity to each other, eye contact is automatic for them. However, among those who are more traditional, women and men who are strangers may avoid eye contact out of modesty and respect for religious rules. The situa- tion is different if the communication is between men and women related by marriage or by blood. Children are taught not to tebarrak (stare), which denotes disrespect for those who are older or higher in status.

Egyptians tend to be congenial and personable, inject- ing humor to lighten stressful encounters or business meetings. They may exaggerate and overly assert judg- ments of events and situations for the sake of emphasiz- ing a particular point of view.

An Egyptian greeting involves every person in a room standing and shaking hands within gender norms. Not standing can be considered an insult. A greeting may be just a nod or a few words. Similar greetings are practiced in the United States among immigrants.

TEMPORAL RELATIONSHIPS

Older Egyptians cherish the past, remembering the days when life was simple and easy. Reminiscing is a cultural pattern that becomes more prominent with age. Younger Egyptians live in the present, with its decreased availabil- ity of options, and in the future, with its potential, realiz- ing that acquisition of goods comes with a high price tag. Thus, this generation is preoccupied with maximizing their incomes, often working two or three jobs to afford luxuries. For professional Egyptian immigrants, working hard has been their ticket to upward mobility and living the good life.

In Egypt, social time takes a high priority, and engage- ments are not concluded because of other scheduled appointments; therefore, guests are expected to arrive late. If a friend drops by as another is getting ready to leave for an appointment, the appointment is missed and the friend is not told about the prior engagement. Arrival at a social gathering, such as a lunch or dinner, as much as 1 or 2 hours late and to be late for business appoint- ments because of heavy traffic and unanticipated and uncontrolled delays is common. A social custom is to offer coffee, tea, or a soft drink to business visitors. Therefore, a planned 10-minute office visit usually takes more time. Egyptian Americans’ perception of time is in the context of the nationality of the group. Therefore, they follow “American time” and are punctual for

160 • CHAPTER 9

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 160 Aptara Inc.

business engagements and meetings with non–Egyptian Americans but prefer to use Egyptian time for Egyptian American gatherings.

FORMAT FOR NAMES

In all Arab countries, both male and female children are given a first name, and the father’s first name is used as the middle name; the last name is the family name. In the Middle East, a person is called formally by the first name, such as Mr. William.

Respect for individuals is demonstrated in the use of certain titles. Inta (you) is saved for those in equal or lower positions, and hadretak (you) is reserved for those in higher-ranking positions or for older people. More flow- ery and more exaggerated variations of both of these appellations are used, such as seyadtak, which is reserved for the highest-level officials. Inta, used in place of hadretak, is an insult to older people and, more important, a reflection of bad manners and the poor upbringing of the young. Older people should never be called by their first names without an adjective or title attached to the name. The accepted custom in the United States of addressing clients by their first name may be insulting to people from other countries. An adjective, such as aunt, uncle, ostaz (Mr., Madame, Mrs.), or an adjective that denotes a profession, such as bashmohandes (engineer, doctor, physician) or a doctoral degree, may be used with the name. Family friends are addressed by both younger and adult children as uncle and aunt. Parental relatives are called either aunt or uncle or a special designation such as ammeti (sister of father), ammy (brother of father), khalty (sister of mother), or khali (brother of mother). Some Egyptian Americans, particularly those from rural Egypt, are addressed by the first name of their son, pre- ceded by “Abu,” which means “father of.” This is more of an Arab custom adapted by Egyptians (Haddad & Hoeman, 2000).

Family Roles and Organization

V I G N E T T E 9 . 2

The Fayez family came to the United States from Cairo, Egypt, in 1976. After spending 6 months with distant relatives in Daly City, California, Anwar and his wife, Fatma, moved into an apartment of their own. Anwar continued the job his Uncle Hussain had helped him get in the construction business. Fatma has never worked outside the home. In 1979, Mr. and Mrs. Fayez had their first child, a son named Moustafa. In 1980, they had their second child, a daughter named Somaya. Two years ago, Fatma miscarried in her 4th month of preg- nancy and lost a male child. At present, Fatma is 6 months’ pregnant, and Anwar owns and operates his own small con- struction and roofing company in the Richmond area of San Francisco. Moustafa is a healthy-looking boy who does well in school, and Somaya is in the first grade.

The public health nurse—a family nurse practitioner assigned to the Fayez family for their well-child and prenatal

care—has made two visits to the family’s home. On both occasions, the nurse noticed that Mrs. Fayez looked very fatigued and short of breath. Both Moustafa and Somaya were very quiet during the visits. Anwar boasted often of his son’s achievements in school and said little about Somaya. Fatma was showing some slight edema in both feet, and the nurse noticed during these visits (both in the evening) that Fatma was frequently getting up to serve the family tea and food. Mr. Fayez described how Moustafa’s teachers complain about his “aggressive behaviors in school.” Mrs. Fayez was concerned about her daughter’s “finicky” eating habits. During both vis- its, the nurse noticed an older, conservatively dressed woman who sat quietly during the early part of the visit and commu- nicated with family members in Arabic. She always left the room soon after the nurse arrived, and the nurse sensed that the family acknowledged her with a great deal of respect. The house was nicely furnished, and no educational toys or books were visible.

1. Identify the strengths in the Fayez family that may sup- port and enhance their health.

2. What problems are inherent in the situation? 3. What assessments are needed? 4. What might some goals be? 5. Identify priorities for health care and give rationales

for these priorities. 6. Identify three cultural factors that influence the health

of the Fayez family. 7. Describe two strategies the nurse might use to help the

Fayez family deal with their son’s “aggressive behaviors.” 8. Describe two strategies the nurse might use to help

the parents deal with their daughter’s “finicky” eating habits.

9. Identify a culturally competent approach to assessing and intervening with the health-care concerns of the Fayez family.

10. Identify three culturally congruent intervention plans for Mrs. Fayez’s pregnancy.

11. Describe three areas of at-risk behaviors that you might want to explore preventively with the Fayez family.

12. Compare and contrast first-wave and second-wave Egyptian immigrants in America according to their reasons for immigration.

13. Identify potential communication concerns in the American workforce with newer Egyptian American immigrants.

14. Identify infectious conditions that may be common among newer Egyptian American immigrants.

15. Identify culturally congruent bereavement patterns for Egyptian Americans.

16. Identify counseling strategies for Egyptian Americans in regard to self-medicating practices.

HEAD OF HOUSEHOLD AND GENDER ROLES

The man is formally considered the head of the house- hold. The demands of life on immigrants and nuclear families drive couples to share responsibilities and deci- sion making. Many Egyptian American men, however, tend to control family budgets, which gives them more

PEOPLE OF EGYPTIAN HERITAGE • 161

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 161 Aptara Inc.

power in the family and causes many interpersonal con- flicts and much distress for Egyptian American women.

Egyptian American family roles change considerably after immigration. The fast pace and complexity of life in America, the many demands of child rearing, and the absence of an extended family to preserve traditional roles contribute to a more egalitarian family organization. Husbands and wives experience greater fluidity in their roles, substitute for each other when needed, and partici- pate fully in all family matters. Egyptian American women tend to work both in temporary occupations and in career positions. Many who do not work outside the home consider their situation temporary, are between jobs, or are retooling their skills to become congruent with American job opportunities. Women who are not working outside the home tend to be more stressed than those who are employed. Unemployment brings with it economic limitations, social limitations in terms of devel- oping a support network, or both. In the absence of extended families, lack of this support network increases vulnerability, isolation, and stress. Although couples may share daily household chores, the norm is similar to that of other educated middle-class families in America. The woman is responsible for the daily management of family affairs. The man is the major breadwinner for the family. Husbands, however, participate in shopping, cleaning, and activities related to entertaining with their wives. Fathers also participate proactively in activities and edu- cation with their children.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

Children are central to Egyptian families; they are trea- sured in the present and viewed as security for their par- ents’ future. During their early years, they are expected to be studious and goal oriented, respectful, and loyal to the family. When they become adults, they are expected to take care of their older parents. However, second-genera- tion Egyptians tend to blend with other Americans. Their sense of responsibility toward their parents is a topic of major concern among Egyptian Americans. Egyptian chil- dren are not permitted to use foul language or swear in the home or in front of parents, although this is true to a lesser degree in the United States. Answering back to par- ents is not condoned and is seen as rude and disrespect- ful. Some families adjust better than others to the Western style of child rearing, which permits and encour- ages the children’s rights to question their parents’ instructions. Families that allow their children more free- dom to express their opinions and ask questions often end up with better-adjusted children and better-preserved family unity as their children grow into adulthood. Religious beliefs and teachings forbid premarital sex and adultery for both Egyptian Muslims and Christians.

As girls reach puberty and questions of dating, court- ing, and prom night arrive, some parents cannot cope with the freedom allowed within American society. They worry more about the consequences of dating and their daughters’ getting pregnant and fleeing the home than about raising a healthy and well-adjusted young woman. In the extreme, a few families send their daughters with

their mothers back to Egypt to complete their education through college under more restrictive conditions or to get married. Some families opt to return for good rather than raise their daughters in the American culture. Egyptian Muslim and Christian families usually have a hard time giving their young daughters enough space to grow (Meleis, 2002).

Hattar-Pollara, Meleis, and Nagib (2000) found that Egyptian American parents fear their daughters’ losing their virginity, representing a major stress in their daily lives. The greatest calamity that may happen in a Christian or Muslim Egyptian American household is to have a daughter lose her virginity prematurely. This fear stems from a potential lack of marriageability of the daughter, loss of face for the father, and gossip within the Egyptian American community. Therefore, parents tend to be restrictive about their daughters’ movements and to monitor their whereabouts carefully. Similar restrictions are placed on teenage sons, although they are allowed more freedom and more autonomy in decision making. Most parents prefer that their sons not date and discour- age sexual activities. However, if sons disobey the rules of the household, the incident is not regarded as gravely as when daughters do.

Second-generation Egyptian Americans are rather philosophical about these restrictions. The open commu- nication in the family allows children to see restrictions as temporary or to devise ways to do what they want without their parents’ knowledge. Whereas similar situa- tions may occur in their original country, the difference is that an extended family in the homeland may help medi- ate when confrontations between parents and children become inevitable. Without extended families, Egyptian Americans are at a loss for help in resolving family issues. The option of going to counselors or health-care profes- sionals for advice is rarely exercised. Preserving family secrets and honor is more important than external sup- port. Just as families have a strong need for virginity to be preserved, teen pregnancy is not openly discussed in the community. Because of the many restrictions placed on daughters’ movements and the limited opportunities for teenage daughters to go out without chaperons, such pregnancies rarely occur. Birth control is not usually dis- cussed in families until marriage, and Pap smears are not sought or accepted until after marriage. Egyptian American children are expected to marry Egyptian Americans. However, because many second-generation Americans do not reside in areas with other Egyptian Americans, cross-cultural marriages are becoming a trend. Many first- generation Egyptian Americans return to their home country to get married. Intermarriages among second- generation Americans are increasing.

FAMILY GOALS AND PRIORITIES

The family is the most sacred institution to Egyptian Americans. Although Egyptians in their own country have extended families, Egyptian American families tend to be more nuclear. Compared with other Arabs in the United States, most Egyptian Americans immigrated indi- vidually, were joined later by a bride, or immigrated as nuclear families. In some families, brothers, sisters,

162 • CHAPTER 9

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 162 Aptara Inc.

nephews, and nieces may arrive later. Even when extended families arrive later, they tend to live apart.

Job opportunities dictate living choices and patterns of living among Egyptian Americans. Egyptians in their own country view the relocation of sons or daughters for edu- cation or an occupation with trepidation and concern. However, once children move, though not bound by their extended family’s geographic location, they remain con- nected with them. In their home country, Egyptians tend to include the extended family in social activities and consult them for advice in all matters pertaining to health, employment, and family. In the absence of such a family in the United States, they either resort to close Egyptian American friends or seek counseling from extended families in their home country. Christian fami- lies may resort to religious leaders in their church or com- munity for assistance. Imams, who are Muslim religious leaders and therefore devout Muslims, who belong to a mosque may choose to consult with other Imams regard- ing marital, family, or mental health problems (Ali, Milstein, & Marzuk, 2005).

The most important goal for Egyptian American fami- lies is to raise children who are well educated, employ- able, and able to secure occupations that allow career mobility, financial security, and an acceptable social sta- tus. To that end, many other goals are subordinated. Because of this goal, parents may move to areas with bet- ter school systems and are willing to withstand financial or other hardships for the sake of their children.

Another goal of Egyptian American families is to keep children geographically close, if not living at home, until they get married to the right partner. Parents consider it their responsibility to assist their children, especially daughters, to find a suitable marriage partner, and they support children financially through wedding prepara- tions. Raising children who are considered moaddabeen by Egyptian standards is important. A child who is moaddab is one who respects parents, defers to them for decisions, is mindful of older people, does not drink or indulge in immoral acts, listens to parents’ advice, and does not answer back during conflict. One final goal of Egyptian families is to maintain a good face in public. This goal is achieved when children do not bring shame by engaging in activities forbidden by their parents, such as drinking, smoking, or going somewhere without their parents’ permission.

As Egyptians grow older, they are considered richer in experiences and wiser and command more respect. They are treated with gentleness and never made to believe that their usefulness is limited just because of aging or retirement. Their children and extended family are expected to care for them. Older people prefer to do less management of their own affairs and expect more ser- vices, respect, and reverence from family members and subordinates. Women gain status with age and with childbearing. Young women know that inequities they may suffer as young brides are more than compensated for when they get older. Older women, however, are expected to care for older men in the family.

Because most of the Egyptian American community immigrated as young adults, as they advance in age they are the first generation to experience growing old in the

United States. Many parents have a morbid fear that they may be forced to move into a nursing home. Many con- sider returning to their home country to avoid the humil- iation of aging in America, with the potential loss of home, family care, and respect. Egyptian Americans do not believe that they can expect or hold their children responsible for becoming their caregivers during old age (Durrani, 2000). Growing old in America is surrounded by many images of abandonment, humiliation, loss of respect, and above all, loneliness. Those who adapt to a life without extended family and create an extended fam- ily will likely establish a new means to deal with their old age. Health-care professionals may consider alternative ways to support this community and enhance their self- care activities to help them avoid feelings of loneliness and a sense of abandonment in old age.

Many Egyptian Americans are part of a network of friends with whom they share their celebrations and calamities. Where mosques or Middle Eastern Orthodox churches exist, these organizations are used to promote social gatherings, maintain cultural norms, reinforce cul- turally driven restrictions on children’s behavior, and promote historical continuity. In the absence of such organizations, Egyptian cultural clubs promote meetings, discussions, and sharing news from the homeland. Comparative analyses of life in Egypt and the United States often dominate these gatherings. During social gatherings, Egyptians are recognized by their elegant clothes, the hustle and bustle of children playing, adults chattering, and fine Egyptian food.

Egyptian Americans prefer family gatherings to adult gatherings for celebrations such as Ramadan (the month of fasting), the Eid feast celebrations, Christmas, and New Year’s. Most often, they include extended family and their new networks of friends. Social networks are connected by their heritage rather than by their occupa- tions. Without these large gatherings, loneliness and a sense of deprivation are exaggerated at times of crises or during normal developmental events such as the birth of a baby or the death of a family member.

In Egypt, extended family members play a strong role in the life of a family. It is an important goal of family members to live in the same city. Extended family mem- bers provide backup and support for working women by providing child care and for nonworking women with multiple children as they need tangible support. Families raise children, not mothers or fathers. All family members freely give advice on child rearing. In the United States, Egyptian immigrants do not usually have extended family members living with them, but they continue to consider the extended family living abroad as their support net- work. For those who have extended family members and professional careers, the relationship tends to be more lim- ited by time, responsibilities, and other demands.

Social status is gained through professional accomplish- ments, financial success, and involvement in Egyptian community affairs. Respect is given to community leaders who give of themselves and share life experiences. No caste system exists based on color, familial lineage, or ancestry among Egyptians or Egyptian Americans. In some com- munities, Egyptian Americans are divided by religion (Muslims and Copts) and by professional status, with clubs

PEOPLE OF EGYPTIAN HERITAGE • 163

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 163 Aptara Inc.

for professionals, blue-collar workers, and other white- collar workers.

ALTERNATIVE LIFESTYLES

The divorce rate among Egyptian immigrants is low, a pat- tern similar to that in Egypt. In cases of divorce in which one parent raises the children, the Egyptian community supports the single parent, including his or her own chil- dren. Divorce is not seen as a stigma, but an unfortunate situation in which the children pay the greatest price. In second marriages, partners work hard to make a new life together and are committed to raising their stepchildren.

Communal and same-sex families are concepts that do not exist in Egyptian societies. Although a community of gays exists, homosexuality is rarely disclosed. They do have meeting places that are frequently ignored, inten- tionally overlooked, and more recently, raided, with jail as a result for those suspected of same-sex activities. The Web site GayEgypt.com includes stories of gay men who have been imprisoned, facing hard labor and torture. To be gay or lesbian is considered immoral and is not accepted by any Arab or Middle Eastern religion. To dis- cover a gay son or lesbian daughter is akin to a cata- strophic event for Egyptians and Egyptian Americans.

Workforce Issues CULTURE IN THE WORKPLACE

Egyptian American nurses, who usually hold a minimum of a bachelor’s degree, cope well with the demands inher- ent in providing nursing care in the United States. In the beginning of their careers in the United States, however, they encounter three challenges. First, Egyptian American nurses frequently expect detailed and careful communi- cation of all steps and aspects of nursing care. This expec- tation is inherent in both their cultural patterns and their educational preparation. Although interactions and com- munications come naturally to Egyptian Americans, this naturalness is usually reserved for family and close acquaintances. In addition, their professional preparation does not emphasize communication skills for interacting with clients. Because Egyptian clients do not expect detailed information from physicians and nurses, the rou- tine of informing clients about the rationale for interven- tions may challenge Egyptian American nurses.

The second challenge relates to the systematic and careful recording and documentation of nursing care. Egyptians are inclined to an oral tradition; therefore, the need to document in writing what can be shared verbally seems foreign to Egyptian American nurses.

The third challenge involves the work environment itself. For Egyptians, the work environment is also their social environment in which friendships are built and life experiences and personal issues are shared with a select few. The emphasis on privacy and separating work and social life expected in American work settings seems artificial to Egyptian Americans. Therefore, they tend to view American work relationships as superficial and often experience a sense of loss in terms of close,

meaningful work relationships and a supportive colle- gial network. This feeling is similar to how women in other professions view satisfying and stressful aspects of their work situation.

Many Egyptian communities in the United States form Egyptian cultural clubs to which a small percentage of these immigrant nurses belong. Such clubs help to decrease their sense of marginality. Activities usually include parties, dinners, picnics, and dances. Some of these clubs offer Arab language classes for the children. The more religious social- ize around their local mosques and churches, which are good and safe forums for their teenage sons and daughters to meet prospective marital partners.

Egyptian immigrants to the United States work hard at becoming integrated into the Western work environ- ment. They thrive on professional satisfaction, defining success in terms of advancement. They tend to be team players and effective contributors to the society at large. They are usually punctual and follow work rules and pro- cedures. Being well assimilated, they create a close net- work of colleagues.

ISSUES RELATED TO AUTONOMY

Most Egyptians prefer to work in a job setting in which they are employees of an organization. They do not expe- rience difficulty in reporting to a superior and following instructions. These cultural patterns do not preclude their being professionally motivated to work hard and advance their careers within respective organizations. As man- agers, leaders, or supervisors, they bring a personal touch and demonstrate human interest in their dealings with subordinates and coworkers. They demand loyalty and respect. On the whole, their religious affiliations do not pose problems for them when dealing with coworkers outside their own religions. However, the long history of Egyptian and Arab Israeli animosity causes some of them to approach their dealings with Jewish coworkers cau- tiously. Egyptian immigrants tend to be respectful of female coworkers, and often, their protective responses may be interpreted as patronizing by some women. They treat women as sisters or daughters.

Few Egyptians are entrepreneurial by nature. Those who opt to start their own businesses struggle to make them work. Egyptian Americans in general value job and economic security over the risk-taking inherent in operat- ing a business. Therefore, they join established organiza- tions with long-term goals.

Egyptians learn British English in schools and universi- ties. On immigrating to the United States, they are con- fronted with unfamiliar slang and idioms. When viewed from an immigrant’s point of view and with only basic knowledge of British English, some of these expressions are hard to interpret and could be construed as insults. An example of this type of misunderstanding happened to one of the authors (MHM). As he narrates it:

When I arrived in the United States (over 30 years ago) as a graduate student in engineering, I had an occasion to be studying at a University of California Los Angeles library on a weekend day with my wife, a graduate student in nursing. When we decided to go to the local school cafeteria for a cup of tea, we noticed one of her psychology

164 • CHAPTER 9

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 164 Aptara Inc.

professors in the library whom we knew very well inside and outside of the school. I approached him, greeted him, and asked if he would like to join us for a cup of tea. He responded by saying, “No, I don’t care to have a cup of tea now.” This, of course, is a very simple and totally accept- able American response. For me, a recent Egyptian immi- grant (less than a year), this was a personal insult. The words “I do not care” meant to me that he did not care about me, not the process of having tea. We discussed this conversation a year later as he and I became close friends and laughed about it. He obviously meant no insult, and I just did not know enough about the idioms and com- monly used expressions to “get it.”

With increasing exposure to the media and life in the United States, it does not take long for a new immigrant to understand and accurately interpret idioms and com- monly used expressions. The media is also a useful tool that helps Egyptian Americans and others to learn the English language and idiomatic and slang expressions.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Most Egyptians have olive skin tones, some are fair- skinned, and others dark-skinned. Northern Egyptians exhibit a fairer complexion than most other Egyptians. Southern Egyptians (Nubians) are generally black, with very fine facial features. Upper Egyptians have a darker complexion. The average height of Egyptian men is about 5 ft 10 in., whereas women average 5 ft 4 in.

DISEASES AND HEALTH CONDITIONS

Several risk factors are peculiar to life along the banks of the Nile. Egyptians suffer from a host of parasitic diseases; the most common is schistosomiasis, known as bilharzia in Egypt. Schistosomiasis has been endemic in Egypt throughout history and has been found in mummified bodies from the pharaonic era. A high percentage of the Egyptian rural population is infected with Schistosoma mansoni or S. haematobium. The life cycle of schistosomia- sis includes snails and human beings as hosts. Microscopic cercariae leave the snail in the warmth of the midday sun and penetrate the skin of humans who enter the shallow canals to irrigate crops, wash dishes or clothes, or swim. The cercariae migrate to areas near the liver, in the case of infection with S. mansoni, or near the bladder, in the case of infection with S. haematobium. The parasitic worms mature, mate, reproduce, and are expelled with urine or stools. If urine or stools are deposited in or near fresh- water canals or rivers where snails live, the eggs seek out a snail to begin the cycle again.

In human hosts, as the female worm expels the eggs, some of them flow with the blood and become lodged in the liver or around the urinary tract. The body, treating the eggs as foreign irritants, surrounds them with granu- lar tissue, leading to cirrhosis, liver failure, portal hyper- tension, esophageal varices, bladder cancer, and renal failure. Filariasis is another challenging parasitic disease endemic to Egyptians.

Rates of blindness in Egypt are among the highest in the world. Trachoma and other acute eye infections affect both rural and urban populations. Trachoma, a chronic infection of the lining of the eyelids caused by infection with Chlamydia trachomatis, is most common among chil- dren and can have severe disabling consequences in adulthood. Gel-like lymphoid follicles that subside over time, leaving residual scarring of the inner eyelids, char- acterize the active inflammatory stage. In the most severe cases, trichiasis, an end-stage complication of chronic tra- choma, occurs when scarring shrinks the lid lining and turns the eyelashes inward, scratching the cornea. This painful condition often leads to corneal ulceration, opac- ity, and eventual blindness. Injuries and corneal ulcers secondary to other infections are also common causes of blindness in Egypt.

Other infectious diseases include typhoid and paraty- phoid fevers, which are more frequent in urban than in rural areas. Streptococcal disease and rheumatic fevers are frequent among children, and tuberculosis continues to be a major problem in Egypt. Egyptian Americans who have positive tuberculin tests should be questioned about a history of Bacille Calmette-Guérin (BCG) vaccination.

Diarrheal diseases result from environmental condi- tions and family lifestyles. Heat contributes to the development of bacterial diseases, and dehydration results from diarrhea and vomiting caused by bacterial infections. Programs and campaigns using rehydration packets with water, salt, and sugar have drastically decreased mortality rates caused by diarrheal diseases. These endemic diseases are more common in rural areas than in urban areas. Egyptian immigrants come mainly from urban areas and, therefore, do not usually suffer from these diseases. However, some may have family members who come to the United States for treatment with complications caused by one of these diseases. Kidney diseases, lack of proper hydration, and eating habits may contribute to kidney failure and the subse- quent need for kidney transplantation. Clinicians in the Middle East suspect that fasting during Ramadan increases the potential for dehydration, contributing to kidney problems.

The people of Egypt also suffer from diseases common to developing countries, such as undernutrition and mal- nutrition, and diseases resulting from overindulging in foods with high-fat and high-sugar contents. Modern dis- eases such as obesity, hypertension, and lower back pain affect a high percentage of Egyptians. Similarly, cardio- vascular diseases resulting from stress, obesity, lack of exercise, and hypertension are on the rise. Egyptians who immigrate to the United States are more likely to become victims of these diseases of modernization than of rural diseases. Whereas breast cancer does not appear to be a uniformly manifest pattern among immigrant popula- tions in an Australian study, rates were somewhat higher among the Egyptian born (McCredie, Coates, & Grulich, 1994). Type 2 diabetes is of concern to Egyptians and is further complicated by obesity. In addition, Egyptians are at a genetic risk for thalassemias, which can be detected from a molecular genetic standpoint through carrier screening and prenatal diagnosis.

PEOPLE OF EGYPTIAN HERITAGE • 165

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 165 Aptara Inc.

VARIATIONS IN DRUG METABOLISM

The literature reports few studies related to variations in drug metabolism and specific drug interactions among Egyptian Americans. Some evidence indicates that Egyptians are poor metabolizers of beta-blockers (Levy, 1993). More research is needed in this area to provide bet- ter health care to Egyptian Americans.

High-Risk Behaviors Certain behaviors may increase the risk of illness for Egyptians in America. One of these is a sedentary lifestyle and lack of regular exercise (Salari, 2002). Information about exercise has just begun to appear in the media in Egypt, and health clubs and gyms have begun to spring up in Cairo and Alexandria. This new phenomenon began after many Egyptians immigrated to America. Although exercise and fitness are regularly included in the curricula of schools and colleges, exercise is not part of the daily lives of adult Egyptians and, even less so, among Egyptian Americans.

Overeating food delicacies high in fat, sodium, and sugar; sedentary lifestyles; and an entertainment style based on eating contribute to obesity and immobility. Although no data exist on health risk factors for Egyptian Americans, the authors suspect that if such data were obtained, they would demonstrate an increased risk for coronary artery diseases, diabetes, and esophageal her- nias. The premature deaths in Egyptian American com- munities are due to massive heart failure. There are also indications of an increase in risk factors for different types of cardiovascular diseases. Hassoun (1999) demonstrated that Arab Americans suffer from hypertension, high cho- lesterol levels, and diabetes more than other immigrants. These findings suggest that a similar pattern may exist among Egyptian Americans (Hatahet, Khosla, & Fungwe, 2002). Many Egyptians came to the United States as young adults; as the community of Egyptian Americans ages, questions related to sedentary lifestyles, overindul- gence in food, and genetic makeup should be of interest.

Egyptian Americans are at risk for stomach and intesti- nal problems that include heartburn, flatulence, constipa- tion, hemorrhoids, and fecal impaction. These conditions result from limited roughage, lack of fluids, and rapid consumption of food. Another factor contributing to con- stipation may be their expectations and the meaning they attach to regularity, which prompts them to push and strain to force a bowel movement prematurely. Egyptian Americans are also at risk for diabetes. Jaber, Brown, Hammad, Zhu, and Herman (2003) found that a decrease in acculturation to the United States is an important ele- ment in the increase in risk factors for Arab immigrants.

Like many less-developed countries, Egypt responded with zeal to campaigns launched by the cigarette indus- try. Cigarette smoking is on the rise in Egypt, mostly among men, but it is also increasing among women. Those who smoke, smoke heavily and are unwilling to quit. Rice, Templin, and Kulwcki (2003) reported that 17 percent of the adolescent Arab Americans in their study smoked, and 34 percent said they had never

smoked. Predictors for tobacco use were poor grades, peer or family smoking, passive smoking, receiving free sam- ples of cigarettes, advertising, and believing that smoking helps in networking and stress. Smoking cessation pro- grams, therefore, should reflect cultural gender norms and religious messages (Islam & Johnson, 2003).

One of the most dangerous risk factors among Egyptians in Egypt is their driving behavior. Most drive recklessly and aggressively, do not wear seatbelts, and drive without respect for speed limits. However, the extreme traffic congestion in Egypt provides a safety cushion. It takes Egyptian immigrants a number of years in America to learn to respect traffic rules, wear seatbelts, and drive cautiously.

The terrorist attacks on the United States on September 11, 2001, have resulted in harsh treatment of Arab Americans, including Egyptian Americans. Perceptions of scapegoating, discrimination, racism, and stigmatization increase their experience of stress. Outcomes of stress and marginalization will most probably be the subject of future research studies (Nieves, 2001; Salari, 2002; Zogby, 2001).

HEALTH-CARE PRACTICES

Two conditions increase the utilization of preventive health care by Egyptian Americans: having health insur- ance and having a health-care provider with whom they can develop a trusting and responsive relationship. Egyptian Americans like prompt and personal attention; they are usually among the most compliant clients if these conditions are met.

One reason for Egyptian Americans’ seeking health care is a perception that they are experiencing high blood pressure. They believe it is important to have frequent readings but prefer to treat hypertension with medica- tions rather than with changes in diet or lifestyle. Hypertension, the silent killer of many Americans, may not be so silent for Egyptians. Whether they can detect fluctuations in their blood pressure remains to be care- fully studied. However, this behavior of reading one’s own body cues should be encouraged and promptly addressed by health-care professionals.

Pap smears and mammograms tend to be new preven- tive health practices for Egyptian Americans. Education about the importance of these tests promotes compliance with regular checkups. As mentioned earlier, Pap smears for unmarried women are discouraged and considered totally unacceptable because of the expectations for pre- serving virginity until marriage. Gynecological examina- tions are given only to married women, usually during the checkup for a first pregnancy.

A study about health concerns among 99 Egyptian women and 135 American women aged 19 to 27 years reported that the top 10 health concerns among Egyptian women were halitosis/body odor, colds, cancer, poor teeth, population explosion, excess weight, birth control, water pollution, headaches, and heart disease. Among American women, the top 10 health concerns were birth problems, what the future would be like in 10 years, auto accidents, excess weight, cancer, use of contraceptives, death, nuclear war, childbirth, and air pollution (Engs &

166 • CHAPTER 9

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 166 Aptara Inc.

Badr, 2001). The differences in health concerns of these two groups are probably due to cultural values and the degree of societal differences between the United States and Egypt. These results reinforce the need for commu- nity health education programs that address the specific needs of individuals.

Nutrition MEANING OF FOOD

Food is an important component of Egyptian social life. Egyptians entertain lavishly and enjoy good food, which represents nurturing. The more food one provides, the more love is portrayed. Egyptians develop trust in each other by having a meal together. The saying Akalt eish wa malh maa baad literally means “eating bread and salt together” and symbolically signifies trust, care, and truth- fulness.

In addition to being part of Egyptian social life, food is associated with health. The more food a person eats, the greater the potential expectation for health. Thus, chil- dren tend to be overfed. Food is also associated with the ability of the head of the family to provide for family members. Therefore, parents take pride in the amount and the quality of food they bring to their families. Because food is associated with caring and nurturing, mothers and wives spend much time and effort shopping and cooking family meals. Finally, food is associated with generosity and giving. To offer food and to accept food are indications of friendship. Mealtime is for eating and for socializing but not for conducting business or dis- cussing issues.

Some beliefs surrounding meals may increase health risks. For example, Egyptians prefer not to drink water or fluids with meals because they believe that fluid displaces the volume that could be used for food, decreasing their appetite for solid nutrients. Some believe that fluids dilute the stomach “juices,” make digestion difficult, and cause indigestion. Another potential risk factor to explore is the amount of salt added to food while cook- ing or at the table.

COMMON FOODS AND FOOD RITUALS

Egyptian food is tasty, well done, and well seasoned. Egyptian Americans take pride in the food they serve and the way they present it. Although in Egypt vegetable dishes are considered main dishes to be complemented by meat and rice dishes, this conception has changed for most Egyptian Americans. Preferred meats are lamb, chicken, beef, and veal. Favorite vegetables are peas, green beans, cauliflower, and molokhia, a green vegetable cooked like soup. Most consider meat dishes as main dishes, complemented by vegetables and rice. Rice, a main staple, adorns dinner or lunch tables on a daily basis even when potatoes are served. Tomato-based red sauces are popular, and some pasta and vegetable dishes are dressed with rich white sauces such as bechamel. Egyptians use lentils, fava beans, and bulgur in their cook- ing. Whole-wheat is the preferred bread.

Egyptians acquired a taste for tea from their years under British rule and drink strong tea with hot milk sev- eral times a day. Those who prefer tea without milk drink it with mint leaves. They tend to use several teaspoons of sugar to sweeten their tea. Although it is not easy for them to decrease their sugar intake, Egyptians do so if they understand its relationship to caloric intake, insulin requirements for those who are diabetic, or for other health considerations. Egyptians also drink coffee, a habit acquired from Turkish rule. The coffee is thick, strong, and served in small demitasse cups, with or without sugar. Egyptians also consume a large quantity of soft drinks.

Hostesses insist on giving guests excessive amounts of food and act insulted if guests refuse the food. Those who understand the ritual may insist on refusal or may take the food and not eat it. Leaving some food on the plate is more polite than refusing it. Completely emptying the plate may be seen as an indication that the guest did not have enough to eat. Egyptian Americans use modified versions of this ritual, depending on the guests and their length of time in the United States.

In Egypt, three main meals a day are served with a late afternoon or early evening snack of sweets with tea. The main meal is lunch, usually consumed at the end of the working day between 2 and 3 p.m., generally followed by a period of rest when many take an afternoon nap. Working men and women in the current economic cli- mate of Egypt either return to work in the early evening between 5 and 6 p.m. or have a second job or business for the remaining part of the evening. Supper, usually a lighter meal, is eaten after 9 p.m.

On religious holidays, certain foods are prepared and shared with family and friends. An example is baking a variety of cookies at the end of the holy month of Ramadan, a time when Muslims fast daily from sunrise to sunset, and during the Small Eid feast (also called the El Eid Alsagheer or Small Barrium). During the Great Eid feast (also called the El Eid Alkabeer or Big Barrium), a sheep is sacrificed; the meat is given to needy families, and the family keeps some for consumption during that feast. Most of these rituals are modified in the United States. For example, Egyptian immigrants follow American eating habits of a small meal for lunch and then dinner at home after work between 6 and 7 p.m. Some immigrant families still make cookies at the end of Ramadan, but very few have a sheep slaughtered. Whether in Egypt or in America, the most devout Muslims do not consume pork or drink alcohol. Egyptian Copts may consume both in moderation.

For Egyptian American Muslims, many rituals are revived during the month of Ramadan, the ninth of 12 Islamic months that follow the lunar calendar. Therefore, Ramadan does not coincide with a particular month in the Christian calendar; instead it rotates and can fall on any of the Christian calendar months. Ramadan rituals are based on the teaching of the Qur’an (Koran) that calls for a month of fasting to experience the plight of the poor and the underprivileged. Fasting precludes tak- ing anything by mouth or intravenously and abstaining from sexual activities. Muslims are expected to donate food for those in need, and they may eat modestly from sunset to sunrise. Egyptian American Christians fast for

PEOPLE OF EGYPTIAN HERITAGE • 167

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 167 Aptara Inc.

a varied number of days for several major religious cele- brations. For them, fasting constitutes not eating any animal products.

Ramadan is a month of prayers and family festivities with many food rituals. At sunset, families gather to eat lavish meals consisting of several kinds of meat and poul- try, rice, dried fruits, and desserts such as konafa (shred- ded phyllo dough stuffed with nuts and raisins and soaked in honey) and kataif (pancake-like dough dressed with nuts, raisins, and sugar and smothered in honey). The meals are usually high in protein, fat, sugar, salt, and calories. Just before sunrise, families consume a lighter meal in preparation for a day of fasting. Some Egyptian American Muslims follow these rituals in the United States. Even Egyptian Americans who do not follow and abide by the teachings of Islam during the year consider this month holy, and they become more devout Muslims during Ramadan. Some Egyptian Americans join others in social clubs and plan weekly potluck “sundown Ramadan breakfasts.” During these gatherings, Egyptian Americans, their friends, and children exchange stories related to Ramadan, read from the Qur’an, and indulge in eating delicacies specific to Ramadan.

DIETARY PRACTICES FOR HEALTH PROMOTION

Egyptian Americans do not mix hot and cold nor sweet and sour foods at the same meal. For example, the accepted habit in America of eating ice cream as dessert with coffee was a foreign concept for Egyptians during the early stages of their immigration. However, they eas- ily accommodate to this food habit. Some Egyptian Americans grew up believing that mixing fish and milk may cause digestive problems or create behavioral prob- lems. Therefore, dairy products and fish are generally avoided in combination. Some may have practiced drink- ing milk with yeast to increase their intake of vitamin B complex, a popular custom in Egypt.

Most Egyptian Muslims do not eat pork, as proscribed by the Qur’an. They eat only well-cooked meat and do not touch rare meat. Recent Egyptian immigrants find it strange to eat cooked corn, which is only barbecued in their country. Most are partial to their own cooking, pre- ferring not to eat in restaurants. They prefer kosher meat, trusting the dietary restrictions and food preparation practices of the Jewish population. In the absence of kosher meat, they shop at regular supermarkets.

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

Egyptians, particularly those who live in rural and poor communities, experience fat-soluble vitamin and iron deficiency anemia. They eat more fresh vegetables, fresh fruits, and enriched or whole-wheat grain breads. Egyptians in the United States, like other Arab Americans, may resort to eating more processed foods and high-pro- tein diets in the form of red meats because of increased availability (Hassoun, 1999). They also tend to eat more junk foods, preferring sweets. Therefore, Egyptian Americans may have a greater tendency to have diets higher in fat and consume fewer fresh fruits and vegeta-

bles. No literature exists about the changes in dietary habits and the effects on vitamin and mineral deficiencies among Egyptian Americans.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

An Egyptian couple is not complete until they have a child and are usually under stress, fearing marriage insta- bility caused by a lack of childbearing, until they con- ceive their first baby (Hattar-Pollara et al., 2000). Even if the husband is the cause of delayed or permanent infer- tility, women are threatened by the potential of divorce and are expected to conceive within their first year of marriage. Egyptian American families are under less stress and pressure to conceive because of the absence of extended family, although extended families continue to pressure their daughters and sons through letters and telephone calls. Pregnancies cement marriages, ensure a more lasting relationship, and are a way of getting men and women to mature in their relationship. Pregnancy brings women a sense of security and their husbands’ and in-laws’ respect. Giving birth, particularly to a son, considerably strengthens the status and power of women. Pregnancy gives women permission to decrease their responsibilities.

Systematic and concerted efforts have been initiated to develop and implement birth control practices in Egypt, with birth control being far more apparent in urban Egypt. Whereas Egyptian Americans may practice family planning and birth control, these are never advocated before conceiving the first child. Family planning is prac- ticed through a variety of methods, including birth con- trol pills, condoms, and early withdrawal. Abortion is used in Egypt, as in other countries, as a method of birth control. Desirable family size in urban Egypt is three or four children, whereas desirable family size in the United States among Egyptian Americans is two or three chil- dren. Women take an active role in limiting pregnancies; they are willing to use any method of birth control to achieve and maintain a small family size. Infertility is shrouded in secrecy and is attributed first and foremost to women. Among poor urban and rural families in Egypt Kabsa is considered to be the cause of infertility (Inhorn, 1994). Kabsa happens when vulnerable women come in contact with “polluted” individuals. Kabsa causes a threat to reproductive organs, a concept close to the way in which the “evil eye” affects an individual. It is unlikely that Egyptians who immigrate hold such a concept about infertility; however, assessing individuals who may be suffering from infertility nonetheless requires communi- cation skills to uncover explanatory frameworks. This will lead to more compliance. It is also important to note that just like other underserved populations, Arab Americans tend to experience difficulties in accessing and receiving care in general, but infertility care in particular because of social marginalization especially after 9/11 (Inhorn & Fakih, 2006).

168 • CHAPTER 9

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 168 Aptara Inc.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Women are expected and advised to curtail physical activ- ities during pregnancy for fear of miscarriage (Meleis, 2002). Women are also advised to eat more because they are feeding two. Some Egyptian American women have strong cravings (waham) for certain foods that may extend to such scarce items as out-of-season strawberries. If these foods are not consumed, babies may be marked with the shape of foods that were craved. Therefore, every effort is made to provide the pregnant woman with the needed foods.

Providing support during labor and delivery is reserved for the woman’s relatives, particularly her mother. Egyptian Americans invariably request that a female fam- ily member accompany the birthing mother. If an Egyptian American woman goes into labor with only her husband in attendance, it is considered an emergency. Acculturated Egyptian American men want to be included in the birthing experience, which may offend Egyptian newcomers. In Egypt, men are excluded from the birthing process because it is believed that men lack the ability to witness this highly emotional and painful process and lack the experience to support their wives.

The cold-and-hot theory for health and illness pre- vents women from bathing during the postpartum period. Bathing or washing hair could expose them to colds and chills. Egyptian Americans respond well to a sound rationale for bathing in a hot tub or taking a shower that dispels beliefs about the potential for infec- tion. Chicken and chicken broth are expected to help women during their postpartum transition. The postpar- tum period lasts 40 days, during which new mothers are expected to rest, eat well, be confined to the house with their babies, and not engage in any sexual activities. They are usually cared for by family members and are not expected to have any demands put on them. This practice is eroding, however, because of increasing demands on women and the migration of families. Information related to birth control is always welcomed after the first pregnancy, although it may not be sought during the postpartum period.

Death Rituals DEATH RITUALS AND EXPECTATIONS

Among Muslims in Egypt, Islam calls for burial of the deceased as soon as possible. The burial ritual includes cleaning the body and wrapping it in a white cotton wrap. Verses from the Qur’an are read and a special prayer is recited at the mosque before the body is buried under- ground in a simple tomb. Islam prohibits fancy tomb- stones; only a simple stone with the name of the deceased is placed above ground. The simple stone suggests that individuals are equal in death when meeting their creator. On the night of the burial, friends and family gather in a large tent outside the deceased’s home to give their con- dolences and respect to the grieving family. No food is served, but Turkish coffee is usually offered. Forty days after the burial, another mourning ritual takes place in

the home of the deceased’s family. Family members listen while passages from the Qur’an are read by a religious man to console the family. Thereafter, a similar ritual takes place on the anniversary of the death. Egyptian Christian death rituals in Egypt and the United States are similar to American Christian death rituals.

For Egyptian immigrants, some cultural rituals are fol- lowed. For instance, the Islamic burial rituals are carried out in designated cemeteries. The evening before the bur- ial, the Qur’an is recited, and occasionally, the mourning ritual is observed for 40 days after burial. The annual death observance ritual is rarely carried out. Some Muslim families insist on having the deceased buried in Egypt, which is a very costly process involving approval from both countries and transporting the deceased in a special casket. Abdel-Khalek and Ahmed (1986) found that Egyptian Americans have slightly higher anxiety about death than Americans. Health-care providers may be involved in and bewildered by the decision-making processes that Egyptian families go through on the death of family members. Plans for death are rarely made ahead of time, though a burial site is invariably selected in advance to protect families against being buried in non- Muslim burial places. Similar practices are observed among Christian Egyptian Americans.

RESPONSES TO DEATH AND GRIEF

Egyptians in Egypt and the United States react vigorously and dramatically to the loss of a family member, express- ing their grief outwardly. Wailing and public crying occur when first learning of death. This public reaction is an expected demonstration of their grief; otherwise, the community may regard them as lacking affection for the deceased. Death is seen as inevitable, although any loss brings shock and despair. Older people speak calmly about their own impending death. Egyptian Americans with a strong religious foundation do not fear the near- ness of death but rather view it as a journey to the other world, which is believed to be better. Egyptian Muslims and Christians believe in an afterlife and expect rewards for good deeds accomplished in their first life. They antic- ipate reuniting with those who preceded them.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

Religious practices for Egyptian Americans are performed during marriage, death, and religious holidays. Egyptian Americans participate in two wedding ceremonies: One is a religious and civil ceremony performed by the mosque’s Imam (usually in place of Maazoon, who performs these rituals in Egypt), and the other a social ceremony in which friends and family gather for a gala evening. Both could be performed on the same day or days, months, or years apart. A separation after the religious ceremony is considered a divorce, but it is customary for brides and grooms to live together only after the social celebration has taken place. Egyptian American Christians have one religious marriage ceremony.

PEOPLE OF EGYPTIAN HERITAGE • 169

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 169 Aptara Inc.

Prayers, even for the nondevout Muslim or Christian, are significant during times of illness. Egyptian Americans may bring the Qur’an or the Bible to their hospital beds and usually put it under the pillow or on the bedside table. Prayers may be recited by the individual, in groups for Muslims, or in religious settings such as mosques or churches. Families and friends pray for each other, invok- ing good health, cure of illness, and peace. Prayers during holidays are enjoyed particularly in groups and in reli- gious settings.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

Religious Egyptians achieve inner peace through practic- ing their respective religious rituals, including individual or collective prayers, reading from the Qur’an or Bible, and other religious texts written by religious scholars. Muslims who can afford the expense and are in good health make the pilgrimage to Mecca sometime during their lifetime. The journey is believed to provide Muslims with a source of inner fulfillment. Similar patterns of ful- fillment through participation in religious activities are common in the United States.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Most Egyptian Americans talk about their religious teach- ings during episodes of illness. They derive comfort, strength, and meaning from verses in the Qur’an and of prophets. Family members use these verses to remind them that they are at the mercy and under the control of God and that God may have a particular reason for their suffering. To lose hope may mean they are losing faith in God and His abilities.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

The health-care practices of Egyptian Americans can best be understood by looking at the historical roots and the meanings of health and health care for Egyptians. The pharaohs are credited with introducing medicine to the world, as evidenced by the writings on papyri from 4000 B.C. The practice of mummification, perfected to ensure that the pharaohs’ bodies were preserved to wait for the return of the departed spirit, may have helped the pharaohs to understand the intricate anatomy of the body. Papyri writings have been found describing body organs, gynecological conditions, surgery, and signs and symptoms of illnesses. There are indications that the early Egyptians also had dental knowledge and had developed treatments for dental problems. Pharaonic writings intro- duced the idea of body parts and segmentation.

Egyptian health care is also influenced by Greek, or unani, medicine. The most famous medical library in the world was built in Alexandria during the reign of Alexander the Great, housing almost all the medical knowledge of the ancient world. The books contained in

this library, which was later burned, chronicled numerous diseases and treatments. The Greeks combined medicine and philosophy and expanded the understanding of anatomy. Their texts influenced the entire region. As early as the 10th century B.C., medical schools based on unani medicine were established by the Arabs. These texts, known as the laws of medicine, were written by early Arab scholars and embodied the teachings of preventive and curative health care.

Egyptian beliefs about health care are also influenced by humoral systems described in Greek documents. The principles behind the humoral system are based on divid- ing many aspects of life into four: the year into four sea- sons; matter into fire, air, earth, and water; the body into black phlegm, black bile, yellow bile, and blood; and the environment into hot, cold, moist, and dry. Diseases fol- low these humors with treatments based on opposite humors. The pharaohs introduced the principle of bal- ance and imbalance as the cause of illness. Egyptians believe that cold and moist environments cause illnesses, by changes from cold to hot or vice versa. The opposite humor is used for treating the illness.

Other influences on the Egyptian health belief system came from the colonization of Egypt by the Turks, French, and British. In addition to illnesses being caused by humoral imbalances, Egyptians believe them to be caused by being presented suddenly with bad news (itkhad, “star- tled/surprised by unexpected calamity”) or by a fight. Whereas a person’s mental and physical health are intri- cately interwoven, treatment sought from the health-care system is focused on physical or biomedical treatment. Family or religious people usually handle mental health problems outside the health-care system. Egyptians tend to manifest symptoms of mental health problems somati- cally. Therefore, they seek medical care to deal with the physical manifestations of mental illnesses.

Whereas Egyptian Americans are usually well edu- cated, their views are colored by beliefs about the influ- ence of imbalances, the evil eye, and Islamic beliefs about the role God plays in their illness. However, they are firm believers in Western medicine’s miraculous ability to treat and cure illnesses. None of their beliefs prevents them from seeking or complying with the prescriptions of Western medicine. If they practice the belief of balancing or of warding off the evil eye, it is done in conjunction with Western medicine. Levels of acculturation and bicul- turalism play an important role in how Arab Americans respond and deal with health-care issues. For example, the level of acculturation was determined to be a risk fac- tor for a number of health problems, such as dysglycemia (Jaber et al., 2003) and coronary artery disease (Hatahet et al., 2002). They are also at higher risk because limited research studies use them as research participants (Sayed, 2003). Finally, they are also at risk because of stereotyping (Soliman et al., 2001).

RESPONSIBILITY FOR HEALTH CARE

The Qur’an and the sayings of Mohammed, the Prophet of Islam, have made a major contribution to Muslim health care. In particular, preventive health care is embodied in many of Mohammed’s prophetic sayings.

170 • CHAPTER 9

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 170 Aptara Inc.

Cleanliness and hygiene are integral to practicing Muslims. A number of elaborate prayer rituals are also related to health care and prevention of illness. For exam- ple, before praying, Muslims must engage in a purifica- tion ritual, which consists of washing every exposed body part. Prayer, required five times daily, consists of elaborate bending and kneeling movements in systematic ways, increasing a person’s range of movements, limbering stretches, and meditative poses. Religion and prayers are believed to provide protection from illnesses.

In Egypt, a government health insurance policy allows every citizen to receive free care, treatments, and medica- tions. However, Egyptians believe that to receive better quality health care, they must shop, bargain, and negotiate. In the process, they learn that quality care means fees. If they can afford it, they prefer quality care. Most Egyptian Americans join a Health Maintenance Organization (HMO) or have private medical insurance. Whereas they may refuse to have life insurance (Islam does not condone insurance), they realize the importance of quality health care. Newcomers, however, may wait to develop finan- cial security before they join a health insurance plan. Typically, Egyptian Americans experiencing a health problem consult family members and friends before vis- iting a trusted health-care professional. Once in the health-care system, they prefer immediate, personalized attention. They value tests and prescriptions for their ill- nesses and follow medical regimens and prescriptions carefully, particularly if they consist of oral medications, injections, or both. However, they tend to be skeptical of treatments such as weight reduction, exercise, and diet restrictions.

The family of a client expects and prefers to be involved in all health-care decisions. Their focus on human relations and interpersonal contact make it diffi- cult for Egyptian Americans who encounter changing staff and assignments during treatments. They believe they have a better chance of receiving quality care if trust- ing relationships are formed. Thus, constancy and consis- tency of contacts decrease potential conflicts in their rela- tionship with the health-care system.

Egyptian Americans may practice self-medication. They tend to share medications freely and use Western medications and home remedies such as herbs, hot com- presses, and hot fluids and foods. Many Egyptians keep a very active medicine cabinet filled with antibiotics, tran- quilizers, sleeping pills, and pain medications. They also believe that vitamins given intramuscularly and intra- venously are more effective than vitamins taken in pills. In Egypt, vitamin B complex injections and iron supple- ments are common self-medicating activities. Some common herbal and home remedies are boiled mint leaves for a stomach ache; boiled cumin for gas; boiled caraway for coughs; and hot pads for aches, pains, and boils. Regulation of prescription drugs in the United States restricts the use of prescriptions, prompting some Egyptian Americans to get their supply of medications from their home country or friends. Use of illegal drugs is minimal in this community. Although some Egyptian Americans may overindulge in alcohol, the teachings of Islam prohibit its use. Many who drink alcohol tend to do so socially and in limited quantities.

FOLK AND TRADITIONAL PRACTICES

According to Islam, illnesses are caused by lack of hygiene, exposure to diseases, or environmental condi- tions, although it is up to God who gets sick and who does not. People are expected to care for themselves and work at preventing illnesses when possible. In addition, beliefs related to the healing powers of shrines and holy men or saints and the counterpowers of the devil (Jenn) and evil spirits (arwah) influence health care. Thus, cer- emonies are designed to eliminate the devastating powers of the Jenn; among them is the famous zar ceremony and the hegab. The zar ceremony includes gathering friends and relatives around a sick person, with loud music play- ing and drums beating to increase the frenzy of dance and movement. The energy of the group and their solidarity help eliminate the bad spirits from the body, taking with them the illness or the handicapping condition. Zar is rarely practiced among Egyptian Americans. A person who is trying to get rid of an illness wears the hegab, an amulet with sayings from the Qur’an. Some also use the amal, which is designed to bring bad luck or illness to an unloved person.

Egyptians believe the evil eye is responsible for per- sonal calamities. The evil eye is cast by those who have blue eyes, by those who tend to speak of an admired per- son or object in a boastful manner, or by the mere description of beauty, wealth, or health without saying some verses from the Qur’an or Bible. These verses protect the person from losing whatever good they possess. Some Egyptian Americans use blue beads or religious verses inscribed on charms to protect them or their children from the evil eye. Children are particularly at risk for the evil eye and need more protection than adults.

BARRIERS TO HEALTH CARE

V I G N E T T E 9 . 3

Mr. Sauri went to the emergency room concerned about his blood pressure. He was having family problems that made him feel rather agitated (asabi) and he felt “he has high blood pressure.” Sauri is a cab driver in an urban city, is married with one daughter, and speaks English moderately well. He is obese, and is fast to suggest all the tests that should be per- formed. He is impatient with the “many questions” that he perceives to be unrelated to his primary complaint. Furthermore, he believes that all he needs are “medications to lower his blood pressure.”

1. What are the best strategies to begin the health assess- ment process?

2. Knowing the barriers to health care for underserved minorities, the schedules and work patterns of cab dri- vers, the meaning of Western medicine for Egyptian Americans, and their narrative style in recounting their illness stories, describe your assessment and interven- tion strategies.

3. Critically discuss a model of care that incorporates patterns of responses and explanatory frameworks of presenting problems and intervention plans.

PEOPLE OF EGYPTIAN HERITAGE • 171

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 171 Aptara Inc.

Barriers to health care among Egyptian Americans are related to economics, work demands, and full schedules. Fitting appointments into their schedules proves to be somewhat difficult, particularly in families in which a spouse is working long hours and the family owns only one car. When the family has two working members, access to the health-care system at designated times is even more challenging. Another barrier is the difference in explaining health problems. The degree of specificity required in the U.S. health-care system, the narrative sto- rytelling nature of Egyptians, and the contextual way in which Egyptians view a situation all contribute to a frus- trating experience for both the immigrant and the health- care professional.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

V I G N E T T E 9 . 4

Salwa and Ahmed Sarhan recently moved from New York to New Jersey, where Ahmed is a cab driver. Salwa has a BA in Egyptology and Ahmed has a BS in Economics. They have three teenaged children—Maha, Saura, and Hazem. Over the past few weeks, Ahmed has been complaining of stomach pains. One night, the pain becomes more severe and feels like “he is being stabbed with a sharp knife.” His brother brings him to the emergency room of a small community hospital. After a series of diagnostic tests, it is discovered that he has first-degree cancer. It is recommended that he undergo surgery to remove part of his stomach. He is given two different treat- ment options: surgery and no chemotherapy, and surgery fol- lowed by chemotherapy. He chooses to have the surgery and no chemotherapy, which is successful. The family indicates that they would like to send his diagnosis, x-rays, and all per- tinent tests to Egypt. They receive many calls from various con- cerned family members. His wife does not want the staff to recount to them all the problems he is having or will have dur- ing his recovery. Ahmed becomes highly agitated and has been described as demanding and high maintenance. He is engaged with the staff at the hospital, but he wants his wife to attend to his wound changes. He does not want his teenaged children to know his diagnosis or prognosis. His daughter appears to be very quiet and withdrawn; one of his sons seems to be in charge. His wife is weepy and appears to be bewil- dered and concerned about her husband. He seems to expect her presence and does not want her to leave the room.

1. Identify three nursing problems and plan interventions in a cultural context.

2. What questions should the nurse ask in the initial family interviews to determine their needs?

3. How should the nurse plan care for Mr. and Mrs. Sarhan’s state of mind?

4. Describe how Egyptian Americans respond to a serious diagnosis.

5. What should a health-care provider keep in mind in car- ing for Egyptian Americans with a terminal diagnosis?

Egyptians avoid pain at all costs by seeking prompt inter- ventions. They tend to be verbally and nonverbally expressive about pain; moaning, groaning, sighing, and

holding the painful body part tightly are common expres- sions of pain. As Reizian and Meleis (1987) demonstrated, Arab Americans tend to respond to an episode of pain depending on the intensity, severity, and their audience. Although they tend to be more constrained in front of health-care professionals or other “strangers,” they are quite expressive in front of family members, using grunt- ing, pushing, screaming, using guttural sounds, or gasp- ing for air. These conflicting behaviors are confusing to health-care professionals when family members insist that the client needs pain relief. The absence of these responses in front of health-care professionals makes ver- ification of the intensity of pain difficult.

Egyptian descriptions of pain may not be as specific as the Western health-care system prefers. Egyptians present a more generalized description of pain, regardless of whether it is localized. They usually describe general weakness, dizziness, or overall tension and stress associ- ated with pain (Reizian & Meleis, 1987). They also use metaphors reflecting humoral medicine such as earth, rocks, fire, heat, and cold to describe their pain.

Age and birth order correlate significantly with indi- vidual responses and descriptions of pain. Younger chil- dren and first-born children are often more expressive about pain. Higher intensities of pain are also associated with increased behavioral responses in children. Egyptian children tend to describe their pain with sensory descrip- tors such as sikkeenah, or “it’s like a knife” (Essaway, 1987). Giving birth is associated with severe pain, and it is not to be endured alone. Therefore, birthing mothers tend to be highly expressive of the intensity of their pain. Having a close family member present during the pain episode may be helpful for Egyptian Americans. Children prefer their mothers (Essaway, 1987), whereas adult women and men prefer female family members who are more nurturing, caring, and capable of comforting a per- son in pain (Meleis & Sorrell, 1981).

Although mental illness has been considered a stigma that should not be disclosed, more tolerance of emotional problems is the norm in modern Egypt. Rural Egyptians explain mental health problems within supernatural frameworks, including the amal (a curse) or Jenn (the devil). Urban Egyptians explain emotional problems in terms of grief, losses, and wrongdoing by others or by blaming the victims for not being able to control and snap out of their distress. Mental and emotional issues tend to be expressed somatically, and therefore, psycho- somatic interventions are more effective than psycholog- ically based interventions. Although Egyptians may seek therapy and counseling, they prefer to seek the advice of family members or trusted friends rather than go to strangers. They also do not like to call treatments psy- chotherapy or analysis. Egyptians tend to place the blame externally, looking for external actions or events to explain the situation. Because Egyptians are more com- munity oriented, they tend to seek the approval and sanc- tion of others; therefore, shame rather than guilt tends to explain their actions and their reactions.

Assessing and treating mental health problems among Egyptian Americans requires careful attention to gender relations, the history of how mental health is viewed in their country of origin, the individual’s and

172 • CHAPTER 9

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 172 Aptara Inc.

family’s level of acculturation, and their explanatory framework (Al-Krenawi & Graham, 2000). Integrating modern, Western, and cultural approaches will make the intervention more successful.

Disabilities are not hidden from public view. Whereas there is public sympathy and acceptance of people with disabilities, families still tend to be protective and shield them from public display. Families assume responsibility for the care of their disabled members, not expecting help or services from society. Egyptian Americans, however, tend to hide their disabled family members from other Egyptian Americans for fear of evoking reactions of pity. They are open, however, with health-care professionals in the hope of receiving better health care.

Egyptian Americans have a general belief that chronic illnesses can be controlled by the scientific sophistication of Western medicine. Therefore, health-care professionals and clients have a general pattern of cooperation on long- term treatments. Less regard is held for complementary therapies, and the demand is greater for scientifically sup- ported remedies, regardless of their intrusiveness. Egyptian Americans tend to be hopeful, persistent, and optimistic about their prognoses. Therefore, they may shop around for health care that promises a better prog- nosis. Rehabilitation programs that include drastic changes in lifestyles are less appealing if the programs are not scientifically supported.

Egyptian families take care of their sick members. Promotion of self-care is viewed with suspicion by Egyptian Americans, just as by other Arab Americans, and sick people are not expected to participate in programs to enhance their self-care capabilities. Rather, they are expected to preserve their energy for healing. Attempts to engage Egyptian clients in self-care by promoting respon- sibility for daily care, for example, by keeping a colostomy incision clean, are resisted and perceived as a request to decrease the work of the nurse and the other staff. Sick people are also relieved from making major health-care decisions. Their families make all health-care decisions for them.

BLOOD TRANSFUSIONS AND ORGAN DONATION

Egyptian Americans have no taboos against blood trans- fusions or organ transplants. All measures needed to heal, cure, or prolong life are welcomed. Their trust and respect for the health-care system and health-care professionals facilitate their decision making, and they support recom- mendations offered by the health-care provider. They are hesitant, however, to pledge their own organs to others or to permit an autopsy. Because of their belief in the after- life, they favor being buried whole.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

Although Egyptian Americans may consult family mem- bers and friends about their health and illnesses, they do

not consult traditional or folk practitioners. In fact, they may be reluctant to seek health care from anyone but physicians. Using the services of acupuncturists, podia- trists, chiropractors, and physical therapists is foreign to those not integrated into the American culture. In gen- eral, members of the Egyptian American community have a positive perception of the American health-care system. They believe that physicians and nurses are experts and are caring and responsive to the needs of their commu- nity. Egyptian Americans are in awe of Western medicine, its scientific basis, and its vast resources. One of their most common responses is, “We were lucky to be in the United States when the illness occurred.”

For some Egyptian Americans, however, the meticu- lous diagnostic approaches practiced by American physi- cians may be misinterpreted. Accustomed to Egyptian physicians whose clinical judgments and skills have been developed within a system that lacks adequate resources for meticulous diagnoses, some may misperceive an American physician’s thoroughness as a lack of experi- ence or appropriate knowledge. Therefore, they may shop for physicians whose clinical judgments are congruent with their cultural expectations of a prompt and firm diagnosis. Others may view the laborious and involved diagnostic process, which uses many resources and tests, as an indication of the gravity of the diagnosis.

A recent trend in Egypt is to consider gender as an important variable in the selection of health-care profes- sionals. Although rural and less-educated urbanites have always valued this, religious influences have prompted a renewed preference for health-care providers of the same gender. Many Egyptian Americans immigrated before the wave of Islamic fundamentalism and its influence on life patterns and expressions. Therefore, first- and second- wave Egyptian Americans may not consider gender as an important criterion in the selection of their health-care providers. Third-wave immigrants may prefer gender- congruent health-care providers, although this preference may be mitigated by their respect for Western medicine. In addition to religious fundamentalism, modesty may influence the desire for gender-congruent health care. For some Egyptian Americans, sharing the intimate details of their health history is enhanced if the health-care provider is the same gender. Egyptian Americans may also view older female physicians as more experienced and, therefore, more trustworthy than younger female physicians.

STATUS OF HEALTH-CARE PROVIDERS

Physicians are highly respected by Egyptians and Egyptian Americans. As in most health-care systems throughout the world, Egyptian physicians expect to be the head of the health-care team and the primary decision makers for all aspects of clinical care. Egyptian Americans prefer physicians affiliated with large, respected organi- zations because they believe them to be more experi- enced. For some, the physician’s age, years of experi- ence, and position in the organization may indicate better qualifications.

As in the United States, nurses in Egypt are educated at many different degree levels and have similar patterns of

PEOPLE OF EGYPTIAN HERITAGE • 173

FABK017-C09[157-174].qxd 12/12/2007 10:39am Page 173 Aptara Inc.

practice. Most graduate from high school programs developed to meet the nursing shortage. Limited resources, an overabundance of physicians, limited edu- cational preparation of the majority of nurses, low pay scales, and long work hours contribute to poor nursing care in Egypt. Consequently, nursing care in Egyptian hospitals is left to family members, who usually surround the client every waking moment. They are expected to carry out most of the care and act as advocates for the clients. Hence, they appear to us in the United States as more intrusive to Western routines, when in fact, they have been conditioned to be vigilant advocates for their family members.

Egyptians’ contacts in the homeland with nurses who are knowledgeable and expert in their fields have been minimal. Consequently, their expectations of nurses are usually far below their experiences in the U.S. health-care system. They view American nurses as well educated and well qualified and are grateful for their expertise and for their attention.

Egyptian American physicians tend to be impressed with American nursing. Their limited views and expecta- tions of nurses based on Egyptian experiences are drasti- cally altered after short contact with American nursing practices. They consider nurses in the United States to be well educated and view their expertise as enhanced by years of experience and availability of resources. The emphasis on higher levels of education for American nurses is congruent with the high value Egyptians place on education. Egyptian physicians also believe that the better pay for American nurses is congruent with better education and better expertise.

REFERENCES Abdel-Khalek, A., & Ahmed, M. (1986). Death anxiety in Egyptian sam-

ples. Personality and Individual Differences, 7(4), 479–483. Al-Krenawi, A., & Graham, J. R. (2000). Culturally sensitive social work

practice with Arab clients in mental health settings. Health & Social Work, 25(1), 9–22.

Ali, O. M., Milstein, G., & Marzuk, P. M. (2005). The imam’s role in meet- ing the counseling needs of Muslim communities in the United States. Psychiatric Services, 56(2), 202–205.

CIA. (2007). World Factbook: Egypt. Retrieved February 22, 2007, from https://www.cia.gov/cia/publications/factbook/geos/eg.html

Durrani, A. (2000). Arab mothers like no other. Arabia Online Ltd. Retrieved February 22, 2007, from http://www.arabia.com

Engs, R., & Badr, L. (2001). The health concerns of young American and Egyptian women: A cross-cultural study. Quarterly of Community Health Education, 4(1), 1983–1984.

Essaway, M. A. H. (1987). The relationship of certain factors on the expression of pain among hospitalized surgical school age children. Unpublished doctoral dissertation, Alexandria University, Alexandria, Egypt.

Haddad, L. G., & Hoeman, S. P. (2000). Home healthcare and the Arab- American client. Home Healthcare Nurse, 18(3), 189–197.

Hassoun, R. (1999). Arab-American health and the process of coming to America: Lessons from the metropolitan Detroit area. In M. W.

Suleiman (Ed.), Arabs in America: Building a new future (pp. 157–176). Philadelphia: Temple University Press.

Hatahet, W., Khosla, P., & Fungwe, T. V. (2002). Prevalence of risk factors to coronary heart disease in an Arab-American population in Southeast Michigan. International Journal of Food Sciences and Nutrition, 53(4), 325–335.

Hattar-Pollara, M., Meleis, A. I., & Hagib, H. (2000). A study of the spousal role of Egyptian women in clerical jobs. Health-care for Women International, 21(4), 305–317.

Inhorn, M. C. (1994). Kabsa (a.k.a. mushahara) and threatened fertility in Egypt. Social Science and Medicine, 39(4), 487–505.

Inhorn, M. C., & Fakih, M. H. (2006). Arab Americans, African Americans, and infertility: Barriers to reproduction and medical care. Fertility and Sterility, 85(4), 844–852.

Islam, S. M., & Johnson, C. A. (2003). Correlates of smoking behavior among Muslim Arab-American adolescents. Ethnicity and Health, 8(4), 319–337.

Jaber, L. A., Brown, M. B., Hammad, A., Zhu, Q., & Herman, W. H. (2003). Lack of acculturation is a risk factor of diabetes in Arab immigrants in the U.S. Diabetes Care, 26(7), 2010–2014.

Levy, R. (1993). Ethnic and racial differences in response to medicines: Preserving individualized therapy in managed programmes. Pharmaceutical Medicine, 7, 139–165.

McCredie, M., Coates, M., & Grulich, A. (1994). Cancer incidence in migrants to New South Wales (Australia) from the Middle East, 1972–91. Cancer Causes and Control, 5(5), 414–421.

Meleis, A. I. (2002). Egyptians. In P. St. Hill, J. Lipson, & A. Meleis (Eds.), Caring for women cross-culturally: A portable guide. Philadelphia: F. A. Davis Co.

Meleis, A. I., & Sorrell, L. (1981). Arab American women and their birth experiences. American Journal of Maternal Child Nursing, 6, 171–176.

Nieves, E. (2001, September 28). Recalling internment and saying “never again.” The New York Times. Retrieved February 22, 2007, from http://www.nytimes.com

Reizian, A. E., & Meleis, A. I. (1987). Arab Americans’ perceptions of and responses to pain. Critical Care Nurse, 6(6), 30–37.

Rice, V. H., Templin, T., & Kulwicki, A. (2003). Arab-American adolescent tobacco use: Four pilot studies. Preventive Medicine, 37(5), 492–498.

Salari, S. (2002). Invisible in aging research: Arab Americans, Middle Eastern immigrants, and Muslims in the United States. The Gerontologist, 42(5), 580–588.

Sayed, M. A. (2003). Psychotherapy of Arab patients in the West: Uniqueness, empathy, and “otherness.” American Journal of Psychotherapy, 57(4), 445–459.

Shaw, I. (2000). The Oxford history of Egypt. Oxford: Oxford University Press.

Soliman, A. S., Levin, B., El-Badawy, S., Nasser, S. S., Raouf, A. A., & Khaled, H., et al. (2001). Planning cancer prevention strategies based on epi- demiologic characteristics: An Egyptian example. Public Health Reviews, 29(1), 1–11.

U.S. Bureau of the Census. (2002). Ancestry first reported (PCTO24) and ances- try second reported (PCTO25), Census 2000 supplementary suvey summary tables. Retrieved February 22, 2007, from http://www.factfinder. census.gov/home/en/datanotes/exp_c2ss.html

Zogby, J. (2001). Testimony of Dr. James. J. Zogby, submission to the United States Commision on Civil Rights, October 12, 2001. Retrieved February 22, 2007, from http://www.aaiusa.org

Zohry, A., & Harrell-Bond, B. (2003). Contemporary Egyptian migration: An overview of voluntary and forced migration (Country Background Papers [WP-C3]). Brighton, United Kingdom: University of Sussex, Development Research Center on Migration, Globalization, and Poverty.

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

174 • CHAPTER 9

FABK017-C09[157-174].qxd 12/12/2007 10:40am Page 174 Aptara Inc.

175

People of Filipino Heritage

Chapter 10

DULA F. PACQUIAO

Overview, Inhabited Localities, and Topography OVERVIEW

The Philippine archipelago consists of 7107 islands located in southeastern Asia, east of Vietnam. With a landmass of 300,000 square kilometers, it is slightly larger than the state of Arizona. The three major islands of Luzon, Visayas, and Mindanao have mostly mountainous terrain with narrow-to-extensive coastal lowlands. The tropical climate consists of dry and rainy seasons suitable for year-round agriculture and fishing, but it is affected by the seasonal northeastern and southwestern monsoons. In 2005, the total population was estimated at 89.5 mil- lion, with an annual growth rate of 2.36 percent. Although the country is rich in natural resources and has a mixed economy of agriculture, light industry, and sup- port services, 40 percent of the population lived below poverty level in 2001 (CIA, 2007).

The Spaniards colonized the country for over 3 cen- turies, 1565 to 1898, and named the islands Las Islas Filipinas, the Philippine Islands. Following the Spanish- American War, the islands were ceded to the United States and given the anglicized name, the Philippines. Filipinas (Pilipinas) and Philippines are used interchangeably today. Native speakers refer to the country as Filipinas or Pilipinas and use Philippines when speaking to outsiders or writing in English.

The issue of whether to use Filipinas or Pilipinas and Filipino or Pilipino in referring to the country, its people, or its national language is a matter of debate among the country’s scholars and historians. There is no letter F in the indigenous Tagalog language, which is spoken in cen- tral Luzon, including Manila, the nation’s capital. When

the country gained its independence from the United States in 1946, it adopted the Tagalog-based Pilipino as its national language. In 1959, Pilipino was officially declared the national language. In 1986, however, the national assembly declared the national language as Filipino, based on existing Philippine and other languages. Generally, Filipino is used interchangeably with Filipino American. The term Pilipino is generally used to distinguish indigenous identity and nationalistic empowerment.

Filipino Americans are a diverse group because of regional variations in the Philippines, which influence the dialect spoken, food preferences, religion, and tradi- tions (Fig. 10–1). Generational differences within families are associated with age and time of migration from the Philippines. Other factors influencing diversity include pre- and postmigration level of education, occupation, and intermarriage as well as other primary and secondary characteristics of culture (see Chapter 1). This chapter dis- cusses the major characteristics of mainstream Filipino culture, offering some insights into some differences among groups. The reader should avoid using this infor- mation as a universal template for every Filipino.

HERITAGE AND RESIDENCE

The Filipino way of life is a tapestry of multicultural influ- ences superimposed on indigenous tribal origins. The people are predominantly of Malayan ancestry, with over- lays of Chinese, Japanese, East Indian, Indonesian, Malaysian, and Islamic cultures. The Philippine culture is distinct from its Asian neighbors largely because of the major influences from the Spanish and American colo- nizations. The Spaniards introduced Roman Catholicism, which has remained the dominant religion in the coun- try. Spanish colonization spanned 350 years and was followed by 50 years of American domination. The

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 175 Aptara Inc.

Americans introduced public education and English as the medium of instruction to give the Filipinos a com- mon language.

The Filipino way of life has evolved from the everyday situations that the people have to deal with living on scat- tered islands surrounded by large bodies of water and exposed to natural disasters such as volcanic eruptions, typhoons, floods, and droughts, as well as threats of for- eign invasion. The Filipino sense of morality and justice evolved from tribal times. Close-knit, kin-based groups known as Barangays emerged to protect communities from outside atrocities. Communal values of collective welfare and solidarity fostered security of its members in an unstable environment. Outsiders to the culture recog- nize these values in the Filipino traits of collective loyalty, generosity, hospitality, and humility. These basic values are strong components of childhood socialization in the family. Filipinos inculcate a strong sense of family loyalty beyond the nuclear family. Family obligations extend to cousins, in-laws, and others who are intimately linked with the family by ceremonies such as serving as sponsors of marriage or baptisms (Bautista, 2002).

Most Filipinos in North America were born in the Philippines. By 2050, the Asian Pacific Islanders (API) are projected to increase from 4 to 11 percent of the U.S. pop- ulation. In 2000, Filipinos composed the second largest group (20 percent) of API after Chinese Americans. The majority of Filipino Americans reside in the states of California, Hawaii, Illinois, New Jersey, New York, Washington, and Texas. Filipinos composed the second largest foreign-born population after Mexicans in the United States (Reeves & Bennett, 2004).

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

The first Filipinos in North America were part of the labor force in Spanish galleons who settled in Louisiana as early as 1753. Filipino immigration to the United States began in 1902, when the Philippines became an American terri- tory. Most of the first groups of migrants were U.S.- sponsored students who completed their college educa- tion and then returned to the Philippines. From 1909 until the 1920s, male Filipino laborers were recruited to work on Hawaiian plantations and businesses on the West Coast. These early migrants were ineligible for citi- zenship and were denied privileges such as employment requiring citizenship, union membership, the right to own land, and the right to marry in states with antimis- cegenation laws. The Depression heightened racial ani- mosity toward Filipino workers, and passage of the Tydings-McDuffie Act (Philippines Independence Act) in 1934 virtually ended immigration (Ceniza-Choy, 2003).

In 1946, immigration restrictions for Filipinos were eased and they were granted naturalization rights. Between 1946 and 1965, 33,000 immigrants entered the United States and contributed to a 44 percent increase in the Filipino population in America. The Immigration Act of 1965 initiated a period of renewed mass immigration by promoting family reunification and recruitment of occupational immigrants. Since the passage of the 1965 Act, the Philippines has become the largest source of immigrants from Asia. The post-1965 Filipino immigra- tion consisted of two distinct chains—one deriving from Filipinos who entered the United States before 1965 and the other from the flow of highly trained personnel who began immigration in the 1960s (Espiritu, 2003). A search for better economic and educational opportunities and reunification with family members in the United States continue to be the primary motivating factors for emigra- tion. Working adult children sponsor their older relatives to come to the United States to care for their young chil- dren. In turn, older people facilitate the subsequent immigration of other children.

Because the Philippine economy has been unable to provide jobs for college graduates, an estimated 6 million Filipino professionals work overseas and as many as 300,000 Filipinos emigrated in 2006. Export of profes- sional and skilled labor is one of the biggest industries in the Philippines. Remittances sent home by Filipinos over- seas contributes as much as 10 percent to the country’s gross domestic product, estimated at between 11 and 13 billion pesos in 2006 (IBON Foundation, 2007).

EDUCATIONAL STATUS AND OCCUPATIONS

In the 1900s, Americans introduced public education in the Philippines. Early training of schoolteachers was provided by the Thomasites, forerunners of the U.S. Peace Corps. The development of educational programs in the Philippines was highly influenced and patterned after those in the United States, as in the case of nursing and medicine. Early missionaries and philanthropic organizations such as the Daughters of the American Revolution, the Catholic Scholarship Fund, and the

176 • CHAPTER 10

FIGURE 10–1 Traditional Filipino costumes.

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 176 Aptara Inc.

Rockefeller Foundation were instrumental in the Westernization of health-care education and practice in the Philippines. American nursing educators went to the Philippines, and Filipino nurses were sent to the United States for training. They subsequently returned to the Philippines and assumed leadership positions in nursing schools and hospitals. Since 1970, all nursing curricula have converted to a 4-year degree program leading toward a BSN (Pacquiao, 2004).

The Philippines has one of the highest literacy rates in Asia (96 percent) and is the third largest English-speaking country after the United States and the United Kingdom (Tatak Pilipino, 2003). Schools are either publicly or pri- vately funded. Formal education starts at the age of 7 years, with 6 years of primary education. Nursery school and kindergarten are offered in most private schools. Students get 4 years of secondary education, in either a vocational- technical or an academic school. A high school graduate is 2 years younger than those graduating from U.S. high schools because of the omission of middle school years.

Filipinos view educational achievement as a pathway to economic success, status, and prestige for the individual and the family. A person’s profession is always identified when introducing, addressing, or writing about the person (e.g., Doctor Magpantay or Engineer Paredes). A family’s status in the community is enhanced by the educational achievement of the children, and a child’s education is considered an investment for the whole family. Both male and female children are expected to do well in school, and parents do their best to provide for their children’s full- time education. Adolescents who closely identify with their families are found to be concerned with the potential effect of their scholastic achievement on their families’ rep- utation (Salazar, Schuldermann, Schuldermann, & Hunyh, 2000). Family members and other relatives commonly contribute toward the education of their kin. Among lower and middle-class families, siblings take turns going to col- lege in order to maximize resources for one member to fin- ish school, who can then contribute to the education of her or his siblings. One’s choice of profession is generally a family decision and is based on potential economic return to the group. Hence, increased demand for nurses abroad attracts higher enrollment in nursing, as families view this occupation as a pathway to economic improvement.

Filipino immigrants since 1965 have had relatively high educational attainment, a high level of labor partici- pation, particularly among women, a high percentage of working professionals, and a low rate of poverty. However, there is a growing concern with the increasing dropout rate among members of the younger generation. Filipino adolescents identified reasons for dropping out of school as intense parental pressure to succeed, fear of not meeting parental expectations, predominance of parental wishes over their own choices, inability to seek support from par- ents for failures in school, differential parental expecta- tions and attitudes toward their sons and daughters, and experienced tension between assimilation and racism in the outside society (Wolf, 1997).

Filipinos appear to be assimilated and successful and tend to blend into American society, which gives them a reputation as a “model minority.” In reality, high educa- tional attainment of American-born and immigrant

Filipinos does not guarantee their entry into well-paying or high-status jobs. Significant discrimination confronts native-born and immigrant Filipinos in the American labor market linked with factors such as gender, region of residence, and level of education (Yamane, 2002). As is the experience of many foreign graduates, Filipinos’ edu- cation and experience are rarely matched with a suitable job because of the restricted labor market, resulting in many individuals competing for low-level jobs for which many are overqualified. Only those who are educated in health-care fields tend to find jobs consistent with their education.

Whereas American nursing education stresses the process of thinking, in the Philippines, mastery of facts and rote learning are emphasized. A defined hierarchy exists in schools, with the teacher as the expert authority. This hierarchy is congruent with the social organization in the broader society, in which age and position are per- manent markers of status and power. The younger gener- ations are rewarded for accepting the ideas and counsel of older people and teachers. Challenging authority and asserting one’s creative ideas are unnatural predisposi- tions, especially for the young. Nursing faculty have iden- tified the tendency of Filipino students to take things at face value, avoid conflict, communicate nonassertively, and learn by rote memorization. Students’ traditional val- ues at home were in conflict with values in school and teacher expectations (Pacquiao, 1996). Facilitating under- standing of the dominant cultural values and norms in school, in addition to teaching the subject matter, is essential to facilitate these students’ academic success.

Communication DOMINANT LANGUAGE AND DIALECTS

Over 100 dialects are spoken in the Philippines; the 8 major dialects are Tagalog, Cebuano, Ilocano, Ilonggo, Bicolano, Waray, Pampango, and Pangasinenses. Most Filipinos speak the national language, Filipino, which is based on Tagalog (Tatak Pilipino, 2003). English is used for business and legal transactions, and in school instruc- tion beyond the third grade. Business and social interac- tions commonly use a hybrid of both Tagalog and English (Tag-Lish) in the same sentence. Tag-Lish is often used in health education.

Many Spanish words are found in the Filipino lan- guage such as sopa (soup), calle (street), hija/hijo (daugh- ter/son), and respeto (respect). The influence of indige- nous Filipino and Spanish languages produces distinct characteristics when Filipinos speak English. There is absence of certain sounds in the Filipino language such as short i, long a, and long o. Hence, liver may be enunciated as lever, make as mik, and flow as flaw. Many Filipinos are unable to differentiate s from sh (physiology as fishiology), u from short o or short a sounds (cut as cot or cat; church as charts). They have a tendency to place emphasis on the second syllable of a multisyllabic word (in ter’fe rence, pen ni’cill in, ro bi’tus sin).

Filipino social hierarchy is evident in the language. Specific nouns rather than pronouns are used to denote a

PEOPLE OF FILIPINO HERITAGE • 177

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 177 Aptara Inc.

person’s age, gender, and position in the social hierarchy. For instance, Manang and Manong are used to refer to or address an older woman and man, respectively. These nouns are used to address the person or when speaking about her or him. There is absence of the “she/he” in the Filipino language. Rather, generic and gender-neutral pronouns siya (singular “she/he”) and sila (plural “they/them”) are used. Hence, many Filipinos may unconsciously use “she” and “he” interchangeably in ref- erence to the same individual.

Although many Filipinos speak English, their ethnic language or dialect, knowledge and use of the English lan- guage, and age of migration to the United States often influence enunciation, pronunciation, and accentuation. Older Filipinos who originated from non–Tagalog-speaking regions may understand and speak better English than other Filipinos. In multigenerational Filipino American families, different languages may be used to communi- cate with family members and friends. Although many Filipinos speak and write fluently in English, they may have difficulty understanding American idiomatic expres- sions. For example, to a new immigrant, “How are you?” may be interpreted as a question about the person’s well- being, requiring an elaboration of one’s situation, rather than a mere greeting. Filipinos may have difficulty com- municating their lack of understanding to others and may use ritualistic language and euphemistic behavior that appears to be the opposite of how they actually per- ceive the situation. Saving face, or concealment (Pasco, Morse, & Olson, 2004), is a characteristic pattern of behavior employed to protect the integrity of both par- ties, which is a consequence of the cultural value on maintaining smooth interpersonal relations. Desirous of group approval, the individual becomes sensitive to the feelings of others and, in turn, develops a high sense of sensitivity to personal insults.

Traditional Filipino communication is highly contex- tual. The individual is enculturated to attend to the con- text of the interaction and to adopt appropriate behav- iors. Many Filipinos are keenly observant, displaying an intuitive feeling about the other person and the contex- tual environment during interactions. Contextual vari- ables include the presence of ibang tao (outsiders) ver- sus hindi ibang tao (insiders) and the age, social position, and gender of the other individual. In the com- pany of insiders, such as one’s family, each member develops an intuitive knowledge of the other so that words are unnecessary to convey a message, and mean- ings are embedded in nonverbal communication. In the presence of outsiders, a child’s emotional outburst may be met with adults’ stern silence, indifference, or euphemistic grins. These behaviors imply to insiders that emotional outbursts are inappropriate in front of out- siders. One may not disagree, talk loudly, or look directly at a person who is older and who occupies a higher posi- tion in the social hierarchy. Honorific terms of address denoting an individual’s status within the hierarchy exist in all dialects. In Tagalog, when communicating to an older person or a person of status, he or she is addressed using gender and age-specific honorific nouns such as Lolo/Lola (Grandpa/Grandma), and ate/kuya (older sis- ter/older brother). Prefixes such as Mr., Mrs., Miss, or Ms.

or the professional title of the person is used in formal interactions.

Filipino interpersonal and social life operates to main- tain smooth interpersonal relationships; communication tends to be indirect and ambiguous to prevent the risk of offending others. Filipinos may sacrifice clear communi- cation to avoid stressful interpersonal conflicts and con- frontations. As saying no to a superior is considered disre- spectful, it predisposes an individual to make an ambiguous positive response. Filipinos are often puzzled, and some- times offended, by the precision and exactness of American communication. Newly recruited Filipino nurses are stunned by their American coworkers’ abra- siveness and open expressions of anger toward each other and their subsequent behavior of sitting down at coffee “as if nothing happened.” To many traditional Filipinos, actions speak louder than words. They value respect and might find questions like “Do you understand?” or “Do you follow?” disrespectful. It is preferable for the speaker to say, “Please, let me know if I understood you correctly.” When speakers occupy different positions in the social hierarchy, an informal and familiar manner of speaking by the subordinate may be perceived as impolite and dis- respectful. Allowing time for a Filipino to respond not only communicates respect but also gives time for trans- lating the dialect into English. Speaking clearly and slowly facilitates appreciation of varying pronunciation and accentuation of the English language across cultures.

CULTURAL COMMUNICATION PATTERNS

Relational orientation has been suggested as the essence of Asian social psychology. Enriquez (1994) posited that the Filipino core values of shame (hiya), yielding to the leader or majority (pakikisama), gratitude (utang na loob), and sensitivity to personal affront (amor propio) emphasize a strong sense of human relatedness. These val- ues originate from the central concept of kapwa, which arises from the awareness of shared identity with others. Kapwa embraces the insider-outsider categories of human relations and prescribes different levels of interrelatedness or involvement with others. Pakakikipagkapwa (“being one with others”) implies accepting and dealing with the other individual as a fellow human being. Kapwa is grounded in the fundamental value of shared inner per- ception or feeling for another, from which all other attrib- utes for human relations are made possible.

Eight levels of social interactions were identified by Enriquez within the core concept of kapwa. These levels demonstrate a hierarchy of human relatedness within the Filipino language and context of meanings. The contex- tual axis of interactions is conceptualized within a contin- uum of how the “other” is categorized—whether as an insider or outsider. The degree of sharing and involvement with outsiders may progress from levels 1 to 5, whereas interactions at levels 6 to 8 are observed with insiders. The eight levels are pakikitungo (civility, level 1), pakikisalimuha (interacting, level 2), pakikihalok (participating, level 3), pakikibagay (conforming, level 4), pakikisama (adjusting, level 5), pakikipagpalagayang loob (understanding and accepting, level 6), pakikisangkot (getting involved, level 7), and pakikiisa (being one with, level 8).

178 • CHAPTER 10

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 178 Aptara Inc.

Developing working relationships with Filipinos requires understanding of where one is situated within the insider-outsider continuum. Outsiders can move toward higher levels of interactions by observing cultural norms of communication, using trusted gatekeepers to mediate conflicts, seeking validation of perceptions of behaviors from more acculturated members of the group, and allowing face-saving opportunities to prevent embar- rassment and personal denigration. When confronting a Filipino coworker, provide privacy and point out positive attributes as well as the problem. Observing nonverbal behaviors and interpreting them within the Filipino cul- tural context promotes culturally congruent interactions. Accommodating differential sharing and involvement between insiders and with outsiders shows cultural understanding that enhances development of intercul- tural relationships. For example, a Filipino speaking Tagalog with another reinforces the value of being one with others. Learning and using some Filipino greetings and honorific terms of address facilitate movement of the relationship to higher levels of involvement. Defining work situations in which Filipino dialects may be spoken demonstrates cultural sensitivity and accommodation. The insider and outsider delineations may be less impor- tant to some Filipinos who are highly educated and take pride in their global outlook. Unlike other immigrants who settle in ethnic enclaves, more recent Filipino immi- grants acculturate and relate well with people from vari- ous cultures.

Smiling and giggling are often observed, especially among young Filipino women. The meanings of these spontaneous and highly unconscious behaviors are embedded in the context of the situation and may range from glee, genuine interest, and agreement to discomfort, politeness, or indifference. It is helpful to point out how the behavior can be misinterpreted by patients and oth- ers, if inappropriate to the situation. Behavior change can be expected if correction is done in a timely, respectful, and sincere manner.

Having a heightened sensitivity to personal insults, Filipinos have a remarkable ability to maintain a proper front to protect their self-esteem when threatened. Conflict-avoidance behaviors to conceal discomfort or distress are evident in euphemistic denial of anger, mini- mization of pain, and silence. However, pent-up emo- tions and accumulated resentment may result in explo- sive anger, depression, and somatization. Practitioners should be sensitized to these behaviors and explore the underlying causes by establishing trust and maintaining respectful relationships. Offering pain medications and attending to nonverbal behaviors, rather than waiting for the patient to verbalize his or her needs, are culturally congruent approaches.

First-generation Filipinos in North America have high regard for health-care practitioners (Abe-Kim, Gong, & Takeuchi, 2004) and present themselves in therapy ses- sions as polite, cooperative, verbal, and engaging. However, agreement with health-care providers does not ensure that clients will follow through with the recom- mendations. Health-care providers should be comfortable with clients’ deferential attitude without resorting to authoritarian approaches, which may be perceived as

oppressive and may encourage euphemistic complaint behaviors. Once trust is developed, expression of authen- tic feelings is possible. Filipinos who are accustomed to indirect communication may perceive focusing on action- oriented strategies and outcomes as intrusive and coer- cive.

Direct eye contact varies among Filipinos depending on the degree of acculturation, length of time in America, age, and education. Some individuals may avoid pro- longed eye contact with authority figures and older peo- ple as a form of respect. Older men may refrain from maintaining eye contact with young women because it may be interpreted as flirtation or a sexual advance. Filipinos are comfortable with silence and may allow the other person to initiate verbal interaction as a sign of respect. During a teaching session, a Filipino client’s nod may have several meanings that can range from, “Yes, I hear you,” “Yes, we are interacting,” “Yes, I can see the instructions,” or some other message that may be difficult for the client to disclose. Validating a client’s response in a sensitive and respectful manner as well as observing her or his behaviors can prevent miscommuniaction.

Touch is used freely, especially with insiders. Greater distance is observed when interacting with outsiders and people in positions of authority. Same-gender closeness and touching, which may be perceived as homosexual adult behavior in America, are considered normal. Young adults of the same gender may hold hands, put one arm over another’s shoulder, or walk arm-in-arm. As they become more acculturated, many Filipinos become aware of the differences and adapt to the new culture.

The implicit rules of the social hierarchy are observed when conflicts arise. A subordinate does not confront his or her superiors. Rather, a mediator who is likely to be a trusted individual at the same level of hierarchy as the superior may be employed to mediate and approach the superior on behalf of the subordinate. This behavior may be interpreted as dishonest by Americans who value direct and assertive communication.

V I G N E T T E 1 0 . 1

Debra Walker, aged 32 years, is a nurse manager in a large Medical-Surgical Unit. She has had a good working relation- ship with one of the Filipino surgeons, 65-year-old Dr. Amador Mendoza, since they worked together on a project. She considers their relationship as collegial and friendly. She often exchanges stories and jokes with Dr. Mendoza and describes him as “competent, easy to get along with, and has a terrific sense of humor.” Debra and Dr. Mendoza attended an administrative meeting to discuss some changes for the unit. Debra remembers this as the last time that Dr. Mendoza was friendly with her. She recalls that at the meeting, she made a joke about what he said. Since then, his behavior toward her has been “cold and formal.”

1. How do you explain the change in the doctor’s behavior toward the nurse manager?

2. What cultural taboos were violated by the nurse manager?

3. How should the nurse manager deal with the situation?

PEOPLE OF FILIPINO HERITAGE • 179

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 179 Aptara Inc.

TEMPORAL RELATIONSHIPS

Filipinos have a relaxed temporal outlook. They have a healthy respect for the past, an ability to enjoy the pre- sent, and hope for the future. Past orientation is evident in their respect for older people and dead ancestors (galang), and a sense of gratitude and obligation to kin (utang na loob). Future orientation is manifested in the family’s commitment to provide for the education of the young, parental participation in the care of their children and grandchildren, and a strong work ethic. A strong pre- sent orientation is associated with the cultural emphasis on maintaining positive relationships with others. Permanent social bonds with kin and significant others outside of kin are nurtured. Filipinos enjoy their families, fiestas, and life. They spend generously to make family events memorable and enjoyable. Although most Filipinos have adapted to American punctuality in the business sphere, promptness for social events is situation- ally determined. “Filipino time” means arriving much later than the scheduled appointment, which can be from 1 to several hours. The focus is on the gathering rather than on the schedule. A Filipino host may invite American guests at least 1 hour later than the Filipino guests in the hope that both will arrive at the same time.

Present-time orientation is evident among many Filipino nurses who have difficulty leaving a patient who is upset or when they are in the middle of doing a proce- dure such as a patient’s bed bath. Addressing the present needs of patients, and ensuring smooth relationships with them, may be interpreted by their American cowork- ers as poor time management and failure to determine work priorities. Newly recruited nurses are distressed by their inability to complete the caretaking tasks that, in their assessment, would clearly please and ensure the comfort of their patients. Differential time orientation between Filipinos and Americans should be made part of job orientations. Defining expressions of these different time orientations can prevent conflicts at work and help provide culturally relevant mentoring.

FORMAT FOR NAMES

The Filipino family is bilineally extended to several gen- erations. Kinship and family affinity can be legally and spiritually claimed equally from both sets of families, giv- ing the child the identity of the extended family. This bilineal kinship is reflected in their names. Children carry the surnames of both parents. For example, Jose Romagos Lopez and Leticia Romagos Lopez are the children of Maria Romagos and Eduardo Lopez. The middle name or initial (R.) is the mother’s maiden name, Romagos. After marriage, Jose keeps the same name, whereas his sister’s name becomes Leticia L. Lukban (her husband being Ernesto Lukban). Leticia’s maiden name, Lopez, is abbre- viated as her middle initial.

Many Filipino names are of Spanish origin. Symbolic of Filipinos’ Catholic faith, saint names are often used with first names. Filipino females may have a Ma. (for Maria) before their given names: For example, Ma. Luisa stands for Maria Luisa. Although the name Maria is often given to girls, some males may use Maria as a first or second name;

hence, Ma. Jose Romagos Lopez and Jose Ma. Paredes Castro. The saint name is an integral part of the first name; thus, an individual uses both first names, Maria Luisa or Jose Maria. Few Filipino American women keep their own surname after marriage, although this may increase among second- and third-generation Filipinos.

Adults use first names to address young children. Nicknames symbolizing affectionate regard for the person (Nini, Baby, Bongbong) are commonly used instead of the first name. These nicknames may indicate special mean- ings, positions, and/or outstanding characteristics of the child. First names are avoided when addressing older adults and those occupying higher positions in the hier- archy. In formal business transactions, prefixes such as Mr., Mrs., Miss, or Ms. or the person’s professional degree are used before the person’s last names (Dr. Abaya or Attorney Abaya).

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

Since the pre-Spanish era, Filipino women have been held in high regard, having rights equal to those of men (Agoncillo & Guerrero, 1987). In contemporary Filipino families, although the father is the acknowledged head of the household, authority in the family is considered egalitarian. The mother plays an equal, and often major, role in decisions regarding health, children, and finances (Fig. 10–2).

Traditional female roles include caring for the sick and children, maintaining kinship ties, and managing the home. Parents and older siblings are involved in the care and discipline of younger children. In extended family households, older relatives and grandparents share much authority and responsibility for the care and discipline of younger members. Traditional Filipino families may not expect female children to engage in activities that are considered appropriate for men, such as driving, bicy- cling, and other functions requiring mechanical or tech- nical skills. Blurring of roles between men and women

180 • CHAPTER 10

FIGURE 10–2 Members of a Filipino family that is bilaterally extended to three generations. (Photograph by Rowena Legaspi.)

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 180 Aptara Inc.

occurs with increased education, urbanization, and emi- gration to a new culture, as in the United States.

In the United States, Filipino families predominantly consist of married couples with both spouses working. Filipino womanhood has evolved from the Spanish con- struct of modesty, demureness, and femininity to a con- temporary image of a woman who is educated, working, and adept at balancing traditional roles and career demands. Since the 1950s, women represent close to 50 percent of university enrollments and pursue careers in law, medicine, and politics. Traditional Filipino parents expect their male and female children to pursue college education and economically productive careers and also to have a family. Family members and Filipino friends or acquaintances are preferred caregivers of young children when parents are working. Older parents, especially grandmothers, emigrate to the United States in time for the birth of their grandchildren and are expected to take care of them on behalf of their working adult children (Pacquiao, 1993).

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

The strong in-group consciousness of Filipinos is rooted in the centrality of family and kin, to the exclusion of others, in the socialization of individuals. As the strongest unit of society, the family demands the deepest loyalties and significantly influences an individual’s social interactions. Ascriptive and particularistic personal ties with kin are significant in the allocation of rank, authority, and power to individuals. Generational posi- tion conditions the status as well as the role performance of individuals. The family and one’s familial role define and order authority, rights, obligations, and modes of interaction. Younger generations are taught to be respect- ful and heed the authority of older siblings and relatives, parents, and grandparents. Respect is manifested in both speech and actions by using honorific terms of address, avoiding confrontation and offensive language, keeping a low tone of voice, greeting older people by kissing their forehead or back of their hand, avoiding direct eye con- tact when being admonished, offering food, touching, and so forth. Husbands and wives address each other using the honorific terms that they wish to model for their children. In front of the children, a husband will address his wife as Inay (mother) and the wife corre- spondingly refers to her husband as Itay (father). Under no circumstance are children permitted to call their par- ents by their first names. Friends of Filipino children are expected to show respect to adult members of the family when they visit.

Reciprocal obligations among kin are embodied in the value of utang na loob, a personal sense of indebtedness and loyalty to kin, which carries an obligation to repay or perform services for one another. Filial respect and oblig- ation for caring for one’s parents is the ultimate conflu- ence of generational respect and reciprocal obligation. Childhood socialization to the mechanism of shame (hiya) reinforces the value of utang na loob and genera- tional respect. Failure to perform or recognize reciprocal obligations, as well as disrespect of older people or people

of authority, results in the loss of one’s self-esteem and status, as well as incurs shame to one’s family.

Children learn early to behave differently toward insid- ers and outsiders. Private affairs are reserved for close kin and are well guarded from outsiders. Filipino American high school students reported that they were taught to keep problems within the family and that talking to out- siders such as friends, teachers, or counselors would bring shame to the family (Wolf, 1997). Conditions such as mental illness, divorce, terminal illness, criminal offenses, unwanted pregnancy, homosexuality, and HIV/AIDS are not readily shared with outsiders until trust is established. The extent to which a Filipino client may disclose per- sonal information is contextualized. Family presence may act as a barrier to full disclosure of conditions that may be perceived as putting the family at risk for shame.

Dating at an early age is discouraged for young daugh- ters who are advised that a short courtship period may suggest that they are “easy to get.” Young men with sin- cere intent must strive to get on the good side of the fam- ily and have patience with a long courtship. Open demonstrations of affection with sexual undertones are to be avoided by the young couple. Ideally, the groom’s par- ents formally ask for the bride’s parents’ consent for the marriage of their children. Traditional families desire that their daughters remain chaste before marriage. Pregnancy out of wedlock brings shame to the whole family. Modernization and urbanization have changed the social mores in the Philippines; yet, many Filipino American families are still perceived by younger family members as having an overly protective attitude toward children in matters of “hanging out” with friends, dating, and courtship. Girls are subjected to greater limitations than boys, which contributes to higher reports of contemplat- ing suicide by Filipino girls. Studies of second-generation Filipino students in high schools revealed greater parental control over daughters, with more latitude allowed for sons. For many Filipinas, high school achievement was met by parental control over their choice of colleges and pressure to remain close to home and family supervision (Wolf, 1997). Compared with other groups, Filipino American teenagers have the lowest rates of teen preg- nancy (U.S. Bureau of the Census, 2002).

FAMILY GOALS AND PRIORITIES

The Filipino family is extended bilineally to several gen- erations with a clear structure and network of relation- ships. In addition to blood relatives, fictive kinship is established through the compadrazgo system in which friends and associates are invited to become godparents or surrogate parents in religious ceremonies, such as baptism and marriage. Fictive kinship is a significant support system for Filipino Americans who left families or relatives in the home country. In times of illness, the extended family provides support and assistance. Sometimes, a family visit to the hospital takes on the semblance of a family reunion.

The family is the basic social and economic unit of Filipino kinship. Family relations strongly influence indi- vidual decisions and actions. Relatives and family consti- tute the reference group for individuals, determining

PEOPLE OF FILIPINO HERITAGE • 181

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 181 Aptara Inc.

their behavior as well as that of their relatives in any social exchange. Family loyalties and obligations super- sede individual interests and residential migration. This is evident in migration patterns of adult children and aged parents, which are planned to maximize the economic welfare and support for group members.

Family emphasis on communal values and genera- tional respect is highly institutionalized. Community activities generally center on the family. Fiestas, wed- dings, baptisms, illnesses, and funerals are occasions for reinvigorating relations with kin and rekindling local connections, in which the presence and, more impor- tantly, the absence of relatives are viewed as highly signif- icant. Early child-rearing practices are permissive, with emphasis on providing an emotionally secure environ- ment for the child. Priority is placed on promoting the child’s well-being and social acceptance. The child is introduced early into various mechanisms designed to impose compliance with family values. A family’s prestige is measured by the upbringing of their children, judged by their adherence to traditional cultural values.

The family emphasis on faithfulness to religious oblig- ations is tied with the cultural values of generational respect and reciprocal obligation. Child-rearing practices stress entire family participation in the religious educa- tion and adherence to rituals by young members. Older generations share the responsibility for reinforcing these values. Religious sacraments, such as marriage, are embedded in the age-grading activities of the extended family (Fig. 10–3).

As the basic economic unit of society, the family defines the economic obligations of kin to each other. Interdependence within and across generations is fos- tered. Children are looked upon as economic assets and as sources of support for parents in old age. Thus, educating young members becomes a family priority. The socioeco- nomic status of the aged is closely linked with the family’s wealth; if resources are limited, older people rely on chil- dren and relatives. Older parents and grandparents are integrated within the family, thus lessening the impact of advancing age. Traditional Filipinos consider institution-

alization of aged parents tantamount to abandonment of filial obligation and respect for older people. Many older people aspire to return to the Philippines to spend their remaining years with loving kin.

The development of pakiramdam (shared perception) and kapwa (shared identity) is the defining goal of the family. Group cohesiveness, loyalty, and faithfulness to shared obligation are expectations that transcend distant migration, marriage, and adulthood. Significant evidence exists for the concept of shared perception and identity among Filipinos. Students who feel obligated to main- tain their family’s reputations believe that effort and interest, rather than ability, can result in school success (Salazar et al., 2000). Filipino American older people have reported experiencing conflict between the maintenance of family obligations, such as babysitting for their grand- children, and their desire to be more independent from their adult children. Family obligations may result in their inability to meet medical appointments, obtain needed medications, and make meaningful social con- nections because of lack of independent transportation. Depression has been associated with loneliness, feelings of isolation, and financial difficulty (McBride & Parreno, 1996). Older Filipino Americans identified integration in the family of their adult children, participation in com- munity activities with family and close friends, and maintaining religious functions as highly important (Pacquiao, 1993).

The family provides primary support during illness. It is common to mobilize the extended family support sys- tem from the Philippines and in many parts of the United States to care for ailing family members. Many Filipinos believe that mental illness brings a stigma to the individ- ual and the family; hence, support will likely come from family members. This is evident in the underutilization of mental health services and presentation of advanced symptoms by the patient on hospital admission. Among Filipino Americans, religiosity was correlated with seeking help from the religious clergy whereas spirituality was associated with less help-seeking from professional men- tal health practitioners (Abe-Kim et al., 2004). The first choice is caring by family members, friends, and relatives rather than seeking health professionals (Gong, Gage, & Tacata, 2003).

Diversity exists in the degree to which Filipino Americans adhere to the traditional cultural values. Some middle-aged immigrant Filipino parents do not expect to live with their children in old age. Diversity in family member roles and priorities exists as a result of the finan- cial resources of the family. Reciprocal obligations with kin are expressed differentially based on the capacity of older people and adult children to meet them and include economic, physical, emotional, and social sup- port dimensions.

ALTERNATIVE LIFESTYLES

Traditional Filipino parents seldom provide sex educa- tion, and sex is not discussed openly at home. Homosexuality may be recognized and considered an aberrant behavior, but it is not openly practiced in order to save face and prevent shame for the family. In recent

182 • CHAPTER 10

FIGURE 10–3 The Spanish influence in the Philippines is depicted in this Roman Catholic wedding featuring godparents as an important part of fictive kinship development for the couple and their families. (Photograph by Rowena Legaspi.)

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 182 Aptara Inc.

years, younger gay, lesbian, bisexual, and transgender Filipinos in the Philippines and in the United States are taking a more active role in being recognized and express- ing their rights.

Although the tenets of the Catholic Church have a direct bearing on sexual mores for older generations of Filipinos, they have less influence on younger genera- tions, as is seen in the high incidence of HIV/AIDS among Filipino compared with that of other API. The family may not be the primary source of support for individuals, who may be isolated to prevent stigma to the family. The nuclear family may protect the affected member from outsiders and intentionally remove them from a network of friends and extended family. Providing an atmosphere that fosters the much-needed sense of belonging should be the goal of culturally congruent services.

Divorce can carry a stigma for older and more tradi- tional Filipinos, especially those who are devout Catholics. The stigma may be worse for Filipinos in the Philippines for whom divorces are not allowed and are considered a religious taboo. Divorces among Filipino Americans gen- erally result from failed marital duties, lack of mutual sup- port between partners, and marital infidelity.

Workforce Issues CULTURE IN THE WORKFORCE

The history of white colonization of the Philippines may influence perceptions of workplace experiences. Experience with racism is a continuing theme voiced by Filipino nurses working with white American nurses (Spangler, 1992). Among Filipino American women nurses and nurses aides, longer residence in the United States was associated with increased stress, evidenced by higher lev- els of serum norepinephrine, and higher diastolic pres- sure and lower dips in blood pressure readings during sleep (Brown & James, 2000). The recent business model used in recruiting nurses from the Philippines has removed some of the benevolent provisions for pro- longed supportive training that were available to those nurses under the Exchange Visitors Program. The require- ment by the American Nurses Association for equal pay for the same job transformed foreign nurse recruitment into a competitive enterprise, in which employers and existing staff expected recruited nurses to be functionally competent on the job as soon as they received their American RN license because they will receive pay com- parable with that of other RNs. In reality, providing tran- sitional support for foreign nurses requires a significant commitment of time and financial investment and a pro- longed acculturation process (Pacquiao, 2004).

Filipino nurses have been recruited in large numbers to staff mostly evening and night shifts in which acute shortages of American trained nurses exist. This has rein- forced the cultural tendency toward collective solidarity by defining the context of interactions within the insider- outsider continuum. Frequent entry of large numbers of new recruits into the same setting has reduced the num- ber of cultural mentors who can help facilitate these

nurses’ acculturation to the organization and the cultural norms of the society at large. American nurses and administrators of health organizations with large contin- gents of Filipino nurses are becoming aware of the need for special knowledge and skills in understanding and managing a diverse workforce and in developing cultur- ally specific staff development programs.

Cultural conflicts in the workplace stem from different communication patterns: the dominant norm of assertive- ness versus the highly contextual Filipino communication. The cultural concept of shared identity with other Filipinos creates a propensity among Filipino nurses to speak in their own dialect with each other to the exclusion of non- Filipino coworkers and patients. Lack of fluency in speak- ing and enunciating English words results in anxiety when interacting with outsiders. Nonsupportive reactions from patients and coworkers discourage attempts to speak more English. Assertive communication is difficult for Filipinos, who have been enculturated to avoid conflict. Filipino nurses may consider it impolite and disrespectful to con- front or challenge the authority of a superior. When a problem with a manager occurs, a Filipino nurse may com- municate through a mediator, usually another Filipino nurse, who is in the same level within the hierarchy as the manager. Communicating disagreement with a physician is difficult for many Filipino nurses. Conversely, Filipino registered nurses expect their subordinates to be deferential toward them.

Conflict can result from different cultural values about caring. Coming from a highly collective orientation, Filipinos define caring in terms of active caring for others. This perspective differs from the American value of self- care. Filipino nurses feel comfortable performing what they perceive as caring tasks for patients that American nurses expect patients to do for themselves. Initially, they may not be inclined to teach and demonstrate procedures to patients because of their traditional belief in doing the caring tasks for patients. Outsiders may misconstrue Filipino nurses’ preoccupation with caring tasks as disor- ganization or lack of assertiveness.

Different views about a valued coworker may be another source of conflict. The Filipino values of shared perception and being one with others create a coopera- tive, rather than a competitive, outlook. A valued individ- ual produces for the group and puts the group above her or his own personal gain. Humility, hard work, loyalty, and generosity are admired. The business-like and com- petitive perspectives of Americans, in which behavior is internally motivated by individual gain, may be inter- preted as selfish and uncaring. Self-proclamations of accomplishments are viewed as cocky and offensive. Instead, it is up to the group to recognize a member’s achievement, which is assessed in terms of how the action benefited the group.

Health-care organizations are cultural entities defined by norms that reflect the dominant values of the host society. Professional schools mirror these dominant soci- etal norms, which are congruent with those of health- care organizations. Among outsiders to the dominant American culture, the experience in nursing schools and health-care organizations is dissonant with previous life experiences, which require an understanding of both

PEOPLE OF FILIPINO HERITAGE • 183

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 183 Aptara Inc.

cultural and occupational role differences. Bicultural development of Filipino and non-Filipino staff should be the goal of occupational orientation and training. Biculturalism requires awareness of self and others and the ability to adapt behaviors that build positive rela- tionships with others who may be different from oneself (Pacquiao, 2003). Understanding cultural differences and similarities allows for the development of intercultural understanding and skills that promote teamwork. Bicultural mentors who can teach cultural norms of the organization and work with diverse patients and staff will foster the individual’s ability to adapt behaviors. Staff development requires training in frame switching— using different frameworks to understand behaviors of others and commitment to the belief that other perspec- tives are equally sound in explaining our experiences. Impression management is a bicultural skill that is grounded in the ability to interpret behaviors of others within their own cultural context and manifest behav- iors that promote relationship and intercultural under- standing (Pacquiao, 2001).

ISSUES RELATED TO AUTONOMY

A core Filipino cultural concept is bahala na, which consists of the belief and predisposition to trust the Divine Providence and social hierarchy to resolve prob- lems. Filipinos may avoid taking an active role in manag- ing problems because of their fatalistic belief that a “greater power” will prevail. Outsiders may interpret this behavior as a lack of initiative or responsibility. Many Filipino nurses are hesitant to assume leadership roles and assert their points of view, especially with outsiders. After an initial effort, further attempts to resolve the problem are generally left to the leader or hierarchy. Providing sup- port and role modeling help these nurses assert them- selves and feel confident in problem solving and conflict resolution. Filipinos are proud people who place impor- tance on maintaining self-esteem and dignity by saving face and avoiding shame. Their sensitivity and attention to other people’s feelings are often exhibited as indeci- siveness, which many Americans interpret as lack of assertiveness.

Filipinos may achieve power and prestige by acquiring wealth, education, and a distinguished position or by age and through marriage. Although this value has weakened among younger Filipinos, respect for older people and those in positions of power is firmly entrenched among most Filipinos, who are taught not to show open disagree- ment. Loquacious Americans who uphold egalitarianism and candid expression of feelings and ideas are perplexed by the Filipino deference to authority. Less-acculturated Filipinos may not understand the directness of Americans and, thus, may find it insulting. European American nurses saw the quiet, observant, tactful, patient, and slow- to-respond behaviors of Filipino nurses as unassertive (Spangler, 1992). By contrast, Filipino nurses saw outspo- ken, impatient, bold, and fast-moving behaviors of European American nurses as crass and insensitive. A Filipino may say “yes” to avoid hurting other people’s feel- ings. Such response should be examined in context to interpret its true meaning.

The Filipino hierarchy and emphasis on collectivity brings a consequent group-oriented sense of responsibil- ity and accountability. The leader is respected, followed, and expected to make decisions on behalf of members. The leader is trusted to act in the best interests of the group. The concept of individual accountability and responsibility in a highly litigious society, such as the United States, may initially be difficult for Filipino nurses to understand. Supportive role modeling in assuming individual accountability is important for Filipino- educated nurses.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Variations in anthropomorphic, physical, and biophysio- logical characteristics of Filipinos exist as a result of eth- nocultural and racial intermingling. One of the Filipino aboriginal tribes, the Aeta, is negroid and petite in stature. They are believed to have migrated from Africa through land bridges during the Ice Age. However, like other tribal groups in the Philippines, they are now a minority.

The typical native-born or immigrant Filipino may be of Malay stock (brown complexion) with a multiracial genetic background. Intermarriage of Filipinos with other ethnic and racial groups occurs in many communities across the world. In clinical assessments, a family genogram identifying ethnic or racial blending is useful in tracking predisposition to genetic disorders.

The youthful features of Filipinos make it difficult to assess their age. Common Filipino physical features may include jet black to brunette or light brown hair, dark to light brown pupils with eyes set in almond-shaped eye- lids, deep brown to very light tan skin tones, and mildly flared nostrils and slightly low to flat nose bridges. The eye structure may challenge health-care providers in assessment such as observing pupillary reactions for increased intracranial pressure, measuring ocular tension, and evaluating peripheral vision. The flat nose bridge may be overlooked by opticians when fitting and dis- pensing eyeglasses.

The high-melanin content of the skin and mucosa may pose problems when assessing signs of jaundice, cyanosis, and pallor. This feature also poses difficulty in diagnosing retinal, gum-related, and oral tissue abnormalities. When performing skin assessments, practitioners should con- sider the complexion and skin tone of the Filipino client. The usual manifestations of anemia (pallor and jaundice) should be assessed in the conjunctiva. Newborns may have mongolian spots (bluish-green discolorations on the buttocks) that are physiological and eventually disappear.

Filipinos range in height from under 5 feet to the height of average Americans. Body weight varies accord- ing to nativity and other factors such as nutrition, physi- cal activity, and heredity. Filipinos commonly gain weight when they come to the United States. There are no defini- tive studies relating nutrition with standard height and weight measures for this population; therefore, it is essen- tial to assess for weight changes on an individual basis.

184 • CHAPTER 10

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 184 Aptara Inc.

Filipinos have a small thoracic capacity. Approximately 40 percent have blood type B and a low incidence of the Rh-negative factor (Anderson, 1983). As more interracial families emerge in Filipino communities, changes in their serologic profile will likely occur.

DISEASES AND HEALTH CONDITIONS

Compared with other Asians, Filipino men and women have the highest prevalence of hypertension characterized by sodium sensitivity (Garde, Spangler, & Miranda, 1994). High incidence of hyperuricemia is attributed to a shift from a Filipino to an American diet (McBride, Mariola, & Yeo, 1995). Liver cancer tends to be diagnosed in the late stages of the disease and appears to be associated with the presence of the hepatitis B virus. Silent carriers of the virus are common among Asians, and its presence is detected only when other problems are being evaluated. Health- care providers should routinely screen for hepatitis B virus, especially among recent immigrants. A high inci- dence of glucose-6-phosphate dehydrogenase (G-6-PD), thalassemias, and lactose intolerance and malabsorption exist among the Filipino population (Anderson, 1983).

Compared with other API and white males, Filipinos are more likely to be diagnosed with advanced-stage col- orectal and prostatic cancer. They have the worst survival rates from these cancers (Lim, Clarke, Prehn, Glaser, West, & O’Malley, 2002). Like other API, Filipinos underuse cancer screening tests (Kagawa-Singer & Pourat, 2000). Filipino Americans are at increased risk for type 2 diabetes and have higher visceral adipose tissue (VAT) than whites and African Americans (Araneta & Barrett-Connor, 2005). The three leading causes of mortality among Filipino Americans are cardiovascular disorders followed by stroke and cancer.

Some of the goals of Healthy People 2010 pertaining to Filipino Americans include (1) reducing overall death rates from cancer (particularly of the breast, cervix, and uterus), coronary disease, and diabetes; (2) reducing the incidence of tuberculosis and diabetes; (3) increasing counseling on tobacco use cessation, physical activity, cancer screening, and adult and adolescent HIV/AIDS prevention; (4) increasing early and adequate prenatal care and reducing rates of low birth weight and gesta- tional diabetes; (5) increasing control of blood pressure among those with hypertension; and (6) decreasing mean cholesterol and low-density-lipoprotein (LDL) lev- els (Ghosh, 2003).

Lack of insurance, low income, and limited access to care were found to have a significant impact on API’s use of health services (Coughlan & Uhler, 2000; Yu, Huang, & Singh, 2004). A Canadian study using the 2001 Community Health Survey revealed that minorities, including Filipinos, were less likely to be admitted in the hospital, tested for prostate-specific antigen (PSA), or given a mammogram or Pap test, despite the fact that they had more contact with a general practitioner than white Canadians (Quan et al., 2006). Among older Filipinas, length of residence in the United States and having had a check-up when no symptoms were present were associated with adherence to cancer screening (Maxwell, Bastani, & Warda, 2000).

Compared with white Americans, Filipinos have higher levels of depression. In contrast, strong ethnic identity characterized by sense of ethnic pride, involve- ment in ethnic practices, and cultural commitment to one’s racial and ethnic identity were significant factors in mitigating depressive symptoms among Filipino Americans (Mossakowski, 2003). Strong bonds with members of the community and access to culturally congruent health ser- vices promoted commitment of older Filipinas to planned physical activity (Maxwell, Bastani, Vida, & Warda, 2002).

Although Filipino Americans’ experiences with unfair treatment were associated with increased illness, instru- mental social support and the city of residence buffered the negative effects of these experiences (Gee et al., 2006). Among Filipina caregivers, significant correlations were found among role stress and overall health, role integration and perceived health, and role satisfaction and psychological well-being (Jones, Jaceldo, Lee, Zhang, & Meleis, 2001).

VARIATIONS IN DRUG METABOLISM

Compared with white Americans, Asians require lower doses of central nervous system depressants such as haloperidol, have a lower tolerance for alcohol, and are more sensitive to adverse effects of alcohol (Levy, 1993). Owing to the sodium-sensitive nature of hyper- tension affecting Filipinos and the high-sodium con- tent of their diet, use of diuretics should be considered. Culturally congruent stress management in addition to dietary modifications and physical activity should be included in the treatment plan to control high blood pressure.

Because of availability of over-the-counter antibiotics and lack of adequate medical monitoring of these drugs in the Philippines, Filipino immigrants may be insensi- tive to the effects of some anti-infectives. A positive reac- tion to tuberculin or the Mantoux test is observed because of the practice of giving bacille Calmette-Guérin (BCG) vaccinations in childhood. Chest x-rays and sputum cul- tures are recommended for screening and diagnosis of tuberculosis. More research is needed to determine phar- macodynamics among Filipinos, including gender differ- ences. Health-care providers need to assess Filipino clients individually when administering and monitoring med- ication effects.

High-Risk Behaviors Gender differences are evident in the Filipino tolerance and acceptance of high-risk health behaviors related to alcohol, drugs, cigarettes, and safe sex, with higher inci- dences in men than in women. More Filipino men than women are heavy drinkers. Most Filipino Americans report drinking socially, with a small number reporting having three or more drinks per day (Garde et al., 1994). Because denial is closely associated with alcoholism, the frequency and amount of alcohol taken are generally underreported.

Cigarette smoking is more prevalent among Filipino men than women. Smoking rates have been positively

PEOPLE OF FILIPINO HERITAGE • 185

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 185 Aptara Inc.

correlated with lower educational levels and income and a tendency to think or speak in a Filipino language, and for women, being born in the United States. Most Filipino youths reported living with an adult who smoked, and their first substance of choice was cigarettes, followed by alcohol and inhalants.

Filipinos constitute the largest number of reported HIV/AIDS cases among API in the United States (Reeves & Bennett, 2004). Low knowledge scores on information about HIV transmission and unprotected sex with multi- ple partners underscore the urgency of HIV and AIDS edu- cation and prevention.

HEALTH-CARE PRACTICES

Early Filipino immigrants did not seek health care in the United States until the illness was far advanced. Cultural, social, and economic factors were implicated as reasons for their underutilization of health services. Lacking the rights and privileges of naturalized citizens, early Filipino immigrants remained in poverty and felt shunned and rejected as they grew older. Typical of the ethnically underserved, older people in the United States, many were unaware of available services and were reluctant to access social and health services, particularly when cul- turally sensitive and bilingual providers were unavailable. Lack of transportation, fear of going to the area where ser- vices were located, and inappropriate program design were some of the other reasons for low utilization of ser- vices by this group. More recent Filipino immigrants dif- fer significantly from their earlier counterparts in their access and utilization of health services. This group is highly educated and accesses many of the health-care ser- vices in the United States.

A study of the experiences of Filipino women with breast screening services identified a pattern of avoidance. Factors contributing to this behavior included cultural beliefs, lack of health insurance, and lack of a familiar source of care (Wu & Bancroft, 2006). Some believe that undergoing the test and attempting to know one’s condi- tion could tempt faith, which can bring bad luck. Avoidance of an unpleasant diagnosis and concealment of serious illnesses are consequent behaviors of this belief. Many Filipinos seek a familiar and consistent health prac- titioner who has established a relationship with them. Gender-congruent practitioners are preferred for condi- tions specific to women’s or men’s health. Preference for culturally congruent services and practitioners and the presence of supportive social connections increased par- ticipation and commitment among older Filipinas for health promotion (Maxwell et al., 2002).

Older Filipinos generally reside in the household of their adult children. Adult children are responsible for the welfare of their own family and aging parents. Older people’s access to health services is influenced by the availability of their adult children who are depended upon to provide transportation, facilitate communica- tion between them and the practitioner, and negotiate with health-care practitioners. Filipino women find the competing demands of caregiving for their children, spouses, and older people as barriers to seeking early screening services.

Family support and caring are central to Filipino health practices. Family members take an active role in health promotion and care during illness. Health beliefs and practices are learned from adults and older family members as well as the community. Whereas Filipinos have high regard for health-care practitioners, advice from family members and trusted friends is also heeded. Adherence to recommended interventions is assured by family commitment and presence of a supportive social network that can draw the individual into action.

Nutrition MEANING OF FOOD

To the Filipino, food is more than nourishment for the body; it is a fundamental form of socialization. Food and meal patterns are integral to the cultural emphasis on generosity, hospitality, and thoughtfulness that support group cohesiveness. No social gathering of Filipinos occurs without food. Food is offered as a token of grati- tude and caring, to welcome others, to celebrate accom- plishments and important events, to offer support in times of sickness or crisis, and to reinforce social bonds in everyday interactions. Younger family members are socialized into the closeness of the extended family, the community, and family values. Sharing food with others, or at the very least inviting others to share one’s food, is expected of Filipinos and considered a sign of good upbringing. The insider versus outsider context influ- ences the choice of food offered (Enriquez, 1994). Outsiders are served Westernized foods, whereas insiders are served native cuisines.

In the Philippines, traditional Filipino meals are labor intensive, requiring participation of several family mem- bers. Meats are costly, so small amounts are cut in pieces and expanded using vegetables and starches to feed an entire family. It is common to offer refreshments and bev- erages or to invite guests to join in the family’s meals. All family members, regardless of age, attend social gather- ings at which a variety of dishes are prepared to accom- modate individual choices. The hosting family serves large amounts of food to accommodate invited guests and those who happen to be around. Guests customarily linger for several meals as the focus is on the gathering. Late-comers are welcomed and expected to fully partici- pate in the entire meal and the company of other guests. Dishes are served all at once from appetizers to desserts so guests are free to eat their courses without waiting for everyone to arrive. Guests are encouraged to return to the table to join arriving guests. Individual servings are not customary as everyone is expected to partake in what is available. More food means more portions for each one and vice versa.

COMMON FOODS AND FOOD RITUALS

Indigenous Filipino cooking is characterized by simplic- ity of methods such as boiling, steaming, roasting, broil- ing, marinating, or sour-stewing to preserve the fresh and natural taste of food. Spanish, Chinese, and American

186 • CHAPTER 10

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 186 Aptara Inc.

influences are integrated into contemporary Filipino cui- sine. Foods may be sautéed, fried, or served with a sauce. Because of the tropical climate of the Philippines, many types of plants and animals flourish. Seafood (fish and shellfish) forms the bulk of the Filipino diet. Fresh, dried, and marinated fish are abundant in the diet.

In the Philippines, animal sources of protein are chicken and pork because cows and water buffalo are pri- marily used for farming. Because protein-rich foods are costly, meals generally consists of larger portions of car- bohydrates, primarily rice. Plants are the second most important food source and include a variety of seaweeds, edible roots, delicate leaves, tendrils, tropical fruits, seeds, and some flowers. Fruits and vegetables are consumed in large quantities in a variety of ways. Rice is a staple food and is eaten at every meal, either steamed, fried, or as a dessert. Less-acculturated Filipinos tend to prepare and serve more traditional Filipino foods at home (De la Cruz, Padilla, & Agustin, 2000). Filipino and Asian food stores are abundant in regions where many API reside.

Except for babies and young children, milk is almost absent in the Filipino diet. This may be partly due to lac- tose intolerance. However, milk in desserts such as egg custard (flan) and ice cream seems to be tolerated. In the Filipino food pyramid, milk and dairy products are incor- porated in the major protein groups rather than as a sep- arate category. Dietary calcium is derived from green leafy vegetables and seafood.

Regional variations in food preparation and use of spices exist in Filipino American households today. Nutrition counseling should take into account these vari- ations when a Filipino needs to alter dietary patterns because of hypertension, diabetes, or other health prob- lems. For instance, coconut milk is a common cooking additive among the Bicolanos of southern Luzon. Salty (soy sauce, fish sauce/patis, salted shrimp fry, or fer- mented fish/bagoong) and spicy sauces known as saw- sawan complement meals. These sauces are distinct from the salt added during cooking.

In the Philippines, breakfast consists of rice, meat or fish and vegetable dishes or dinner leftovers. The break- fast beverage may be coffee, chocolate, or juice. In urban areas, Western-style meals are more common. For many Filipinos, breakfast, lunch, and dinner are not complete without steamed or fried rice served with fish, meat (espe- cially pork), and vegetables. Snacks of bananas, yams, rice cake, and rice-flour cake are served as midday snacks, between meals, and before bedtime. The midday meal is the heaviest meal of the day, although this pattern is becoming more difficult among urban dwellers who can- not go home during lunchtime. Filipinos drink water with meals independently or in addition to another bev- erage of juice, soda, tea, or coffee.

DIETARY PRACTICES FOR HEALTH PROMOTION

Filipinos believe health is maintained by moderation. Although Filipinos enjoy food and love to eat, they adhere to the wisdom that too much of a good thing can be harm- ful. In some parts of the Philippines, it is considered polite to leave food on one’s plate. For many Filipino Americans, moderation in food intake is a special challenge because of

the abundance and great variety of quality products at reasonable costs. Significant increases in weight patterns among new immigrants are associated with changes in dietary.

The principle of hot and cold is observed by many tra- ditional Filipinos to promote health. A warm beverage is served first at breakfast after a long evening fast, and hot soups are served as the first course to enhance digestion. Cold drinks may be avoided when one has a cold or fever to restore balance and promote harmony between the body and its environment. Eating rice is considered to be essential to a healthy life. Arroz caldo, chicken and rice soup, is generally offered to promote recovery after an ill- ness. Chicken soup with malunggay leaves is believed to cleanse the blood.

Garlic and onions are believed to thin the blood and combat hypertension. Ginger root is boiled and served as a beverage to relieve sore throats and promote digestion. Guava shoots are eaten to treat diarrhea. Drinking coconut juice and water from boiled fresh corn silk pro- motes diuresis. Bitter melon is eaten as a vegetable to pre- vent diabetes. Greens such as malunggay and ampalaya leaves are used in stews to regain stamina for someone believed to be anemic or run down.

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

In the Philippines, nutrition is greatly affected by socioe- conomic factors. Malnutrition persists in the country, especially among the poor and less educated, and is one of the leading causes of infant mortality. In the United States, Filipino immigrants may be at risk for nutritional deficiencies during their adjustment period, especially when they come with limited resources and without a support network of family and friends. Postmenopausal and pregnant women may be vulnerable to calcium defi- ciency owing to lactose intolerance and decreased intake of seafood and green leafy vegetables that were plentiful in the Philippines but limited in availability and variety in American food stores. Changing food patterns and lifestyle is associated with migration and acculturation. Filipino Americans experience similar problems such as obesity, hyperlipidemia, and diabetes seen in the general population. Knowledge of indigenous food sources and meal patterns, nutritional content of foods, changes in nutritional patterns, and accessibility of traditional ingre- dients is important for nutritional assessment and coun- seling.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

The Roman Catholic Church and Filipino family values significantly influence childbearing and fertility practices. In marriage, the only acceptable method of contraception is the rhythm method. Abortion is considered a sin and is generally not acceptable. Whereas these beliefs remain

PEOPLE OF FILIPINO HERITAGE • 187

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 187 Aptara Inc.

strong among many Filipinos, education, global commu- nication, and modernization are causing changes, partic- ularly in metropolitan cities such as Manila. Recent Filipino immigrants who come from large urban areas are more educated and less committed to the Church’s posi- tion on birth control and premarital sex. Between 1990 and 1997, fertility rates in the Philippines declined from 4.1 to 3.7, partly because of increased contraceptive use among married women. Although female sterilization rates remain stable, use of the contraceptive pill has risen. However, there are high rates of discontinuation of con- traceptive methods ranging from 14 percent (intrauterine device) to 60 percent (condoms) (National Statistics Office, Philippines, 2005).

Filipino culture is child-centered, and abortion evokes strong reactions, even among liberal Filipinos. Though some may support the right to abortion, they may have difficulty having one themselves and feel guilty for con- sidering this option. Pregnancy is considered normal and is a time when a woman can demand attention and pam- pering from her husband and family members. Health- care providers who do not understand this special period for the pregnant Filipino woman may feel that the client is “lazy and spoiled.” Pregnancy and childbirth are times for the family to draw closer together. Everyone assists in anticipation of the new baby, especially the pregnant woman’s mother, who has a strong influence during this period. For mother and daughter, this is a special event in which the bond between them becomes closer.

In the Filipino American community, women openly give advice to pregnant women, share their own birthing experiences, and ask personal questions that may be con- sidered rather intrusive by outsiders. Elaborate baby showers are hosted by family members and friends, and it is customary to invite male spouses, relatives, and friends as well as children. Male guests do not join in the activi- ties and congregate separately from the women.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Filipino practices surrounding pregnancy are influenced by indigenous beliefs, Western practices, and socioeco- nomic factors. In the Philippines, although most moth- ers (86 percent) receive prenatal care from a doctor, nurse, or midwife, tetanus toxoid immunization is declining. As two-thirds of births are delivered at home, only 56 percent receive assistance at delivery from a doc- tor, nurse, or midwife and 41 percent are assisted by tra- ditional birth attendants (hilots). Local hilots employ massage and are consulted for physical, spiritual, and psychological advice and guidance (National Statistics Office, Philippines, 2005).

After childbirth, the new mother continues to be pam- pered. Relatives help with the new baby and in running the household. Eighty-eight percent of Filipino babies are breastfed for some time, with a median duration of 13 months. However, supplementation of breastfeeding with other liquids and foods occurs too early, with 19 percent of newborns less than 2 months of age receiving supple- mental foods or liquids other than water (National Statistics Office, Philippines, 2005). Lactating mothers are

encouraged to take plenty of hot soups (chicken with papaya) to promote milk production (Hawaii Community College, 2005).

Some Filipino American women refuse to take vita- mins during pregnancy for fear that these could deform the fetus. Some believe that when pregnant women crave certain foods, especially during the first trimester, the craving should be satisfied to avoid harm to the baby. Some women continue to believe that the baby takes on the appearance of the craved food. Thus, if the mother craves dark-skinned fruit or dark-colored food, the infant’s skin will be dark. Pregnant women are protected from sudden fright or stress because of the belief that this may harm the developing fetus. Table 10–1 provides a summary of traditional beliefs and practices observed among some Filipinos in Hawaii. Becoming aware of the pregnant Filipino woman’s network of family and com- munity health advisers, whose opinions she respects, is important for building trust and rapport in the client- provider relationship.

Some women prefer to have their mothers rather than their husbands in the delivery room. Mothers of pregnant women serve as coaches and teachers and are often respected over health-care professionals for their experi- ence and knowledge. This may be puzzling to profession- als who view pregnancy as an emancipating event. Conflicts are likely to occur if the coach and teacher believe in practices that are contrary to Western child- bearing practices.

During postpartum, exposure to cold is avoided. Showers are prohibited because these may cause an imbal- ance and predispose illness. However, the mother is given a sponge bath with aromatic oils and herbs, or a hilot gives an aromatic herbal steam bath followed by full body massage, including the abdominal muscles, stimulating a physiological reaction that has both physical and psycho- logical benefits.

Childbirth experiences of Filipino women immigrants in a hospital in Australia revealed language and commu- nication problems as barriers to seeking antenatal care, perceived discrimination by the hospital staff, and con- flicting expectations of delivery practices between the mothers and the practitioners. The women preferred to be examined by female practitioners and assume a squatting position for birthing. Contrary to their birthing practices, practitioners expected the husbands to be with them dur- ing delivery. The women felt that they were not consulted about their care and preferred to deliver at home (Asian Pacific Islander Maternity Coalition, 2001).

Death Rituals DEATH RITUALS AND EXPECTATIONS

In the Filipino culture, death is a spiritual event. Illness and death may be attributed to supernatural and magi- coreligious causes such as punishment from God, angry spirits, or sorcery. Religiosity and fatalism contribute to stoicism in the face of pain or distress as a way of accept- ing one’s fate (Lipson & Dibble, 2005). Planning for one’s death is taboo and may be considered tempting fate.

188 • CHAPTER 10

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 188 Aptara Inc.

Hence, many traditional Filipinos are averse to discussing advance directives or living wills (Pacquiao, 2001). When death is imminent, contacting a priest is important if the family is Catholic. Religious medallions, rosary beads, scapulars, and religious figures may be found on the patient or at the bedside. Family members generally wish to provide the most intimate care to the patient.

After death, a wake is planned. In the Philippines, the wake may last 3 days or longer to allow time for relatives to arrive from distant places. In the United States, the wake is much shorter because it is costly. Although a wake is generally held in the home in the rural regions, funeral parlors are used in urban areas and in the United States. Families and friends gather to give support and recall the special traits of the deceased. Food is provided to all guests throughout the wake and after the burial.

The burial rites are consistent with the religious tradi- tions of the family, which may be Judeo-Christian, Muslim, Buddhist, or other religions. Among Catholics, 9 days of novenas are held in the home or in the church. These special prayers ask God’s blessing for the deceased. Depending upon the economic resources of the family, food and refreshments are served after each prayer day. Sometimes, the last day of the novena takes on the atmos- phere of a fiesta or a celebration. Filipino families in the United States follow variations of this ritual according to their social and economic circumstances. Funerals in the Philippines can be simple or elaborate, with a band accompaniment, several priests officiating, and a large throng of mourners. Reciprocal obligation continues in death through the performance of rituals such as the wake, novenas, and establishing a burial site acceptable for the entire family.

On the 1-year anniversary of death, family and friends are reunited in prayer to celebrate this memo- rable event. Most Filipino women wear black clothing for months or up to a year after the death of a spouse or close family member. The 1-year anniversary ends the ritual mourning. Before this period, family members postpone weddings and other celebrations in deference to the memory of the deceased. Memories and love for the deceased are shown on All Soul’s Day, a Catholic feast day celebrated in November, when families visit and decorate the graves of their loved ones. Filipino American families may continue these traditions, partic- ularly when strong kinship is present and the clan lives in close proximity. Many who die in the United States are buried in the Philippines, and the family in that country continues the tradition.

Beliefs related to cremation vary according to individ- ual preference. Ordinarily, bodies are buried, but crema- tion is acceptable to avoid the spread of disease and limit the high costs of burial plots. In America, some Filipinos who wish to return their deceased family members to the Philippines may choose cremation for practical and eco- nomic reasons.

RESPONSES TO DEATH AND GRIEF

Most Filipinos believe in life after death. Caring for the spiritual needs of the dying is one way of ensuring peace- ful rest of the soul or one’s spirit. Family presence around the dying and immediate period after death to pray for the soul of the departed is considered a priority. If the patient is Catholic, the priest anoints the patient and gives Holy Communion if the patient is able to participate. Caring is

PEOPLE OF FILIPINO HERITAGE • 189

T A B L E 10.1 Traditional Filipino Beliefs and Practices Surrounding Pregnancy and Childbirth

Prenatal Postpartum

Eating blackberries will make the baby have black spots. Use warm water to drink and bathe for a month. Eating black plums will give the baby dark skin. Don’t name the baby before it is born. Eating twin bananas will result in twin births. Don’t name the baby after a dead person. Eating apples will give the baby red lips. Give money to charity or the needy when a baby comes to your

house the first time. When a woman’s stomach is not round, the baby will be a boy. Eating sour or ice-cold foods may cause abdominal cramps. If a woman’s face is blemished, the baby will be a boy. Wrap the baby’s abdomen with a cloth until the umbilical cord

falls off. Going outside during a lunar eclipse is harmful to the baby. The mother and baby should not go out for a month except to

visit a doctor. Going out in the morning dew is bad for the baby because Putting garlic, salt, or a rosary near the baby’s crib will keep evil

evil spirits are present. spirits away. Funerals are avoided because the spirit of the dead person

may affect the baby. Wearing necklaces may cause the umbilical cord to wrap

around the baby’s neck. Sitting by a doorway will make the delivery difficult. Sitting by a window when it is dark may let evil spirits

come to the pregnant woman. Sweeping at night may sweep away the good spirits. Knitting might tangle the baby’s intestines at birth.

Source: Adapted from http://www.hawcc.Hawaii.edu/nursing/RN/Filipino, 2005

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 189 Aptara Inc.

shown by providing a peaceful environment, speaking in low tones, and praying with the ill person.

After death, grief reaction varies. Women generally show emotions openly by crying, fainting, or wailing. Men are expected to be more stoic and grieve silently. Young children are admonished for behaving inappropri- ately because this is considered disrespectful to the deceased. Family members gather together and provide physical and emotional support for each other. Praying for the deceased and following the implicit guidelines of behavior during mourning are ways of demonstrating grief appropriately. Wearing black or subdued colors (gray, white, navy, brown), avoiding parties and playing loud, distracting music, postponing weddings, or devoting time to one’s studies to honor the dead are some of the accept- able ways of expressing grief. Honoring the memory of the deceased is a continuing obligation among close kin.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

The Philippines is the only predominantly Christian country in the Far East. In 2000, Roman Catholics accounted for 80.9 percent of the total population. Other religious groups include Muslims (5 percent), other Christians (4.5 percent), Evangelicals (2.8 percent), Iglesia ni Kristo (2.3 percent), Aglipay (2 percent), and others (2.5 percent) (CIA, 2007). The spread of the fundamental- ist movement within Roman Catholicism is becoming more evident. Christianity in the Philippines is a blend of Spanish Catholicism, American Christianity, and surviv- ing indigenous animistic traditions (Fig. 10–4).

Although Filipinos seek medical care, they believe that part of the efficacy of a cure is in God’s hands or by some mystical power. Novenas and prayers are often said on behalf of the sick person. Families may bring religious items such as rosaries, medals, scapulars, and talismans for the sick person to wear. Talismans and amulets are believed to protect one from the forces of darkness, one’s enemies, and sickness. Performance of religious obliga- tions and sacraments and daily prayers are some of the

ways many Filipinos believe health and peaceful death are achieved. Providing for spiritual needs of Filipino clients requires accommodation to their various ways of practicing beliefs.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

Filipinos consider a meaningful existence to be a healthy and appropriate relationship with nature, God, and kin. Indigenous Filipino beliefs are embedded in the relationship between humans within the cosmology of the universe. This concept is demonstrated by the integration of supernatural, magicoreligious, and nat- ural phenomena in the belief system and practices toward health and illness. Filipinos do not see them- selves as victims, but rather as part of the larger cosmos, subject to both the controllable and the uncontrollable forces of nature. To the traditional Filipino, strength comes from an intimate relationship with God, family, friends, neighbors, and nature. The concept of self is formed from the relationship with a divine being and the social collective.

Many Filipinos find religion a source of strength in their daily lives. Some Filipinos are considered fatalistic in that they tend to accept fate easily, especially when they feel they cannot change a situation. Moreover, the accep- tance of fate or destiny comes from their close relation- ship and healthy respect for nature. The acceptance of events they cannot change is tied to their religious faith. A common expression uttered by Filipinos is bahala na, originating from bathala na (it is up to God). Bahala na is often used when the person has used all resources to deal with a problem, and it is up to a higher power to take care of the rest (Enriquez, 1994). Nevertheless, an element of self-reliance exists among Filipinos, manifested by their confidence that the situation is within their sphere of influence through education and hard work.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Holism and integration characterize Filipino health-care beliefs and practices. Religious and spiritual dimensions are important components in health promotion. Belief in harmony between humans and nature and the role of natural and supernatural forces in health and illness are found in their beliefs about causes of illness and healing modalities. Prayers, religious offerings, appeasing nat- ural spirits, and witchcraft may be practiced simultane- ously along with biomedical interventions. Despite increasing notoriety and scandal associated with Filipino faith healers, this healing modality is widely sought in the Philippines. Many Filipinos seek biomed- ical and integrative ways of healing and do not subscribe to the competitive reductionism of the West. They believe in the synergistic relationship of differing modalities and have no problem subscribing to both ways of healing. Many Filipino American health-care professionals participate in religious pilgrimages to Lourdes, France, and the shrine of Fatima in Portugal to pray for good health and healing.

190 • CHAPTER 10

FIGURE 10–4 Filipino folk dance depicting indigenous Muslim and Malayan influences.

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 190 Aptara Inc.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

Filipinos seek out family and close kin first for help when they are ill. When illness is more defined, mobilization of support occurs within the family. Decisions about when, where, and from whom to seek help are largely influenced by the intimate circle of family. Among Filipino older people in the United States, the choice of practitioners is based on accessibility and availability to their working adult children (Pacquiao, 1993). Linguistically and ethni- cally congruent practitioners are preferred. A dual system of personal health care exists for many Filipinos, includ- ing those who are established in American communities. Filipinos may accept and adhere to medical recommenda- tions and may use alternative sources of care suggested by trusted friends and family members. Often, they adhere to Western and indigenous medicine simultaneously, cre- ating more choices to deal with their own or their family’s health issues.

Many Filipinos consult an informal network of friends and family members who may be physicians, nurses, pharmacists, or neighbors who have had similar symp- toms. Once the person finds the brand name of the “effec- tive” medicine, the person can easily purchase the drug by asking family or friends to purchase medication in the Philippines. Hoarding prescription drugs and sharing medicine may be practiced by Filipinos in the United States. Those who do not believe in wastefulness or who believe that office visits are expensive may practice these behaviors.

When educating Filipino clients about medication, health-care professionals should stress that medications need to be taken as prescribed; medications are ordered specifically for each ailment; unused drugs should be dis- carded; and the use of medications by individuals other than the intended patient may have serious conse- quences. Assessing these behaviors and delivering the message in a respectful, courteous, and unhurried manner may enhance the client-provider relationship, especially for traditional Filipino clients.

Health-care practices stress balance and moderation for the Filipino. Health is the result of balance, and illness is the consequence of imbalance. Imbalances that threaten health are brought about by personal irresponsi- bility or immorality. Care of the body through adequate sleep, rest, nutrition, and exercise is essential for health. A high value is also placed on personal cleanliness. Keeping oneself clean and free of unpleasant body odors is viewed as essential to health and social acceptance. To be slovenly and disorderly is to be shamelessly irresponsible. Aromatic baths are taken both for pleasure and to restore balance.

V I G N E T T E 1 0 . 2

Alfonso Trinidad, aged 66 years, and his wife Carmen, aged 60 years, moved to the United States to babysit for their young grandchildren. They are devout Catholics. For several years,

they lived in the home of their son and daughter-in-law to be near their grandchildren. Once the grandchildren were grown, they moved to the one-bedroom apartment of their youngest daughter, Tessie, who is single.

Recently, Alfonso has been complaining to his wife about persistent low back pain. He also told her that he noted red- dish streaks in his stool. He told his wife not to tell Tessie so as not to worry her. He also did not wish to encumber his daugh- ter, who had to take a second job when they moved in with her. He finally requested his daughter to take him to a local Filipino faith healer, who administered several enemas with boiled onions. After a few weeks, the pain increased and Tessie noted that her father was losing weight. She insisted on taking him to the hospital for a checkup. After a diagnosis of colon cancer, Alfonso was operated on immediately. Tessie and her brother have been paying for his surgery, as neither Alfonso nor his wife has medical insurance.

1. What Filipino cultural values predisposed Alfonso’s professional help–seeking behavior?

2. Describe the Filipino family kinship system and the roles of older parents and adult children.

3. Identify potential problems of the family and recom- mend culturally congruent interventions.

RESPONSIBILITY FOR HEALTH CARE

Parents may seek all possible assistance that they can per- sonally generate from family, friends, the church, the community, and the formal health-care system (often in that order) for a child with a serious illness such as cancer, eventually accepting the inevitability of death. From a Western perspective, the outcome may be slightly differ- ent than if formal services were accessed as early as possi- ble. Adult children, especially those working in the United States, are responsible for the health care of their aged parents and extended kin. Responsibility may be in different forms such as decision making, accepting finan- cial responsibility, providing supportive presence, per- forming caretaking tasks, or negotiating with the health- care practitioner and the system.

In general, older adult women provide direct care for younger members. Older men participate in caring tasks such as driving the patient to the clinic. Decisions and financial support are relegated to family members who are deemed qualified and able. The family acts as a unit, and the individualistic paradigm commonly used by American caregivers is replaced by a social ethic of care. Before the decision is made to inform the patient about his or her terminal condition, a discussion among family members occurs, and they may request the doctor not divulge the truth to protect the patient. The ethical prin- ciples of beneficence and nonmaleficence take prece- dence over patient autonomy (Pacquiao, 2003).

Filipino family hierarchy may require consulting with family members before decisions are made. This may pose a problem to Western practitioners who believe in the adult patients’ autonomy to make decisions about their own lives. The same perspective of Filipinos may result in their inability to question and assert ideas with physi- cians, who are regarded to be in a higher position of

PEOPLE OF FILIPINO HERITAGE • 191

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 191 Aptara Inc.

authority. Major decisions may be delegated to the physi- cian rather than the patient or family taking an active col- laborative role in decision making. Failure to develop a trusting relationship with the practitioner can lead to noncompliance with prescribed regimens because of lack of participation in the decision-making process.

FOLK AND TRADITIONAL PRACTICES

Supernatural and magicoreligious beliefs about health and illness are integrated with scientific medicine. Mental illness may be attributed to an external cause such as witchcraft, soul loss, or spirit intrusion. Illness in infancy and childhood may be attributed to the evil eye. This belief system is consistent with the variety of Filipino folk healers. Healing rituals may involve religious rites (prayers and exorcism), sacrifices to appease the spirits, use of herbs, and massage.

Balance and moderation are embedded in the hot-and- cold theory of healing. The ideal environment is warm, moderate, and balanced. The underlying principle is that change should be introduced gradually. Sudden changes from hot to cold, from activity to inactivity, from fasting to overeating, and so forth, introduce undue bodily stresses, which can cause illness. After strenuous physical activity, a rest should precede a shower; otherwise, the person could develop arthritis. Cold drinks or foods such as orange juice or fresh tomatoes are not served for break- fast to prevent stomach upset. Exposure to sudden cold drafts may induce colds, fever, rheumatism, pneumonia, or other respiratory ailments. Some Filipinos in the United States avoid handwashing with cold water after

ironing or heavy labor. Exposure to cold such as showers is avoided during menstruation and the postpartum period.

The Department of Health in the Philippines (2005), through its Traditional Health Program, has endorsed ten herbs that have been thoroughly tested and clinically proven to have medicinal value in the relief and treat- ment of various ailments (Table 10–2). The Philippine government has encouraged production of these herbal medicines to provide affordable medicines for the popu- lations who have limited or no access to Western health care. Widespread acceptance of these herbal medicines is evident among educated and higher-income groups.

BARRIERS TO HEALTH CARE

Studies of Filipinos in the United States show that, for many reasons, Filipinos generally do not seek care for ill- ness until it is quite advanced. Some take minor ailments stoically and consider them natural imbalances that will run their normal course and disappear. Others claim to watch the progress of their illness so that the appropriate health-care provider can be consulted. Still others may not seek help because of economic reasons, lack of insur- ance, distrust of the health-care system, religious reasons, lack of knowledge, or an inability to articulate their needs (McBride et al., 1995).

Some Filipinos may not have a primary health-care provider and may rely on emergency services instead. Many Filipinos are reluctant to participate in health- promotion programs such as cancer screening and health education. Aging Filipino veterans may be

192 • CHAPTER 10

T A B L E 10.2 Herbal Medicines Approved by the Department of Health in the Philippines

Filipino Name/Generic Name English Name Uses

Akapulko (Cassia alata) Ringworm bush Ringworms and skin fungal infections “bayas-bayasan” Ampalaya (Momordica charantia) Bitter gourd or bitter melon Non–insulin-dependent diabetes Bawang (Allium sativum) Garlic Cholesterol reduction

Blood pressure control Bayabas (Psidium guajava) Guava Antiseptic to disinfect wounds

Mouthwash to treat tooth decay and gum infection

Lagundi (Vitex negundo) Five-leaf chaste tree Relief of coughs and asthma Niyog-niyogan (Quisqualis indica) Chinese honeysuckle Dried matured seeds to eliminate intestinal

worms, particularly Ascaris and Trichina Sambong (Blumea balsamifera) Blumea camphora Diuretic, helps in the excretion of urinary

stones and treatment of edema Tsaang gubat (Ehretia microphylla lam) Taken as tea; used in treating intestinal

motility and as a mouthwash because leaves have a high fluoride content

Ulasimang bato (Pepperomia pellucida) Arthritis and gout; may be prepared as tea or “pansit-pansitan” eaten as a salad Yerba buena (Clinopodium douglasii) Peppermint Analgesic to relieve body aches and pain; may

be taken internally or applied locally

Source: Adapted from Department of Health. (2005). Ten herbal medicines approved by the DOH.

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 192 Aptara Inc.

denied health services because of lack of insurance and consequently referred to various nonprofit community clinics. Older Filipino émigrés did not have adequate health benefits through their place of employment. Thus, they may have been used to postponing seeking care until the illness was quite advanced. In contrast, recent immigrants have health insurance and behave differently, seeking preventive medical services regu- larly (Garde et al., 1994).

Health-care providers should expect wide variations in health behaviors among Filipino American clients. A nonjudgmental history taking should be well docu- mented. Turning on the “multicultural ear” and listening with care to the context of these actions can provide insight for practitioners, particularly when the practi- tioner is under time pressure.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

Filipinos view pain as part of living an honorable life. Some view this as an opportunity to reach a fuller spiri- tual life or to atone for past transgressions. Thus, they may appear stoic and tolerate a high degree of pain. Health-care providers may need to offer and, in fact, encourage pain relief interventions for clients who do not complain of pain despite physiological indicators. Others may have a strong sensitivity to the “busyness” of health- care providers, quietly diminishing their own need for attention so that others can receive care, or they may sim- ply have little knowledge of how pain management can be maximized.

Minimal expression of psychological and emotional discomfort may be observed. The discomfort in discussing negative emotions with outsiders may be manifested by somatic complaints or ritualistic behaviors, such as pray- ing. Exploring the underlying meaning of somatization (loss of appetite, inability to sleep) and observing the client’s interactions with others can provide valuable information. Filipino clients may display visible evidence of their religion such as religious medals, prayer cards, and rosary beads to manage anxiety and pain. These arti- facts should be incorporated into their treatment regi- men. Using cultural mediators or brokers to probe inner- most feelings of patients may be helpful if used appropriately. Pain assessment can include the role of prayer by the patient and members of the support net- work. Questions such as “Do you have someone praying for you?” or “Is there a special prayer to help you deal with pain?” may provide vital information for individual- izing care.

Most Filipinos believe that mental illness carries a cer- tain amount of stigma, and some believe that it is hered- itary. Family members tend to take care of emotional problems to minimize exposing the problem to outsiders. Among rural residents and less-educated Filipinos in the Philippines, mental illness is generally attributed to external causes such as sorcery, soul loss, or spirit intru- sion. Witch doctors, fortunetellers, and faith healers are often sought. Filipinos in the United States seek profes- sional interventions when symptoms are advanced. Psychiatric symptoms are precipitated by a loss in self- esteem, loss of status, and shame related to the stresses of

immigration. Separation from family, inability to find suitable employment, uncertainty, lack of money, and other relocation stressors create serious psychological reactions among Filipinos. Talking to a trusted family member or friend, undergoing psychotherapy, staying involved, participating in support and prayer groups, maintaining employment, and taking medication are the preferred treatments.

Using sociocultural behaviors learned early in life, Filipinos have a remarkable ability to maintain a proper front to protect their self-esteem and self-image. However, this front may be fragile, and chronic repression of resent- ment and anger may build up and erupt violently. Mental health providers should recognize that despite the possi- bility of a Filipino client’s refusing professional mental health services, involving a trusted family member or friends, initiating contact with a Filipino mental health worker, especially a Filipino physician, or using both practices may increase the odds of getting the person into a culturally compatible treatment program. Deference to authority may successfully bring the Filipino client into treatment, with the client’s expectation that the authority figure will fix the problem. A family therapy framework can have a more beneficial outcome.

The birth of a child with a developmental disability may be viewed as God’s gift, an opportunity to become a better person or family, a curse from some unknown “angry spirit,” negligence while pregnant, or a family matter that should be kept private. Health-seeking behav- iors are conditioned by the perceived cause. American- born Filipinos may be more inclined to accept rehabilita- tion services through a homecare program than through institutional placement, such as special schools and long- term care facilities.

The cultural value of reciprocal obligation and the fam- ily as the main support exaggerate the burden of caring for a chronically ill family member. Institutionalization may not be readily accepted, causing considerable strains on the family relationships and resources. Self-sacrifice is believed to be virtuous and rewarded spiritually and in future life. Verbalization of caretaking hardships may not be tolerated and may cause guilt feelings on the individual caregiver. Practitioners should be sensitive to the needs of the family caregiver and work with the family unit in find- ing alternative ways of providing care for the chronically ill members. Reluctance to join support groups composed of outsiders and non-Filipinos can be offset by involving other family members or friends.

BLOOD TRANSFUSIONS AND ORGAN DONATION

The value of blood transfusion is recognized and accepted by Filipinos. However, organ donation may be less accept- able, except perhaps in cases in which a close family member is involved. Many Filipinos who follow Catholic traditions believe that keeping the body intact as much as possible until death is a reasonable preparation for the afterlife. Asian Americans, including Filipinos, hold more negative attitudes toward organ donation. They are less likely to participate in large, urban organ donor program (Alden & Cheung, 2000).

PEOPLE OF FILIPINO HERITAGE • 193

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 193 Aptara Inc.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

Western medicine is familiar and acceptable to most Filipinos. Many recent Filipino immigrants are educated in the health-care field. Some Filipinos accept the effi- cacy of folk medicine and may consult both Western- trained and indigenous healers. Traditional healers are sought more in the rural areas of the Philippines. Folk healers are less common in the United States, with the exceptions of the West Coast and Hawaii. When avail- able, they contribute by facilitating cultural rapport between health-care providers and the client and by increasing utilization of needed health-care services. For example, the hilot is often willing to be included in the counseling session and provide support for the patient’s compliance with the medical treatment. The hilot may provide a special prayer to be incorporated into the med- ically prescribed treatment plan to increase the client’s sense that all available resources are being used. In some areas on the West Coast, the hilot has a distinct role and function in the Filipino community. A few Filipino health professionals have learned the hilot’s art, skills, and spiritual approach, which they blend into their pro- fessional practice.

A practitioner of the same gender and the same culture may encourage more Filipinos to take advantage of dis- ease prevention services. The availability of Filipino pri- mary-care providers and, whenever possible, a bilingual person are critical to improving health care for older Filipinos.

STATUS OF HEALTH-CARE PROVIDERS

Filipinos generally consider the physician as the primary leader of the health-care team, and other providers are expected to defer to the physician. As Filipino families become more acculturated and aware of how health-care services are accessed in the United States, changes in atti- tude and behavior may be expected.

When ill, Filipinos may first consult a family member or a friend who is a physician or other professional before arranging a medical appointment. Some prefer physicians from their own region, when possible, whereas others indicate preference for physicians who are knowledgeable and competent and have good bedside manners regard- less of culture or ethnic background. Factors considered in choosing health-care providers by middle-aged immi- grant Filipino women were concern for privacy, feelings of modesty, approval from family members (especially the spouse), and most important, the overall caring environ- ment in the system.

Interactions of Filipinos with Canadian nurses in the hospital reflected their kapwa-oriented worldview, which categorized nursing approaches and interactions within the insider-outsider continuum. Sensitivity of nurses to patient’s verbal and nonverbal cues allowed them to move toward a more intimate status as insiders, hindi ibang tao. Patients based their preferences for which nurses to perform their personal and private tasks or

receive information on the nurses’ ability to provide spontaneous and unsolicited care and monitoring of their condition. Organizational policies and protocols, in addi- tion to short hospital stays, were identified as barriers toward moving the patient-nurse relationship toward higher intimacy and trust (Pasco et al., 2004).

V I G N E T T E 1 0 . 3

Jenny Dorn, aged 26 years, has been the primary nurse for 55- year-old Nicanor Abaca, who is hospitalized with a possible myocardial infarction. Jenny welcomes the opportunity to care for Nicanor because he is “not demanding, easy to please, grateful, and enjoys their conversations.” After Jenny returned from her day off, she was told by her nurse manager that Nicanor’s daughter stated that her father does not want Jenny to be assigned to him anymore. The daughter did not share any explanation with the nurse manager.

1. What precipitated the conflict? 2. How would you describe Nicanor’s attempt to deal

with the conflict? 3. How should the nurse manager handle the conflict? 4. How should the nurse deal with the conflict?

REFERENCES

Abe-Kim, J., Gong, F., & Takeuchi, D. (2004). Religiosity, spirituality, and help-seeking among Filipino Americans: Religious clergy or mental health professionals? Journal of Community Psychology, 32, 675–689.

Agoncillo, T., & Guerrero, M. (1987). History of the Filipino people (7th ed.). Manila, Philippines: Garcia Publishing.

Alden, D. L., & Cheung, A. H. S. (2000). Organ donation and culture: A comparison of Asian American and European American beliefs, atti- tudes, and behaviors. Journal of Applied Social Psychology, 30(2), 293–314.

Anderson, J. N. (1983). Health and illness in Pilipino immigrants. Western Journal of Medicine, 139(6), 811–819.

Araneta, M. R. G., & Barrett-Connor, E. (2005). Ethnic differences in vis- ceral adipose tissue and type 2 diabetes: Filipino, African-American, and White women. Obesity Research, 13, 1458–1465.

Asian Pacific Islander Maternity Coalition. (2001). Retrieved March 3, 2007, from http://www.maternitycoalition.org.au

Bautista, V. (2002). The Filipino Americans (1763–Present): Their history, cul- ture, and tradition (2nd ed.). Naperville, IL: Bookhaus.

Brown, D. E., & James, G. D. (2000). Physiological stress responses in Filipino-American immigrant nurses: The effects of residence time, life-style, and job strain. Psychosomatic Medicine, 62, 394–400.

Ceniza-Choy, C. (2003). Empire of care: Nursing migration in Filipino American history. Durham, NC: Duke University Press.

CIA. (2007). World FactBook: Philippines. Retrieved March 1, 2007, from https://www.cia.gov/cia/publications/factbook/geos/rp.html#People

Coughlan, S. S., & Uhler, R. J. (2000). Breast and cervical cancer screening practices among Asian and Pacific Islander women in the US, 1994–1997. Cancer Epidemiology Biomarkers and Prevention, 9, 597–603.

De la Cruz, F. A., Padilla, G. V., & Agustin, E. O. (2000). Adapting a mea- sure of acculturation for cross-cultural research. Journal of Transcultural Nursing, 11(3), 191–198.

Department of Health. (2005). Ten herbal medicines approved by the DOH. Retrieved February 27, 2007, from http://herbal-medicine. philsite.net/doh_herbs.htm 2005

Enriquez, V. G. (1994). From colonial to liberation psychology: The Philippine experience. Manila, Philippines: De La Salle University Press.

Espiritu, Y. L. (2003). Homebound: Filipino American lives across cultures, communities and countries. Ewing, NJ: University of California Press.

Garde, P., Spangler, Z., & Miranda, B. (1994). Filipino-Americans in New Jersey: A health study. Final Report of the Philippine Nurses’ Association of America to the State of New Jersey Department of Health, Office of Minority Health.

194 • CHAPTER 10

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 194 Aptara Inc.

Gee, G. C., Chen, J., Spencer, M. S., See, S., Kuester, O. A., Tran, D., et al. (2006). Social support as a buffer for perceived unfair treatment among Filipino Americans: Differences between San Francisco and Honolulu. American Journal of Public Health, 96(4), 677–684.

Ghosh, C. (2003). Healthy People 2010 and Asian Americans/Pacific Islanders: Defining a baseline of information. American Journal of Public Health, 93(12), 2093–2098.

Gong, F., Gage, S.-J. L., & Tacata, L.A., Jr., (2003). Helpseeking behavior among Filipino Americans: A cultural analysis of face and language. Journal of Community Psychology, 31(5), 469–488.

Hawaii Community College. (2005). Traditional Filipino health beliefs. Retrieved February 27, 2007, from http://www.hawcc.hawaii.edu/ nursing/tradfil2.htm

IBON Foundation. (2007). Retrieved September 14, 2007, from http://www. ibon.org

Jones, P. S., Jaceldo, K. B., Lee, J. R., Zhang, X. E., & Meleis, A. I. (2001). Role of integration and perceived health in Asian American women caregivers. Research in Nursing and Health, 24(2), 133–144.

Kagawa-Singer, M., & Pourat, N. (2000). Asian American and Pacific Islander breast and cervical carcinoma screening rates and Healthy People 2000 objectives. Cancer, 89(3), 696–705.

Levy, R. (1993). Ethnic and racial differences in response to medicines: Preserving individualized therapy in managed pharmaceutical pro- grammes. Pharmaceutical Medicine, 7, 139–165.

Lim, S., Clarke, C. A., Prehn, A. W., Glaser, S. L., West, D. W., & O’Malley, C. D. (2002). Survival differences among Asian subpopulations in the United States after prostate, colorectal, breast, and cervical carcino- mas. Cancer, 94(4), 1175–1182.

Lipson, J. G., & Dibble, S. L. (2005). Culture and clinical care. San Francisco: University of California San Francisco Nursing Press.

Maxwell, A. E., Bastani, R., Vida, P., & Warda, U. S. (2002). Physical activ- ity among older Filipino-American women. Women Health, 36(1), 67–79.

Maxwell, A. E., Bastani, R., & Warda, U. S. (2000). Demographic predictors of cancer screening among Filipino and Korean immigrants in the United States. American Journal of Preventive Medicine, 36(1), 67–68.

McBride, M., Mariola, D., & Yeo, G. (1995). Aging and health: Asian Pacific Islander American elders. Stanford, CA: Stanford Geriatric Education Center.

McBride, M., & Parreno, H. (1996). Filipino American families and care- giving. In G. Yeo & D. Gallagher-Thompson (Eds.), Ethnicity and the dementias. Washington, DC: Taylor & Francis.

Mossakowski, K. N. (2003). Coping with perceived discrimination: Does ethnic identity protect mental health? Journal of Health and Social Behavior, 44(3), 318–331.

National Statistics Office, Philippines (2005). Index of demographic and health. Retrieved February 27, 2007, from http://www.census.gov.ph/ data/sectordata/datandhs.html

Pacquiao, D. F. (1993). Cultural influences in old age: An ethnographic comparison of Anglo and Filipino elders. Doctoral dissertation,

Graduate School of Education, Rutgers University, New Brunswick, NJ. Ann Arbor, MI: University Microfilms, Inc. (number 9320788).

Pacquiao, D. F. (1996). Educating faculty in the concept of educational biculturalism: A comparative study of sociocultural influences in nurs- ing students’ experience in school. In V. M. Fitzsimons & M. L. Kelley (Eds.), The culture of learning: Access, retention, understanding and mobil- ity of minority students in nursing (pp. 129–162). New York: National League for Nursing Press.

Pacquiao, D. F. (2001). Cultural incongruities of advance directives. Bioethics Forum, 17(1), 27–31.

Pacquiao, D. F. (2003). Cultural competence in ethical decision-making. In M. M. Andrews & J. S. Boyle (Eds.), Transcultural concepts in nursing care (4th ed., pp. 503–532). Philadelphia: Lippincott.

Pacquiao, D. F. (2004). Recruitment of Philippine nurses to the US: Implications for policy development. Nursing and Health Policy Review, 3(2), 167–180.

Pasco, A. C. Y., Morse, J. M., & Olson, J. K. (2004). Cross-cultural relation- ships between nurses and Filipino Canadian patients. Journal of Nursing Scholarship, 36(3), 239–246.

Quan, H., Fong, A., De Coster, C., Wang, J., Musto, R., Noseworthy, T. W., et al. (2006). Variation in health services utilization among ethnic populations. CMAJ: Canadian Medical Association Journal, 174(6), 787–791.

Reeves, T. J., & Bennett, C. E. (2004). We the people: Asians in the US. Census 2000 Special reports. Washington, DC: U.S. Deptartment of Commerce.

Salazar, L. P., Schuldermann, S. M., Schuldermann, E. H., & Hunyh, C. (2000). The Filipino adolescents’ parental socialization for academic achievement in the United States. Journal of Adolescent Research, 15(5), 564–587.

Spangler, Z. (1992). Transcultural nursing care values and caregiving prac- tices of Philippine-American nurses. Journal of Transcultural Nursing, 4(2), 28–37.

Tatak Pilipino. (2003). Profile of the Philippines. Retrieved February 26, 2007, from http://www.filipinoheritage.com

U.S. Bureau of the Census. (2002). The Asian Population: 2000. Retrieved March 2, 2007, from http://www.census.gov/prod/2002pubs/c2kbr01- 16.pdf

Wolf, D. L. (1997). Family secrets: Transnational struggles among children of Filipino immigrants. Sociological Perspectives, 40(3), 457–483.

Wu, T.-Y., & Bancroft, J. (2006). Filipino American women’s perceptions and experiences with breast cancer screening. Oncology Nursing Forum, 33(4), 1–11.

Yamane, L. (2002). Native-Born Filipina/o Americans and labor market dis- crimination. Feminist Economics, 8(2), 125–144.

Yu, S. M., Huang, Z. J., & Singh, G. K. (2004). Health status and health ser- vices utilization among US Chinese, Asian Indian, Filipino, and other Asian/Pacific Islander children. Pediatrics, 113(1), 101–107.

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

PEOPLE OF FILIPINO HERITAGE • 195

FABK017-C10[175-195].qxd 12/12/2007 10:40am Page 195 Aptara Inc.