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People of Haitian Heritage

Chapter 13

JESSIE M. COLIN and GHISLAINE PAPERWALLA

Overview, Inhabited Localities, and Topography OVERVIEW

Haiti, located on the island of Hispaniola between Cuba and Puerto Rico in the Caribbean, shares the island with the Dominican Republic. With a population of 8.5 mil- lion inhabitants, Haiti covers an area of 27,750 square kilometers (10,714 square miles), about the size of the state of Maryland. The capital and largest city, Port-au- Prince, has a population of over 800,000. The per capita annual income is $450, with a daily wage rate of $3 (World Bank Annual Report, 2006). Widespread unem- ployment and underemployment exist; more than two- thirds of the labor force do not have formal jobs owing to the marked decrease in assembly sector jobs, plummeting from a high of 80,000 in 1986 to 17,000 in 2006. About 80 percent of the population lives under the poverty line, with 57.4 percent living in abject poverty. The yearly inflation rate has fallen from 42.7 percent in 2003 to 15 percent in April of 2006. Nearly 70 percent of all Haitians depend on the agricultural sector, mainly small-scale sub- sistence farming, and remain vulnerable to damage from frequent natural disasters, exacerbated by the country’s widespread deforestation. The infant mortality rate is high with 95.23 deaths per 1000 live births, the average life expectancy is 53 years, and only 13 percent of the people have access to potable water (CIA, 2006).

Columbus landed on the island in 1492 and named it Hispaniola, which means Little Spain. Haiti, or Ayti, mean- ing “land of mountain,” was given its name by the first inhabitants, the Arawak and the Caribe Indians. Before 1492, there were five well-organized kingdoms: the

Magua, the Marien, the Xaragua, the Managua, and the Higuey (Dorestant, 1998). Two-thirds of Haiti contains mountains, great valleys, and extensive plateaus; small plains mark the rest of the country.

The Haitian population in the United States is not well documented; this may be because of the U.S. Bureau of the Census’s failure to track the large numbers of undocu- mented immigrants. According to the 2000 census, 548,199 Haitians live in the United States. An additional 122,000 live in Canada, of which 90 percent live in Quebec (Statistics Canada, 2006). In 2001, 7,200 immigrants from Haiti were living in Canada for 5 years or less. However, Haitian leaders and activists believe that close to 1.5 million Haitians live in the United States: 500,000 in New York; 150,000 each in Boston and Chicago; 100,000 in California; and the rest scattered throughout the United States (H. Frank, personal communication, December 2006). An esti- mated 267,689 documented Haitians live in Florida. However, if the undocumented population is included, this number may be as high as 400,000 (Elliot, 2001).

Haitians, like other ethnic groups, are very diverse. They come from urban and rural Haiti and represent all socioeconomic classes. Factors affecting Haitians’ accul- turation and assimilation include the primary and sec- ondary characteristics of culture (see Chapter 1).

HERITAGE AND RESIDENCE

Before the time of Columbus, the various indigenous tribal groups intermarried. With the arrival of Europeans, and then Africans, the people of Haiti became more diverse. Today, Haitians range from light- to dark- skinned, and social identity is shaped by sharp class strat- ification and color consciousness.

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In 1697, Haiti came under French rule. By the end of the 18th century, the slave population numbered 500,000. In 1791, a slave insurrection broke the chain of slavery, and on January 1, 1804, Haiti gained its inde- pendence from France. The French plantation owners were removed and replaced by the generals of the indige- nous Haitian Army, which ruled mercilessly (Louis-Juste, 1995). Agricultural workers and peasants were trapped in a semifeudal system: They were exploited by landowners, terrorized by the section chiefs of police, and forced to obey laws explicitly. The coffee fields of the peasants served as the primary source of revenue for the govern- ment coffers, thereby guaranteeing all government debt payments between 1826 and 1932 (Louis-Juste, 1995). These harsh conditions did not prevent the peasants from rising up against injustice and exploitation, as evi- denced by the Goman uprising in 1820, the Acaau in 1880, and the peasant movement of Jean Rabel (Louis- Juste, 1995).

Haitian immigrants have a sense of national pride, including a high level of self-esteem regarding their black- ness, although in both public and private discourse, they may focus on color and class division—two painful wedges within Haitian society.

Haiti’s independence from France in 1804 did not resolve the division among the descendants of French colonists, the African slaves, and the core of the popula- tion, who were largely of African descent and culture. Many members of the upper class used the markers of mulatto (color), the French culture, and the French lan- guage to differentiate themselves from the lower class, who were mostly black and Creole and spoke a predomi- nantly African language.

Ti Manno, a Haitian singer who migrated to New York, used satire and irony to expose and deride the type of thinking that divides Haitians in Haiti and abroad. The following song depicts the turmoil and struggle that pro- mote the division within the Haitian society (Jean- Baptiste, 1985):

The Black Man

Neg Kwens dil pa Kanmarad neg Brooklyn. Neg Potopwens dil pa anafe ak neg pwovens. Mon Che se-m nan fe yon ti pitit. M’rayi ti pitit la A fos li led. Li nwa tankou bombon siwo. Nen-l pa pwenti. Ti neg mwe ala nou pa gen chans o. La vi nou toujou red o. Nou deyo, pi red. Se neg nwe cont milat o. Nou deyo nap soufri. Nou lakay se pi red.

Haitians in Queens feel superior to those who live in Brooklyn.

Haitians in Port-au-Prince despise those who live in the provinces.

My dear, my sister had a little baby. I hate this little kid. This baby is ugly. He is as dark as sugarcane syrup cake. His nose is not pointy.

We Haitians, we are so unlucky. Life is always hard for us. Away from home we suffer more. It’s black against mulatto. Abroad we suffer. At home it is even worse.

Despite independence, colonial prejudices about skin color have persisted. Internal social rivalries and the scale of Haitian mobility are tied to a European color, race, and class model. This model relates to skin pigmentation, hair texture, the shape of the nose, and the thickness of the lips. Whereas the structure of Haitian society continues to be built on a neocolonial model, relationships based on color are extremely complex. For example, dark skin color tends to be associated with underprivileged status. Although more black-skinned people have entered the circle of the privileged, most blacks are poor, underprivi- leged, and unemployed.

Haiti defines itself as a black nation. Therefore, all Haitians are members of the black race. In Haiti, the con- cept of color differs from the concept of race. The Haitian system has been described as one in which there are no tight racial categories, but in which skin color and other phenotypic demarcations are significant variables.

In the 1940s, a black middle class emerged in Haiti and claimed to represent the majority. The development of this class and its rhetoric served as a springboard for Francois Duvalier, a rural physician who was elected president for a 4-year term in 1957. In 1964, he became president-for-life, using the issue of black empowerment and a promise to eliminate the color and class privileges of the mulattos. By the late 1970s, a group of dark- skinned, primarily American-educated and English- speaking technocrats had attained positions of promi- nence and influence in the government. However, the mulatto retained social prominence, and color contin- ued to play a major role in the perception of class in Haiti.

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Haitian immigration and travel to the United States have continued for many years. Most, but not all, of those who emigrated were members of the upper class. Before 1920, Haitians traveled to North America and Europe only for educational purposes. In 1920, the United States occupied Haiti; the first wave of Haitian migration to North America soon followed. Over the next decade, more than 40,000 Haitian peasants were forced to go to Cuba and the Dominican Republic to cut sugarcane in the bateys (plantations). Haitian land was taken and used for apple and banana plantations, and many acres of land through- out Haiti were controlled by the United States. The atroc- ities that accompanied the American occupation resulted in a small group of Haitians leaving Haiti and settling in the Harlem section of New York City, where they assimi- lated into American society.

The late 1950s showed signs of weakness in Haitian agriculture. The peasants started leaving the provinces in search of work and a better life. Migrating to the capital,

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Port-au-Prince, they established Lasalin, the first slum of Port-au-Prince (Aristide, 1995). Today, approximately 1.5 million people live in and around the capital (Regan, 1995), many in large slums such as Cite Soley, Lasalin, Karidad, Dedye, Delwi, and Fo Mekredi.

A significant turning point in Haitian migration occurred in 1964 when Duvalier was elected president- for-life. As a result of his government, many Haitians began fleeing the island. These emigrants were primarily relatives of politicians who opposed the political philoso- phy of Duvalier. When Duvalier died in 1971, his son, Jean Claude, age 19, was appointed president-for-life. In addition, during this era, Haiti was suffering from eco- nomic deprivation, which motivated a major exodus of urbanites and peasants. Because many Haitians were unable to pay for their transportation, passports, and visas, some covertly emigrated to the United States in small sailboats.

From 1980 to the present, Haitian immigrants have been divided into two groups: those who have arrived in the United States legally and those who have entered through the underground. An explosion of immigration took place in 1980, in part because of a short-lived (April to October) change in U.S. immigration policy during the period of the Mariel boat lift from Cuba. The influx of Cuban refugees required that a special status be created by the State Department called “Cuban-Haitian entrant: sta- tus pending.” According to Health and Rehabilitation Services, Haitian refugees were included in this status to prevent the policy from being discriminatory. This group of immigrants were labeled boat people, a term associ- ated with extreme poverty. Today, this term does not evoke as much negativism, although it continues as a reminder of a painful emigration period in Haitian history.

From 1990s to the present, political unrest, coups, and protests occurred. The tides of history were changing, Jean-Bertrand Aristide was elected in the first democrati- cally held election in many years. The democratic process did not last; in that same year, a coup d’état on Aristide and a hemisphere-wide embargo was imposed on Haiti. In 2001, Aristide was re-elected in a flawed election. In February 2004, an armed rebellion led to the departure of President Jean-Betrand Aristide; an interim government took office to organize new elections under the auspices of the United Nations Stabilization Mission in Haiti (MINUSTAH). Continued violence and technical delays prompted repeated postponements, but Haiti finally did inaugurate a democratically elected president, Rene Preval, and parliament in May of 2006. The Prime Minister, Jacques-Edouard Alexis, is appointed by the president and ratified by the National Assembly to serve a 5-year term, with new elections in 2010.

In Haiti, most major industries are owned and oper- ated by the government. Unemployment is 66 percent. Those who are employed often work under such poor conditions that they have become unmotivated and take little pride in their work, which results in low productiv- ity. In general, Haitians are entrepreneurial, operating their own shops, marketplaces, or schools. Among these entrepreneurs, the motivation, spirit, and pride in their work are readily apparent.

EDUCATIONAL STATUS AND OCCUPATIONS

Following Haiti’s independence in 1804, the new rulers of Haiti began advocating French cultural patterns and repli- cating the French value system. A French model of educa- tion was informally adopted and codified in 1860, in accord with the Roman Catholic Church. This resulted in two major changes: The Catholic Church became the offi- cial church of Haiti, and Catholic missionaries became responsible for education. The accepted language for communication was now French. During this era, Creole, the language of the uneducated, was perceived as inferior. Social mobility was possible only for French- speaking Haitians. While the educated elite became accul- turated into the European value system, the illiterate masses tended to perpetuate the traditional values and customs of their African heritage.

Even though Haitians value education, only 15 percent are privileged enough to attain a formal education. In the past, the government appropriated only 1.8 percent of the total budget for education. The Haitian school system is based on the French model and offers free primary and secondary education. Public schools include those oper- ated and controlled by religious orders as well as those under the direct jurisdiction of the Minister of Education. Children from families with financial means attend pri- vate schools. The educational model emphasizes liberal arts and humanities rather than technical and vocational studies.

The Haitian educational system continues to empha- size 19th-century values, which promote good manners, the classics, literature, philosophy, Latin, and Greek. It de- emphasizes the physical and social sciences. The Haitian educational system is based on a two-level curriculum. In the first level, the student receives a certificate of primary education. To receive this certificate, the student must sit for a rigorous test, which includes spelling, reading com- prehension, composition, Haitian history and geography, general knowledge, arithmetic, and biology. At this level, the student can speak, read, and write French at the basic level.

The next level consists of two parts: The first is reached after 6 years of secondary education. To receive this diploma, the student must pass examinations in French, English, and Spanish; Haitian literature and history; mathematics; and sciences such as physics, chemistry, biology, and botany. Students in the classical track also take Latin and Greek examinations. A student who has received the first-level certificate should be able to enter the first year of college in American schools. The second- level baccalaureate is likened to the first year of college in North America; the emphasis is on the liberal arts. Again, the student must pass an examination in all the areas cov- ered in the first level plus philosophy. The results of these national examinations are announced on the radio over a 2-day period.

Although Haiti has several universities, they are mainly located in Port-au-Prince. Most of them are state universities. With proper credentials, anyone can enter the university system. However, since the early 1980s, only those in positions of influence have been able to benefit from the state universities. Haitian professionals

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mirror those of American society; they are lawyers, physi- cians, nurses, engineers, educators, electricians, plumbers, and construction workers.

The literacy rate, which means that those age 15 and over can read and write, is 52.8 percent. The level of illit- eracy continues to be a major concern in Haiti. Since 1940, the government has conducted several literacy pro- grams. In 1948, Haiti had its first experience with com- munity education. This public educational system was based on the growth model of development, a UNESCO education project, which duplicated experiences in Latin America (Jean-Bernard, 1983).

Among Haitian immigrants, women work in hotels, hospitals, and other service industries in domestic and nursing assistant roles. Men work as laborers and factory helpers. Many more Haitians are in the workforce today than there were in the early 1980s, although data for the years 1974 and 1994 from the U.S. Immigration and Naturalization Service (2006) revealed that a dispropor- tionate number of legal Haitians were not employed. In addition, when comparing data by specific groups, a dra- matic increase in the number of Haitians in all work envi- ronments is found. Data about the work structure of undocumented people are not available because these people technically are “underground” and do not exist.

Communication DOMINANT LANGUAGE AND DIALECTS

The two official languages in Haiti are French and Creole. Creole, a rich, expressive language, is spoken by 100 per- cent of the population, whereas French is spoken by 15 percent of the population. Since 1957, Creole has been the unofficially accepted language in the internal affairs of the Haitian government, and in 1987, it was designated in the Haitian Constitution as one of the official lan- guages. Because Creole is the official language, it is used for internal communication within the island.

In contemporary society, the Haitian dilemma can best be understood through this dual-language system. Language is one of the vehicles used to depersonalize those of the lower classes. French is the dominant lan- guage of the educated and the elite, whereas Creole is the language of those who are suppressed, the lower classes. The emphasis on French served as a barrier to the early social dynamism that permitted Creole to develop and serve as a unifying force among the African slaves, who came from many different tribes and spoke differ- ent languages. In spite of its suppression in formal edu- cation, Creole has inspired a very rich and interesting oral literature comprising songs, proverbs, and tales. This oral literature is the most significant aspect of Haitian folklore.

Understanding the language dilemma and the literacy issues assists health-care practitioners in developing cre- ative tools for educating Haitians. Some of these tools may include video programs, audiocassettes, and radio programs in Creole. Because of the masses of people who are unable to read, printed literature in Creole is not a helpful educational tool.

CULTURAL COMMUNICATION PATTERNS

Haiti has an oral culture with a long tradition of proverbs, jokes, and stories reflecting philosophical systems. These are used to pass on knowledge, convey messages, and communicate emotions. For example, Pale franse pa di lespri pou sa means “To speak French does not mean you are smart.” Crayon Bon Die pa gin gum (“God’s pencil has no eraser”) conveys the concept of fatalism. Another proverb frequently used is sonje lapli ki leve mayi ou (“remember the rain that made your corn grow”), which means that one must show gratitude to those who have helped them or done good for them.

Haitians are very expressive with their emotions. By observing them, one can tell whether they are happy, sad, or angry. Haitians’ communication patterns include loud, animated speech and touching in the form of handshakes and taps on the shoulder to define or reconfirm social and emotional relationships. Pain and sorrow are very obvi- ous in facial expressions. Most Haitians are very affec- tionate, polite, and shy. Uneducated Haitians generally hide their lack of knowledge to non-Haitians by keeping to themselves, avoiding conflict, and sometimes, project- ing a timid air or attitude. They smile frequently and often respond in this manner when interacting with Americans or when they do not understand what is being said. Many may pretend to understand by nodding; this sign of approval is given to hide their limitations. Therefore, health-care providers must use simple and clear instructions. One strategy to ensure proper under- standing is to ask family members to assist with transla- tion and interpretation if an interpreter is not available. Because Haitians are very private, especially in health matters, it is inappropriate to share information through friends. Many may prefer to use professional interpreters who will give an accurate interpretation of their concerns. Most importantly, the translator should be someone with whom they have no relationship and will likely never see again.

Voice intonations convey emotions. Haitians speak loudly even in casual conversation among friends and family; the pitch is moderated in formal encounters. When the conversation is really animated, the conver- sants speak in close proximity and ignore territorial space, especially when emphasizing a point or an issue. Sometimes, the conversation is at such a high pitch and speed that, to an outsider, the conversation may appear disorganized or angry. Haitians love political discussions. In these instances, the conversation may appear stressful and hostile; however, to the participants, the conversa- tion is enjoyable, motivating, and meaningful.

Traditional Haitians generally do not maintain eye contact when speaking with those in a position of author- ity. In the past, maintaining direct eye contact was con- sidered rude and insolent, especially when speaking with superiors (e.g., children speaking with parents, students with teachers, or employees with supervisors). However, the influence of American education seems to be chang- ing this trend. Most adults maintain eye contact, which means “We are on equal terms, no matter who you are. I respect you and you respect me as an equal human being.” For children, however, the custom of not maintaining eye

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contact with superiors remains deferential. Thus, health- care providers may need to assist children in dealing with conflicting messages.

Haitians touch frequently when speaking with friends. They may touch you to make you aware that they are speaking to you. Whereas Haitian women occasionally walk hand-in-hand as an expression of their friendship, this trend is disappearing both in Haiti and in Haitian communities in North America. This behavior may be changing because of the concept of homosexuality, which is taboo within the Haitian culture.

Haitians greet each other by kissing and embracing in informal situations. In formal encounters, they shake hands and appear composed and stern. Men usually do not kiss women unless they are old friends or relatives. Children greet everyone by kissing them on the cheek. Children refer to adult friends as uncle or auntie out of respect, not necessarily because they are related by blood.

TEMPORAL RELATIONSHIPS

The temporal orientation of Haitians is a balance among the past, the present, and the future. The past is impor- tant because it lays the historical foundation from which one must learn. The present is cherished and savored. The future is predetermined, and God is the only Supreme Being who can redirect it. One hears Bondye Bon (“God is good”), meaning if you conduct yourself conservatively and the right way, God will be there for you. The future is left up to God, who is trusted to do the right thing. In a study by Prudent, Johnson, Carroll, & Culpepper (2005), several of the informants voiced their belief in God’s will when talking about whether or not they would survive being HIV positive and/or having AIDS.

Haitians have a fatalistic but serene view of life. Some believe that destiny or spiritual forces are in control of life events such as health and death, so they say, Si Bondye Vle (“If God wants”). Given the belief in a predetermined path of life, one can understand this view. Haitians believe that they are passive recipients of God’s decisions. Health-care practitioners must be clear, honest, and open when assessing Haitian individuals’ perceptions and how they perceive the forces that have an influence over life, health, and illness. Acceptance of these beliefs is an important factor in building trust and ensuring compli- ance.

Most Haitians do not respect clock time; flexibility with time is the norm, and punctuality is not valued. They hold to a relativistic view of time, and although they try, some find it difficult to respond to predetermined appointments. Arriving late for appointments, even med- ical appointments, is not considered impolite. In North America, Haitians may be more readily compliant with business appointments; but socially, the margin around expected time is very wide—anything or anyone can wait. It is not unusual to see an invitation to a social function listed with an invitation time an hour earlier than the actual time of the function. For example, a wedding invi- tation may reflect a 6:00 p.m. wedding when, in fact, the ceremony is actually scheduled for 7:00 p.m. to ensure that all invitees are there for the start of the ceremony.

Health-care practitioners should be mindful of this time orientation by making reminder calls for appointments and encouraging the client in a respectful and caring manner about the importance of timeliness. A thorough assessment of time and temporal view helps practitioners to plan appointments so that clinic or office backlogs and disruptions are minimized.

FORMAT FOR NAMES

Haitians generally have a first, middle, and last name: for example, Marie Maude Guinard. Sometimes the first two names are hyphenated as in Marie-Maude. The family name, or nom de famille, is very important in middle- and upper-class society; it helps to promote and communicate tradition and prestige. However, friends call individuals by their first names. Families usually have an affectionate name or nickname for individuals. The father, mother, grandparent, or any close family member gives this affec- tionate name at birth.

When a woman marries, she takes on her husband’s full name. For example, if Marie-Carmel Guillaume mar- ries Charles Guy Lespinasse she is always called Mrs. Lespinasse. In an informal setting, she might even be called Mrs. Charles. She loses her name except on paper. Her name and identity are subsumed by her husband’s name. This is a reflection of Haitian society in which women are considered subservient to men. Haitian names are primarily of French origin, although many Arabic names are now heard since the migration of Arabs to Haiti in the 1920s. Haitians are formal and respectful and, as such, should be addressed by their title: Mr., Mrs., Miss, Ms., or Doctor.

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

Traditionally, the head of the household was the man, but in reality, most families today are matriarchal. Haitian men prefer and choose to believe that they make the deci- sions, but most major decisions are made by the wife and/or mother, with the man remaining a distant figure with a great deal of authority. Today, joint decisions are common. The man is generally considered the primary income provider for the family, and governance, rules, and daily decision-making are considered his province. Sociopolitical and economic life centers around men. Men are expected to be sexual initiators, and the concept of machismo prevails in Haitian life. Women are expected to be faithful, honest, and respectable. Men are usually permitted freedom of social interaction, a freedom not afforded to women. The opportunities offered in North America for women to become income providers, together with their observations of different male-female interactional styles, have encouraged many Haitian women to reject their native, subservient role. This change in the marital interaction has created much stress on marital relationships and an increase in domestic vio- lence, although domestic violence remains one of those closeted issues that are not publicly discussed.

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PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES FOR CHILDREN AND ADOLESCENTS

Children are valued among Haitians because they are key to the family’s progeny, cultural beliefs, and values. Children are expected to be high achievers because Sa ki lan men ou se li ki pa ou (“What’s in your hand is what you have”). In other words, education can never be taken away. Children are expected to be obedient and respectful to parents and elders, which is their key to a successful future. They are not allowed to express anger to elders. Madichon is a term used when children are disrespect- ful; it means that their future will be marred by misfor- tune. Another proverb used to scare and compel children to behave is ti moun fwonte grandi devan baron (“an impu- dent or insolent child will grow under the Baron’s eye [Baron Samedi is the guardian of the cemetery in the voodoo religion] and therefore won’t have a long life”).

Physical punishment that is often used as a way of dis- ciplining children is sometimes considered child abuse by America’s standards. Fear of having their children taken away from them because of their methods of discipline can cause parents to withdraw or not follow through on health-care appointments if such abuse is evident (e.g., bruises or belt marks). Haitians need to be educated about American methods of discipline and laws so that they can learn new ways of disciplining their children without compromising their beliefs or violating American laws.

Many parents feel confused about how to raise their children in the United States. Their authoritarian behav- ior is challenged in American society, which they per- ceive as being too permissive. They feel powerless in understanding how to raise their children in America, while retaining Haitian traditions. The liberal American approach to child rearing poses a great dilemma for Haitian children. They find themselves living in two worlds: the American world, which allows and supports self-actualization and oneness, and the Haitian world, which promotes silence, respect, and obedience.

In the summer, Haitian parents engage their children in certain health-promotion activities such as giving them lok (a laxative), a mixture of bitter tea leaves, juice, sugarcane syrup, and oil. In addition, children are also given lavman (enemas) to ensure cleanliness. This is sup- posed to rid the bowel of impurities and refresh it, pre- vent acne, and rejuvenate the body.

Because Haitian life is centered on male figures, the education of boys is different from that of girls. The fam- ily is more indulgent of the behavioral deviations of boys. Boys are given more freedom and are even expected to receive outside initiation in social and sex- ual life. However, girls are educated toward marriage and respectability. Their relationships are closely watched. Even when they are 16 or 17 years of age, they cannot go out alone because any mishap can be a threat to the future of the girl and bring shame to her family. These beliefs increase Haitians’ frustrations and challenges of rearing their children, especially girls, in America.

Health-care practitioners need to be aware of these var- ious challenges and be prepared to assist children and family members to work through these cultural differ- ences, while conveying respect for family and cultural

beliefs. Health-care practitioners can play a significant role by helping children and their parents to better under- stand American practices.

FAMILY GOALS AND PRIORITIES

The family is a strong component of the Haitian culture. The expression “blood is thicker than water” reflects fam- ily connectedness. An important unit for decision-mak- ing is the conseil de famille, the family council. This coun- cil is generally composed of influential members of the family, including grandparents. The family structure is authoritarian and includes linear roles and responsibili- ties. Any action taken by one family member has reper- cussions for the entire family; consequently, all members share prestige and shame.

The family system among Haitians is the center of life and includes the nuclear, consanguine, and affinal rela- tives, some or all of whom may live under the same roof. Families deal with all aspects of their members’ lives, including counseling, education, crises, and marriage. Each family has its own traditions, which form the basis for a family’s reputation and are generalized to all mem- bers of the family. The prestige of a family is very impor- tant and is based on attributes such as honesty, pride, trust, social class, and history. Even families who experi- ence economic difficulties are well respected if they are from a grande famille. Wealthy families who have no his- torical background or tradition are referred to as nouveaux riche and find it difficult to marry into the more well- established grandes familles, even though they have money.

The family is an all-encompassing concept in the Haitian culture. By including family members in the care of loved ones, health-care practitioners can achieve more trusting relationships, which foster greater compliance with treatment regimens. Haitians believe that when family members are ill, there is an obligation to be there for them. If a family member is in the hospital, all fam- ily members try to visit. Many visitors may cause con- cern to health-care practitioners who are not accus- tomed to accommodating large numbers of visitors. Practitioners need to be patient with them and facilitate their visits.

When grandparents are no longer able to function independently, they move in with their children. The house is always open to relatives. Elders are highly respected and are often addressed by an affectionate title such as aunt, uncle, grandma, or grandpa, even if they are not related. Their children are expected to care for and provide for them when self-care becomes a concern. The elderly are family advisers, babysitters, historians, and consultants. Migration to America poses a tremendous challenge in caring for elderly Haitians. The nursing home concept does not exist in the Haitian culture; there- fore, Haitians are generally very reluctant to place their elderly family members in nursing homes.

ALTERNATIVE LIFESTYLES

Homosexuality is taboo in the Haitian culture, so gay and lesbian individuals usually remain closeted. If a family

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member discloses that he or she is gay, everyone keeps it quiet; there is total denial. Gay and lesbian relationships are not talked about; they remain buried. There are no gay bars in Haiti, and overt homosexual conduct is not pub- licly displayed.

Although divorce is common among Haitians, before it becomes final, family members, friends, the church, and elders try to counsel the couple. Health-care providers must approach this issue carefully and establish a trusting relationship before discussing divorce.

Single parenting, widespread in Haiti, is well accepted and closely tied to the issue of concubinage. In Haitian society, a well-accepted practice is for men to have both a wife and a mistress, with the latter relationship referred to as placage. Both women bear children. The mistress raises her children alone and with minimal support from the father. These children are often known by the man’s fam- ily, but are not known to the wife. Haitian women in gen- eral know that their husbands are involved in extramari- tal relationships but pretend not to know. Health education, birth control, and safe sex are issues that should be approached with sensitivity and acceptance within cultural boundaries.

Workforce Issues

CULTURE IN THE WORKPLACE

Haitians living in America have demonstrated a very strong motivation for work and a continued commitment to the entrepreneurial spirit. They can be found in every sector of the American workforce. They are hard workers, and many work two jobs to provide for their American family while sending money to Haiti for those left behind. In the first year of migration, they are generally forced to take lower-status and low-paying jobs. These jobs are used as stepping stones to better jobs until they are able to communicate in English and legalize their immigrant status. A literature search did not reveal offi- cial statistics, or even rough estimates, on the income dis- tribution of Haitian immigrants. Work is a necessity, and they conform to the rules and regulations of the work- place. Haitian immigrants have taken menial, low-paying jobs that many Americans would not accept even when unemployed. Haitians appreciate comfort, and they work to be able to afford the necessities of life. The economic survival of Haiti is closely tied to the financial support provided to family members in Haiti by Haitians who have migrated to the United States and Canada.

ISSUES RELATED TO AUTONOMY

In America, educated Haitians seek job opportunities in their fields. Those who have a trade try to find employ- ment in that area. Uneducated, undocumented, and illit- erate individuals experience much more difficulty in entering the job market, where employment opportuni- ties are restricted to working in places in which there is overcrowding, poor ventilation, and high pollution, all of which place them at high risk for occupational diseases.

Immigrants from various Haitian villages and cities tend to settle in clusters with their relatives or neighbors from their areas of origin. This pattern of settlement by area of origin helps immigrants adapt to the demands of their new environment and assure that they have some- one living nearby whom they can call on in time of illness or other crisis. However, when people live and work pri- marily in an ethnic enclave, the native culture becomes a barrier to assimilation and acculturation into the domi- nant society.

The educational level of health-care professionals in Haiti is different from that in America. For example, med- ical education is not research-based, and nursing pro- grams for the most part are at the diploma level with an apprenticeship. The only nursing baccalaureate program is the Faculté des Sciences Infirmiere de L’ Universite Episcopal D’Haiti (Faculty of Nursing Science of the Episcopal University of Haiti), in Leogane on the southern coast of the island. Establishing this school and adopting this name was a major accomplishment. Nursing is finally accepted on par with the medical community as well as with the other professional schools. All other professional schools start with those three words “Faculté des Sciences . . .” and continues with whatever the science is (e.g., medicine, law, engineering).

Haitian health-care professionals who migrate to the United States have experienced a great deal of difficulty in obtaining licensure to practice. Those who learned their

PEOPLE OF HAITIAN HERITAGE • 237

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

Mrs. Solange Perard, a 42-year-old Haitian, migrated to the United States 15 years ago. She lives with her two daughters, ages 16 and 17, in a two-bedroom apartment in North Miami, Florida, in a predominantly Haitian community. They feel supported by and secure with their Haitian neighbors. Mrs. Perard takes comfort in knowing that her neighbors share her culture and beliefs.

Mrs. Perard is a Haitian graduate diploma nurse who ini- tially worked in the pharmacy department as a courier for a local hospital. As her English improved, she transferred to a Patient Care Technician position in the oncology unit. Mrs. Perard speaks Creole and English but prefers to speak Creole with her coworkers. She also works for a home health agency on her days off and weekends in order to send money to her mother in Haiti. Mrs. Perard has attempted unsuccessfully to pass the NCLEX-RN twice. Owing to her multiple jobs, she is unable to dedicate the necessary time to her studies. Her coworkers praise her hard work and for being a supportive coworker.

1. Is Mrs. Perard’s acculturation hindered because she lives in a Haitian-predominant neighborhood? Why? Why not?

2. Describe the differences between the Haitian nursing educational system and the nursing educational sys- tem in the United States.

3. Is it common for Haitian workers to socialize with other Haitian coworkers in Creole? Do you feel that this is done to upset members of other cultures?

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profession in Haiti were taught in French and the test-tak- ing approach is different; multiple-choice examinations are a new and difficult concept for Haitians.

Haitian nurses are very skilled clinically; however, sometimes, they may experience difficulty in applying theoretical knowledge to practice. This may be due in part to language barriers and their diploma education, which focuses on tasks and skills development. Haitian profes- sionals struggle with professional cohesiveness and colle- giality. Many groups have established professional soci- eties whose goals are to support each other, to promote professional development, and to promote collegial rela- tionships. Some examples of these professional groups are the Haitian Nurses Association, the Haitian-American Medical Association, the Haitian Educator Association, the Haitian-American Engineers, and the Haitian-American Lawyers.

Sometimes, Haitians in the workplace greet each other in their native tongue because it is easier to articulate ideas and feelings and to express support in their native language. This may be irritating to non-Haitians who consider it rude.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Different assessment techniques are required when assess- ing dark-skinned people for anemia and jaundice. One must examine the sclera, oral mucosa, conjunctiva, lips, nailbeds, palms of the hands, and soles of the feet when assessing for cyanosis and low blood hemoglobin levels. To assess for jaundice, one must examine the conjunctiva and oral mucosa for patches of bilirubin pigment because dark skin has natural underlying tones of red and yellow.

DISEASES AND HEALTH CONDITIONS

Because Haiti is a tropical island, prevalent diseases include cholera, parasitosis, and malaria. Haiti has no mosquito control, so newer immigrants should be assessed for signs of malaria such as chills, fever, fatigue, and an enlarged spleen. Other diseases of increased incidence among Haitian immigrants are hepatitis, tuberculosis, HIV/AIDS, venereal diseases, and parasitosis from inadequate potable water sources in their homeland. Actual tuberculosis rates for Haitians are misleading because, until a few years ago, Haitians living in Haiti were routinely vaccinated with Bacille bilié de Calmette-Guérin, thus making all subsequent skin tests positive, even though they may not actually have had the disease. Unfortunately, upon immigration, many Haitians continue to live in overcrowded areas, are mal- nourished, and live in very poor sanitary conditions, fac- tors that increase their risk for infectious diseases.

Haitians are prone to diabetes and hypertension—a reflection of genetics and their diet, which is high in fat, cholesterol, and salt. Data on the prevalence of diabetes and hypertension among Haitian Americans are difficult to assess because they are categorized as black. In addition to type 1 and type 2 diabetes, there is a type 3 malnutrition- related diabetes, also known as tropical diabetes. The preva- lence ranges from 2 to 8 percent, accounting for different parts of the island (Pan American Health Organization, 2001). In addition, Haitians experience a high incidence of heart disease. Cerebrovascular diseases are the third lead- ing cause of death; other cardiopathies are in fifth place, and arterial hypertension is in eleventh place. More deaths are registered among females than males. In addition to cardiovascular diseases, there is a high incidence of cancer. The National Cancer Institute statistics showed that the most frequent type of cancer treated was cervical cancer, representing 40 percent of cases. Breast cancer ranked sec- ond with 30 percent. Nasopharygeal cancer ranked in third position with 10 to 15 percent of the cases (Pan American

238 • CHAPTER 13

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

Jean-Claude Auguste, a 25-year-old with a history of attention deficit hyperactivity disorder (ADHD), has been overactive since early infancy. His parents initially attributed his behav- ior to the natural tendencies of being male. Mr. Auguste’s par- ents tried to control his behavior by corralling him in his crib, verbally disciplining him, and occasionally, spanking him. His parents realized that he had a problem when he was about 3 years of age. He was hyperactive, impulsive, and unable to follow simple directions. Throughout his preschool years, he was repeatedly suspended from school. Jean- Claude’s mother initially accepted the use of medication, but stopped it and refused to consider any other medication when side effects placed him into a “zombie-like” state that included sluggishness, difficulty sleeping, and loss of appetite. In his community, he developed a reputation for being mal élevé—a French term for “badly reared”—which in turn, reflected negatively on his parents within their extended family and community.

When his parents halted his medication, school staff regis- tered their concern with the Department of Social Services by filing a child neglect report. His parents were placed on the defensive and began to feel threatened, stating, “the focus was no longer on [their] child’s condition, but rather on [their] parental abilities.” Unable to navigate the different agencies that had become involved with their family, and believing a more disciplinary and controlled environment might help, his parents sent Jean-Claude to Haiti to live with grandparents who eventually sent him to a Haitian boarding school. Neither environment had an effect on his behavior. Two years later, he returned to live with his parents in the United States. With much difficulty, he graduated from high school but con- tinues to be hyperactive and unfocused. His parents are finally convinced that medication would be beneficial, but Jean- Claude refuses to take medications and denies his disorder.

1. Is ADHD a recognized and understood illness in the Haitian community?

2. Why were his parents not able to manage Jean-Claude? 3. Within the Haitian belief system, is ADHD considered

a natural or an unnatural illness? Why? 4. What approach might social services have taken to

assist his family?

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Health Organization, 2001). Both cancer and heart disease are related to a high-fat diet. Today, Haitians in Haiti and in the United States are very conscious of the need to limit the fat content in their diets; as a result, the Haitian diet is not as fatty as it once was.

Attention-deficit/hyperactivity disorder (ADHD) is a commonly diagnosed chronic mental condition in Haitian children (Prudent, Johnson, Carroll, & Culpepper, 2005). This disease has a large genetic component (McCann, Scheele, Ward, & Roy-Byrne, 2006). In the Haitian culture, there is no conceptual term for ADHD, nor is there a Creole term to describe it. Unfortunately, in the Haitian culture, the behavior displayed with this diagnosis may be interpreted as an ill-behaved or a “poorly raised” child or a psychically vic- timized child suffering from an “unnatural” condition. Parents may believe that this behavior can be controlled by parental discipline, or they may seek an alternative health consult such a Hougan or voodoo priest. Although medica- tions are the preferred treatment for ADHD, which may be combined with psychological intervention, Haitians are fearful of psychoactive drugs because they see them as the cause of substance abuse and even possibly mental illness (Prudent et al., 2005). Therefore, assessing the parents’ per- ceptions of the cause of the ADHD behavior and assisting them in holistic treatment are important.

VARIATIONS IN DRUG METABOLISM

The literature reveals no studies on drug metabolism specific to Haitians or Haitian Americans. When Haitians are included in drug studies, it is assumed that they are included under the category of African American. Therefore, health- care providers may need to start with the literature for this broad category of ethnicity to posit and test theories of eth- nic drug metabolism among Haitian Americans.

High-Risk Behaviors

Haitian refugees are one of the most at-risk populations living in the United States. Therefore, it is important for health-care practitioners to consider a number of factors in providing health-care services. An in-depth assessment of the person’s environmental, occupational, socioeco- nomic, demographic, educational, and linguistic status enables the development of strategies that are culturally appropriate, adequate, and effective. As a new group of immigrants, Haitians bring to the health-care system a different set of beliefs and values about health and illness. These differences challenge health-care practitioners who must try to explain treatments while acknowledging, but not changing, their clients’ cultural convictions. Attempts to change firmly held beliefs are counterproduc- tive to establishing trusting provider-client relationships.

Behaviors that may be considered high risk in American society are generally viewed as recreational or unimportant among Haitians. Alcohol, for example, plays an important part in Haitian society. Drinking alcohol is culturally approved for men and is used socially when friends gather, especially on weekends. Women drink socially and in moderation. Cigarette smoking is another high-risk behavior practiced by Haitian men, whereas Haitian women have a very low rate of tobacco use. The trend toward decreasing cigarette use in America has not influenced Haitian society. Drug abuse among Haitians used to be low; however, there seems to be an increase in drug abuse, concentrated in the adolescent population.

In 1982, Haiti became the first developing country to be blamed for the origin of AIDS. As a result, Haitians have had to endure the stigma associated with the belief that Haitians are “AIDS carriers.” Unfortunately, HIV/AIDS has continued to spread in the Haitian com- munity in Haiti and in the United States. Heterosexual transmission is the primary source mode of HIV transmis- sion in the Haitian community and is rapidly becoming a disease of women and children (Santana & Dancy, 2000). Health professionals need to recognize the impact the stigma has had on male-female relationships as well as familial relationships in the Haitian community. Health professioanls must be mindful of the impact the stigma has had on Haitians. Health professionals must broaden their scope and approaches to HIV prevention by incor- porating societal, contextual, and economic factors designed to modify traditional gender roles germane to influencing beginning negotiations of safer sex practices.

High-risk behavior in the Haitian culture includes the nonuse of seat belts and helmets when driving or riding a motorcycle or bicycle. Most cars in Haiti do not have seat belts, and there are no laws regarding the use of seat belts and helmets. Haitian cities are extremely overpopulated and traffic laws are very loose, resulting in hazardous dri- ving conditions. Everyone tries to gain the upper hand. Haitian Americans must be educated about traffic laws, seat belt use, car seats for youngsters, and the need for helmets. Health-care practitioners may have to use graphic videos or skits when instructing clients about these safety practices. Practitioners may also use Haitian radio stations for educational programs when they are available. Other strategies that may be used to help promote behavioral changes are through church and community group activities. Through these avenues,

PEOPLE OF HAITIAN HERITAGE • 239

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

The St. Fleur family is well respected in the Haitian community because they are religious with great moral values. They moved to the United States because of political issues in Haiti. Ronald, the youngest son of this family, is 27 years old and lives at home with his mother and father. Recently, he began having fevers and subsequently developed pneumonia. He was admitted to the hospital, where laboratory tests were HIV positive. Ronald was in shock when the doctor informed him that he was HIV positive. He confessed to the doctor that he was gay but he could not tell his family. He said that he did not want to bring shame to the family. Because he couldn’t be in a formal rela- tionship owing to his family and the Haitian community’s view of homosexuality, he has been very promiscuous over the years.

1. What are Haitians’ views of homosexuality? 2. If Ronald’s parents were to learn of his positive HIV

status, how might they react if they are religious and traditional?

3. Identify three major culturally congruent strategies to address in designing HIV-prevention practices in the Haitian community?

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health-care providers can have a significant impact on health promotion and health risk prevention among Haitian Americans.

HEALTH-CARE PRACTICES

To Haitians, good health is seen as the ability to achieve internal equilibrium between cho (hot) and fret (cold) (see also Nutrition and Health-Care Practices). To become bal- anced, one must eat well, give attention to personal hygiene, pray, and have good spiritual habits. To promote good health, one must be strong, have good color, be plump, and be free of pain. To maintain this state, one must eat right, sleep right, keep warm, exercise, and keep clean.

Haitians who believe in voodoo and other forms of folk medicine may use several types of folk healers. These healers include a voodoo practitioner, a docte fey (leaf doc- tor), a fam saj (lay midwife), a docte zo (bonesetter), and a pikirist (injectionist). Depending on whether the individ- ual believes that the illness is natural or unnatural, she or he may seek help other than Western medicine from one of these healers.

Nutrition MEANING OF FOOD

For many Haitians in lower socioeconomic groups, food means survival. However, food is relished as a cultural treasure and Haitians generally retain their food habits and practices after emigrating. Food practices vary little from generation to generation. Most Haitians are not culi- nary explorers. They prefer eating at home, take pride in promoting their food for their children, and discourage fast food. When hospitalized, many would rather fast than eat non-Haitian food. Haitians do not eat yogurt, cottage cheese, or “runny” egg yolk. Haitians drink a lot of water, homemade fruit juices, and cold fruity sodas.

COMMON FOODS AND FOOD RITUALS

The typical Haitian breakfast consists of bread, butter, bananas, and coffee. Children are allowed to drink coffee, which is not as strong as that consumed by adults. Generally, the largest meal for Haitians is eaten at lunch. At lunchtime, a basic Haitian meal might include rice and beans, boiled plantains, a salad made of watercress and tomatoes, and stewed vegetables and beef or cornmeal cooked as polenta. Table 13–1 lists popular foods in the Haitian community.

DIETARY PRACTICES FOR HEALTH PROMOTION

Hot and cold, acid and nonacid, and heavy and light are the major categories of contrast when discussing food. Illness is caused when the body is exposed to an imbal- ance of cold (fret) and hot (cho) factors. For example, sour- sop, a large green prickly fruit with a white pulp that is used in juice and ice cream, is considered a cold food and is avoided when a woman is menstruating. Eating white beans after childbirth is believed to induce hemorrhage. Foods that are considered heavy, such as plantain, corn- meal mush, rice, and meat, are to be eaten during the day because they provide energy. Light foods, such as hot chocolate milk, bread, and soup, are eaten for dinner because they are more easily digested. Table 13–2 presents a classification of hot and cold foods.

To treat a person by the hot-and-cold system, a potent drink or herbal medicine of the class opposite to the dis- ease is administered. Cough medicines, for example, are considered to be in the hot category, whereas laxatives are in the cold category. Certain food prohibitions are related to particular diseases and stages of the life cycle. Teenagers, for example, are advised to avoid drinking cit- rus fruit juices such as lemonade to prevent the develop- ment of acne. After performing strenuous activities or any activity that causes the body to become hot, one should not eat cold food because that will create an imbalance, causing a condition called chofret. A woman who has just

240 • CHAPTER 13

T A B L E 13.1 Popular Foods in the Haitian Community

Bouillon Soup made with beef broth mixed with various green vegetables (e.g., spinach, cabbage, watercress, string beans, carrots), meat or poultry, plantain, sweet potato, and Malaga, a sweet aromatic wine

Chiquetaille Codfish or smoked herring, unsalted, shredded finely, mixed with onions, shallots, finely chopped hot pepper, vinegar, and lime

Fritters Marinade: flour, water, eggs, parsley, onions, garlic, salt and pepper, chicken, hot pepper, and a pinch of baking soda powder, mixed together to pancake consistency and deep-fried

Acra: chopped parsley, eggs, garlic, and onion mixed with Malaga; finely shredded codfish or smoked herring and hot pepper may be added

Beignet: sweet ripe banana, sugar, and eggs, mixed with cinnamon, milk, margarine, flour, nutmeg, and vanilla extract

Green plantain Boiled or fried, usually eaten with griot Griot Marinated pork cut up in small pieces and fried Lambi Conch meat softened and prepared in a sauce Legume Vegetables such as chayote and eggplant cooked with meat Patee Pastry dough filled with choice meat, chicken, or smoked herring Pumpkin squash soup Meat or poultry mixed with vegetables and pureed cooked squash and spices Tomtom Similar to dumplings, cooked and made into round balls and eaten with beef stew and okra

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straightened her hair by using a hot comb and then opens a refrigerator may become a victim of chofret. This means she may catch a cold and/or possibly develop pneumonia.

When they are sick, Haitians like to eat pumpkin soup, bouillon, a special soup made with green vegetables, meat, plantain, dumplings, and yams. The Haitian diet is high in carbohydrates and fat. Eating right entails eating sufficient food to feel full and maintain a constant body weight, which is often higher than weight standards med- ically recommended in the United States. Men like to see “plump” women. Furthermore, weight loss is seen as one of the most important signs of illness. Additional compo- nents of what Haitians consider a healthy diet are tonics to stimulate the appetite and the use of high-calorie sup- plements such as Akasan, which is either prepared plain or made as a special drink with cream of cornmeal, evap- orated milk, cinnamon, vanilla extract, sugar, and a pinch of salt.

A thorough nutritional assessment is very important to effectively promote nutritional health. Understanding food rituals assists health-care providers in designing individualized dietary plans, which can be incorporated into the diet to facilitate compliance with dietary regi- mens that promote a healthier lifestyle.

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

Many Haitian women and children who come from rural areas have significant protein deficiencies owing to Haiti’s economic deprivation. A cultural factor contribut- ing to this problem is the uneven distribution of protein among family members. However, the problem is not one of net protein deficiency in the community but, rather, the unwise distribution of the available protein among family members. Whenever meat is served, the major portion goes to the men, under the assumption that they must be well fed to provide for the household. This same pattern exists today among Haitian immi- grants. Being aware of this cultural factor enables health- care practitioners to prepare nutritional plans that meet clients’ dietary needs.

Another major concern in this area is that of food inse- curity and short intervals between births, chronic malnu- trition, and anemia, which are widespread among Haitian women of childbearing age. These health inequalities result in a high prevalence of low birth weight, estimated

at 15 percent; anemia, ranging from 35 to 50 percent; a body mass index under 18.5 kg/m2, estimated at 18 per- cent; and a high maternal mortality rate, estimated at 456 per 100,000 live births (Pan American Health Organization, 2001).

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

Pregnancy and fertility practices are not readily discussed among Haitians. Most Haitians are Catholic and are unwilling to overtly engage in conversation about birth control or abortion. This does not mean that these two practices do not occur, but rather, that they are just not openly discussed. Abortion is viewed as a woman’s issue and is left to her and her significant other to decide. Accurate assessments and teaching related to these sensi- tive areas require tact and understanding. Initially, health-care practitioners should be cautious in assessing and gathering information related to fertility control. Pregnancy is not considered a health problem, but rather, a time of joy for the entire family. Pregnancy does not relieve a woman from her work. Because pregnancy is not a disease, many Haitian women do not seek prenatal care. Pregnant women are restricted from eating spices that may irritate the fetus. However, they are permitted to eat vegetables and red fruits because these are believed to improve the fetus’s blood. They are encouraged to eat large quantities of food because they are eating for two. Pregnant women who experience increased salivation may rid themselves of the excess at places that may seem inappropriate. They may even carry a “spit” cup in order to rid themselves of the excess saliva. They are not embar- rassed by this behavior because they feel it is perfectly normal.

Fifty percent of women living in Port-au-Prince give birth in a hospital, compared with 31 percent of births in other urban areas, and only 9 percent of births in rural areas. The leading causes of maternal deaths are obstructed labor (8.3 percent), toxemia (16.7 percent), and hemorrhage (8.3 percent). The high maternal mortal- ity rate is mainly the result of inadequate prenatal care (Pan American Health Organization, 2001).

PEOPLE OF HAITIAN HERITAGE • 241

T A B L E 13.2 Haitian Hot and Cold Food Classification

Very Cold (!3) Quite Cold (!2) Cool (!1) Neutral (0) Warm (") Very Hot ("2)

Avocado Banana Tomato Cabbage Eggs Rum Cashew nuts Grapefruit Cane syrup Conch Pigeon Nutmeg Mango Lime Orange Carrot Soup Garlic Coconut Okra Cantaloupe Watercress Bouillon Tea Cassava Watermelon Chayote Brown rice Pork Cornmeal mush

Source: Adapted from M. S. Laguerre (1981, pp. 194–196).

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The most popular methods of contraception are the birth control pill, female sterilization, injections, and condoms (3 percent each). Among sexually active women, 13 percent use a modern method of contracep- tion and 4 percent relied on traditional methods. Among sexually active men, 17 percent used a modern method (6 percent used condoms) and 16 percent relied on tradi- tional methods (Pan American Health Organization, 2001).

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

During labor, the woman may walk, squat, pace, sit, or rub her belly. Generally, Haitian women practice natural childbirth and do not ask for analgesia. Some may scream or cry and become hysterical, whereas others are stoic, only moaning and grunting. What they need is support and reassurance; for example, applying a cold compress on the woman’s forehead demonstrates caring and sensi- tivity on the part of the practitioner. Since migrating, some Haitian women have adopted American childbear- ing practices and request analgesics. Cesarean birth is feared because it is abdominal surgery. Women in higher social strata are more amenable to having cesarean deliv- eries. Fathers do not generally participate in the labor and delivery, believing that this is a private event best handled by women. The woman is not coached; female members of the family give assistance as needed.

The crucial period for the childbearing woman is post- partum, a time for prescription and proscription. The woman takes an active role in her own care. She dresses warmly after birth as a way to become healthy and clean. Haitians believe that the bones are “open” after birth and that a woman should stay in bed during the first 2 to 3 days postpartum to allow the bones to close. Wearing an abdominal binder is another way to facilitate closing the bones.

The postpartum woman also engages in a practice called the three baths. For the first 3 days, the mother bathes in hot water boiled with special leaves that are either bought or picked from the field. She also drinks tea boiled from these leaves. For the next 3 days, the mother bathes in water prepared with leaves that are warmed by the sun. At this point, the mother takes only water or tea warmed by the sun. Another important practice is for the mother to take a vapor bath with boiled orange leaves, a practice believed to enhance cleanliness and tighten the internal muscles. At the end of the 3rd to 4th week, the new mother takes the third bath, which is cold. A cathar- tic may be administered to cleanse her intestinal tract. When the process is completed, she may drink cold water again and resume her normal activities.

In the postpartum period, Haitian women avoid white foods such as lima beans, as well as other foods, including okra, mushrooms, and tomatoes. These foods are restricted because they are believed to increase vaginal discharge. Other foods are eaten to give the new mother strength and vitality. Foods associated with this prescrip- tive practice are porridge, rice and red beans, plantains boiled or grated with the skins and prepared as porridge (the skin is high in iron, which is good for building the

blood), carrot juice, and carrot juice mixed with red beet juice.

Breastfeeding is encouraged for up to 9 months post- partum. Breast milk can become detrimental to both mother and child if it becomes too thick or too thin. If it is too thin, it is believed that the milk has “turned,” and it may cause diarrhea and headaches in the child and, possibly, postpartum depression in the mother. If milk is too “thick,” it is believed to cause impetigo (bouton). Breastfeeding and bottle feeding are accepted practices. If the child develops diarrhea, breastfeeding is immediately discontinued. Practices that do not put the mother or the child at risk should be supported and encouraged. Respecting the clients’ cultural beliefs and practices helps to establish trust between the client and the caregiver and demonstrates caring. By being familiar with these health practices and beliefs, health-care practitioners can assist women in making culturally safe decisions related to pregnancy and plans for delivery.

Another prescriptive postpartum practice among Haitian women is to feed their infant a lok similar to the one administered to the older children in the summer. The laxative is administered as the initial feeding and is intended to hasten the expulsion of meconium. Because Haitians are fearful of diarrhea in children, health-care providers should stress the risks associated with lok and any other type of bowel-cleansing cocktails in infants and children. It is important to stress the impact of laxative use on the body system and educate the woman about the need to prevent dehydration.

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V I G N E T T E 1 3 . 4

Natasha Saint-Fleur, a 32-year-old Haitian-American, is 9 months’ pregnant. She lives with her husband and parents. During her pregnancy, Mrs. Saint-Fleur has been very happy and excited about the upcoming birth of her first baby. Although Mrs. Saint-Fleur has had no prenatal complications, she has stopped working until the arrival of her new infant. Natasha eats four small meals a day and her mother feels that it is inadequate and feels this is why her daughter has not gained enough weight during her pregnancy. She fears that the baby’s blood will not be “strong.”

Natasha delivers a healthy baby. Upon her discharge to home, her mother takes full responsibility for the care of the baby and the afterbirth rituals. One day postpartum, Natasha is wearing shorts and a small tank top, the air conditioner is set at 70°F, and she is drinking a soft drink with a lot of ice. When Natasha’s mother sees this, she is very upset.

1. Is it common practice for Haitian women not to work when pregnant?

2. Why does Natasha’s mother feel that the baby’s blood will not be strong? What diet might be adequate, in her opinion?

3. During the postpartum period, what is a common Haitian ritual provided to the mother?

4. Why did the grandmother take over care of the infant? 5. What types of foods do you expect Mrs. Saint-Fleur to

eat after childbirth?

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Death Rituals DEATH RITUALS AND EXPECTATIONS

Generally, Haitians prefer to die at home rather than in the hospital. Since migrating to America, many have accepted death in a health-care facility to alleviate the heavy burden on the family during the last stage of the loved one’s life. When death is imminent, the family may pray and cry uncontrollably, sometimes even hysterically. They try to meet the person’s spiritual needs by bringing religious medallions, pictures of saints, or fetishes. When the person dies, all family members try, if possible, to be at the bedside and have a prayer service. If possible, and if it is not too disturbing to other clients, health-care practi- tioners should encourage this practice and involve a fam- ily member in the postmortem care.

RESPONSES TO DEATH AND GRIEF

Death in the Haitian community mobilizes the entire family, including the matrilineal and patrilineal exten- sions and affines. Death arrangements in America are sim- ilar to those in Haiti. Generally, a male kinsman of the deceased makes the arrangements. This person may also be more fluent in English and more accustomed to deal- ing with the bureaucracy. The kinsman is responsible for notifying all family members wherever they might be in the world, an important activity because family members’ travel plans influence funeral arrangements. In addition, he is responsible for ordering the coffin, making arrange- ments for prayer services before the funeral, and coordi- nating plans for the funeral service.

The preburial activity is called veye, a gathering of fam- ily and friends who come to the house of the deceased to cry, tell stories about the deceased’s life, and laugh. Food, tea, coffee, and rum are in abundant supply. The intent is to show support and to join the family in sharing this painful loss. Another religious ritual is called the dernie priye, a special prayer service consisting of 7 consecutive days of prayer. Its purpose is to facilitate the passage of the soul from this world to the next. It usually takes place in the home. On the 7th day, a mass called prise de deuil offi- cially begins the mourning process. After each of these prayers, a reception/celebration in memory of the deceased is held.

Haitians have a very strong belief in resurrection and paradise; thus, cremation is not an acceptable option (Father Darbouze Gerard, personal communication, September 2001). Haitians are very cautious about autop- sies. If foul play is suspected, they may request an autopsy to ensure that the patient is really dead. This alleviates their fear that their loved one is being zombified. According to this belief, this can occur when the person appears to have died of natural causes but is still alive. About 18 hours after the burial, the person is stolen from his or her coffin; the lack of oxygen causes some of the brain cells to die, so the mental facilities cease to exist while the body remains alive. The zombie then responds to commands, having no free will, and is domesticated as a slave.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

Clients’ cultural beliefs and religion can have a great impact on their acceptance of health care and compliance and, therefore, on the outcomes of treatment. Catholicism is the primary religion of Haiti. Since the early 1970s, however, Protestantism has gained in popu- larity throughout the island and has seriously challenged the Catholic Church, especially among the lower socioe- conomic classes. Even though Haitians are deeply reli- gious, their religious beliefs are combined with voudou (voodooism), a complex religion with its roots in Africa (Fig. 13–1). Voudou, in the most simplistic sense, involves communication by trance between the believer and ancestors, saints, or animistic deities. Voudou is not con- sidered paganism among those who practice it, even though many of the rituals resemble paganism. Participants gather to worship the loa or mystere, deities or spirits who are believed to have received their powers from God and are capable of expressing themselves through possession of a chosen believer. With their great powers, the loa or mystere can provide favors such as pro- tection, wealth, and health to those who worship and believe in them.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

The family system among Haitians is the center of life and includes the nuclear, consanguine, and affinal relatives. They may all live under the same roof. The family deals with all aspects of a person’s life, including counseling, education, crises, marriage, and death.

The best way to understand and assess the spiritual beliefs and needs of Haitian American clients is to under- stand their culture. This is especially important because

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FIGURE 13–1 Santeria evolved from two main cultural antecedents: the worship of orisha among the Yoruba tribe of Nigeria and the cult of saints from the Roman Catholicism of Spain. (Retrieved September 15, 2007, from http://archive.nandotimes.com/prof/caribe/ShangoAltar.html)

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Haitian clients may express their concerns in ways that are unique to their cultural and religious beliefs. To ensure accurate assessments of these clients, it is essen- tial to ask questions carefully and to completely under- stand the answers in order to gain an understanding of clients’ perceptions of health and illness as dictated by their culture and religious beliefs. By recognizing and accepting clients’ beliefs, health-care providers may alle- viate barriers and clients may feel more at ease to discuss their beliefs and needs.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Voudou believers may often attribute their ailments or medical problems to the doings of evil spirits. In such cases, they prefer to confirm their suspicions through the loa before accepting natural causes as the problem, which would lead to seeking Western medical care. For Haitian clients, the belief in the power of the supernatural can have a great influence on the psychological and medical concerns of the client.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

For Haitians, illness is perceived as punishment, consid- ered an assault on the body, and may have two different etiologies: natural illnesses, known as maladi Bondye (“dis- ease of the Lord”), and supernatural illnesses. Natural ill- nesses may occur frequently, are of short duration, and are caused by environmental factors such as food, air, cold, heat, and gas. Other causes of natural illness are movement of blood within the body, disequilibrium between hot and cold, and bone displacement. Supernatural illnesses are believed to be caused by angry spirits. To placate these spirits, clients must offer feasts called manger morts. If individuals do not partake in these rituals, misfortunes are likely to befall them. Illnesses of supernatural origin are fundamentally a breach in rapport between the individual and her or his protector. The breach in rapport is a response from the spirit and a way of showing disapproval of the protégé’s behavior. In this instance, health can be recovered if the client takes the first step in determining the nature of the illness. This can be accomplished by eliciting the help of a voudou priest and following the advice given by the spirit itself. To accurately prescribe treatment options, health-care providers must be able to differentiate between these belief systems.

Physical illnesses are thought to be on a continuum beginning with Kom pa bon (“I do not feel well”). In this phase, the affected person is not confined to bed; illness is transitory, and the person should be able to return to his or her normal activities. The next phase is moin malad (“I am sick”), in which the individuals stay at home and avoid activity. The third phase is moin malad anpil (“I am very sick”). This means that the person is very ill and may be confined to bed. The final phase is Moin pap refe (“I am dying”).

Haitians believe that gas (gaz) may provoke pain and anemia. Gas can occur in the head, where it enters through the ears; in the stomach, where it enters through the mouth; and in the shoulders, back, legs, or appendix, where it travels from the stomach. When gas is in the stomach, the client is said to suffer kolik, meaning stom- ach pain. Gas in the head is called van nan tet or van nan zorey, which literally means “gas in one’s ears,” and is believed to be a cause of headaches. Gas moving from one part of the body to another produces pain. Thus, the movement of gas from the stomach to the legs produces rheumatism, to the back causes back pain, and to the shoulder causes shoulder pain. Foods that help dispel gas include tea made from garlic, cloves, and mint; plantain; and corn. To deter the entry of gas into the body, one must be careful about eating “leftovers,” especially beans. Since migrating to the United States, Haitians have begun eating leftovers, which is believed to cause many of their ailments. After childbirth, women are par- ticularly susceptible to gas, and to prevent entry of gas into the body, they tighten their waist with a belt or a piece of linen.

RESPONSIBILITY FOR HEALTH CARE

Haitians engage in self-treatment and see these activities as a way of preventing disease or promoting health. Haitians try home remedies as a first resort for treating illness. They are self-diagnosticians and may use home remedies for a particular ailment, or if they know some- one who had a particular illness, they may take the pre- scribed medicine from that person. They keep numerous topical and oral medicines on hand, which they use to treat various symptoms. For example, an individual who suspects a venereal disease may buy penicillin injections and have someone administer them without consulting a physician. In Haiti, many medications can be pur- chased without a prescription, a potentially dangerous practice. However, health-care providers must be very discrete in assessing, teaching, and guiding the client toward safer health practices. Admonishing clients may cause them to withdraw and not listen to instructions. Haitians may also lead practitioners to believe that they are interested, when in fact, they have already discred- ited the practitioner. When taking the client’s history, the practitioner should inquire if the patient has been taking medication that was prescribed for someone else. Moreover, when prescribing a potentially dangerous drug, the practitioner should be sure to caution the client not to give the medication to ailing friends or rel- atives. Even though the practitioner may not be com- pletely successful at stopping the practice of exchanging medications, with continued reminders, she or he may be successful later.

FOLK AND TRADITIONAL PRACTICES

Haitians may use others’ experiences with a particular ill- ness as a barometer against which to measure their symp- toms and institute treatment. If necessary, a person living in the United States may ask friends or relatives to send medications from Haiti. Such medications may consist of

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roots, leaves, and European-manufactured products that are more familiar to them. Therefore, it is very important to ascertain what the client is taking at home to avoid serious complications.

Constipation, referred to as konstipasyon, is treated with laxatives or herbal tea. Sometimes, Haitians use ene- mas (lavman). Diarrhea is not a major concern in adults; however, it is considered very dangerous in children and sometimes interpreted as a hex on the child. Parents may try herbal medicine, may seek help from a voudou priest, or hougan, or if all else fails, may consult a physician. It is very important to assess the child carefully because he or she may have been ill for quite some time.

A primary respiratory ailment is oppression, a term used to describe asthma. However, the term really describes a state of anxiety and hyperventilation rather than the condition. Oppression is considered a cold state, as are many respiratory conditions. Clients say M’ ap toufe or mwen pa ka respire. A home remedy for oppression is to take a dry coconut and cut it open, fill it with half sugarcane syrup and half honey, grate one full nutmeg and add it to the syrup mix, reseal the coconut, and then bury it in the ground for a month. The coconut is reopened, the content is stirred and mixed, and 1 table- spoon is administered twice a day until it is finished. By the end of this treatment, the child is supposed to be cured of the respiratory problem.

BARRIERS TO HEALTH CARE

Because orthodox medicine is often bypassed or perceived as a second choice among Haitians, the potential delay of medical care can pose an increased risk to clients. The view that physicians of conventional medicine do not understand voudou, and therefore, cannot cure magical illness, or that an illness worsens if the bewitched person seeks a physician, is enough to persuade these individuals to seek unconventional modes of therapy with which they are more comfortable. The health-care team should understand some of the basic principles and practices of folk medicine, particularly root medicine, because this can play a significant role in determining the progress of the client’s health status.

Many Haitians are in low-paying jobs that do not pro- vide health insurance, and they cannot afford to purchase it themselves. Thus, economics acts as a barrier to health promotion. In addition, for those who do not speak English well, it is difficult for them to access the health- care system, fully explain their needs, or understand pre- scriptions and treatments.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

The root-work system is a folk medicine that provides a framework for identifying and curing folk illnesses. When illness occurs, or when a person is not feeling well or is “disturbed,” root medicine distinguishes whether the symptoms and illness are of natural or unnatural origin. An imbalance in harmony between the physical and the spiritual worlds, such as dietary or lifestyle excesses, can cause a natural illness. For example, diabetes is considered a natural illness; however, most Haitians do not seek

immediate medical assistance when they detect the symptoms of polyuria, excessive thirst, and weight loss. Instead, they attempt symptom management by making dietary changes on their own by drinking potions or herbal remedies. When the person finally seeks medical attention, she or he may be very sick. At this point, the practitioner should be cautious in explaining the condi- tion and use a culturally specific approach when explain- ing the medical regimen, diet, and medications.

Pain is commonly referred to as doule. Many Haitians have a very low pain threshold. Their demeanor changes, they are verbal about the cause of their pain, and they sometimes moan. They are vague about the location of the pain because they believe that it is not important; they believe that the whole body is affected because dis- ease travels. This belief makes it very difficult to accu- rately assess pain. Injections are the preferred method for medication administration, followed by elixirs, tablets, and finally, capsules.

Chest pain is referred to as doule nan ke mwen, abdom- inal pain is doule nan vent, and stomach pain is doule nan ke mwen or doule nan lestomak mwen. Oxygen should be offered only when absolutely necessary because the use of oxygen is perceived as an indicator of the seriousness of the illness.

Nausea is expressed as lestomak/mwen ap roule, M santi m anwi vomi, lestomak/mwen chaje, or ke mwen tounin. Those who are more educated may express their discom- fort as nausea. Because of modesty, they may discard vomitus immediately so as not to upset others. Specific instructions should be given regarding keeping the speci- men until the practitioner has had a chance to see it.

Fatigue, physical weakness known as febles, is inter- preted as a sign of anemia or insufficient blood. Symptoms are generally attributed to poor diet. Clients may suggest to the health-care provider that they need special care—that is, to eat well, take vitamin injections, and rest. To counteract the febles, the diet includes liver, pigeon meat, watercress, bouillon made of green leafy vegetables, cow’s feet, and red meat.

Another condition is fright or sezisman. Various exter- nal and internal environmental factors are believed to cause sezisman, thereby disrupting the normal blood flow. Sezisman may occur when someone receives bad news, is involved in a frightful situation, or suffers from indigna- tion after being treated unjustly. When this condition occurs, blood is said to move to the head, causing partial loss of vision, headache, increased blood pressure, or a stroke. To counteract this problem, the client may sit qui- etly, put a cold compress on the forehead, drink bitter herbal tea, take sips of water, or drink rum mixed with black, unsweetened coffee.

Haitian Americans may strongly resist acculturation, taking pride in preserving traditional spiritual, religious, and family values. This strong hold on cultural views sometimes creates stress leading to depression. The stigma attached to mental illness is strong, and most Haitians do not readily admit to being depressed. A major factor to remember is the strong prevalence of voudou, which attributes depression to possession by malevolent spirits or punishment for not honoring good protective spirits. In addition, depression can be viewed as a hex placed by

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a jealous or envious individual. Factors that may trigger depression are memories of family in the homeland, thoughts about spirits in Haiti, dreams about dead family members, or guilt and regrets about abandoning one’s family in Haiti for the abundance in America. Health-care providers need to be sensitive to the underlying causes of problems and ascertain the need for comfort within spe- cific religious beliefs.

In the case of an unnatural illness, the person’s poor health is attributed to magical causes such as a hex, a curse, or a spell, which has been cast by someone as a result of family or interpersonal disagreement. The curse takes place when the intended victim eats food contain- ing ingredients such as snake, frog, or spider egg powder, which cause symptoms of burning skin, rashes, pruritus, nausea, vomiting, and headaches (Fishman, Bobo, Kosub, & Womeodu, 1993). These symptoms often coincide with psychological problems manifested by violent attacks, hallucinations, delusions, or “magical possession.” Because, under Western medical standards, an evil spirit would be classified as a true psychiatric problem with “culturally diverse manifestations” and not as an actual case of possession, the health-care practitioner is chal- lenged in assessing and making the appropriate interven- tion (Fishman et al., 1993). If the practitioner is aware of witchcraft, voudou practices, and the symptoms associated with them, it may prevent (1) incorrectly diagnosing an individual as mentally ill, (2) giving advice that frightens or confuses the patient into thinking an illness is unnat- ural in origin, or (3) initiating symptomatic treatment that does not reach the underlying stress. The role of the health-care provider is to be sensitive and understanding toward the patient who holds a belief in these traditional practices. Health-care providers should realize that hesi- tating to offer a specific diagnosis might be more detri- mental to the client than a negative diagnosis.

BLOOD TRANSFUSIONS AND ORGAN DONATION

Most Haitians are extremely afraid of diseases associated with blood irregularities. They believe that blood is the central dynamic of body functions and pathological processes; therefore, any condition that places the body in a “blood-need” state is believed to be extremely danger- ous. Clients and their families become emotional about blood transfusions. Thus, these are received with much apprehension. In addition, as in all societies, blood trans- fusions are feared because of the potential for HIV trans- mission. Health-care providers should explain the need for a blood transfusion factually and carefully clarify the pro- cedure along with the involved risks. Practitioners should involve clients and their families in the care as much as possible. Precautionary measures that have been taken to prevent blood contamination should also be explained.

Because Haitians hold strong religious beliefs about life after death, the body must remain intact for burial. Thus, organ donation and transplantation are not generally dis- cussed. Since migrating to the United States, some Haitians have, with considerable distress, participated in organ transplantation. A prime concern is transference, believing that through the organ donor, the donor’s per-

sonality will “shift” to the recipient and change his or her being. Health-care providers should assess Haitian clients’ beliefs about organ donation and involve a religious leader to provide support and help facilitate a decision regarding organ donation or transplantation. Because some Haitians’ knowledge and understanding in this area is limited, the health-care provider should be proactive by promoting health education.

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

In general, most Haitians resort to symptom management with self-care first and then spiritual care. They com- monly use traditional and Western practitioners simulta- neously (see Spirituality and Folk Practices).

STATUS OF HEALTH-CARE PROVIDERS

Haitians are very respectful of physicians and nurses. Physicians are men and nurses are women. Nurses are referred to as Miss. By incorporating culturally specific strategies in their program, practitioners inspire confi- dence and trust. Haitian clients who have had limited contact with American health-care systems may have lim- ited understanding of biomedical concepts. Health-care providers need to take the time to explain and re-explain relevant points to compensate for clients’ knowledge deficit or language limitations. Health-care providers who show compassion and sensitivity toward Haitian clients achieve greater success in educating clients, families, and the community.

REFERENCES Aristide, M. V. (1995). Economics of liberation. Roots, 1(2), 20–24. CIA. (2006). World Factbook: Haiti. Retrieved December 12, 2006, from

http://www.odci.gov/cia Dorestant, N. (1998). A look at Haitian history from a Haitian perspective.

Retrieved February 3, 2007, from http://www.geocite.com Elliot, A. (2001, August 6). South Florida Caribbean population has almost

doubled. The Miami Herald. Retrieved February 3, 2007, from http://www.miamiherald.com

Fishman, B. M., Bobo, L., Kosub, K., & Womeodu, R. J. (1993). Cultural issues in serving minority populations: Emphasis on Mexican Americans and African Americans. American Journal of Medical Science, 306, 160–166.

Jean-Baptiste, A. R. (1985). The black man: Ti Manno in public. New York: St. Aude Records.

Jean-Bernard, L. (1983). Impossible alphabetization. Port-au-Prince, Haiti: Des Antilles SA.

Laguere, M. S. (1981). Haitian Americans. In L. Sana (Ed.), Handbook of immigrant health (pp. 194–196). New York: Springer Publishing Co.

Louis-Juste, A. (1995). Popular education and democracy. Roots, 2(1), 14–19.

McCann, B. S., Scheele, L., Ward, N., & Roy-Byrne, P. (2006). Childhood inattention and hyperactivity symptoms self-reported by adults with Asperger syndrome. International Journal of Descriptive and Experimental Psychopathology, Phenomenology and Psychiatric Diagnosis, 39, 45–54.

Pan American Health Organization. (2001). Regional core health data sys- tems. Retrieved November 22, 2006, from http://www.paho.org/ English/SHA/glossary.htm

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Prudent, N., Johnson, P., Carroll, J., & Culpepper, L. (2005). Attention deficit disorder: Presentation and management in the Haitian American child. Primary Care Companion Journal Clinical Psychiatry, 7(4), 190–197.

Regan, J. (1995). Behind the invasion more misery. Roots, 1(2), 7–13. Santana, M. A., & Dancy, B. L. (2000). The stigma of being named “AIDS

carriers” on Haitian-American women. Health Care for Women International, 21, 161–171.

Statistics Canada. (2006, February 8). Ethnic origin. The Daily. Retrieved December 18, 2006 from http://www.statcan.ca

U.S. Immigration and Naturalization Service. (2006). Statistical yearbook of the Immigration and Naturalization Service 2005. Washington, DC: U.S. Government Printing Office.

World Bank Annual Report. (2006). Countries eligible for borrowing from World Bank. Retrieved January 30, 2007, from http://www. worldbank.org

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

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248

People of Iranian Heritage

Chapter 14

HOMEYRA HAFIZI, MARYAM SAYYEDI, and JULIENE G. LIPSON

Overview, Inhabited Localities, and Topography OVERVIEW

Iran is a geographically and ethnically diverse, non–Arabic- speaking, Muslim country. Iran’s 1979 Revolution gener- ated a steady wave of immigration to North America, Europe, and Australia. Prior to the 1979 Revolution, the main reason for immigration was educational advance- ment. The few who immigrated had little impact on the host country’s social make-up and the health-care system. But in the past 10 to 15 years and with the marked increase in immigration, some Iranian communities, such as that in Los Angeles, have begun to influence the regional economy.

Since the 1979 Revolution, Iran’s socioeconomic and political instability has spurred emigration. Among immi- grants, a deep generation gap, both within the family unit and with the larger population, frequently occurs. First- generation Iranian-born immigrants often live between the two worlds. Their age and reason for immigration are mitigating factors. The generation gap has widened as each subgroup adopts the new culture, tries to fit into the environment, and garners new ways of self-expression. A study of Iranian immigrants in New South Wales, Australia, noted that women’s roles were changing slowly from the more traditional roles of home manager and nurturer to those of education and employment (Omeri, 1997). In another study conducted in Los Angeles, Iranian women who left Iran at a young age had more lib- eral attitudes toward sex and intimate relationships and more conflicts between their Iranian and American iden-

tities (Hanassab, 1998). Evidence suggests that, in general, women acculturate at a faster rate than men and begin to undermine the patriarchal and sexist cultural values (Darvishpour, 2002).

Many Iranian immigrants face considerable ethnic bias in the United States, with an intensity directly linked to the ongoing events in the Middle East. Anger and preju- dice toward Iranians began in November 1979 with the 14-month occupation of the U.S. Embassy in Tehran. The hostility was manifested in many ways and experienced by Iranians of all ages. Some trilingual immigrants identi- fied themselves by their ethnicity rather than their place of origin. For example, one would identify himself or her- self as Turkish rather than as an Iranian Turk. The tragic events of 9/11, the ongoing instabilities in the Middle East, the current Iran’s nuclear ambitions, and the Iraq war have marginalized the Iranian immigrant. By virtue of its location, predominant religion, and the central gov- ernment’s reaching out to neighboring countries, Iran is a figure in international policy making. The U.S. media overemphasize the influence of Islamic fundamentalism, and the public tends to view Middle Eastern immigrants as a homogenous population. In actuality, most Iranians are more secular and nationalistic than people from Sunni Arab nations, who may hold a more common Islamic identity (Sayyedi, 2004).

The U.S. Bureau of the Census estimates the number of Iranians in the United States at 400,000. Unofficially, the estimate is closer to 1 million. The political climate dis- courages Iranian immigrants from disclosing their native origin; hence, they self-identify as “other” or “Caucasian.” The 2002 Census described the California Iranian American population as largely concentrated in the Los Angeles area, which consequentially has the largest concentration

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of Iranians outside of Iran. Totaling 159,016 persons, this population is larger than the combined number of Iranians in 20 other states. The Los Angeles population is ethnically and religiously diverse. Although Muslims are still the majority, the Armenian, Jewish, and Baha’i com- munities have a strong presence (Bozorgmehr, Sabagh, & Der-Martirosian, 1993). Divided by political, religious, and social class differences, most live in small social networks.

In this chapter, the terms Persian and Iranian are used interchangeably. For mainly political reasons, some immigrants call themselves Persian. In 1935, the country’s name was changed from Persia to Iran (from the word aryana) to present an image of progress and to unify the many ethnicities, tribes, and social classes. The original Persians were an Indo-European group, the Aryans of India. The Persian Empire, founded by Cyrus the Great in 559 BC, covered an area from the Hindu Kush (now in Afghanistan) to Egypt. Iranians are proud of their her- itage, which includes ancient empires, the Zoroastrian religion, and some of the world’s greatest poets and lead- ers in philosophy, astronomy, and medicine.

Even though the focus of this chapter is on cultural commonalities, health-care providers must recognize that Iranians are a highly diverse popluation. We encourage readers to carefully assess each client’s and each family’s beliefs and circumstances. Overemphasis on culture, reli- gion, and ethnicity as the defining factors in the expres- sion of health and illness, treatment-seeking behaviors, and health-maintenance practices can lead to stereotyp- ing (Hollifield, 2002).

Iran covers an area of about 636,000 square miles and is bordered by the Caspian Sea on the north and the Persian Gulf on the south. Neighboring countries are Turkmenistan, Azerbaijan, Armenia, Turkey, Iraq, Afghanistan, and Pakistan. Iran is home to many agricul- tural communities, nomadic tribes with livestock, and several highly industrial regions. Fertile agricultural lands are found in the southwest and on the Caspian Sea shore. The dry lakes of the interior regions are less conducive to farming. Both northern and southern shores are extremely humid. A large area of the country is moun- tainous. The climate varies with altitude, including hot, dry summers and extremely cold, snowy winters.

Iran has a population of over 70 million, three-quarters of whom are under the age of 30 and live in urban areas. The annual population growth rate is 1.4 percent. Almost one-fifth of the inhabitants live in an impoverished state with no basic public-health infrastructure, including drink- ing water, electricity, and sewage. The overwhelming majority of the people practice Shiite Islam. Christianity, Judaism, and Zoroastrian, an ancient Persian faith, are recognized in Iran, and adherents enjoy a degree of pseudo-freedom. However, the Baha’i community has experienced discrimination since the religion was estab- lished in the 19th century.

HERITAGE AND RESIDENCE

In Iran, ethnic groups with differing dialects and strong heritage coexist in a somewhat conflict-free environment, and the many groups embrace and identify with the core

of the Iranian culture and the Persian civilization. For example, regardless of ethnicity or religion, the country unifies around Eid Norouz as a symbol of national iden- tity and as a significant cultural event. The practice of vis- iting during Eid Norouz is an important expression of care, both within the family structure and as a community activity (Omeri, 1997). As commonly practiced in Iran, immigrant families continue to gather for important occasions such as weddings, births, and funerals.

Iran is divided into regions, each inhabited by people of differing ethnicities and traditions. For example, Iranian Turks live in the northwest, Kurds live along the western borders, and Arabic-speaking Iranians live in the south and southwest. Ethnic interdependence is being cautiously tested by the central government in Iran. The many years of occupation by the Greeks, Arabs, Mongols, and Turks have made Iranians cautiously resilient; the Iranians developed an uncanny ability to assimiliate without a complete loss of the collective self or their national identity.

Most Persians remained Zoroastrian until the Sunni Arabs conquered the land in the 7th century. Con- sequently, Iranians, except for the Shiite sect, converted to Islam. Iran is the only Muslim country in the Middle East that uses the solar calendar and celebrates Eid Norouz at the spring equinox in celebration of the New Year with- out any religious undertones. Centuries of occupation and the void of a central government committed to the country’s welfare placed Iran at economic and industrial disadvantage. The reality became painfully noticeable to the people of Iran in the early 1900s when trading expanded to Europe and the West. The awareness marked the very slow beginning of emigration.

In the mid-1900s, several political parties—Nationalist, Communist, and Religious in ideology—literally pushed Iran toward becoming a more independent nation. To this day, even though it was short-lived, the nationalistic movement of Dr. Mosadeq resonates fondly in people’s minds. The Pahlavi Dynasty (father and son) followed this movement, but it was mired in corruption and unethical alliances with foreign governments. Moreover, Mohammed Reza Shah reinstituted the secret police and did not tolerate political opposition. The 1979 Revolution and the establishment of the Islamic Republic of Iran were direct consequences of Pahlavi’s management of the country. However, some powerful social and economic reforms were instituted during Pahlavi’s reign, such as national public health, literacy programs, and a creation of a more secular society with decreased power for the reli- gious clergy. Women’s rights advanced until they were fully enfranchised in 1963. The 1979 Revolution drove the social and secular gains underground. Today, Iranian society is facing one of its greatest challenges; this time the occupying force has originated from within and its people are trapped by friendly fire.

To this day, a central tenet of Iranian social life and per- sonal development is the boundary between inside/pri- vate (baten) and outside/public (zaher). Stimulated by the long history of occupation, the most private and true self is always kept for intimate spaces and trusted relations. “Inside” and “outside” define both individuals and fami- lies, in which honor and social shame play powerful roles.

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REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Three waves of immigration contribute to the diversity of Iranians in the United States and elsewhere. In addition, each wave of immigrants appears to respond differently to the stress of migration. The first two waves of immi- grants, 1950s to 1970 and 1970 to 1979, are demographi- cally more cohesive. The second wave was more varied in social class and included a higher proportion of minority Iranians, such as Baha’is and Jews. The second wave included mostly young urban technocrats, scientists, pro- fessionals seeking advanced education, and adolescents of upper-middle class or privileged families who came to study at U.S. universities. Fluent in English, familiar with Western culture, and financially supported by govern- ment grants, scholarships, or family wealth, these indi- viduals were better able to adjust to life in the United States. For this population of immigrants, a primary source of stress was distance from family and friends (Jalali, 1996).

The third wave immigrated from the early 1980s to the mid-1990s to escape the Iran-Iraq war and/or the Islamic government’s political persecution. They were forced rather than voluntary migrants; some sought refugee sta- tus and continue to consider themselves in exile. This wave includes older individuals, fewer professionals, a higher percentage of high-ranking members of the pre- Revolution Iranian armed forces, owners of mid-size busi- nesses, industry managers, and clerks.

Challenges particular to this older population of Iranian immigrants have been learning the language, adapting to the new culture and lifestyle, and redefining the relationship between parents and children (Emami, Benner, & Ekman, 2001). Older immigrants often express their ambivalence about being in the United States and may strongly believe they immigrated for the sake of their children and to provide emotional and financial support, similar to that of older immigrants in Sweden (Emami, Torres, Lipson, & Ekman, 2000). Older people often feel isolated, and their desire to return home keeps them from making permanent commitments. They are concerned about how their children will fare as they adopt less appealing aspects of the new culture. Older people view lack of respect for older people, loose family ties, and insufficient social support as examples of an unfavorable Western culture (Omeri, 1997). At times, to avoid isola- tion and to emulate the past, some immigrants “befriend” other Iranians despite having little in common but their national heritage and language; hence, creating a com- munity weak in infrastructure and ties.

In summary, lack of fluency in the English language, education, and familiarity with Western culture are char- acteristics that differentiate the last wave of immigrants from those who immigrated prior to the 1980s (Bozorgmehr, 1997). The third wave has experienced mul- tiple losses and witnessed role reversals between parents and children. These families left Iran under duress and lost their financial assets and status. Many experienced a profound degree of hardship, such as fleeing Iran by rely- ing on smugglers and other high-risk means only to seek refugee status (Koser, 1997).

EDUCATIONAL STATUS AND OCCUPATIONS

Iranians greatly value education and expect their children to do well. Individuals who immigrated before the 1979 Revolution have most often obtained college degrees and are professionally successful and active. Iranian immi- grants strive to maintain a social façade of affluence and upper-class status because family judgment and social shame weigh heavy on their decision-making. These issues have rarely been mentioned in studies addressing the health and mental health needs of immigrants in the United States (Sayyedi, 2004).

Many middle-aged immigrants who held white-collar positions in Iran were unable to find comparable work in the United States. As a result, they are self-employed in businesses such as pizza parlors or gas stations, using their business acumen to maintain a middle-class or better lifestyle. In Los Angeles, 61 percent of Iranian heads of household claimed to be self-employed in 1987 and 1988 (Dallalfar, 1994); 82 percent of Iranian Jews were self- employed. Only 10 percent reported employment in blue-collar jobs (Bozorgmehr et al., 1993). Health-care providers should not assume education and social class from occupation alone.

Communication DOMINANT LANGUAGE AND DIALECTS

Farsi (Persian) is the national language of Iran, and all school children are taught in Farsi. An indication of mod- ern Iran’s Indo-European heritage is found in words simi- lar to English words. As mentioned previously, nearly half the country’s population speaks different languages and dialects, such as Turkish, Kurdish, Armenian, or Baluchi. Well-educated and well-traveled immigrants and those who might have stayed in an intermediate country prior to entering another country may speak three or more lan- guages.

CULTURAL COMMUNICATION PATTERNS

The health-care provider should attempt to distinguish cultural patterns from individual personality characteris- tics. Communication among Iranians must be under- stood within the context of their history, the personality styles valued in the culture, and the structure of social relationships. Iranians are very cautious in their interac- tions with outsiders.

Not verbalizing one’s thoughts is viewed as a custom- ary and useful defensive behavior. This form of commu- nication, also known as ta’arof, can effectively hinder open exchange of feelings with the health provider. Time to complete assessment, history-taking, and therapeutic approaches must be planned accordingly. Clearly imple- mented in the practice of ta’arof is the road map to com- munication whereby being other-centered, not self- centered, is expressed with distinct and respectful forms of speech and behavior. Whereas the constant offers of hospitality and compliments may sound insincere to non-Iranians, the dynamic is hard at work to set the boundaries of the relationship (Sayyedi, 2004).

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Bagheri (1992) described such highly valued personal- ity characteristics in Iranians as indirectness, subdued assertiveness, modesty, and politeness. Iranians are very concerned with respectability, a good appearance of the home, and a good reputation. Social behavior is also influenced by a constant awareness of others’ judgment. Spontaneity is limited by rules that clearly define how and when to approach people of different ages and mem- bers of the opposite gender.

Communication also occurs on a continuum anchored by baten (inner self) and zaher (public persona). Baten is personal feelings, and zaher is a collection of proper and controlled behaviors. What lies in between is a buffer zone. The Persian language and its nonverbal accompani- ments have evolved to help the expression of this com- plexity. Ta’arof is an example of a tool in verbal commu- nication.

Health-care providers should be aware of the manner in which Iranians handle potentially disturbing informa- tion. Discussing serious diagnoses must be handled with respect to the family dynamics. Care is expressed in sup- portive gestures and by maintaining family relationships in times of health and need. Frequent visiting and keep- ing in contact by any available means are care practices (Omeri, 1997).

More traditional married couples do not display out- ward affections to each other in public. Greeting is often accompanied by a kiss on each cheek and/or a handshake. Strangers and health-care providers may be greeted with both arms held at the sides. A slight bow or nod while shaking hands shows respect. Iranians generally stand when someone enters or leaves the room for the first time. It is appropriate to offer something with both hands. Crossing one’s legs when sitting is acceptable, but slouching in a chair or stretching one’s legs toward another is considered offensive; showing the sole of one’s foot is rude. Nonverbal beckoning is done by waving the fingers with the palm down. Tilting the head up quickly means no. Tilting the head to the side means what?, and tilting it down means yes. Extending the thumb (like thumbs-up) is considered a vulgar sign.

As in other Mediterranean cultures, personal distance is generally closer than that of Americans or Northern Europeans. The strength of the relationship affects how freely participants touch each other.

Iranians maintain intense eye contact between inti- mates and equals of the same gender. This behavior may be observed less in traditional Iranians. Conversations are expressive, as body language is used and the tone is loud.

TEMPORAL RELATIONSHIPS

Time orientation is a combination of emphasis on the present and on the future. In other words, time is contin- uous; what is anticipated in the future shapes the current lived experience. The ideal is to maintain a balance between enjoying life to the fullest and ensuring a com- fortable future. Iranians’ understanding of time as a con- textual and directional phenomenon enhances the effec- tiveness of health promotion and education. At the same time, a fatalistic theme among many Iranians’ may hin- der their understanding of health risk assessment and risk

reduction. Continuity and balance in life is the definition of health and well-being. Obtaining the diagnosis of a chronic or terminal illness is tolerated as an expected out- come of aging. Any disappointments in and derailments from the culturally accepted process of caring are reasons for ill health (Emami et al., 2001).

Iranians are feeling oriented. Interestingly, in business, they portray a strong work ethic; they are time-conscious and intensely competitive. Although social time is ex- tremely flexible, Iranians respond to time requirements at work.

FORMAT FOR NAMES

Iranians refrain from calling older people and those in higher status by their first names. A man may wait before extending his hand to a woman as a measure of respect for her comfort with the practice. One is expected to greet every member of the family. To begin an interaction, the younger person initiates the greeting process.

Family Roles and Organization Consistent with traditional collectivistic cultures, Iranian families value harmony within an established patriarchal hierarchy. Also valued are avoidance of open conflict, unconditional respect for parents, and indirect and figura- tive communication to maintain social hierarchy and group harmony. As a norm, they tend to be fatalistic and have an external locus of control and destiny (Daneshpour, 1998).

HEAD OF HOUSEHOLD AND GENDER ROLES

In this patriarchal and hierarchical culture, the father has authority and expects obedience and respect. In the father’s absence, the oldest son has authority. Traditionally, families were large in Iran, with male chil- dren being highly desirable. Today’s families have fewer children, and the authority figure may be a working female adult. As a father ages, he may give control of the business and all property to the oldest son. In more tradi- tional families, older male siblings have the authority to make decisions about their younger siblings, even in the father’s presence. However, more acculturated families are more flexible. Most sibling relationships are deep, trust- ing, and lively. Health-care providers should understand the decision-making dynamics of the family. The process is highly collaborative in enlisting trusted friends and rel- atives who are subject-matter experts.

Young people are free to select their life (marriage) part- ners, but families prefer to have the voice to approve. Husbands are often a few years older than their wives. Male immigrants experience emotional stress when they lack social status, which is tied to finances and occupation.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

Most immigrant Iranian families are child-oriented, sometimes to a fault, as they become overprotective.

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Manners are considered important even outside the home. Children and teens are usually included in adult gatherings. Young children are rarely left with babysitters as families rely on friends and family suppport.

Taboo behaviors for teens in Iran and in the United States differ only in degree and intensity. In Iran, parents are concerned about smoking, drugs, alcohol, and sex. Young women are expected to remain virgins until they marry, but sexual activity by men outside marriage is tol- erated. Dating is not allowed in the most traditional Iranian families but is tolerated in more acculturated families.

Whereas many Iranian adolescents in the United States resemble their American counterparts in dress and outward behavior, they often behave more respectfully toward family members, particularly older people and other highly respected individuals. The fear of shaming the family and losing face in public acts as a strong social constraint.

FAMILY GOALS AND PRIORITIES

The family is the most important institution in the Iranian culture. Members often live in close proximity to minimize isolation and to maintain strong intergenera- tional ties. The intensity of such strong relationships can be a double-edged sword; it brings comfort as it generates conflict. The key is to find a healthy balance.

A strong family unit ensures the continuation of the family name and lineage. If parents are able, they support their children financially by providing assistance with educational expenses, home buying, or starting a busi- ness. The children’s academic or career achievement is considered the family’s.

Parenting values and behaviors vary dramatically across immigrant Iranian families. Parents are conscien- tious in meeting their children’s needs for comfort, safety, and success, but similar to parents from other collectivistic and traditional cultures, they expect their children’s absolute devotion to the ancestral lineage. Since the mid-1990s, immigrant parents have become interested in improving their parenting skills by chal- lenging some of the more traditional views. They attend parenting classes taught by Iranian American psycholo- gists, social workers, and marriage and family therapists and are learning to rely on such behavioral modifica- tion techniques as rewards or time-outs for discipline (Sayyedi, 2004).

Some Iranians have clothing that is worn only inside the home. Often, they remove their shoes at the door and wear slippers inside. Outside the home, they tend to dress conservatively. Religious women living outside Iran may avoid bright colors, cover their arms and legs, and conceal their heads with head covers or scarves (hejab). In Iran, wearing the hejab is mandatory.

Age is a sign of experience, worldliness, and knowl- edge. Regardless of kinship or relationship, an older per- son is treated with respect. Older people are cared for at home. Skilled nursing facilities are viewed negatively. Despite their esteemed role within the Iranian family, older immigrants with minimal language skills feel iso- lated when their adult children work and the grandchil-

dren are in school. Loneliness and isolation among older people are particularly common in neighborhoods where transportation is unavailable or walking is unsafe. In some enclaves of Southern California and Sweden, Iranians have established adult day-care centers in response to this issue (Emami et al., 2000).

Iran does not have a formal caste system; however, social status is both inherited and gained. Some are born into the upper class, but one can also ascend the class hierarchy through higher education and attainment of professional status. Parents often try to arrange marriages with families of higher status.

ALTERNATIVE LIFESTYLES

The religion of Islam has a conservative point of view about the male-female relationship, as is true of the Iranian society. Most Iranians strongly disapprove of the practice of living together before marriage. Although divorce is viewed negatively, the rate has been increasing among Iranians abroad, partly as a result of the many stressors of immigration and an increase in intercultural marriages. Rezaian (1989) found that intraculturally married Iranians reported more marital satisfaction than Iranians married to Americans or other intraculturally married Americans. One reason may be that cultural mores advocate for ignoring minor marital discord to maintain family stability. Collectivist cultures place greater emphasis on one’s role in a kinship structure.

In Iran, out-of-wedlock teen pregnancy is neither talked about nor prevalent, and it can have a devastating outcome. Although homosexuality undoubtedly occurs in Iranians as frequently as in any other group, it is highly stigmatized. Iranian gays and lesbians do not easily dis- close their sexual orientation because they are going against both a religious and a cultural norm. Since 1979, when the judicial system became one with the religious doctrine, homosexuality, which is considered unnatural and sacrilegious, is a crime punishable by death (Clark, 1995). Members of an Iranian gay support group in the San Francisco Bay area use anonymity and pseudonyms to protect themselves from potential physical harm by fundamentalist groups. In contrast to the older genera- tion, younger Iranians are increasingly tolerant of alter- native lifestyles.

Workforce Issues CULTURE IN THE WORKPLACE

Iranian immigrants face several difficulties, among them are acquiring legal residency and suitable employment opportunities. For example, a physician who works as a plebotomist experiences continual bitterness that mani- fests itself either outwardly as anger and discord or inter- nally with serious outcomes to personal health and familial relations.

Iranians may perceive and actually experience a degree of bias at work. Prejudice is less evident in highly multi- cultural and metropolitan areas. There is a general lack of understanding that the countries of the Middle East and

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their people are very different in ethnic identity and culture. For the most part, Iranians are secular and nationalistic and do not adhere to an Islamic identity common to the Arab nations (Biparva, 1994). More acculturated immigrant professionals respond flexibly in the workplace. For example, when one of the authors (Hafizi) perceives that a client is uncomfortable with her background or overtly expresses dislike, she uses ta’arof. Using formal speech, she addresses clinical tasks with minimal personal touch and interaction. Efficiency and efficacy supersede personal communication and human connection.

ISSUES RELATED TO AUTONOMY

Most newcomers may not be familiar with American ver- nacular or slang. An ongoing stressor is the condescend- ing attitudes directed at individuals with a strong accent. For example, a nurse with a master’s degree described her first year in the United States as follows:

I was seen as an ignorant nurse’s aide who couldn’t even speak English. One nurse used to follow me around, checking everything I did. I resented being treated that way, and my own self-esteem suffered (Lipson, 1992, p. 16).

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Iranians are white Indo-Europeans. Their skin tones and facial features resemble those of other Mediterranean and Southern European groups. Their coloring ranges from blue or green eyes, light brown hair, and fair skin to nearly black eyes, black hair, and brown skin.

DISEASES AND HEALTH CONDITIONS

In Iran, the estimated 2006 birth rate was 17 per 1000 people, and the infant mortality rate was 40.3 deaths per 1000 (CIA, 2007).

Heat and humidity in some provinces provide fertile ground for the spread of cholera, including new and mutant strains. Malaria is widespread in Baluchistan (in the southeast), with serologic test results sometimes showing more than one strain in a single client. In rural areas that lack standardized sanitary systems, viral and bacterial meningitis, hookworm, and gastrointestinal dysenteries caused by parasites are prevalent. Hyper- tension is widespread, and in Tehran, 22 percent of adults are affected (Azizi, Ghanbarian, Madjid, & Rahmani, 2002).

Ischemic heart disease is on the rise secondary to the stress of living under economic and social constraints. Health-care providers should screen newer immigrants for diseases and illnesses common in their home country.

The most common health problems in Iran are linked to underdevelopment, the recent economic downturn, mental stress, and lack of coordination of scarce resources.

Examples of common health conditions are malnutrition (caused by protein and vitamin deficiencies), hepatitis A and B (caused by poor sanitary conditions, such as poor aseptic technique, or public-health measures), rising rates of tuberculosis and syphilis, genetic problems (owing to interfamily marriages), and genetic blood dyscrasias. Interfamily marriage used to be common; however, increasing urbanization and scientific data have resulted in a decline.

The head of Iran’s Institute of Mental Health estimates that 1.2 million people in Iran suffer from acute psycho- logical illnesses. Forty to 60 percent of all Iranians suffer from an episode of mental illness that requires specialized medical intervention. The prevalence of diabetes is 1.5 percent, but about 50 percent of those diagnosed were unaware of having this disease despite clear symptoms. Thalassemias, prevalent in the northern and eastern provinces, are now being addressed through premarital screening for carriers and through genetic counseling. Individuals are also tested for vitamin B12 or folic acid deficiencies linked to an enzyme deficiency. Mediter- ranean glucose-6-phosphate dehydrogenase (G-6-PD) deficiency is also common among people of Iranian her- itage and can precipitate a hemolytic crisis when fava beans are eaten; it can also affect drug metabolism, such as increasing sensitivity to primaquine.

In the United States, many Iranians experience stress- related health problems from culture conflict and loss, homesickness, and the previous conditions of war. Although Northern California Iranians in Lipson’s study (1992) were generally healthy, many expressed their ongoing stress somatically, through intermittent physi- cal discomfort. Several articulated a direct connection between their worries and their illness; for example, three of the first seven people interviewed had suffered from ulcers and attributed their “stomach problems” to their “worries” and “troubles.” Others complained of headaches, backaches, a racing heart, or other manifes- tations of anxiety or depression. Iranians often focus their acute generalized stress on the alimentary system, attributing illness or its severity to something eaten (Emami et al., 2001).

High-Risk Behaviors Iranians’ high-risk health behaviors are similar to those in the general population. Among both men and women, smoking is more prevalent in Iran than in the immigrant population residing in the United States. In general, health education, through the media and the influence of their children, encourages many to quit smoking. A degree of alcohol and recreational drug use occurs in the Iranian immigrant population, but the rate is no higher than that of the population at large. Alcohol is prohibited by the Qur’an, Holy Book of the Islamic faith. However, Iranians who are not devoutly religious drink socially, a few to excess. In Iran, the most popular street drug among the older generation is opium, tradi- tionally used for medicinal purposes. However, years of opium use has created both a psychological and a phys- ical addiction. The prevalent drugs in Iran are heroin

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and opium, mostly used by younger, unemployed adults. Family responses to drug use range from com- plete support of the family member to disownment. However, more families support their child to reduce the social burden and to save face.

Moderate alcohol use is openly accepted among immi- grant Iranians. Substance abuse in this population is related to low levels of acculturation, a perception or experience of prejudice, and a sense of helplessness and loneliness. Sometimes Iranian men demonstrate their “masculinity” by claiming to “hold” their liquor well. The need to assert masculinity combined with a poor self- esteem increases the risk of alcohol addiction and spousal abuse.

HEALTH-CARE PRACTICES

Because of city planning and self-contained neighbor- hoods, walking is a great form of mobility in Iran. Soccer remains a passion, regardless of age and gender. Men con- tinue to play soccer and encourage their children’s partic- ipation to promote family activity. Iranian women partic- ipate in a wide range of physical activities such as walking, swimming, or aerobics depending on finances and time availability.

Mandatory seat belt use on intercity highways in Iran was instituted in the 1990s; compliance is periodically monitored and enforced. Radio and TV stations are state owned and, therefore, at the state’s disposal for any form of campaign. In the United States, most Iranians comply with safety laws such as wearing seat belts and using child seats and restraints.

Nutrition MEANING OF FOOD

Food is a symbol of hospitality and kinship. Iranians pre- pare their best dishes and insist on the consumption of several servings. More food than necessary is prepared and presented to preserve public face and to show respect. Tea is the hot beverage of choice and is offered with cubed sugar, dates, pastries, fruits, and nuts.

COMMON FOODS AND FOOD RITUALS

Iranian food is flavorful, with a lengthy preparation time. Working immigrants have created shortcuts and healthier versions of traditional recipes. Presentation is important. At any given table, a pleasing mixture of foods of different colors and ingredients, composed of a balance of garm (hot) and sard (cold) (see Dietary Practices for Health Promotion), are usually served. Tea, fruit, and pastries are served both before and after each meal. Iranians prefer fresh ingredients, although cost and availablity are deter- mining factors. Canned, frozen, and fast foods are per- ceived to be less nutritious and contain preservatives harmful to health and well-being. Eating fast food is less common, especially among older immigrants, mainly owing to poor nutritional value, associated cost, and taste preference.

The most common carbohydrates are rice and sheet breads (wheat and white). The art of preparing rice is the measuring stick of a good cook. Long-grained white rice is preferred. The bread of choice is flat like lavash or pita. Corn and potatoes are used but are less favored. Beans and legumes (e.g., pinto, mung, kidney, lima, and green beans; and split and black-eyed peas) make up a high pro- portion of the dietary intake and are commonly used in rice mixtures.

Dairy products are dietary staples, particularly eggs, milk, yogurt, and feta cheese. Dairy by-products, such as doog, yogurt soda, and kashk, milk by-product, are other favorites. Meat and protein choices are beef, lamb, poul- try, and fish. Shellfish is also consumed, but it is a regional favorite of Iran’s southern region. Fresh fruit is always found in Iranian homes. Green, leafy vegetables are used in cooking, and herbs such as parsley, cilantro (corian- der), dill, fenugreek, tarragon, mint, savory, and green onions are served fresh at a meal or included in stews served over rice.

Similar to Judaism, Islam has a strict set of dietary pre- scriptions, halal, and proscriptions, haram. Slaughter of poultry, beef, and lamb must be done in a ritual manner to make the meat halal. Strict Muslims avoid pork and alcoholic beverages; a few avoid shellfish. Historically, pork was prohibited for hygienic reasons. Compliance with proscriptive food and beverage items is seen less fre- quently among the younger generations.

Health-care providers can make simple adjustments to accommodate traditional food practices of Iranians by making provisions for home-cooked meals or identifying more appealing foods on the hospital menu. One of the authors (Hafizi) noted by experience that hospitalized Iranian older people would identify and select one or two food items for the duration of their stay and greatly appreciated any form of spice to add flavor to their hospi- tal meal. A simple slice of lemon or a cup of hot tea are pleasing items.

DIETARY PRACTICES FOR HEALTH PROMOTION

Based on humoral theory, Iranians classify foods into one of two categories, garm (hot) and sard (cold). The categories sometimes correspond to high-caloric and low-caloric foods. The key to humoral theory is balance and moderation. The belief is that too much of any one category can cause symptoms of being “overheated” or “chilled.” Therefore, symptoms are treated by eating foods from the opposite group. Becoming overheated is manifested by sweating, itching, and rashes as a result of eating too many walnuts, onions, garlic, spices, honey, or candy. Conversely, the stomach may become chilled, causing dizziness, weakness, and vomiting after eating too many grapes, rhubarb, plums, cucumbers, or too much yogurt. Susceptibility is believed to be gender- dependent. Women are more susceptible to sardie, caused by eating too much cold food, than to garmie, a digestive problem from eating too much hot food. Health-care providers may need to incorporate Iranian foods and dietary practices into health teachings in order to improve compliance with special dietary restrictions.

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VIGNETTE 14.1

The diabetic nurse educator is teaching Mrs. Bahrami, a newly diagnosed insulin-dependent Iranian immigrant aged 65 years who immigrated from Iran in 1986. She has three adult children who live independently of their parents; two are attending college in another state and the oldest is work- ing as a pharmacist. Mr. Bahrami, aged 72 years, is a retired educator who is experiencing a new onset of mild dementia. The family lives in a neighborhood with minimal access to Iranian markets. The family owns an automobile and Mrs. Bahrami is able to drive; however, her husband has lost his driver’s license owing to his health condition.

1. What specific cultural communication strategies should the nurse use in teaching Mrs. Bahrami about her diabetes?

2. How would you go about assisting Mrs. Bahrami with balancing her diabetic diet with garm and sard food properties?

3. What problems do you foresee with transportation for food purchasing and appointments with her physician?

4. If Mrs. Bahrami cannot afford or find fresh foods that she prefers, what might the nurse suggest?

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

Economic problems and unemployment in Iran have made certain foods unavailable, resulting in an increased incidence of protein and vitamin deficiencies. Although influenced by food marketing campaigns and younger people who have traveled abroad, the older generation’s basic food beliefs remain mostly unchanged. Almost all ingredients used in Iranian cooking are available in Middle Eastern markets or via the Internet. The same is true for medicinal herbs. Health food stores stock some of the items but at a higher price.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

Iran adopted a national family planning program in 1967 at a time when traditional values and low literacy pre- vented people from clearly understanding the impact of rapid population growth. High fertility was valued for reli- gious and economic reasons and as insurance against potential loss of children and poverty in old age. In 1989, the plan was revitalized by the Islamic Republic; however, this time the populace was markedly educated and urban- ized, and the plan was fully supported by the religious and political leaders. As a result of this plan’s evolution over the years and a combination of modern and traditional con- traceptive use, the fertility rate is on the decline (Mehryar, Roudi, Aghajanian, & Tajdini, 1997). Vasectomies are slowly beginning to gain acceptance.

Traditional Iranian beliefs and practices are influenced by Galenic or humoral medicine, particularly with regard

to hot and cold temperament and the conditions of preg- nancy and birth. Menstrual blood is believed to be unclean; therefore, menstruating women refrain from participating in religious activities and intercourse. Menstruation is also considered a time of great fragility for woman.

Historically, infertility was blamed on the woman. Baluch, Al-Shawaf, and Craft (1992) found that reasons for seeking infertility treatment differed for men and women: Men wanted children to ensure future support, and women wanted to fulfill social expectations of having babies, especially early in the marriage.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Food cravings during pregnancy are believed to result from the needs of the fetus; thus, cravings must be satis- fied. Women generally avoid fried foods and foods that cause gas; fruits and vegetables are recommended, with special attention given to the balance of hot and cold. Heavy work is believed to cause miscarriage. Sexual inter- course is allowed until the last months. The pregnant woman receives considerable support from female kin both during the pregnancy and postpartum.

During the birthing process in the more traditional families, the father is usually not present. The choice for delivery is mainly based on the medical status of the mother and child. The postpartum period can be as long as 30 to 40 days. Some families believe in keeping an infant home for the first 10 to 15 days, after which time, the infant is strong enough to handle environmental pathogens. The more-acculturated families utilize mother and child education classes to prepare for delivery, but their choices greatly depend on the assistance of close family and friends.

Death Rituals DEATH RITUALS AND EXPECTATIONS

Family members and friends gather to support the dying person and one another. Among devote Muslims, the deathbed, or at least, the patient’s face, is turned to face Mecca. In the 1980s and early 1990s, Muslim burial ser- vices were few and scattered. In some instances, family members assisted in preparing the body for burial. This is less common because more facilities have been estab- lished to handle the many rituals of preparing a body for burial. For example, when using soap and water, washing proceeds from the head to the toes and from front to back. The body is then wrapped in a special white cotton shroud while prayers are read.

Death and dying is an anticipated and expected process in the cycle of life among Iranianas (Emami et al., 2001). In a fatalistic culture and Islam, the locus of con- trol is outside one’s power and ability, commonly referred to as the will of God. Withdrawal of life support may be considered as “playing God.” However, there may be no objection to beginning life support, viewing it as a gift of medical technology (Klessig, 1992). As cultural meanings

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and practices evolve over time, so will one’s perception of health and illness; therefore, assessing the patient and the family’s beliefs within the context of life changes and experiences is essential (Emami et al., 2001).

No specific religious rules against autopsy exist. How- ever, the reason to proceed must be clear and legitimate; some families may still refuse. In Iran, embalming is not practiced, and coffins are not used. The body is buried quickly and directly in the earth to facilitate the transi- tion from “dust to dust.” Cremation is not practiced in Iran. It is unlikely for Iranians outside of their mother country to practice cremation.

RESPONSES TO DEATH AND GRIEF

Loss of a loved one is met with strong and expressive grieving among family and friends. Death is perceived as a beginning in which the mortal life gives way to the spir- itual existence and unification with God.

After burial, relatives, friends, and acquaintances gather on the 3rd, 7th, and 40th days. Special foods are served, and grieving may be expressed outwardly and loudly. Attendance at funerals is a sign of caring as well as a socially expected way to pay respect to the dead and to support survivors. Black is the customary color for cloth- ing. On the anniversary of the death, the family gathers again. Some families donate money to charity in lieu of a ceremony. In either case, relatives observe the date by vis- iting the gravesite, especially on the first anniversary. Spouses or parents regularly visit the grave site.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

Islam exerted its influence on Iran and its culture in terms of temporality, fate, and dietary practices (Pliskin, 1987). However, certain culturally embedded norms, such as family loyalty and respect for older people, transcend reli- gious and ethnic boundaries. During the month of Ramadan, individuals fast from sunrise to sundown, although pregnant women, the young, older people, and those who are ill are exempt from fasting. The beliefs and practices of Jewish, Christian, and Baha’i Iranians may be significantly different and must be specifically addressed.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

Family, friendship, and social support are sources of strength and comfort, particularly in times of illness or crisis (Omeri, 1997). Iranians are highly affiliative and thrive on social relationships. Given the importance of such contact, health-care providers may need to adjust visiting policies.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Tagdir means God has power over one’s fate in life and death. The belief is more characteristic of older immi- grants than the younger ones. Hafizi’s research (1990)

illustrated this concept and the integration of religion and health. In the words of a highly educated and devout Muslim man:

To ask me what health means is to ask me how I see myself in relation to God, my family, the society as a whole, and my relation to my material body. Man is the embodiment of the unworldly being. To excel through this journey, the body and spirit work as a unit. The mortal life represents only one stage of this voyage, while death another. Death is not the end, death signi- fies one’s “graduation” to a higher level. I believe in God and His plan for the future. Simply said, being sick is not having a cold; rather it is not having the vision and the ability to deal with the cold (Hafizi, 1990).

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

Traditional Iranian health beliefs and therapeutic prac- tices are a combination of three schools of medicine: Galenic (humoral), Islamic (sacred), and modern biomedicine. In classic humoral theory, illness arises from an imbalance, excess or deficiency, in the basic qual- ities, hot and cold or wet and dry. The purpose of treat- ment is to restore balance. The Galenic-Islamic tradition of humoral medicine is widely practiced throughout Iran and continues to influence the beliefs of the immigrant population. In Galenic thought, every individual has a distinctive balance of four humors, or mezaj, resulting in a unique temperament, or tabi’at. An emotional upset can cause physical illness and vice versa. Climate and weather are believed to significantly affect health. For example, wetness and wind are avoided. Ears might be covered on a windy day because wind is believed to cause earache or infection. Sacred medicine is from the Qur’an and hadith, in which holy men are considered healers. The sacred tra- dition includes beliefs in the evil eye and jinns as evil spir- its. Healing is reached through manipulating impurities or by prayers.

Among Iranians, narahati is a general term used to express a wide range of undifferentiated, unpleasant emo- tional or physical feelings such as feeling depressed, uneasy, nervous, disappointed, or generally speaking, not well. Iranians often use somatization to communicate emotional distress. In doing so, they construct an illness that is culturally sanctioned and socially understood. The stressor can be personal, social, spiritual, or psychological. Narahati allows individuals to distance themselves from the actual problem while putting the responsibility and focus on the metaphoric body. Because Iranians generally shy away from overt expressions of “personal self,” the “somatic self” becomes a focal point in the health-care encounter. The concepts of zaher (and baten) once again manifest themselves in the health arena, creating a safe communication tool. The ritual of ta’arof creates the same safety zone in social, nonmedical interactions.

Somatization is also expressed in a cultural syndrome called ghalbe gerefteh (narahatiye ghalb, or distress of the heart). Good’s classic study (1977) in rural Iran found that two-thirds of women of all ages reported experiencing

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heart distress, the same proportion found in Lipson’s study (1992) of immigrants in California. Heart distress was attributed to having great sadness, being homesick, or having problems that are overwhelming or seem impossible to resolve. One woman stated, “I get it when I read Persian newspapers about the situation in Iran.”

A widespread belief among Iranians is that fright or being startled by bad news negatively affects health out- comes. Symptoms caused by fright range from mild to extreme fatigue accompanied by chills and fever. When appropriate, identify the family spokesperson for commu- nicating matters of grave concern, because losing hope is the greatest illness.

In some instances, a sudden ailment may be attributed to the evil eye, cheshm-i-bad, the belief that negative thoughts and jealousy can cause illness. Cheshm-i-bad can be the result of an intentional or unintentional thought projection. Acculturated immigrants use the terminology in everyday speech and encounters; however, most do not fully believe in the concept.

Cheshm-i-bad and other folk syndromes are better understood by viewing the body in the context of its social and supernatural environment. Similar to somatiz- ing, which distances an individual from the actual prob- lem, cheshm-i-bad attributes illness to an outside person or force. In reality, the evil eye gives meaning to an occur- rence of puzzling origin and puts the blame on something other than the affected person.

Hafizi’s research (1990) found that Iranians’ concepts of health represented two of Smith’s (1983) four domains: the clinical view, health as absence of disease, and the adaptive view, health as the ability to cope successfully. Healthy people are able to cope successfully with their changing world and have a harmonious exchange between available resources and their ability to use them. Health is a lifestyle marked by demands and adaptations (Hafizi, 1990). Similar health concepts were found among older Iranian people in Sweden (Emami et al., 2000).

Iranians accept both biomedical diagnoses and cul- tural illness categories. The concept of the body is viewed in relation to its total environment: society, God, and the supernatural. When someone has a discomforting symp- tom, the first question is often whether she or he ate something that did not agree with her or his mezaj, humoral temperament. If the answer is no, then other causes are explored.

RESPONSIBILITY FOR HEALTH CARE

Iranians often seek treatment relatively soon after the onset of symptoms. If within their ability, they will “shop around” until they find a provider of choice. They will seek advice from acquaintenances or family in the med- ical field and will use home remedies for symptom man- agement.

Self-medication, prescription, over-the-counter, and homemade herbal remedies are commonly used simulta- neously. Antibiotics, codeine-based analgesics, mood-alter- ing drugs in the benzodiazepine family, and intramuscular vitamins are available over the counter in Iran. Immigrants commonly bring these medications for personal use. Medication self-adjustment is also a common practice,

especially when finances are an issue or symptoms are not resolved. Health-care providers should carefully consider dosage and medication type. In some instances, because of previous inappropriate use, a first-generation antibiotic may not affect the microorganism because of inappropri- ate and repeated use.

When ill, Iranians are more inclined to be passive and to seek care and attention from family members. The patient may behave passively, while the family appears demanding. This unceasing and, at times, overbearing attention is an expected behavior for caring. If a patient is hospitalized, visiting is frequent, sometimes excessive according to some. Dealing with the patient’s right to pri- vacy and the good intentions of the visiting relatives is a balancing act.

Two cultural traits among the more-traditional and less-acculturated immigrants can complicate help-seeking behaviors. Ta’arof may keep patients from sharing their personal feelings. Zaher, a social façade of decorum and composure to hide one’s unwanted negative feelings or attitudes, may further preclude the communication nec- essary for a meaningful assessment. More-acculturated immigrants tend to be more open and direct.

FOLK AND TRADITIONAL PRACTICES

Herbal remedies are used in a complementary manner to prevent illness, to maintain health, and to manage symp- toms. Iranians believe strongly in combination therapy. Herbal remedies became increasingly popular in post- Revolutionary Iran because of the economic embargo and scarcity of biomedical supplies.

Common herbal remedies include dried flowers, seeds, leaves, and berries steeped in hot or cold water and drunk for digestive problems, coughs, aches, and pains, fevers, nerves, or fear. Some common herbal medications include gol-i-gov zabon, dried foxglove flowers, for digestive problems or nervous upsets, which is sometimes taken with nabat, a concentrated sugar (Lipson, 1992). Khakshir (flat, brown rocket seed) is used for stomach problems; razianeh is used for halitosis; quince seeds are sucked or used to create a thick syrup with hot water for sore throats; and sedr is used to pre- vent or treat dandruff.

BARRIERS TO HEALTH CARE

Lack of adequate language skills, inadequate financial resources, lack of insurance, immigration status, and lack of transportation are the top five barriers for accessing health care for most Iranians. Physicians and nurses should work with social workers and community agencies to help decrease these barriers.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

Iranians are expressive about their pain. Some justify suf- fering in the light of rewards in the afterlife. For example, the grandmother of a young women with a slow-growing brain tumor consoled herself and her granddaughter with the statement that “suffering in this world assures her a place in heaven.”

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Mental illness is highly stigmatized and is believed to be genetically predisposed. Mental illness is likely to be called a “neurological disorder” or narahati-e-asa’b in order to emphasize the physical ailment. Bagheri (1992) found that Iranians consider psychopharmacological treatment to be most effective for somatic illness.

Iranian immigrants experience numerous stressors related to resettlement in a foreign culture. As measured by the Health Opinion Survey, 44 percent of Lipson’s (1992) newer immigrant interviewees experienced medium or high stress compared with 14 percent of the long-term-res- ident group. With reference to mood, about 35 percent of the informants answered yes when asked if they consid- ered themselves to be “nervous,” and about the same per- centage stated that they did not have “peace of mind.” The reasons were adjusting to their new life in the United States, missing family members, and having concerns about relatives left behind. Despite these problems, most Iranian immigrants had no plans to seek counseling or treatment, preferring to rely on family support (Lipson & Meleis, 1983). However, in recent years, psychotherapy and counseling have become acceptable treatment modal- ities, particularly in dealing with children (Sayyedi, 2004).

Since the return of the injured soldiers from the Iran- Iraq war, physical disability has begun to receive atten- tion. Before then, the handicapped and the mentally challenged were kept at home with few care and treat- ment options. The outcome of the war and the World Health Organization’s Year of the Disabled stimulated Iran to promulgate the civil rights of people with disabili- ties and to guarantee access to health care. Today, physi- cal therapy and art and music therapy are used as adjunct treatments.

VIGNETTE 14.2

Mrs. Rastinpour is a 46-year-old Iranian immigrant. On admission, she self-identified as being Jewish. She and her family (immediate and extended) immigrated to the United States in 1981. She is 2 days’ postoperative for mitral valve replacement and is scheduled for discharge in 2 days. Her wound is healing well. She has a clear understanding of her plan of care at home. Today, the nurse noticed a degree of anxiety, especially when discussing discharge plans. When the nurse approached her, she became tearful. Mrs. Rastinpour assured the nurse that both her children are a great help and that they have a complete understanding of her lim- itations. When the nurse asked about her husband, Mrs. Rastinpour avoided eye contact and squirmed in her chair, stating her husband is super busy with business; her close friend and the many relatives will gladly fill in the gap. Later that day, the nurse discussed her concerns with the discharge coordinator. The day of discharge, while meeting with the coordinator and Mr. and Mrs. Rastinpour, the nurse asked Mr. Rastinpour if he had any particular concerns or questions that had not been addressed. Mr. Rastinpour angrily replied, “Since my wife has been cut, she is now imperfect. I refuse to share my bed with any woman who has a scar on her chest.”

1. What cultural versus personal issues might exist between Mr. and Mrs. Rastinpour?

2. What recourse does the nurse have with Mr. Rastinpour’s comment made on discharge?

3. What religious issues might be present? 4. Should the nurse get the Rastinpour children involved

at this stage? 5. How might the nurse determine the role of extended

family and friends in the care of Mrs. Rastinpour?

BLOOD TRANSFUSIONS AND ORGAN DONATION

Blood transfusions, organ donations, and organ trans- plants are widely accepted among Iranians. In Iran, dona- tion of organs has become a business transaction—if a kidney is needed, it can be purchased (Zargooshi, 2001).

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

Iranians appreciate state-of-the-art facilities, high-techno- logical equipment, and skilled professionals. At the same time, the expense of health care is a widespread concern. Immigrants are confused by differences in the mannerisms and attitudes of the health-care providers in Iran versus those abroad. According to one woman, “Doctors here don’t listen to you, they are always careful of malpractice; they don’t want to be specific” (Lipson, 1992). Many Iranian clients expect to receive a prescription for medication and quick results. Iranian women are modest in front of men; if possible, male health-care providers should not ask women to undress fully for an examination or procedure.

STATUS OF HEALTH-CARE PROVIDERS

Religious and folk practitioners are generally not sought by most Iranian immigrants. The most respected health- care provider is an educated and experienced male physi- cian. In Iran, medical imaging equipment, such as com- puted tomography scanners, is scarce. The government of Iran has supported medical school admissions based on influential kin rather than merit; therefore, graduates are of mixed quality.

Nursing as a profession in Iran remains in its infancy. Nurses are accorded less respect compared with physicians and, as a whole, receive mixed reviews. Whereas nursing education has evolved from an apprenticeship to a bac- calaureate degree, nurses are still striving for acceptance and recognition as professionals (Nasrabadi, Lipson, & Emami, 2004). Immigrants have repeatedly stated that nursing care in the United States is far more interactive, communicative, and people-oriented than it is in Iran.

VIGNETTE 14.3

Hamid, his pregnant wife, Jaleh, and their two children moved to the United States within 5 years of the 1984 revolu- tion. The third pregnancy was problematic, and without the support of her sisters and mother, Jaleh’s recovery has been

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slow and troublesome. Jaleh is 2 months’ postpartum, but her mental and physical states have continuously declined. She feels their situation is worse than what they would, and could, have had if they had remained in Iran. Hamid works long hours and is rarely home before 8 p.m. The family lives in a neighborhood isolated from friends and family.

Unfortunately, as Hamid continues to work harder and longer, Jaleh becomes even more depressed and nonattentive to the three children. Hamid has decided to seek help from a friend, but the friend is so concerned that he has convinced Hamid to have Jaleh admitted to the hospital and assessed for depression. The nurse assigned to Jaleh notices that Hamid and the three children, ages 10 and 8 years and 2 months, are nearby. Hamid is overtly upset, the two children are holding hands, and the baby is starting to fuss.

1. Should the nurse talk with Jaleh alone or with the fam- ily present? Why? Why not?

2. How might the nurse develop a trusting relationship in order to ask Jaleh personal questions?

3. How might Jaleh perceive her changing behaviors and mood?

4. What is the name of the Iranian concept of depression and how is it explained from a cultural perspective?

5. What should the nurse do with Hamid and the children while the nurse is admitting Jaleh?

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