People of Haitian Heritage and Iranian Heritage

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Copyright © 2013 F.A. Davis Company

Transcultural Health Care
Haitian Americans
Larry Purnell, PhD, RN, FAAN

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview

• Haiti shares the Island of Hispaniola with the Dominican Republic.
• Dominican Republic and Haiti have little in common culturally.
• Haiti is the poorest country in the Western hemisphere with a per capita income of less than $450.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview Continued

• Over 500,000 Haitians live in the United States, with more arriving after the Haitian earthquake in 2010. Their numbers may exceed 1.5 million.
• Most live in NYC, FL, Boston, Chicago, and CA
• Most come here for better economic opportunities and political freedom. People of Haitian Heritage and Iranian Heritage

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview Continued

• Haitians are a mix of Arawak Indian, Spanish, French, and African Black resulting in sharp class stratification and color consciousness
• 1791 ended slavery in Haiti

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications

• Languages are primarily Creole (for the poor) and French (wealthier) and English although many speak all three languages
• Black, mulatto, or white and colors in-between
• Most Blacks are poor and underprivileged

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview

• Early immigration to the United States was the wealthier groups for education, followed by general immigration after 1920 and the United States occupation of Haiti
• After 1964, Duvalier became president for life, mass exodus because of oppression politically and economically. People of Haitian Heritage and Iranian Heritage

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview Continued

• 1980 immigration with the Mariel Boat Lift from Cuba brought first legal and then the Boat People from Haiti.
• Many had left Haiti to Cuba in previous generations and this group joined in coming to the United States.
• Resulted in Cuban-Haitian entrant: status pending

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview Continued

• French model of education with liberal arts, philosophy, classics, and languages—Latin and Greek and de-emphasizes technical and vocational training and the social and physical sciences
• Educated Haitians are multilingual
• Only 15% to 20% receive an education—high illiteracy rates

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications

• French and Creole official languages
• 15% speak French, 100% speak Creole
• Oral communication patterns to pass on culture through proverbs and storytelling
• Smile timidly to hide lack of education and understanding
• Nod of the head does not mean “I understand”

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued

• Most are private individuals who do not want friends or family to interpret for them
• Traditional Haitians do not usually maintain eye contact
• Touching is common
• Women may hold hands while walking in public

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued

• Most are present oriented out of necessity, the past is cherished and the future is predetermined —many remain rather fatalistic
• Punctuality is not valued—flexible time is the norm

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued

• First and middle name are usually hyphenated
• Woman takes her husband’s name upon marriage
• Last names are usually French or Arabic in origin
• Formality in name is the norm

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles

• Matriarchal or shared decision-making is the norm—although there are variations
• Male is the primary breadwinner
• Concept of machismo prevails
• Not uncommon to have more than one mistress or for women male partners. People of Haitian Heritage and Iranian Heritage

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles Continued

• Children are valued and expected to be well behaved—otherwise physical punishment may be used
• Most feel US society is too permissive
• Boys are given more freedom and permissive behavior
• Girls cannot go out alone until age 17+

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles Continued

• Nuclear, consanguine, and affinal relatives are the norm
• Family lineage is what denotes respect, not money
• Children expected to care for parents when self-care is a concern

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles Continued

• Single parenting is well accepted
• Homosexuality is taboo—if known, total denial from both sides
• Mistress supports her children with little to no financial help

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

ClickerCheck

The nurse is providing insulin injection instructions to Mrs. Paul, a 44-year-old Haitian. When the nurse asks her if she understands the instructions, she nods. To assure understanding, the nurse should

Ask her to repeat the instructions.

Give her written instruction to ensure.

Have her demonstrate an injection.

Give the instructions to a family member.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Correct Answer

Correct answer: C

The best way to assure understanding is for the patient to demonstrate the injection.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health Conditions

• Cholera, parasitosis, and malaria without malaria control measures
• Hepatitis, tuberculosis, venereal disease have high rates
• Most test positive for TBC because of Bacille bilie de Calmette-Guerin vaccinations
• High rates of diabetes and hypertension

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition

• For many, food means survival
• Prefer eating at home and dislike fast food
• When hospitalized, many prefer to fast rather than eat hospital food
• Dislike yogurt, runny eggs, and cottage cheese
• Staples are rice and beans, plantains, salad

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition Continued

• Lists of foods are in the Haitian–American chapter
• Foods are classified as cold (fret) and hot (cho), acid and non-acid, and heavy and light
• Must balance fret and cho foods or illness occurs

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition Continued

• Cough medicines are hot, laxatives are cold
• Avoid citrus, causes acne
• After ironing do not open refrigerator door
• Do not shower when you are hot
• Do not put warm feet directly on the cold floor

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition Continued

• Diet high in carbohydrates and fat
• Being overweight is seen as positive
• Major portion of meat protein is given to men

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy

• Pregnancy is not an illness so why seek prenatal care
• Spicy foods will cause the fetus to be irritable
• Vegetables and red fruits build blood for the fetus
• Increased salivation—“use a spit cup”

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Pregnancy Continued

• Prefer natural childbirth, although changing somewhat in the United States
• Men usually not present during labor—female family members are preferred
• Dress warmly and stay in bed 2 to 3 days after birth and use an abdominal binder to close the bones so cold air does not enter and cause illness

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Postpartum

• Three baths postpartum, more difficult in the United States
• Avoid food believed to increase vaginal discharge—lima beans, okra, mushrooms
• Other foods are strength foods
• Breastfeeding is encouraged
• All infants receive lok to help meconium pass. People of Haitian Heritage and Iranian Heritage

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

ClickerCheck

Most Haitians practice the hot and cold dichotomy of foods. This is know in Haitian Creole as

a. Yin and yang.

b. Calor y frio.

c. Fret and cho.

d. Am and duong.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Correct Answer

Correct answer: C

Fret and cho are the Haitian Creole words for hot and cold.

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

• Prefer to die at home
• Death watch by family who brings religious pictures and have bedside prayer
• Male kinsman responsible for funeral arrangements, notifying all family members, and coordinating the service
• Preburial veye to celebrate deceased’s life

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals Continued

• Seven consecutive days of prayer in the home to help the passage of the soul into the next life
• Believe in resurrection so no cremation
• Autopsy may relieve fear of deceased becoming a zombie

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality

• Family is the center of life
• Catholicism is the primary religion of Haiti
• Religious practices combined with voodooism
• Loa, the gods or spirits, believed to receive powers from God can provide protection and wealth

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices

• Good health is balance between hot and cold, eat well, be plump, pray, be free of pain, eat and sleep right, and exercise
• Illness is seen as punishment and comes of two types—natural and supernatural
• Natural illnesses of two types—short duration caused by environmental factors. People of Haitian Heritage and Iranian Heritage

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices Continued

• Natural longer term illness due to disequilibria between hot and cold and bone displacement
• Supernatural illnesses are caused by angry spirits, which are placated by ceremonial feasts
• Gas is a major cause of illness and can be in any part of the body

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices Continued

• Certain foods can dispel gas
• Postpartum more susceptible to gas
• Traditional Haitians have a low pain (doule) threshold and is difficult to assess because of vague terms used to describe pain
• Injections are preferred to oral medications

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices Continued

• Condition is deemed very serious if oxygen is needed
• Special diet for physical weakness—vitamins, liver, pigeon meat, leafy green vegetables, and cow’s feet
• Sezisman, similar to susto or magical fright, is caused by unexpected bad news and fright

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices Continued

• Strong stigma with mental illness
• Self-treat and self-medicate or take friends medicine
• May bring medicines from Haiti
• Cultural bound illness—oppression

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Barriers

• Delay seeking care because of self-care
• No health insurance
• View that Western medicine does not understand voodooism
• Language difficulties
• Very reluctant to receive blood transfusions or engage in organ donation

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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practitioners

• Use traditional and Western practices simultaneously
• Respectful of Western healthcare providers
• May have limited understanding of Western healthcare providers and their functions and capabilities

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Copyright © 2013 F.A. Davis Company

Iranian

Larry Purnell, PhD, RN, FAAN

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage

• Over 400,000 in the United States with about ½ living in California
• Currently about 76 million in Iran with 75% under the age of 30
• Much diversity in Iran (Persia) among its inhabitants and also much diversity among Iranians in the United States

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage Continued

• The reform institutions of current Iran are colored by religious traditions and ideology of Islam.
• Current industrialization of Iran has been from the outside, not from the inside and is due to the oil production industry.
• Political instability continues with clashes between conservatives and liberals. People of Haitian Heritage and Iranian Heritage

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage Continued

• First wave of immigration between 1950 and 1970 were mostly students and professionals from the social elite and many stayed in the United States.
• Second wave between 1970 and 1978 were varied in their background, but most were still affluent and urban and came for education and to be with family.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage Continued

• Not a major influence in the United States because they did not live in ethnic enclaves and assimilated into the United States culture easily
• The third wave of immigration began in 1979 at the time of the Islamic revolution and included voluntary and involuntary political exiles and others who come for economic and personal security

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage Continued

• The hostage crisis between 1979 and 1981 increased ethnic tension of Iranians in the United States
• Many are unable to find work in the United States that is compatible with their education in Iran
• Most highly educated immigrant group in the United States. People of Haitian Heritage and Iranian Heritage

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications

• Farsi (Persian) is the national language of Iran but half speak another language with the educated group speaking three or more languages, including English
• Invasions by numerous other nations have caused a mistrust and suspicion of foreigners resulting in not sharing one’s feeling with strangers

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued

• Tell stories rather than being blunt and to the point in conversations leading to politeness and sometimes disguised as modesty
• Hierarchical relationships dictate politeness and social communication resulting in a public self and a personal self

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued

• Family affairs remain within the family
• Self-control is valued and therefore do not show anger or emotions
• Men can show affection for men and women for women in public, but not men and women
• Stand close in conversations, regardless of social status between conversants

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued

• Maintain intense eye contact between intimates, but avoid eye contact with superiors and elders
• Expressive gesturing
• Balance in temporality
• Clock time is meaningless, even with appointments unless well acculturated

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Communications Continued

• Formality in addressing each other unless close friends
• More traditional men do not mention their wives’ names in public
• Man should wait for woman to extend her hand for a greeting

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Name Format

• Order of the name is the same as the Western method with the given name followed by the surname.
• Traditional women do not take their husband’s last name although some in the United States and elsewhere may upon immigration.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles

• Society is patriarchal and hierarchical
• Oldest son takes over if father is not present or unable to carry out decision-making
• Male children are more desirable than female children—true in other cultures as well

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles Continued

• Men deal with finance and matters outside the home.
• Women care for the home and children.
• Before 1960s social reform, women were legally expected to be obedient and submissive to their husbands.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles Continued

• Marry early and have children. New law says women cannot marry until age 14—was 12 and marriages may still be arranged, but less so in the United States
• Respect elders and never speak rudely to them
• Children rarely left with babysitters

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles Continued

• Traditional do not allow dating; women are expected to remain virgins until married, but not men
• Strong intergenerational ties and family life together or nearby
• May dress conservatively outside the home but less so while at home

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles Continued

• Divorce uncommon in Iran and carries a stigma—if divorce, it is the woman’s fault, never the man’s—varies in the United States
• Pregnancy before marriage can have devastating outcomes and is not talked about, it does not happen—it is just taken care of
• Gay and lesbianism highly stigmatized and is a capital crime punishable by death in Iran

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

• Wide variations in skin color, hair color, and eye color and depends on heritage from previous domination by other countries and cultures
• Common illnesses in Iran include malaria, hypertension, meningitis, hookworms, and parasitosis

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology Continued

• Great numbers with genetic disorders brought on by close sanguinity marriages resulting in blindness, epilepsy, anemias, hemophilias
• Glucose-6-phosphate dehydrogenase deficiency —fava bean allergies can cause hemolytic crisis. People of Haitian Heritage and Iranian Heritage

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition

• Food is a symbol of hospitality; serve the best food for guests who are expected to eat several servings.
• Polite to refuse snacks and beverages when first offered—accept it on the third offering
• Rarely eat fast food; fresh food is greatly preferred, and many hours are spent preparing meals

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition Continued

• Strict Muslims avoid pork and alcohol and meat must be prepared with ritual slaughter called halal.
• Food should be eaten with the right hand (clean hand) and food should be passed with the right hand or both hands.
• Traditional prefer family to bring food from home if hospitalized.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition Continued

• Balance food between garm (hot) and sard (cold) —if balance does not occur, one may become “chilled” or “overheated.”
• Women are more susceptible to these conditions than are men.
• Newer immigrants may have protein and vitamin deficiencies.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family

• Menstruating women are not allowed to touch holy objects, have intercourse, exercise, or shower.
• Iran is changing from openly discouraging birth control to now cautiously and secretly encouraging birth control because of the population explosion.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family Continued

• Cravings must be satisfied because the fetus needs the craved food
• Avoid fried foods or foods that cause gas
• Eat lots of fruits and vegetables
• Balance garm and sard foods
• Pregnant woman should not work after the sixth month

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family Continued

• The father should not be present at birth in the traditional family
• 30- to 40-day postpartum period where other women are to care for the new mother
• Ritual bath after this period so religious obligations can continue
• Eat different foods if a boy baby versus girl baby
• Eat an herbal extract (taranjebin) to have a boy. People of Haitian Heritage and Iranian Heritage

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

• Okay to begin life support, but usually not okay to end life support
• Multiple family members come to bedside of the dying person and recite/read prayers
• Bed should be turned to face Mecca
• More traditional want to return to Iran to die

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals Continued

• Even though death is seen as a beginning, not an end, mourning and grief are displayed openly and even dramatically to encourage letting go
• After death, relatives and friends gather on days 3, 7, and 40 to pray and grieve with family and friends

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals Continued

• All wear black for mourning and women should not wear makeup
• On the anniversary of the death, family and friends again gather to express grief and pay respect to their loved one

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals Continued

• Ritual body washing by another Muslim after death and dressed in a white shroud; body orifices stuffed with cotton and ritual prayers said during the cleansing
• If non-Muslim, touch the body only with gloves
• No embalming in Iran nor is cremation practiced

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality

• Specific Muslim practices include praying 5 times each day and need privacy and ritual washing before prayer
• During Ramadan, fasting from sunup to sundown unless pregnant or ill
• Family relationships and friendships are primary sources of strength

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality Continued

• Sadness is valued and a sad person is considered to be deep, thoughtful, and sensitive
• God’s Will and power over one’s fate fosters passivity and dependence

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

ClickerCheck

A 76 year old Iranian, Muslim male is in the process of dying after a long debilitating illness. The nurse would

Have his Imam visit.

Make sure no one touches him with bare hands.

Turn him to face Mecca.

Place him in a supine position.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Correct Answer

Correct answer: C

At the time of death, the dying person should be positioned to face Mecca. This can be accomplished by moving the bed or at a minimum of turning the patient’s face towards Mecca.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices

• Combination of humoral medicine, Islam, and biomedical practices
• Humoral medicine—illness is caused from an imbalance in wet and dry and hot and cold forces
• Sacred men are able to heal
• Evil eye is alive and well

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices Continued

• Good health is a daily way of life
• Seek care immediately and shop around for the right treatment
• Use traditional herbs and over-the-counter medicine to relieve symptoms and seek care provider to determine the cure
• Able to purchase a wide variety of drugs over-the-counter in Iran and bring them to the United States

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices Continued

• Narahati—general term to express unpleasant emotional or physical illnesses and somatization is common and accepted and can be treated religiously or medically, depending on what the cause might be
• Ghalbam gerefteh—distress of the heart—is an expression of emotional turmoil or homesickness

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices Continued

• Various remedies for the evil eye and dependent on the age and family of the person afflicted
• Language can be a barrier to care for some
• Descriptions of conditions may be different from the US description
• Many do not have health insurance

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practices Continued

• Concept of insurance may not be known to some
• Usually very expressive with pain and discomfort
• Mental illness is highly stigmatized and may hinder other family members from marriage
• Prefer drugs, the stronger the better, and prefer IV over IM, and IM over pills
• The more invasive, the better

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practitioners

• Organ donations and transplantations may be seen as a business transaction
• Folk or religious practitioner used for narahatis
• Most respected biomedical practitioner is a middle-aged male with a title and white hair
• Firm believers in high technology

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Healthcare Practitioners Continued

• Nurses are usually afforded little respect—partially because of training
• Physicians are on top—all other healthcare providers take a lesser position
• If self-care is encouraged, it may be seen as non-caring

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

ClickerCheck

Mrs. Said is brought to the nurse practitioner by her daughter because she has naharati. The nurse recognizes this condition as

Equivalent to congestive heart failure.

Generalized distress.

Generalized weakness of aging.

Abdominal pain.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Correct Answer

Correct answer: B

Naharati is generalized distress that can be brought on by stress, anxiety, homesickness, or other things that can cause emotional turmoil.