Culture-Sensitive Health Care: Middle Eastern-American Patients
Keys to Establishing Successful Relationships with Middle Eastern American Patients
This section summarizes the cultural and health care behavior and beliefs of the diverse groups of people often referred to by the general term "Middle Easterner". These groups include Arab and Iranian Americans (see list below). While Egyptian Americans speak Arabic, both their language and culture are as different from other Arab groups as the British are from Americans. Most of both groups are of Semitic origin. Armenians and Assyrians who have immigrated (or are descendents of immigrants) from Arab speaking countries have not been included in this chapter because most have maintained their ethnic and cultural ties with Armenia and Assyria. Iranian-Americans, speakers of Farsi (sometimes called Persian) of Indo-European rather than Semitic origin have been included because of the strong cultural similarities between these groups. Israelis, who also come from the geographic area referred to as the Middle East, have not been included in this chapter.
The table below lists the countries of origin of the cultural groups living in the United States that we loosely refer to as Middle Easterners. It lists the primary languages which are spoken by each of these groups, and the major religions practiced in each of these regions. In spite of similarities in culture and health beliefs and practices, caregivers are advised to inquire about the patient's country (and, when appropriate) language of origin as a first step in establishing a successful relationship. Although the chart illustrates that the majority of Middle Easterners are Muslim, many are also Christian, Coptic Christian, or Jewish. As religious factors may play an important part in health believes and practices, caregivers should not assume that every Middle Eastern patient is a follower of Islam.
Values Which Influence Lifestyle, Attitudes, and Behavior Toward Health Care Providers
Trust as a Result of a Personal Relationships
Family ties are the most important relationships for most Middle Easterners. These relationships form the first source of support and advice during any illness and the core of the sick person's coping strategies. Anyone outside this "inner circle" - including health professionals- is often viewed with distrust. However, it is fairly easy for a caregiver to move from the position of stranger to trusted affiliate. Once this relationship is established, it may also elicit requests and expectations from the patient and his or her family that will seem "out of bounds" to most Western caregivers.
Trust is established only when a personal relationship is formed between the caregiver and the patient and his or her family. People are judged not so much as individuals, but as members of families, groups, professional organizations, and even universities. Therefore, it is important for the Middle Eastern patient to be able to "place" the caregiver in one or more of a trusted or known group. A caregiver who takes the time to "warm-up" the patient by exchanging a few questions about his or her personal life and family and discloses some personal information, will develop a positive relationship much sooner than one who limits discussion to the purpose of the visit.
The sharing of food and drink is also an important means of establishing trusting relationships. The caregiver who offers the Middle Eastern patient a cup of tea during the visit or who accepts a gift of a Middle Eastern sweet will establish a positive beginning. Note: If offered a cup of tea, the patient is likely to refuse the first offer. This is because it is considered impolite to accept the initial offer of food or drink. It is important that the offer be made a second or even a third time.
The development of a personal relationship with a Middle Eastern patient is time consuming and a successful appointment will take longer than with many other patients. Appointment schedules should be arranged accordingly.
The immediate and extended family forms the most important social institution in the Middle East. Parents are expected to care for children until they are married and children are not only expected to remain in close contact with parents after marriage but also to care for aged parents as long as they live. The family structure is patriarchal in form and even adult children are expected to submit to the father's authority.
This close family structure often breaks down when Middle Easterners immigrate to the United States. Family members often live far from one another and the close multigenerational family unit is dismantled. As a result, children become more independent and aging parents often experience a strong feeling of isolation and abandonment.
Communicating Medical Problems to Caregivers
Middle Easterners are very modest and value privacy and, therefore, have a strong resistance to disclosing personal information to strangers. They are likely to resent as a gross invasion of privacy the physician's history and physical or the health assessment upon admission to a hospital. This resistance can be overcome once a more personal relationship is developed, and therefore, the caregiver should avoid soliciting information not needed immediately.
In addition, when providing medical information, patients are often vague not only due to language difficulties, but also because there is little distinction between mental and physical states. There is also a lack of experience that would help Middle Easterners to describe signs and symptoms in relation to specific parts of the body.
These difficulties are compounded by a view of the caregiver as an authority figure. The patient tends to remain passive in the physician's presence. This desire to show "proper respect" includes refraining from asking questions or presenting any information that might challenge the physician's authority, including his or her diagnosis. The Middle Eastern patients' tremendous respect for American health professionals also makes it difficult for them to understand the need for tests and (what they consider) irrelevant questions. After all, the physician should have the expertise to make a diagnosis without these things!
Disclosing Medical Information or Bad News to the Patient and the Patient's Family
When medical information is communicated to the patient, it is important to include a family head or spokesperson. This spokesperson is usually the oldest male in the family. If no male is present, the spokesperson may be a female, although females are considered more emotionally susceptible to bad news.
In Middle Eastern cultures, negative information is usually presented in stages. The withholding of a negative prognosis may present an ethical dilemma for American health professionals who commonly disclose a full and truthful diagnosis. However, when treating Middle Eastern patients, it is more humane and culturally appropriate to present a poor prognosis gradually and to incorporate it within the context of other information and events. Patients who are told about a fatal illness often give up hope.
In instances of a grave illness, the family can serve as both a buffer and a clearinghouse for information that it can then "filter" to the patient. In general, there is a belief that to speak of death is to bring it about. Therefore, once the caregiver presents a grave diagnosis to family members, it should not be discussed again. It is also inappropriate to suggest a visit from a religious official prior to death because to predict and plan for death prior to the event is believed to take fate out of God's hands. Because hope is kept alive until the last moment, family and friends will not show their grief at the bedside of a dying patient. They will gather around the patient to give him or her hope. Death is to be accepted as "the will of God Grieving is postponed until after death and though it may be accompanied by loud wailing. To Muslims, death is preordained and life is considered but a preparation for eternal life."
The length of mourning for family and relatives is specifically stated in the Koran as limited to 3 days. A wife may mourn her husband for a period of 4 months and 10 days.
Middle Eastern Orientation to Time and Space
Planning ahead is an American and Western European value "foreign" to Middle Easterners. Middle Easterner's view planning as an effort to "defy" Gods will. It is thought that it can bring on the evil eye or other negative conditions. Because of this fear of "tempting the Gods", it is rare for a Middle Eastern woman to buy clothing or fix up a room for her unborn child, or for the dying person or his or her family to make any sort of preparation for their death. Birth control or other types of family planning are also viewed as going against God's will and "tempting fate. It is considered unlucky and even dangerous to try to interfere with God's plans.
Attitudes Toward and Criticisms of Western Medicine
Western medicine is sought after and practiced in Arab countries and there is a preference for anything from the West. However, in most of oil-rich Arab countries, medical care is free. It is possible to medicate oneself through the availability of over-the-counter pharmaceuticals. The Arab-American patient, therefore, is frequently shocked by and resentful of the high cost of care and the limited number of over-the counter medications available in the United States. Their great respect for physicians as authority figures who should have the expertise and power to make decisions for their patients makes it difficult for them to comprehend or accept the American concept of treatment options or taking responsibility for their own health and choice of treatment. The Arab patient may sign a consent form for a treatment plan or surgical intervention when asked to do so; however the caregiver should not assume that the patient accepts responsibility for the outcome. In there view, this responsibility can only be taken by the medical professionals who have the education to make these decisions.
Germ theory is generally accepted by most members of Arab cultures. However, this belief is often combined with stronger beliefs in the evil eye, bad luck, emotional and spiritual distress, winds and drafts, and a lack of balance in hot and cold (see below), inadequate diet, and exposure of one's stomach during sleep as possible causes for physical illness. Mental Illness is thought to be caused by sudden fears or God's will. Mental health care is usually only sought after all family and community resources have been exhausted. Good health, on the other hand, is seen as the ability to fulfill one's roles and is considered a gift of God.
Hot & Cold Theory of Illness (adopted from the Theory of Humors)
Many Arabs attribute illnesses such as headaches, colds, flu, and other bodily aches and pains to extreme shifts from hot to cold and vice versa. For this reason, Arab-American parents may over-dress their children—even as a precaution for a possible change in the weather. A feverish patient is often covered with many layers of clothing and blankets as a means of maintaining body heat.
Foods are also classified as either hot or cold. It is believed that the digestive system has to be given the opportunity to adjust to a hot or cold food before introducing its opposite. Therefore, there is an effort to avoid eating hot and cold foods during the same meal. Hot and cold, however, do not necessarily correspond to the temperature of the food. For example, honey and walnuts are considered "hot" foods, while cucumbers and yogurt are considered "cold" foods. An inadequate diet is believed to cause weakness or illness and a physically robust person is considered healthier than a thin person.
Arab Americans may attribute the genetic defect of a child to God's will, or as God's test of endurance for the parents. While religious beliefs require the acceptance of these defects, the family may try to isolate themselves or hide the defective child because of social expectations. These children are usually cared for at home rather than in an institution. Genetic counseling may also be refused because it is thought to involve tampering with the will of God.
While it is common for Arab-Americans to seek care when symptoms of illness or disease occur, it is less common for them to seek preventive care. This may result from an Arab reluctance to plan ahead and because of the fear that to "talk about illness is to make it happen." This lack of preventive care is also seen in pediatric clinics which tend to be used by Arab American parents as a place to take children to treat accidents or injuries rather than for child wellness measures. Because male children are preferred, there has been some evidence in poorer families that boys are better-nourished then girls.
Attitudes Toward Fertility and Birth Control
Due to the popular belief that "God decides the size of the family," there are formal Islamic rules regarding the treatment of infertility and birth control. The value placed upon the family and the belief that children are a means of strengthening the family favor high fertility. In fact, among Arab women, infertility can lead to rejection and divorce. Although Islam condones treatment for infertility, the approved methods are limited to artificial insemination of the woman and IVF using the husband's sperm. The use of the sperm of another man is forbidden because it is considered adulterous.
Procreation is considered the purpose of marriage and, therefore, irreversible forms of birth control such as vasectomy and tubal ligation are forbidden. These practices are labeled as haram or absolutely unlawful by Islamic jurists. Abortion is also considered haram unless the pregnancy involves the question of legitimacy or presents a threat to the woman's life, or the risk of a genetic disorder. Although unwanted pregnancies are sometimes aborted covertly, they are often left to a hope for miscarriage.
Childbearing Taboos and Practices
The cravings of the pregnant woman are eagerly satisfied because of a belief that she or the unborn child may develop a birthmark in the shape of the unsatisfied craving. While the pregnant woman is indulged by all, the preference for a male child is often a stressor for the mothers who have no sons. Women who are carrying "high" are believed to be bearing a girl while women who are carrying "low" are believed to be carrying a boy. Practices which may adversely influence the growth of the fetus may include the habit of a woman giving "the best" food to her husband or children, the consumption of large quantities of olive oil, the failure of the woman to stop smoking or to limit the intake of caffeine. Delivery is considered woman's business and in Arab countries home deliveries with the help of a midwife or neighbors is common. One source reported that Iraqi immigrants living in Detroit tended to follow this same practice. Women openly express pain during labor, but do not ordinarily accept breathing and relaxation techniques. Epidural and spinal anethesia are often refused because of fear that it may injure the child.
As in many other cultures, there exists a belief that air may enter a postpartum woman and cause illness if she bathes. There is also a belief that her milk is thinned by washing the breasts. A belief that the postpartum woman must have complete rest in order to recover from the ordeals of labor may delay breast feeding for two or three days. It is also thought by some that nursing at birth causes "colic" pain for the mother and that this condition of the mother can make the baby dumb. Special foods, such as lentil soup, are often given to the mother to increase her milk production; special teas are also drunk to flush and cleanse her body.
It is customary to wrap the baby's stomach at birth to protect the child from cold or wind which are believed to enter the child's body through the stomach. Sometimes the Muslim call to prayer is whispered into the baby's ear. Circumcision of the male child is required by Muslim law.
When postpartum depression occurs, it is often managed through the assumption of the woman's responsibilities toward child and family by other female family members. The mother is simply told that she needs more rest and help.
Arabs feel that pain need not be endured and should be relieved through medication or other measures. Confidence in Western medicine makes Arabs anticipate immediate relief from pain after surgery and they are often confused and disappointed by the discomfort that often occurs postoperatively. This belief combined with the belief that complete bed-rest is necessary for a fast and full recovery often makes Arab patients non-compliant with postoperative ambulatory regimes.
Pain is expressed more freely in the presence of the family than in the presence of caregivers. Therefore, conflicts often arise when nurses assess that pain medication is adequate and the patient's family demands the administration of stronger doses.
Masking of Symptoms of Mental Illness
Because mental illness carries a social stigma, the mentally ill Arab patient is likely to present with abdominal pain, lassitude, anorexia, shortness of breath and a variety of other vague symptoms. These patients are likely to insist upon tonics or vitamins or medications for physical disorders and refuse psychodropic medications. Even when a diagnosis of mental illness is accepted, somatic medications rather than psychotherapy is preferred.
A dying patient's bed is often turned to face Mecca. Family and friends may also read to the patient from the Koran. Sections from the Koran that stress hope and acceptance are particularly favored. After death, the body is washed three times by a Muslim of the same sex and then wrapped in white material and buried as soon as possible. All body orifices are closed and tightly packed with cotton in order to prevent bodily fluids (considered unclean) from escaping. Traditionally, the grave must be made of brick or lined in cement and must face Mecca. Men recite prayers at the grave, while women who are not close relatives or the deceased's wife, gather at the home to recite verses from the Koran. These women do not attend the burial. Cremation is not practiced and autopsy is not usually approved out of respect for the dead and a feeling that the body should not be mutilated. Autopsy for forensic reasons or for scientific research and instruction is allowed.
Spirituality and Health-care Practices
The majority of Arabs are Muslims. A devoted Muslim patient may request that his bed or chair be turned toward Mecca and that he be provided with a bowl for religious cleansing or ablution before prayer. Prayer is not acceptable unless the person's body, clothing, and place of prayer is clean.
Muslims are required to eat wholesome food and abstain from eating pork, drinking alcohol, and taking illicit drugs. He or she is expected to be conscious of hygiene, practice moderation in all activities, and remain faithful in adversity by maintaining faith in Allah's mercy and compassion.
Illness is often viewed as a punishment for one's sins. Allah is considered merciful and compassionate by providing a vehicle for repentance and gratitude. One accepts one's faith as the will of Allah. Euthanasia and suicide are forbidden because they tamper with Allah's will.
Muslim Concepts of Responsibility and Fate
The American view of individual responsibility and control over life's events is in direct opposition to the Arab view of responsibility for health. The family is the context through which health care is delivered. Family members indulge the patient and assume responsibility for all decisions. The Koran puts forth gender-specific role responsibilities for family members.
As stated earlier, the American practice of full disclosure of diagnosis and possible complications is in direct conflict with the Arab physician's practice of withholding information about a grave diagnosis or the full details of a surgical procedure. Preoperative instructions are often withheld in the belief that they will cause needless anxiety. Patients are not usually interested in participating in medical decision making. Medical successes are attributed to the expertise of the physician, while failures are attributed to the will of Allah.
The humoral theory described in ancient Greek texts is the basis of traditional Islamic medicine. Many aspects of life are divided into four: the year is divided into four seasons, matter into fire, air, earth and water, the body into black bile, blood, phlegm, and yellow bile, and the environment into hot, cold, moist, and dry. Each illness is treated with the opposite humor—for example, a hot disease is treated with a cold therapy, a "wet" illness with a dry therapy, etc. Cupping, cautery, phlebotomy are also used, although special prayers or foods such as honey, dates, olive oil, and salt are preferred to these approaches.
The evil eye, the powers of jealous people, supernatural powers such as the devil and jinn are all part of the Muslim culture. The gaze of an envious person gives one the evil eye and is believed to upset the victim's natural balance. Children, especially newborns, are thought to be very susceptible to this and amulates such as blue beads and figures involving the number 5 are often pinned to the infants clothing. The devil is thought responsible for unacceptable wishes, feelings and acts. In this way those that experience them can blame them on the devil rather than themselves. It is interesting to note that the Arabic word for insanity, jenun is derived from the word jinn.
Although Egyptians are Arabs, some of their health beliefs and practices are somewhat different from other Arab groups.
Diseases and Health Conditions in Egypt
Many Egyptians suffer from parasitic diseases. The most common is Schistosoma mansoni or Scistosomahaematobium. These diseases may have human hosts. In human hosts, the female worm expels the eggs which then are carried by the blood stream and become lodged in the liver or urinary tract. The body, which treats the eggs as foreign matter, surrounds the eggs with granular tissue. Some of the results are cirrhosis, liver failure, portal hypertension, esophageal varice, bladder cancer and renal failure may result from these parasites.
Egyptians have one of the highest rates of blindness in the world. Trachoma and other acute eye infections affect 5% of the rural population and 2% of the urban population. Other infectious diseases include typhoid and paratyphoid fevers, streptococcal disease, rheumatic fever, and tuberculosis. Egyptian-American patients who test positive for TB should be questioned regarding whether they have a history of BCG injection.
Recent Egyptian immigrants to the United States are likely to become victims of the host of "modern diseases" now effecting Egypt. Some of these are obesity, hypertension, lower back pain, and cardiovascular diseases resulting from stress, obesity and lack of exercise. Type II diabetes, another more recent disease affecting Egyptians, is likely to be exacerbated by obesity.
Egyptians are at genetic risk for b-thalassemia. This can be detected through carrier screening and prenatal diagnosis.
High Risk Behaviors of Egyptian Americans
Although the importance of regular exercise has recently been publicized in Egypt, it is not part of the life-style of adult Egyptians or Egyptian Americans. Food is an essential part of the Egyptian social system and Egyptians develop trust through sharing a meal together. Traditional food is rich, high in fat, sodium, and sugar. This, and a sedentary lifestyle based upon overindulgence in food has contributed to premature deaths due to massive heart failure. Overeating is also encouraged by other beliefs. Because food is associated with health, many Egyptian-Americans believe that the more food one eats the greater the potential for health. This causes parents and relatives to overfeed their children. Food is also associated with both the ability of the head of the family to feed his family and with caring and nurturing. Thus families take pride in the amount of food made available to their family. Food is also considered a demonstration of generosity and the giving and sharing of food demonstrates friendship.
Whereas in Egypt, meat dishes were accompaniments to the main vegetable dishes, in the United States this custom has been reversed. The Egyptian-American meal is made of one or more meat dishes with accompanying vegetables and rice. The drinking of tea became popular during British rule. However, unlike the English, most Egyptians sweeten their tea with two or three teaspoons of sugar.
Stomach and intestinal problems such as heartburn, flatulence, constipation and hemorrhoids and fecal impaction may be caused from limited roughage, lack of fluids, and rapid consumption of foods. Because Egyptian-Americans place great stress on the need for regularity, they tend to push and strain to achieve a bowel movement.
Some Egyptian-Americans avoid drinking water and fluids with meals because they believe that all liquids displace the volume available for solid nutrients or dilute the stomach "juices" causing indigestion by making digestion more difficult.
Family Planning, Pregnancy and Childbearing Practices
Birth control and family planning are never advocated before the birth of the first child because no Egyptian family is considered complete before a child is born. While the desirable family size in urban Egypt is three or four children, the majority of Egyptian-Americans desire a family comprised of two to three children. Families are under stress until their first child is born. Women are threatened with the possibility of divorce if they don't conceive during the first year of marriage—even if the husband is the cause of temporary or permanent infertility.
Shopping for Quality Medical Care
In Egypt, medical care is free or available at a low cost. However, it is believed that good medical care can only be obtained by shopping, bargaining, and negotiation. When they arrive in the United States Egyptian-Americans try to join an HMO or purchase health insurance. Some have to postpone the purchase of these services until they achieve financial security. When a health problem develops, family members and friends are usually consulted prior to a health professional. Once they do enter the health system, they tend to demand immediate, personalized attention. They believe in the value of medical tests and expect to be given medical regimens and prescriptions, which they tend to follow carefully. They prefer to be given medications and injections but tend to be skeptical of medical advice involving weight reduction, exercise and diet restrictions. Self-medication is often practiced and the Egyptian-American's medical cabinet is often filled with antibiotics, tranquilizers, sleeping pills, and pain medications. These are often shared with other family members and friends. Because many of the medications familiar to Egyptian immigrants are unavailable in the United States without prescription, they are often brought from Egypt by family and friends. Inter-muscular vitamin injections are preferred over vitamin pills. In Egypt, vitamin B complex injections and iron suppliments were common forms of self medication.
The American system of meticulous diagnostic approaches may be viewed by some Egyptian immigrant patients as proof of lack of expertise or knowledge. Therefore, they may shop around for a physician who lives up to their cultural expectations of a quick authoritative diagnosis. Others may interpret the need for tests and other resources as an indication of the gravity of their illness.
Gender Based Preferences
Egyptian Americans who immigrated to the United States before the wave of Islamic Fundamentalism may not make gender an important consideration in the choice of a health care provider. Later immigrants will prefer same gender providers.
Care of Iranian-American Patients
Although Iranians come from the geographic area of the world referred to as the Middle East, they are not Arabs because they are of Indo-European origin and the primary language of the country is Farsi or Persian rather than Arabic. Iran is an extremely heterogeneous country, with nearly half of the country belonging to other ethnic and linguistic groups. Some of the other languages common to Iran are Turkish, Armenian, Baluchi and Kurdish. French is used as the language of culture and English as the language of business.
Although there had been previous Iranian immigrations to the United States the largest took place after 1979, as a result of the Iranian revolution. Between 1980-1990, an estimated 800,000 Iranians of very diverse social, religious, and economic backgrounds immigrated to the United States. Iranian immigrants may be of the university educated middle class and include physicians, pharmacists, nurses, engineers, professors and lawyers. Others may be grammar-school educated merchants and artisans. Some were able to bring their own money and started businesses in the United States, others lost all their resources upon leaving Iran.
Although Iranians share many cultural and health/illness, and illness-prevention practices with Arab peoples, a number of these are unique to those who immigrated from Iran. The most important of these are discussed below.
In Iran, a number of health problems exist that are common to developing countries such as protein and vitamin deficiency, hepatitis A & B, and high rates of TB and syphilis. Other problems caused by interfamily marriages such as epilepsy, blindness, anemia, hemophilia and birth defects are becoming increasingly rare. Thalassemia, once prevalent in northern and eastern provinces, is being addressed through premarital screening. Other common problems are vitamin B12 or folic acid deficiencies and Mediteranean glucose-6-phosphate dehydrogensase deficiency.
Some of the primary problems of Iranian immigrants to the US are stress-related and are due to culture conflict and loss, homesickness, and the stress of living under revolutionary conditions. These are discussed in a section below.
Although Islam prohibits the consumption of alcohol, many Iranians are not religious and drink socially. A low level of acculturation and a sense of helplessness experienced by some Iranian immigrants especially among men sometimes leads to misuse of alcohol.
As for other Middle Easterners, food is a symbol of hospitality. The presentation of Iranian dishes (which usually take hours to prepare) involves a pleasing mixture of colors, textures and ingredients. The freshness of foods is important and canned, frozen, and fast foods are avoided because the are believed to have less nutritional value and contain preservatives which can be harmful to health. Tea is served with every meal and fresh fruit and green leafy vegetables and fresh herbs are important features of the Iranian diet.
Traditional Health Beliefs and Practices
Traditional Iranian health beliefs are strongly influenced by the same humoral theory described in the previous section. When someone feels ill, he is first asked whether he has eaten something that did not agree with his mezaj (personal humoral temperament). Other causes are explored if the answer is no.
Fertility, Pregnancy, and Childbearing Practices
According to Iranian tradition, the man contributes his seed and the woman provides the vessel in which the seed grows.
Menstrual blood is considered ritually unclean and physically polluting and menstruating women are forbidden to touch holy objects or to have intercourse. Women are not supposed to exercise or shower excessively during menstruation because they are thought to be fragile and susceptible to hemorrhage. At the end of menses and prior to participating in any religious rituals, women are expected to wash and purify themselves. Pregnancy soon after marriage is considered desirable, not only to make the family complete, but also because of the belief that a woman's body is polluted by menstrual blood until she has her first child.
Because Iranians believe it is necessary for the woman to discharge blood monthly, Iranians discourage the use of any form of birth control which decreases the menstrual blood flow.
Prior to the revolution in 1979, birth control was rarely used in rural areas because children insured the financial success of the family. In instances of infertility, the woman was always blamed. It was thought that fertility depended upon the health of the uterus and home remedies focused upon ways of improving the health of the uterus. After 1979, contraception was discouraged because of the Islamic belief that children are God's blessing. One traditional method of birth control was prolonged breast feeding. The desired number of children for an urban educated Iranian family is 3 to 4 children in Iran but only 2 to 3 children for Iranians living in the United States.
The cravings of a pregnant woman are thought to represent the need of the fetus for those foods. Failure to satisfy these needs is believed to cause the child to be born with a birthmark in the shape of the food that was craved.
Sexual intercourse is allowed until the last month of pregnancy. Because heavy work is believed to cause miscarriage, the pregnant woman receives a great deal of help and support from female relatives - including relief from household chores from the sixth month of pregnancy through the months immediately after giving birth. During pregnancy the woman avoids fried foods and those that are believed to cause gas. Fruits and vegetables are recommended.
It is common for the woman's mother, sister, or aunt to be present during birth. Shouting and expressing pain fully prior to delivery is common. Natural childbirth is favored and Iranian women in the United State are generally agreeable to Lamaze classes. Although in traditional Iranian families, the husband is not involved during birth, in the United States Iranian families follow the diverse practices of the dominant culture. Some women involve their husbands fully in the birthing process with some expressing a preference for natural childbirth and others for medication.
Breastfeeding is usually preferred over bottle feeding and is mixed with solid food at about 4-6 months of age. Breastfeeding may last as long as one year and is not usually mixed with bottle feeldng unless the mother is working outside the home.
Narahati is the Iranian word for feeling depressed, ill at ease, nervous, inconvenienced or anxious. Iranians sometimes express the cultural and social losses associated with war and immigration through somatization. Others may manifest such losses psychologically through either withdrawal or expressions of anger. Narahati is expressed non-verbally through one of the following 3 ways:
Often narahati is camouflaged because of a feeling of personal powerlessness, a belief that it results from fate and therefore one can do nothing about it, or a fear that an expression of one's own narahati will make someone else narahati.
Where anger is considered unacceptable because it disrupts social life, sadness is accepted as a profound condition. The adjective for angry in Farsi, asaabani, is derived from the Arabic word asab, which means "nerve", rather than "nervous". In other words, it signifies that the nerves are not functioning properly because to be angry is to be out of control. Being out of control could cause personal or familial embarrassment or shame. Showing insensitivity to others may cause narahat. Anger , in Iranian socieity is a somatopsychic phenomenon. It has social causes and very definite social repercussions. Ghamgini is the Iranian word for sorrow or sadness. It cannot be camouflaged because it is visible (omit) displayed on the person's face. This sense of sadness is considered an almost poetic condition in Persian culture and is thus accepted. It indicates a loss. This loss can be a person, livelihood, country. It is a private emotion which is publically expressed.
Narahati and anger are somatized when they cannot be expressed (verbally or non-verbally) in socially appropriate ways. In these cases, the body becomes a metaphor for personal distress. In this way the person can distance him/herself from the personal problem and can be absolved of responsibility for them. Common physical complaints such as chest pains, stomach aches, other digestive problems and pains in the limbs are acceptable, but it is not acceptable to express personal narahati.
Suggested Approach to Somatization
Iranian refugees suffer from a variety of physical and somatized ailments. These may be expressed in a number of culturally distinctive ways. Patients may complain in a high pitched voice of pains or speak softly and bow their heads to show respect for the physician as an educated authority figure. A caregiver who acknowledges their personal and social situation will be better able to establish a trusting relationship with the patient. Although the patient may not see a connection between his or her personal problems and physical pain, it may be helpful to ask the patient about his or her difficulties in adjusting to life in the United States. It is also helpful to ask about any herbal remedies which the patient may be taking. If any of these are contraindicated, the patient can be advised not to use that remedy while taking the prescribed drug. The patient should be encouraged to follow the hot-cold dietary régime and to continue taking any herbal remedies which will not do harm.
Iranian patients, regardless of their religious affiliation, tend to oppose the cessation of life support. This opposition is due to the cultural belief that life and death are controlled by God. The right to die is not recognized because only God can decide when a person will die. However, it is advised that the caregiver make an individual assessment of the family. If death is imminent, the caregiver may initiate a discussion with the family spokesperson suggesting that mechanical means of life support may itself be usurping God's will. It may also be helpful to refer to the Muslim belief that death is not the termination of life but the beginning of a new and better afterlife.
Iranian Definitions of Health and Illness
Iranians view health as both an absence of disease and the ability to cope successfully. It results from a dynamic relationship between the individual and the environment. Health cannot be achieved through any preplanned schedule of diet, exercise, and therapy. Because Iranians believe in both biomedical and cultural sources of illness, the body is viewed in relation to the total environment which includes God, the supernatural, and society.
Responsibility for Health Care
Many Iranians use a combination of humoral, Islamic, and modern biomedical approaches to both cure and prevent illness. Often they will seek advice about herbal remedies from elders. Herbal remedies are primarily used to relieve symptoms. When they seek biomedical advice, they tend to expect immediate relief or cures. They may shop around for a physician whom they like or who offers them hope for an immediate or complete cure. Iranians watch their diets to promote health. They are especially careful about ingredients and food preparation. Like other Middle Easterners they practice self-medication with prescriptions, over-the-counter medicines, and herbal remedies. They may also adjust the dosage of prescribed medications—especially when finances are a problem. Because of prior over-use of antibiotics, a first generation antibiotic may not be strong enough for an Iranian. In Iranian culture, the sick person is expected to transfer the responsibility for care into the hands of close family and friends. This may be misinterpreted by American caregivers in a lack of desire for recovery. One approach the health professional can take is to encourage family members to administer appropriate care to the sick person.