People of Egyptian Heritage and People of Filipino Heritage

Transcultural Health Care: A Culturally Competent Approach, 4th Edition Filipino Americans Larry Purnell, PhD, RN,

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FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage ▪ Almost 2 million in the United States ▪ Literally all speak English and Tagalog (Pilipino), and many speak Spanish and another language ▪ Predominantly from Malayan ancestry with influence and mixtures from other Asian groups, Spanish, and Arab Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Americanization of the Philippines began after the Spanish–American War ▪ Immigrant Filipinos make up the majority of Filipinos in the United States ▪ Unrestricted immigration in the early 1900s then very restricted in 1924 because of the Exclusionist policies of Immigration Act of 1924 Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ Immigration and Nationality Act of 1965 eliminated the quota system for the Philippines resulting in large numbers of middle class and professionals coming to the United States ▪ Included relatives of Filipinos living in the United States Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ First group were primarily single men who were brought to the United States to work in Alaskan canneries, farms in California, and plantations in Hawaii and endured much discrimination ▪ Most were restricted from owning or leasing land and could not become US citizens Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview/Heritage Continued ▪ After WW II, many Filipino Veterans immigrated and settled on the West Coast ▪ Now more women than men immigrate to the United States ▪ Well educated immigrants continue to have difficulty in finding similar work in the United States unless they are in the healthcare field Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications ▪ Tagalog is the national language with English the second official language ▪ Eight other dialects are spoken as well as Spanish ▪ Taglish is common among immigrants and American born Filipinos ▪ Highly contextual communication patterns Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Pakikisama—smoother interpersonal relationships and sacrifice exact meaning ▪ External or outsider communication and internal or one-of-us communication proceeds on different levels Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ ▪ ▪ ▪ ▪ ▪ ▪ Interacting level Participating level Conforming level Adjusting level Understanding and acceptance level Getting involved level Being one with level Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ An exclusive “we” and an inclusive “we” ▪ Eye contact varies with age, education, and acculturation ▪ Many ways to say yes, but how do you say no? Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Respect the past, enjoy the present, and hope for the future ▪ Filipino time for social events, clock time if really important events, business, and work usually ▪ Many names are Spanish in origin ▪ One of the middle names is the mother’s maiden name Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Many Filipinos speak Tag-Lish, which is a. A combination of Tagalog and English. b. The indigenous language of the Philippines. c. The official language of the Philippines. d. A combination of Spanish and English. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: A Tag-Lish is a combination of Tagalog and English. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles ▪ Matriarchal before Spanish, then Patriarchal, now more egalitarian in decision making ▪ Gender neutral pronouns causing confusion with he and she in English ▪ Respect is a dominant family value and older children may assume the role of parent Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Honor and care for parents or brings shame to the family ▪ Nuclear family is dominant although polygamous families exist among Moslem Filipinos ▪ Extended family members are important ▪ Education is paramount for children and parents sacrifice so at least one child will become educated and help the others if necessary Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Respect is shown to elders with deferential behavior ▪ Grandparents become surrogate parents for their grandchildren in the United States especially ▪ Advance degree brings higher social status Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles Continued ▪ Filipino organizations targeted to gays and lesbians ▪ Chastity is valued premaritally ▪ Single parenting becoming more common in the United States Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Varying skin tones of brown and tan with dark eyes, flat nose bridges, and mildly flared nostrils ▪ Most are of smaller stature than European Americans ▪ More difficult to determine age than in European Americans because of youthful face Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology Continued ▪ Endemic conditions in the Philippines include malaria, tuberculosis, gastrointestinal disorders, due to parasitosis, cardiovascular related disease, cancer, respiratory diseases, nutritional diseases, HTN, and diabetes ▪ Sensitive to the effects of alcohol and require lower doses of neuroleptics Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Fundamental form of socialization ▪ Any occasion is an occasion for food ▪ Wide variety of foods and prepared in a variety of ways ▪ Outsiders are served western food ▪ Insiders are served Filipino food ▪ To help in the kitchen you are really an insider Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Rice may be served at every meal, most common meats are fish, chicken, and pork ▪ Diet varies among urban and rural areas ▪ Lactose intolerance among adults ▪ Milk in cooked desserts is tolerated well ▪ Salt and vinegar are used frequently ▪ Moderation in food is considered important Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Considered polite to leave some food on your plate ▪ Herbs are grown in many homes to be used for cooking and for medicinal purposes ▪ Newer immigrants are at risk of nutritional deficiencies if unfamiliar with American foods Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family ▪ Catholic religion influences birth control practices —rhythm method only ▪ Abortion is considered a sin, carries a stigma, and leads to back door abortions ▪ Pregnancy is a time for pampering and attention from entire family ▪ Mother of pregnant woman has a very special role Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Consult healthcare provider plus a massage therapist for advice ▪ Reluctant to take any medicine during pregnancy, even vitamins for fear of harming the fetus ▪ Satisfy cravings so baby will not be marked with the craving Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Family Continued ▪ Should be protected from a sudden fright for fear it will harm the fetus ▪ Mother rather than husband may be the coach during birthing ▪ Traditional may not want to bathe but engage in sponge bath and aromatic oils ▪ Soup increases lactation Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Three days to week for wake after death to await for family to come together—varies in United States because of work schedules ▪ Plenty of food available and family support ▪ Nine days of novenas in the home or church are common ▪ Ritualistic mourning wearing black for one year Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals Continued ▪ Burial is the most common but cremation is okay ▪ Body or ashes may be returned to the Philippines ▪ Open expression of emotions and may include fainting Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ 80% Christian with 90% of them Roman Catholic ▪ 5% practices Islam ▪ Many returning to Bathala, ancestral religion with a spiritualist guide who is usually a woman Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality Continued ▪ Novenas and prayers are commonly said for the sick person ▪ Good health comes to those who are in good with God and is the “Will of God” ▪ Many are considered fatalistic, life is up to God, there is little one can do to change life circumstances and the forces of nature, monsoons, tides, volcanoes, earthquakes, etc. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices ▪ Adhere to Western medicine and traditional practices simultaneously ▪ Health is the result of balance and moderation and God’s Will ▪ Adequate sleep, rest, nutrition, and cleanliness are important for good health ▪ Aromatic baths restore balance Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ In the Philippines many medicines can be purchased over-the-counter ▪ May hoard and share medicine ▪ Many do not seek care until the illness is advanced ▪ Many distrust the healthcare environment ▪ In the Philippines, one pays for testing before the testing is done Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ ▪ ▪ ▪ Protect oneself from wind and cold Avoid extremes of hot and cold—balance Introduce changes gradually Pain is part of life and may be atonement for immoral behavior and leads to stoicism ▪ Mental illness carries a stigma, is hereditary and may affect one’s ability for a spouse Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Mental illness may be severe before help is sought —take care of family member at home ▪ Somatization of symptoms is common ▪ Important to maintain self-esteem and self-image for self and family ▪ Able to enter the sick role easily Transcultural Health Care: A Culturally Competent Approach, 4th Edition ClickerCheck Mrs. Lino, age 38 years, has been seeing a traditional Filipino healer for her pregnancy complications. A Filipino traditional healer is a. Galang. b. Utang na loob. c. Hilot. d. Hiya. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Correct Answer Correct answer: C A hilot is a traditional Filipino healer. 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 1 Chapter 28 People of Egyptian Heritage Afaf Ibrahim Meleis and Mahmoud Hanafi Meleis Overview, Inhabited Localities, and Topography Overview Egypt, the country of origin of Egyptian Americans, has a landmass of 386,900 square miles (about one and a half times the size of Texas) and a population of over 82 million people, giving it a population density of over 177 per square mile. More than 95 percent of the land is barren desert, resulting in 90 percent of the population’s living on 3 percent of the total land area, in the Nile Valley and Delta (CIA World Factbook, 2011). The Nile has been and still is significant in shaping life and living patterns in Egypt. The average annual rate of population increase is 1.75 percent, with a birth rate of 22.94 per 1000 and an infant mortality rate of 25.2 per 1000 (CIA World Factbook, 2011). The capital, Cairo, has almost 11 million people, followed in population by Alexandria with 4.3 million people (CIA World Factbook, 2011). Egypt is bordered by Libya on the west, Sudan on the south, the Mediterranean Sea on the north, and the Red Sea and Israel on the east. The eastern region, across the Suez Canal, is Sinai. Egypt’s climate is hot and dry most of the year. The average daily temperature on the Mediterranean coast is 68°F with a maximum of 88°F, and in Aswan, average temperatures are 80°F but can reach 120°F with little or no humidity. The Mediterranean region receives most of the country’s annual rainfall (7.5 in.). The northern summers are balmy with moderate temperatures and 80 percent humidity. Between March and April, khamsi winds blow in from the Western Desert at up to 93 miles per hour. Except for a few hills outside Cairo, Egypt has a flat terrain on both sides of the southern Nile valley and the Sinai Peninsula. The Nile River, a main artery for Egypt and an orientation point for its terrain, runs through the center of the country from south to north to the Mediterranean Sea. The Nile—considered to be Egypt’s lifeline—provides water and supports agriculture. Egypt is considered by many politicians, historians, and social scientists to be part of 22 Arabic-speaking countries in North Africa. Others write about Egypt as a Middle Eastern country and count its population as Middle Eastern. A review of scholarly literature about Egyptian Americans is embedded in writing that aggregates them with Arab Americans, African Americans, and Middle Eastern Americans, as well as separates them out as Egyptian Americans. Scholarly literature about Egyptians in the United States is limited; therefore, the reader will find citations that reflect a broader geographic territory, which in turn reflects how Egyptians are often connected to or embedded in many Arab, Middle Eastern, African, and Muslim cultures. This chapter is also based on the authors’ own experiences. Both authors are Egyptian Americans who came to the United States in the early 1960s and observed many Egyptian Americans as they defined themselves within the multiple identities generated by the different groupings, such as generation and length of time away from the country of origin. Both authors have been insiders as well as outsiders to Middle Eastern communities in the United States and globally. They have participated in different community celebrations, experienced immigrants’ grief over the impending or actual death of a family member, provided social and emotional support during times of crisis, and counseled many immigrants. One of the authors has been professionally involved with health care for this population for over 30 years as part of a project that was designed to provide health-care services to Middle Eastern immigrants in California. Therefore, data in this chapter are from our lived experiences in the two worlds Egyptian Americans claim as their own—Egypt and the United States. Arab Americans are estimated to number anywhere between 1.5 and 3.5 million (Shah, Ayash, Pharaon, & Gany, 2007). Over 80 percent of Arabs living in the United States are citizens (El-Sayed & Galea, 2009). 1 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 2 2 Aggregate Data for Cultural-Specific Groups Egyptians reside in most states in the United States; 2.3 million of Arab Americans reside in 10 states: 1.2 million live in California, New York, and Michigan (Arab American Institute, 2011). New York alone has an estimated number of 405,000 Arab Americans residents (Shah et al., 2007). Michigan has a population of 490,000 Arab Americans, and California has the highest number of Arab Americans with a population of 715,000 (El-Sayed & Galea, 2009). Other heavily populated states are New Jersey and Illinois. Approximately 94 percent of Arab Americans live in major cities, with the top five being Los Angeles, Detroit, New York, Chicago, and Washington, DC. Lebanese Americans are the largest group of Arab Americans living in the United States, comprising 37 percent of the total Arab American population. Egyptians comprise approximately 12 percent of the Arab American population (Shah et al., 2007). However, Egyptian Americans are the largest Arab American group in the State of New Jersey (Arab American Institute, 2011). Egyptian Americans’ religious affiliations resemble those of others from the rest of the Arab countries. The majority are Christians, and among the Christians are Orthodox (Greek and Copts), Catholics, and Protestants. Egyptian American Muslims who are Sunni are increasing in numbers and represent the fastest-growing religious group among Egyptian immigrants (Salari, 2002). Ninety percent of Egyptians are Muslims, and the overwhelming majority of these are Sunni Muslims. Egyptian Americans are diverse in other ways. They come from urban and rural communities, upper and lower Egypt, and diverse educational backgrounds, and they possess a wide range of cultural characteristics influenced by colonialization, occupations, and a variety of immigration experiences that shaped their responses. However, only the most common patterns of responses and experiences of Egyptian Americans with regard to health and illness are presented in this chapter. Diversity among Egyptians is not well depicted, and this description does not represent a universal profile. By defining the similarities among Egyptian Americans, we hope to stimulate interest in more systematic scholarship about this unique community and their lifestyles, health, and health-care practices. Heritage and Residence In spite of the many attributions of geographic belonging to Egypt, the Egyptian people have a strong sense of identity with their country and demonstrate pride in coming from such an old civilization. Egyptian history is inextricably connected to the Nile River and dates back to about 4000 B.C., when the kingdoms of upper and lower Egypt were united by King Menes, who presented himself as a god. The ancient Egyptians were the first to believe in life after death, mummify bodies, and build elaborate tombs to preserve and protect these bodies for the afterlife. Egyptians also developed the plow, a system of writing, and medical skills such as surgical operations. The Arab conquest of Egypt around A.D. 641, which spread the Islamic and Arabic culture among the Egyptians, has lasted to this day. The minority (Christian) Copts, who preserved the African-Asiatic language of ancient Egypt, now use the Arabic language and have been assimilated into the Arabic culture. The Ottoman Turks invaded Egypt in 1517, adding it to their vast empire. While living under Turkish rule, Egypt enjoyed religious and cultural stability because the Turks shared the Islamic and Arabic cultures. In the last two centuries, Egypt experienced invasions by the French, followed by the British in 1882, who remained in the country until 1954. In 1952, an Egyptian army group led by Lieutenant Colonel Gamal Abdel Nasser took control of the government and removed King Farouk from power. Since then, Egypt has been an independent state called the Arab Republic of Egypt (CIA World Factbook, 2011). An influential part of modern Egyptian history is the Arab–Israeli conflict. The conflict between Egypt, as part of the Arab League, and Israel ended in 1979 when the two countries signed the Camp David Accords. Anwar Sadat was the president of Egypt at the time. Egypt continues to be involved in diplomatic efforts to arrive at peace between Israel and its neighboring Arab countries. This long history and the diversity of populations have influenced the value systems, beliefs, and explanatory frameworks Egyptians use in their daily lives and have contributed to the diverse thinking processes they use to resolve issues and conflict. Another important turning point for Egyptians, as well as Egyptian Americans, in their identity and connection to their cultural heritage is the February 2011 revolution that ousted President Hosni Mubarak. Reasons for Migration and Associated Economic Factors Many Egyptians immigrated to the United States in an attempt to escape economic stagnation during President Nasser’s regime and his failed economic policies that nationalized all privately owned companies and enterprises. The United States offered educational opportunities, career options, and economic incentives that rewarded hard-working individuals. After the 1952 military revolution, Egyptians immigrated in three main waves. The first wave, in the 1950s, consisted of graduate students who came to the United States to obtain advanced degrees. This was followed by Egyptians who escaped Gamal Abdel Nasser’s regime (Amer & Hovey, 2007). After the defeat of the Egyptian army by the Israelis in 1967, many of these students, believing the totalitarian military regime of Egypt did not offer hope for 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 3 People of Egyptian Heritage economic recovery, changed their status to immigrant. For most, this ensured a promising future for their children, even though they would have been assured decent positions in Egypt because of their American education. The second wave of immigration resulted from the heightened mass dissatisfaction, hopelessness, and anger toward the government of the educated and professional community after the 1967 war. A lenient government policy made it easy and safe for anyone who wanted to leave the country, resulting in the largest exodus from Egypt in modern history. Included in this wave were many Coptic and other Egyptian Christians (Shaw, 2000). The third wave, in the 1980s and beyond, had many more risk takers. They came to seek better lives and forsake the security of government jobs for unknown adventures. They sought new opportunities such as cab driving and working at food outlets in large cities (Meleis, 2002). Some of these immigrants are temporary, others are permanent, and still others are in circular migration (Nassar, 2008). It is important to note here that the terrorist attacks in New York, Pennsylvania, and Washington, DC, and the tragic consequences of September 11, 2001, have rendered many newly immigrated Egyptian Americans vulnerable to profiling and stereotyping in their newly adopted country, the United States. Therefore, a newly acquired sense of stigma tends to influence their patterns of responses in ways that were not manifested previously. Long-term effects of this situation on their patterns of behaviors have yet to be studied and understood. It remains to be seen whether the youth Tahrir Square Revolution of 2011 and the referendum in the constitution will instigate circular migration (Medina, 2011). Educational Status and Occupations Most of the first-wave Egyptian immigrants were highly educated individuals with graduate and postgraduate degrees earned in the United States. Members of this group were able to obtain teaching and research positions in universities or work in industries. Some joined companies or started their own businesses in the high-technology industries. Egyptians in the second and third waves were more diverse in their educational backgrounds, although most of them were college graduates. Second-wave immigrants worked as engineers, physicians, dentists, accountants, and technicians; however, some with college degrees initially accepted employment as gas station attendants, cab drivers, security guards, and other blue-collar positions to ensure employment. After improving their language skills and obtaining degrees from American universities, many obtained professional positions. A small minority never achieved an occupational status equivalent to their 3 original training. Many from this group returned to their home country or plan for such a return. Communication Dominant Languages and Dialects The dominant language of Egyptians is Arabic, a Semitic language understood by all Arab nationals, who hear it in popular Egyptian movies, songs, and television programs. The written Arabic language is the same in all Arab countries, but spoken Arabic is dialectal and does not necessarily follow proper Arabic grammar. A number of Arabic dialects are spoken in Egypt. The Saiidis (Egyptians south of Cairo) have a different dialect from the northerners. The Nubians (who live around and south of Aswan) have another unique dialect, as do the Bedouins, who live in the desert. Despite these different dialects and their distinct vocabularies, neither Egyptians nor Egyptian Americans have any noticeable communication barriers among themselves. For Egyptian immigrants in the United States, English is the language of communication in business and contact with American society. Within their own gatherings, they speak a mixture of Arabic and English, switch with great ease from one language to another, and sometimes speak a mixture of Arabic, English, and French. Egyptian social gatherings usually involve large numbers of people, with multiple conversations occurring simultaneously. When they are discussing subjects such as politics or religious issues, the level of excitement heightens and the tone of the speech is sharpened, so an outside observer may mistakenly characterize the exchanges as chaotic or angry. Cultural Communication Patterns Several values govern interaction patterns among Egyptians. The first is respect (ihteram), which is expected when speaking with those who are older and those in higher social positions. Respect is demonstrated in the Arabic language by differentiation in the words used to address those who are equal in age or position and those who are older in age or higher in position (see Format for Names). A second important value, politeness (adab) is related to what is appropriate, expected, and socially sanctioned. Truth and reality may be sacrificed for what is appropriate and polite. Politeness results in a preference for more indirect modes of communication. Sharing negative news directly or asking for things directly is not polite. Therefore, a poor prognosis of an illness is not immediately shared; calamities should be slowly and deliberately introduced and shared in stages. It is more appropriate and expected that such news will be shared first with other family members who will provide a buffer that helps those coping with and responding to such news. 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 4 4 Aggregate Data for Cultural-Specific Groups Significant value is related to the status of insiders and outsiders, the private and public spheres. Private spheres are reserved for immediate family, some members of the extended family, and friends who are elevated to the status of family. The public sphere includes acquaintances, public officials, and the rest of the world. Those who occupy a public sphere may get completely different communications and versions of the same events or incidents. Because Egyptian Americans tend to be externally driven, they are concerned about what others think of their behaviors, which are considered a direct reflection on their entire family. Therefore, parents tend to be overzealous and anxious about the good or bad behaviors of children and adult sons and daughters. These behaviors reflect a measure of how well or how badly parents have raised their children. Egyptian Americans tend to be in touch with their inner feelings and are highly expressive of them; however, this expression is governed by external orientation, spontaneity, and the differences between private and public spheres. Egyptians in America tend to share problems and the minutest details about their lives with their trusted circle of insiders. However, because they are externally oriented, they tend to look outside for explanations of their feelings, rather than to focus on their own actions. Egyptians tend to be comfortable and generous in sharing ideas and giving advice to others who might be family members or friends. This behavior stems from close family ties and trust that ensures the family will always be there to provide help. Advice is offered (even when not requested) out of love, care, and a sense of loyalty to friends or relatives. They do not shy away from becoming involved in the problems, trials, and tribulations of those in their private sphere. The extent and depth of involvement is less for those in the public sphere. Although these behavior patterns are a part of the lifestyle of first-generation immigrants, second-generation immigrants may not necessarily maintain them. Egyptian Americans’ nonverbal communication patterns are expressive. Because their personal space boundaries tend to be small, they stand and sit very close to each other. In spite of their preference for closeness, women and men use personal space boundaries differently during interactions. Women tend to keep male friends as far away as male strangers. Egyptian Americans speak with expressive words and facial expressions, gesticulating with hands and using body movements. They communicate with their entire body as much as with verbal language. Their facial expressions are mirrors of their internal processes and reflections of their inner evaluations of their situations. They tend to touch each other frequently and easily, and touch is both reflexive and deliberative. For example, they tend to touch others while speaking to solicit attention, concentration, and emphasis. REFLECTIVE EXERCISE 28.1 Eshe Halabi, age 74 years, lives near Cairo, Egypt. She speaks an Arabic dialect, Saiidis, some French, and a little English. While visiting her son and daughter-in-law in the United States, she suffered a bowel obstruction and underwent surgery. She is now 2 days postoperatively and has been progressing without complications. Her son and daughter-in-law have graduate degrees from the United States and speak English well. When her son visits, she complains of fire-like pain in her abdomen. Her son immediately contacted the nurse demanding pain medicine for his mother. The nurse explained that Mrs. Halabi had received an injection for pain control about 20 minutes previously and that she should give the medicine time to work. He said this was unsatisfactory and that she should have the pain medicine intravenously right now. 1. Is the description of fire-like pain common among Egyptians? 2. What other descriptions for pain are used by Egyptians? 3. What response should the nurse give when Mrs. Halabi’s son demands intravenous pain medicine? 4. What else might the nurse do to assist with pain control? 5. Do you think the son is an adequate interpreter for his mother in this scenario? To demonstrate trust, increase trust, or emphasize a point, they tend to touch each other on the hands, arms, legs, and shoulders. Men, whether strangers or acquaintances, touch each other. Similarly, it is acceptable for women to touch. Family members and friends of the same gender always hug and kiss on both cheeks. Friends of different sexes normally shake hands. However, traditionally, it is unacceptable for women and men to touch each other. Touch between the sexes is accepted in private and only between husbands and wives, parents and children, and adult brothers and sisters. Levels of religiosity govern the protocols about touching between males and females. The more religious are the individuals, the more prohibitions exist about touching between males and females. Devout Muslim men and women do not touch each other; even a handshake is not practiced. In these situations, a head nod substitutes for a physical greeting. Among devout Muslims, only mahrams, those individuals who are not permitted to marry (e.g., sisters and brothers) are permitted to greet each other with hugs. Among Christians and Westernized Egyptians and Egyptian Americans, greetings usually include formal courteous hugs and kisses on the cheeks. In Egypt, it is very common to see Egyptian men or women walking in public places holding hands or embracing each other. In the United States, Egyptians are more selfconscious about touching members of the same sex, touching non-Egyptians only on the arm or shoulder as an expression of caring, assuring them that one is 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 5 People of Egyptian Heritage a friend. Some Westerners may be uncomfortable with these gestures. Egyptians have their own nonverbal facial expressions. A momentary wide-eyed gaze to a child means “stop it now.” A wink to an adult means “watch what you are saying” or “change the subject because you are treading on dangerous ground.” Dissatisfaction is demonstrated by intentionally looking through the person or by avoiding eye contact. Egyptians think of those who do not maintain eye contact or have shifty eye contact as people who should not be trusted. Because Egyptians tend to stand in close proximity to each other, eye contact is automatic for them. However, among those who are more traditional, women and men who are strangers may avoid eye contact out of modesty and respect for religious rules. The situation is different if the communication is between men and women related by marriage or by blood. Children are taught not to tebarrak (stare), which denotes disrespect for those who are older or higher in status. Egyptians tend to be congenial and personable, injecting humor to lighten stressful encounters or business meetings. There are differences in the nature of humor between Americans and Egyptians, and these differences may create communication issues. For example, Americans tend to have self-enhancing and self-defeating humor styles. This humor style may be misinterpreted and leave a negative impression on Egyptian Americans. Health-care providers or managers using self-defeating humor may be perceived as weak (Kalliny, Cruthirds, & Minor, 2006). They may may exaggerate and overly assert judgments of events and situations for the sake of emphasizing a particular point of view. An Egyptian greeting involves every person in a room standing and shaking hands within gender norms. Not standing can be considered an insult. A greeting may be just a nod or a few words. Similar greetings are practiced in the United States among immigrants. Temporal Relationships Older Egyptians cherish the past, remembering the days when life was simple and easy. Reminiscing is a cultural pattern that becomes more prominent with age. Younger Egyptians live in the present, with its decreased availability of options, and in the future, with its potential, realizing that acquisition of goods comes with a high price tag. Thus, this generation is preoccupied with maximizing their incomes, often working two or three jobs to afford luxuries. For professional Egyptian immigrants, working hard has been their ticket to upward mobility and living the good life. It is this generation of young adults living for the present and the future who decided to organize using modern technology to demand more representation and voice in a government that has not been responsive to them. 5 While social time takes a high priority, engagements are not concluded because of other scheduled appointments, and guests are expected to arrive late, they showed up in masses in Tahrin Square to make their united voices heard. It is important to note temporal relations in Egyptian Americans regarding appointments. If a friend drops by as another is getting ready to leave for an appointment, the appointment is missed and the friend is not told about the prior engagement. Arrival at a social gathering, such as a lunch or dinner, as much as 1 or 2 hours late and to be late for business appointments because of heavy traffic and unanticipated and uncontrolled delays is common. A social custom is to offer coffee, tea, or a soft drink to business visitors. Therefore, a planned 10-minute office visit usually takes more time. Egyptian Americans’ perception of time is in the context of the nationality of the group. Therefore, they follow “American time” and are punctual for business engagements and meetings with non– Egyptian Americans but prefer to use Egyptian time for Egyptian American gatherings. Format for Names In all Arab countries, both male and female children are given a first name, and the father’s first name is used as the middle name; the last name is the family name. In the Middle East, a person is called formally by the first name, such as Mr. William. Respect for individuals is demonstrated in the use of certain titles. Inta (you) is saved for those in equal or lower positions, and hadretak (you) is reserved for those in higher-ranking positions or for older people. More flowery and more exaggerated variations of both of these appellations are used, such as seyadtak, which is reserved for the highest-level officials. Inta, used in place of hadretak, is an insult to older people and, more important, a reflection of bad manners and the poor upbringing of the young. Older people should never be called by their first names without an adjective or title attached to the name. The accepted custom in the United States of addressing patients by their first name may be insulting to people from other countries. An adjective, such as aunt, uncle, ostaz (Mr., Madame, Mrs.), or an adjective that denotes a profession, such as bashmohandes (engineer, doctor, physician) or a doctoral degree, may be used with the name. Family friends are addressed by both younger and adult children as uncle and aunt. Parental relatives are called either aunt or uncle or a special designation such as ammeti (sister of father), ammy (brother of father), khalty (sister of mother), or khali (brother of mother). Some Egyptian Americans, particularly those from rural Egypt, are addressed by the first name of their son, preceded by “Abu,” which means “father of.” This is more of an Arab custom adapted by Egyptians (Haddad & Hoeman, 2000). 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 6 6 Aggregate Data for Cultural-Specific Groups Family Roles and Organization Head of Household and Gender Roles The man is formally considered the head of the household; however, the demands of life on immigrants and nuclear families drive couples to share responsibilities and decision making. Many Egyptian American men, however, tend to control family budgets, which gives them more power in the family and causes many interpersonal conflicts and much distress for Egyptian American women. Egyptian American family roles change considerably after immigration. The fast pace and complexity of life in America, the many demands of child rearing, and the absence of an extended family to preserve traditional roles contribute to a more egalitarian family organization. Husbands and wives experience greater fluidity in their roles, substitute for each other when needed, and participate fully in all family matters. Egyptian American women tend to work both in temporary occupations and in career positions. Many who do not work outside the home consider their situation temporary, are between jobs, or are retooling their skills to become congruent with American job opportunities. Women who are not working outside the home tend to be more stressed than those who are employed. Unemployment brings with it economic limitations, social limitations in terms of developing a support network, or both. In the absence of extended families, lack of this support network increases vulnerability, isolation, and stress. Immigrant women in general are at risk of not having a network of supporters, and this is particularly true for women who do not work outside the house (Aroian, Templin, & Ramaswamy, 2010). Women are expected to maintain Egyptian values and simultaneously ensure the integration of the family in U.S. culture. This may increase the demands more for women than men, although some research findings indicate women and men do not differ in their stress and depression levels (Amer & Hovey, 2007). While some couples may share daily household chores, the norm is similar to that of other educated middle-class families in America. The woman is responsible for the daily management of family affairs. The man is the major breadwinner for the family. Husbands, however, participate in shopping, cleaning, and activities related to entertaining with their wives. Fathers also participate proactively in activities and education with their children. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Children are central to Egyptian families; they are treasured in the present and viewed as security for their parents’ future. During their early years, they are expected to be studious and goal oriented, respectful, and loyal to the family. When they become adults, they are expected to take care of their older parents. However, second-generation Egyptians tend to blend with other Americans. Their sense of responsibility toward their parents is a topic of major concern among Egyptian Americans. Egyptian children are not permitted to use foul language or swear in the home or in front of parents, although this is true to a lesser degree in the United States. Answering back to parents is not condoned and is seen as rude and disrespectful. Some families adjust better than others to the Western style of child rearing, which permits and encourages the children’s rights to question their parents’ instructions. Families that allow their children more freedom to express their opinions and ask questions often end up with better-adjusted children and better-preserved family unity as their children grow into adulthood. Religious beliefs and teachings forbid premarital sex and adultery for both Egyptian Muslims and Christians. Gender is an important variable in parenting adolescents. Female adolescents in Egypt tend to report more psychological disorders than male adolescents perhaps due to authoritarian attitudes that exist toward girls (Dwairy & Menshar, 2006). Whether these findings hold true for Egyptian American adolescents would warrant more research in the United States. What we do know is that as girls reach puberty and questions of dating, courting, and prom night arrive, some parents cannot cope with the freedom allowed within American society. They worry more about the consequences of dating and their daughters’ getting pregnant and fleeing the home than about raising a healthy and welladjusted young woman. In the extreme, a few families send their daughters with their mothers back to Egypt to complete their education through college under more restrictive conditions or to get married. Some families opt to return for good rather than raise their daughters in the American culture. Egyptian Muslim and Christian families usually have a hard time giving their young daughters enough space to grow (Meleis, 2002). Hattar-Pollara, Meleis, and Nagib (2000) found that Egyptian American parents fear their daughters losing their virginity, representing a major stress in their daily lives. The greatest calamity that may happen in a Christian or Muslim Egyptian American household is to have a daughter lose her virginity prematurely. This fear stems from a potential lack of marriageability of the daughter, loss of face for the father, and gossip within the Egyptian American community. Therefore, parents tend to be restrictive about their daughters’ movements and to monitor their whereabouts carefully. Similar restrictions are placed on teenage sons, although they are allowed more freedom and more autonomy in decision making. Most parents prefer that their sons not date and discourage sexual activities. However, if sons disobey the rules of the household, the incident is not regarded as gravely as when daughters do. 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 7 People of Egyptian Heritage Second-generation Egyptian Americans are rather philosophical about these restrictions. The open communication in the family allows children to see restrictions as temporary or to devise ways to do what they want without their parents’ knowledge. Whereas similar situations may occur in their original country, the difference is that an extended family in the homeland may help mediate when confrontations between parents and children become inevitable. Without extended families, Egyptian Americans are at a loss for help in resolving family issues. The option of going to counselors or health-care professionals for advice is rarely exercised. Preserving family secrets and honor is more important than external support. Just as families have a strong need for virginity to be preserved, teen pregnancy is not openly discussed in the community. Because of the many restrictions placed on daughters’ movements and the limited opportunities for teenage daughters to go out without chaperones, such pregnancies rarely occur. Birth control is not usually discussed in families until marriage, and Pap smears are not sought or accepted until after marriage. Egyptian American children are expected to marry Egyptian Americans. However, because many second-generation Americans do not reside in areas with other Egyptian Americans, cross-cultural marriages are becoming a trend. Many first-generation Egyptian Americans return to their home country to get married. Intermarriages among second-generation Americans are increasing. Growing up as a Muslim and Egyptian in the post 9/11 era in the United States may contribute to the development of identity issues for children and adolescents. It could put their psychological well-being at risk. Formation of identity is influenced by peer group interaction, school environments, and media portrayal of Arab Americans. If these influences convey negative stereotypes leading to discrimination and isolation, children and adolescents may face a dislocated sense of identities (Britto, 2008). The youth revolution in February 2011, which ousted President Mubarak, may support restoring a positive identity and sense of pride in Egyptian Americans, which was lost due to the 9/11 terrorist attack in New York. Family Goals and Priorities The family is the most sacred institution to Egyptian Americans, and members of families are involved in all aspects of family members’ lives such as raising and educating children, finding work opportunities, and maintaining a moral code (Singerman, 2006). Although Egyptians in their own country have extended families, Egyptian American families tend to be more nuclear. Compared with other Arabs in the United States, most Egyptian Americans immigrated individually, were joined later by a bride, or immigrated as nuclear families. In some families, brothers, sisters, nephews, and nieces 7 may arrive later. Even when extended families arrive later, they tend to live apart. Job opportunities dictate living choices and patterns of living among Egyptian Americans. Egyptians in their own country view the relocation of sons or daughters for education or an occupation with trepidation and concern. However, once children move, though not bound by their extended family’s geographic location, they remain connected with them. In their home country, Egyptians tend to include the extended family in social activities and consult them for advice in all matters pertaining to health, employment, and family. In the absence of such a family in the United States, they either resort to close Egyptian American friends or seek counseling from extended families in their home country. Christian families may resort to religious leaders in their church or community for assistance. Imams, who are Muslim religious leaders and therefore devout Muslims, who belong to a mosque may choose to consult with other Imams regarding marital, family, or mental health problems (Ali, Milstein, & Marzuk, 2005). The most important goal for Egyptian American families is to raise children who are well educated, employable, and able to secure occupations that allow career mobility, financial security, and an acceptable social status. To that end, many other goals are subordinated. Because of this goal, parents may move to areas with better school systems and are willing to withstand financial or other hardships for the sake of their children. Another goal of Egyptian American families is to keep children geographically close, if not living at home, until they get married to the right partner. Parents consider it their responsibility to assist their children, especially daughters, to find a suitable marriage partner, and they support children financially through wedding preparations. Raising children who are considered moaddabeen by Egyptian standards is important. A child who is moaddab is one who respects parents, defers to them for decisions, is mindful of older people, does not drink or indulge in immoral acts, listens to parents’ advice, and does not answer back during conflict. One final goal of Egyptian families is to maintain a good face in public. This goal is achieved when children do not bring shame by engaging in activities forbidden by their parents, such as drinking, smoking, or going somewhere without their parents’ permission. As Egyptians grow older, they are considered richer in experiences and wiser and command more respect. They are treated with gentleness and never made to believe that their usefulness is limited just because of aging or retirement. Their children and extended family are expected to care for them. Older people prefer to do less management of their own affairs and expect more services, respect, and reverence from family 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 8 8 Aggregate Data for Cultural-Specific Groups members and subordinates. Women gain status with age and with childbearing. Young women know that inequities they may suffer as young brides are more than compensated for when they get older. Older women, however, are expected to care for older men in the family. Because most of the Egyptian American community immigrated as young adults, as they advance in age they are the first generation to experience growing old in the United States. Many parents have a morbid fear that they may be forced to move into a nursing home. Many consider returning to their home country to avoid the humiliation of aging in America, with the potential loss of home, family care, and respect. Egyptian Americans do not believe that they can expect or hold their children responsible for becoming their caregivers during old age Growing old in America is surrounded by many images of abandonment, humiliation, loss of respect, and above all, loneliness. Those who adapt to a life without extended family and create an extended family will likely establish a new means to deal with their old age. Health-care professionals may consider alternative ways to support this community and enhance their selfcare activities to help them avoid feelings of loneliness and a sense of abandonment in old age. Many Egyptian Americans are part of a network of friends with whom they share their celebrations and calamities. Where mosques or Middle Eastern Orthodox churches exist, these organizations are used to promote social gatherings, maintain cultural norms, reinforce culturally driven restrictions on children’s behavior, and promote historical continuity. In the absence of such organizations, Egyptian cultural clubs promote meetings, discussions, and sharing news from the homeland. Comparative analyses of life in Egypt and the United States often dominate these gatherings. During social gatherings, Egyptians are recognized by their elegant clothes, the hustle and bustle of children playing, adults chattering, and fine Egyptian food. Egyptian Americans prefer family gatherings to adult gatherings for celebrations such as Ramadan (the month of fasting), the Eid feast celebrations, Christmas, and New Year’s. Most often, they include extended family and their new networks of friends. Social networks are connected by their heritage rather than by their occupations. Without these large gatherings, loneliness and a sense of deprivation are exaggerated at times of crises or during normal developmental events such as the birth of a baby or the death of a family member. In Egypt, extended family members play a strong role in the life of a family. It is an important goal of family members to live in the same city. Extended family members provide backup and support for working women by providing child care and for nonworking women with multiple children as they need tangible support. Families raise children, not mothers or fathers. All family members freely give advice on child rearing. In the United States, Egyptian immigrants do not usually have extended family members living with them, but they continue to consider the extended family living abroad as their support network. For those who have extended family members and professional careers, the relationship tends to be more limited by time, responsibilities, and other demands. Social status is gained through professional accomplishments, financial success, and involvement in Egyptian community affairs. Respect is given to community leaders who give of themselves and share life experiences. No caste system exists based on color, familial lineage, or ancestry among Egyptians or Egyptian Americans. In some communities, Egyptian Americans are divided by religion (Muslims and Copts) and by professional status, with clubs for professionals, blue-collar workers, and other white-collar workers. Alternative Lifestyles The divorce rate among Egyptian immigrants is low, a pattern similar to that in Egypt. Most Egyptian Americans who are divorcing try to follow Egyptian and U.S. laws simultaneously because Egyptian laws have created many difficult issues for women as they do not have balanced views between men and women seeking to end their marriage (Bernard-Maugiron & Dupret, 2008). In cases of divorce in which one parent raises the children, the Egyptian community supports the single parent, including his or her own children. Divorce continues to be seen as a stigma and an unfortunate situation in which the children pay the greatest price. Who keeps and raises the children are governed by Egyptian laws which some Egyptian Americans continue to want to follow. In second marriages, partners work hard to make a new life together and are committed to raising their stepchildren. Communal and same-sex families are concepts that do not exist in Egyptian societies. Although a community of gays exists, homosexuality is rarely disclosed. They do have meeting places that are frequently ignored, intentionally overlooked, and more recently, raided, with jail as a result for those suspected of same-sex activities. The Web site GayEgypt.com includes stories of gay men who have been imprisoned, facing hard labor and torture. To be gay or lesbian is considered immoral and is not accepted by any Arab or Middle Eastern religion. To discover a gay son or lesbian daughter is akin to a catastrophic event for Egyptians and Egyptian Americans. Workforce Issues Culture in the Workplace Egyptian American nurses, who usually hold a minimum of a bachelor’s degree, cope well with the demands 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 9 People of Egyptian Heritage inherent in providing nursing care in the United States. In the beginning of their careers in the United States, however, they encounter three challenges. First, Egyptian American nurses frequently expect detailed and careful communication of all steps and aspects of nursing care. This expectation is inherent in both their cultural patterns and their educational preparation. Although interactions and communications come naturally to Egyptian Americans, this naturalness is usually reserved for family and close acquaintances. In addition, their professional preparation does not emphasize communication skills for interacting with patients. Because Egyptian patients do not expect detailed information from physicians and nurses, the routine of informing patients about the rationale for interventions may challenge Egyptian American nurses. The second challenge relates to the systematic and careful recording and documentation of nursing care. Egyptians are inclined to an oral tradition; therefore, the need to document in writing what can be shared verbally seems foreign to Egyptian American nurses. The third challenge involves the work environment. For Egyptians, the work environment is also their social environment in which friendships are built and life experiences and personal issues are shared with a select few. The emphasis on privacy and separating work and social life expected in American work settings seems artificial to Egyptian Americans. Therefore, they tend to view American work relationships as superficial and often experience a sense of loss in terms of close, meaningful work relationships and a supportive collegial network. This feeling is similar to how women in other professions view satisfying and stressful aspects of their work situation. The fourth challenge is similar to the challenge that all nurses face, which is the integration of technology in their daily nursing care. With the implementation of electronic health systems and recording of nursing care notes in hospitalized patients’ notes, immigrant nurses in particular will face English and computer language challenges. Many Egyptian communities in the United States form Egyptian cultural clubs to which a small percentage of these immigrant nurses belong. Such clubs help to decrease their sense of marginality. Activities usually include parties, dinners, picnics, and dances. Some of these clubs offer Arab language classes for the children. The more religious socialize around their local mosques and churches, which are good and safe forums for their teenage sons and daughters to meet prospective marital partners. Egyptian American nurses, like other Egyptian workers who work internationally, most likely will have the ambitions to learn new knowledge and master new skills on the job. They seek new job opportunities and work hard to reach the next levels in their positions (Sidani & Jamali, 2010). 9 Egyptian immigrants to the United States work hard at becoming integrated into the Western work environment. They thrive on professional satisfaction, defining success in terms of advancement. They tend to be team players and effective contributors to the society at large. They are usually punctual and follow work rules and procedures. Being well assimilated, they create a close network of colleagues. Issues Related to Autonomy Most Egyptians prefer to work in a job setting in which they are employees of an organization. They do not experience difficulty in reporting to a superior and following instructions. These cultural patterns do not preclude their being professionally motivated to work hard and advance their careers within respective organizations (Sidani & Jamali, 2010). As managers, leaders, or supervisors, they bring a personal touch and demonstrate human interest in their dealings with subordinates and coworkers. They demand loyalty and respect. On the whole, their religious affiliations do not pose problems for them when dealing with coworkers outside their own religions. However, the long history of Egyptian and Arab Israeli animosity causes some of them to approach their dealings with Jewish coworkers cautiously. Egyptian immigrants tend to be respectful of female coworkers, and often, their protective responses may be interpreted as patronizing by some women. They treat women as sisters or daughters. International market competition, economic changes, and transitions to free market in Egypt have provided new opportunities for Egyptians to embrace risk taking and become entrepreneurs (Farid, 2007). Few Egyptian Americans are entrepreneurial in developing their own businesses. Those who opt to start their own businesses tend to struggle to make them successful. Egyptian Americans in general value job and economic security over the risk taking inherent in operating a business. Therefore, they join established organizations with longterm goals. Yet when they cannot find employment in organizations, the third wave of young immigrants have populated New York street corner food carts and developed their driving skills for cab and limousine driving in some of the major U.S. cities such as New York City. Egyptians learn British English in schools and universities. On immigrating to the United States, they are confronted with unfamiliar slang and idioms. When viewed from an immigrant’s point of view and with only basic knowledge of British English, some of these expressions are hard to interpret and could be construed as insults. An example of this type of misunderstanding happened to one of the authors (MHM). As he narrates it: When I arrived in the United States (over 30 years ago) as a graduate student in engineering, I had an occasion to be studying at a University of California Los Angeles 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 10 10 Aggregate Data for Cultural-Specific Groups library on a weekend day with my wife, a graduate student in nursing. When we decided to go to the local school cafeteria for a cup of tea, we noticed one of her psychology professors in the library whom we knew very well inside and outside of the school. I approached him, greeted him, and asked if he would like to join us for a cup of tea. He responded by saying, “No, I don’t care to have a cup of tea now.” This, of course, is a very simple and totally acceptable American response. For me, a recent Egyptian immigrant (less than a year), this was a personal insult. The words “I do not care” meant to me that he did not care about me, not the process of having tea. We discussed this conversation a year later as he and I became close friends and laughed about it. He obviously meant no insult, and I just did not know enough about the idioms and commonly used expressions to “get it.” With increasing exposure to the media and life in the United States, it does not take long for a new immigrant to understand and accurately interpret idioms and commonly used expressions. The media is also a useful tool that helps Egyptian Americans and others to learn the English language and idiomatic and slang expressions. Biocultural Ecology Skin Color and Other Biological Variations Most Egyptians have olive skin tones, some are fair skinned, and others are dark skinned. Northern Egyptians exhibit a fairer complexion than most other Egyptians. Southern Egyptians (Nubians) are generally black, with very fine facial features. Upper Egyptians have a darker complexion. The average height of Egyptian men is about 5 ft 10 in., whereas women average 5 ft 4 in. Diseases and Health Conditions Several risk factors are peculiar to life along the banks of the Nile. Egyptians suffer from a host of parasitic diseases; the most common is schistosomiasis, known as bilharzia in Egypt. Schistosomiasis has been endemic in Egypt throughout history and has been found in mummified bodies from the pharaonic era. A high percentage of the Egyptian rural population is infected with Schistosoma mansoni or S. haematobium. The life cycle of schistosomiasis includes snails and human beings as hosts. Microscopic cercariae leave the snail in the warmth of the midday sun and penetrate the skin of humans who enter the shallow canals to irrigate crops, wash dishes or clothes, or swim. The cercariae migrate to areas near the liver, in the case of infection with S. mansoni, or near the bladder, in the case of infection with S. haematobium. The parasitic worms mature, mate, reproduce, and are expelled with urine or stools. If urine or stools are deposited in or near freshwater canals or rivers where snails live, the eggs seek out a snail to begin the cycle again. In human hosts, as the female worm expels the eggs, some of them flow with the blood and become lodged in the liver or around the urinary tract. The body, treating the eggs as foreign irritants, surrounds them with granular tissue, leading to cirrhosis, liver failure, portal hypertension, esophageal varices, bladder cancer, and renal failure. Filariasis is another challenging parasitic disease endemic to Egyptians. Rates of blindness in Egypt are among the highest in the world. Trachoma and other acute eye infections affect both rural and urban populations. Trachoma, a chronic infection of the lining of the eyelids caused by infection with Chlamydia trachomatis, is most common among children and can have severe disabling consequences in adulthood. Gel-like lymphoid follicles that subside over time, leaving residual scarring of the inner eyelids, characterize the active inflammatory stage. In the most severe cases, trichiasis, an endstage complication of chronic trachoma, occurs when scarring shrinks the lid lining and turns the eyelashes inward, scratching the cornea. This painful condition often leads to corneal ulceration, opacity, and eventual blindness. Injuries and corneal ulcers secondary to other infections are also common causes of blindness in Egypt. Other infectious diseases include typhoid and paratyphoid fevers, which are more frequent in urban than in rural areas. Streptococcal disease and rheumatic fevers are frequent among children, and tuberculosis continues to be a major problem in Egypt. Egyptian Americans who have positive tuberculin tests should be questioned about a history of Bacille Calmette-Guérin (BCG) vaccination. Diarrheal diseases result from environmental conditions and family lifestyles. Heat contributes to the development of bacterial diseases, and dehydration results from diarrhea and vomiting caused by bacterial infections. Programs and campaigns using rehydration packets with water, salt, and sugar have drastically decreased mortality rates caused by diarrheal diseases. These endemic diseases are more common in rural areas than in urban areas. Egyptian immigrants come mainly from urban areas and, therefore, do not usually suffer from these diseases. However, some may have family members who come to the United States for treatment with complications caused by one of these diseases. Kidney diseases, lack of proper hydration, and eating habits may contribute to kidney failure and the subsequent need for kidney transplantation. Clinicians in the Middle East suspect that fasting during Ramadan increases the potential for dehydration, contributing to kidney problems. The people of Egypt also suffer from diseases common to developing countries, such as undernutrition and malnutrition, and diseases resulting from overindulging in foods with high-fat and high-sugar contents. Modern diseases such as obesity, hypertension, and lower back 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 11 People of Egyptian Heritage pain affect a high percentage of Egyptians. Similarly, cardiovascular diseases resulting from stress, obesity, lack of exercise, and hypertension are on the rise. Egyptians who immigrate to the United States are more likely to become victims of these diseases of modernization than of rural diseases. Whereas breast cancer does not appear to be a uniformly manifest pattern among immigrant populations in an Australian study, rates were somewhat higher among the Egyptian born (McCredie, Coates, & Grulich, 1994). Type 2 diabetes is of concern to Egyptians and is further complicated by obesity. In addition, Egyptians are at a genetic risk for thalassemias, which can be detected from a molecular genetic standpoint through carrier screening and prenatal diagnosis. In spite of the increasing numbers of Arab Americans and Egyptian Americans among them and the available evidence that they may differ from other ethnic groups in the United States, there is still very little research to document the evidence related to prevalence and incidence of diseases and illnesses (El Sayed & Galea, 2009; Shah et al., 2007). In one study, the conclusion was that nativity status was not associated with diabetes and hypertension (Dallo & Borrell, 2006). However, others have determined that Arab Muslims in the United States are at an increased risk for heart diseases, diabetes, and cancer due to marginalization, stereotyping, levels of acculturation, lack of knowledge needed for prevention, and barriers to health care systems due to their cultural beliefs such as modesty, gender preference in health-care providers, and illness causation misconceptions (Yosef, 2008). Variations in Drug Metabolism The literature reports few studies related to variations in drug metabolism and specific drug interactions among Egyptian Americans. Some evidence indicates that Egyptians are poor metabolizers of beta-blockers (Levy, 1993). More research is needed in this area to provide better health care to Egyptian Americans. High-Risk Behaviors There is very limited research about Egyptian American risk factors and little consensus about the burdens of such diseases as cardiovascular diseases and diabetes among Arab Americans in general (El-Sayed & Galea, 2009). Certain behaviors may increase the risk of illness for Egyptians in America. One of these is a sedentary lifestyle and lack of regular exercise (Salari, 2002). Information about exercise has just begun to appear in the media in Egypt, and health clubs and gyms have begun to spring up in Cairo and Alexandria. This new phenomenon began after many Egyptians immigrated to America. Although exercise and fitness are regularly included in the curricula of schools and colleges, exercise is not part of the daily lives of adult Egyptians and, even less so, among Egyptian Americans. Recent studies tend 11 to report Egyptian Americans as being healthier than in earlier studies, having fewer health problems and higher activity scores (meeting the minimum public health guidelines for activity); yet they still have a long way to go to attain the level of physical activity that Healthy People 2010 calls for (Qahoush, Stotts, Alawneh, & Froelicher, 2010). It is important to note that as with other minorities, Arab Americans’ acculturation, immigration, and discrimination associated with stress may trigger cardiovascular diseases, diabetes, mental illness, or adverse birth outcomes (El-Sayed & Galea, 2009). Overeating food delicacies high in fat, sodium, and sugar; sedentary lifestyles; and an entertainment style based on eating contribute to obesity and immobility. Although no data exist on health risk factors for Egyptian Americans, the authors suspect that if such data were obtained, they would demonstrate an increased risk for coronary artery diseases, diabetes, and esophageal hernias. The premature deaths in Egyptian American communities are due to massive heart failure. There are also indications of an increase in risk factors for different types of cardiovascular diseases. Hassoun (1999) demonstrated that Arab Americans suffer from hypertension, high cholesterol levels, and diabetes more than other immigrants. These findings suggest that a similar pattern may exist among Egyptian Americans (Hatahet, Khosla, & Fungwe, 2002). Many Egyptians came to the United States as young adults; as the community of Egyptian Americans ages, questions related to sedentary lifestyles, overindulgence in food, and genetic makeup should be of interest. Egyptian Americans are at risk for stomach and intestinal problems that include heartburn, flatulence, constipation, hemorrhoids, and fecal impaction. These conditions result from limited roughage, lack of fluids, and rapid consumption of food. Another factor contributing to constipation may be their expectations and the meaning they attach to regularity, which prompts them to push and strain to force a bowel movement prematurely. Egyptian Americans are also at risk for diabetes. Jaber, Brown, Hammad, Zhu, and Herman (2003) found that a decrease in acculturation to the United States is an important element in the increase in risk factors for Arab immigrants. Like many less-developed countries, Egypt responded with zeal to campaigns launched by the cigarette industry. Cigarette smoking is on the rise in Egypt, mostly among men, but it is also increasing among women. Those who smoke, smoke heavily and are unwilling to quit. Rice, Templin, and Kulwicki (2003) reported that 17 percent of the adolescent Arab Americans in their study smoked, and 34 percent said they had never smoked. Predictors for tobacco use were poor grades, peer or family smoking, passive smoking, receiving free samples of cigarettes, advertising, and believing that smoking helps in networking 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 12 12 Aggregate Data for Cultural-Specific Groups and stress. Smoking cessation programs, therefore, should reflect cultural gender norms and religious messages (Islam & Johnson, 2003). One of the most dangerous risk factors among Egyptians in Egypt is their driving behavior. Most drive recklessly and aggressively, do not wear seat belts, and drive without respect for speed limits. However, the extreme traffic congestion in Egypt provides a safety cushion. It takes Egyptian immigrants a number of years in America to learn to respect traffic rules, wear seat belts, and drive cautiously. The terrorist attacks on the United States on September 11, 2001, have resulted in harsh treatment of Arab Americans, including Egyptian Americans. Perceptions of scapegoating, discrimination, racism, and stigmatization increase their experience of stress. Outcomes of stress and marginalization will most probably be the subject of future research studies (Salari, 2002; Zogby, 2001). Health-Care Practices Two conditions increase the utilization of preventive health care by Egyptian Americans: having health insurance and having a health-care provider with whom they can develop a trusting and responsive relationship. Egyptian Americans like prompt and personal attention; they are usually among the most compliant patients if these conditions are met. One reason for Egyptian Americans seeking health care is a perception that they are experiencing high blood pressure. They believe it is important to have frequent readings but prefer to treat hypertension with medications rather than with changes in diet or lifestyle. Hypertension, the silent killer of many Americans, may not be so silent for Egyptians. Whether they can detect fluctuations in their blood pressure remains to be carefully studied. However, this behavior of reading one’s own body cues should be encouraged and promptly addressed by health-care professionals. Pap smears and mammograms tend to be new preventive health practices for Egyptian Americans. Education about the importance of these tests promotes compliance with regular checkups. As mentioned earlier, Pap smears for unmarried women are discouraged and considered totally unacceptable because of the expectations for preserving virginity until marriage. Gynecological examinations are given only to married women, usually during the checkup for a first pregnancy. A study about health concerns among 99 Egyptian women and 135 American women aged 19 to 27 years reported that the top 10 health concerns among Egyptian women were halitosis/body odor, colds, cancer, poor teeth, population explosion, excess weight, birth control, water pollution, headaches, and heart disease. Among American women, the top 10 health concerns were birth problems, what the future would be like in 10 years, auto accidents, excess weight, cancer, use of contraceptives, death, nuclear war, childbirth, and air pollution (Engs & Badr, 2001). The differences in health concerns of these two groups are probably due to cultural values and the degree of societal differences between the United States and Egypt. These results reinforce the need for community health education programs that address the specific needs of individuals. Nutrition Meaning of Food Food is an important component of Egyptian social life. Egyptians entertain lavishly and enjoy good food, which represents nurturing. The more food one provides, the more love is portrayed. Egyptians develop trust in each other by having a meal together. The saying Akalt eish wa malh maa baad literally means “eating bread and salt together” and symbolically signifies trust, care, and truthfulness. In addition to being part of Egyptian social life, food is associated with health. The more food a person eats, the greater the potential for being healthy. Thus, children tend to be overfed. Food is also associated with the ability of the head of the family to provide for family members. Therefore, parents take pride in the amount and the quality of food they bring to their families. Because food is associated with caring and nurturing, mothers and wives spend much time and effort shopping and cooking family meals. Finally, food is associated with generosity and giving. To offer food and to accept food are indications of friendship. Mealtime is for eating and for socializing but not for conducting business or discussing issues. Some beliefs surrounding meals may increase health risks. For example, Egyptians prefer not to drink water or fluids with meals because they believe that fluid displaces the volume that could be used for food, decreasing their appetite for solid nutrients. Some believe that fluids dilute the stomach “juices,” make digestion difficult, and cause indigestion. Another potential risk factor to explore is the amount of salt added to food while cooking or at the table. Common Foods and Food Rituals Egyptian food is tasty, well done, and well seasoned. Egyptian Americans take pride in the food they serve and the way they present it. Although in Egypt vegetable dishes are considered main dishes to be complemented by meat and rice dishes, this conception has changed for most Egyptian Americans. Preferred meats are lamb, chicken, beef, and veal. Favorite vegetables are peas, green beans, cauliflower, and molokhia, a green vegetable cooked like soup. Most consider meat dishes as main dishes, complemented by vegetables and rice. Rice, a main staple, adorns 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 13 People of Egyptian Heritage dinner or lunch tables on a daily basis even when potatoes are served. Tomato-based red sauces are popular, and some pasta and vegetable dishes are dressed with rich white sauces such as bechamel. Egyptians use lentils, fava beans, and bulgur in their cooking. Whole-wheat bread is preferred. Egyptians acquired a taste for tea from their years under British rule and drink strong tea with hot milk several times a day. Those who prefer tea without milk drink it with mint leaves. They tend to use several teaspoons of sugar to sweeten their tea. Although it is not easy for them to decrease their sugar intake, Egyptians do so if they understand its relationship to caloric intake, insulin requirements for those who are diabetic, or for other health considerations. Egyptians also drink coffee, a habit acquired from Turkish rule. The coffee is thick, strong, and served in small demitasse cups, with or without sugar. Egyptians also consume a large quantity of soft drinks. Hostesses insist on giving guests excessive amounts of food and act insulted if guests refuse the food. Those who understand the ritual may insist on refusal or may take the food and not eat it. Leaving some food on the plate is more polite than refusing it. Completely emptying the plate may be seen as an indication that the guest did not have enough to eat. Egyptian Americans use modified versions of this ritual, depending on the guests and their length of time in the United States. In Egypt, three main meals a day are served with a late afternoon or early evening snack of sweets with tea. The main meal is lunch, usually consumed at the end of the working day between 2 and 3 p.m., generally followed by a period of rest when many take an afternoon nap. Working men and women in the current economic climate of Egypt either return to work in the early evening between 5 and 6 p.m. or have a second job or business for the remaining part of the evening. Supper, usually a lighter meal, is eaten after 9 p.m. On religious holidays, certain foods are prepared and shared with family and friends. An example is baking a variety of cookies at the end of the holy month of Ramadan, a time when Muslims fast daily from sunrise to sunset, and during the Small Eid feast (also called the El Eid Alsagheer or Small Barrium). During the Great Eid feast (also called the El Eid Alkabeer or Big Barrium), a sheep is sacrificed; the meat is given to needy families, and the family keeps some for consumption during that feast. Most of these rituals are modified in the United States. For example, Egyptian immigrants follow American eating habits of a small meal for lunch and then dinner at home after work between 6 and 7 p.m. Some immigrant families still make cookies at the end of Ramadan, but very few have a sheep slaughtered. Whether in Egypt or in America, the most devout Muslims do not 13 consume pork or drink alcohol. Egyptian Copts may consume both in moderation. For Egyptian American Muslims, many rituals are revived during the month of Ramadan, the ninth of 12 Islamic months that follow the lunar calendar. Therefore, Ramadan does not coincide with a particular month in the Christian calendar; instead it rotates and can fall on any of the Christian calendar months. Ramadan rituals are based on the teaching of the Qur’an (Koran) that calls for a month of fasting to experience the plight of the poor and the underprivileged. Fasting precludes taking anything by mouth or intravenously and abstaining from sexual activities. Muslims are expected to donate food for those in need, and they may eat modestly from sunset to sunrise. Egyptian American Christians fast for a varied number of days for several major religious celebrations. For them, fasting constitutes not eating any animal products. Ramadan is a month of prayers and family festivities with many food rituals. At sunset, families gather to eat lavish meals consisting of several kinds of meat and poultry, rice, dried fruits, and desserts such as konafa (shredded phyllo dough stuffed with nuts and raisins and soaked in honey) and kataif (pancake-like dough dressed with nuts, raisins, and sugar and smothered in honey). The meals are usually high in protein, fat, sugar, salt, and calories. Just before sunrise, families consume a lighter meal in preparation for a day of fasting. Some Egyptian American Muslims follow these rituals in the United States. Even Egyptian Americans who do not follow and abide by the teachings of Islam during the year consider this month holy, and they become more devout Muslims during Ramadan. Some Egyptian Americans join others in social clubs and plan weekly potluck “sundown Ramadan breakfasts.” During these gatherings, Egyptian Americans, their friends, and children exchange stories related to Ramadan, read from the Qur’an, and indulge in eating delicacies specific to Ramadan. Dietary Practices for Health Promotion Egyptian Americans do not mix hot and cold nor sweet and sour foods at the same meal. For example, the accepted habit in America of eating ice cream as dessert with coffee was a foreign concept for Egyptians during the early stages of their immigration. However, they easily accommodate to this food habit. Some Egyptian Americans grew up believing that mixing fish and milk may cause digestive problems or create behavioral problems. Therefore, dairy products and fish are generally avoided in combination. Some may have practiced drinking milk with yeast to increase their intake of vitamin B complex, a popular custom in Egypt. Most Egyptian Muslims do not eat pork, as proscribed by the Qur’an. They eat only well-cooked meat and do not touch rare meat. Recent Egyptian immigrants find it strange to eat cooked corn, which 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 14 14 Aggregate Data for Cultural-Specific Groups is only barbecued in their country. Most are partial to their own cooking, preferring not to eat in restaurants. They prefer kosher meat, trusting the dietary restrictions and food preparation practices of the Jewish population. In the absence of kosher meat, they shop at regular supermarkets. Nutritional Deficiencies and Food Limitations Egyptians, particularly those who live in rural and poor communities, experience fat-soluble vitamin and iron deficiency anemia. They eat more fresh vegetables, fresh fruits, and enriched or whole-wheat grain breads. Egyptians in the United States, like other Arab Americans, may resort to eating more processed foods and high-protein diets in the form of red meats because of increased availability (Hassoun, 1999). They also tend to eat more junk foods, preferring sweets. Therefore, Egyptian Americans may have a greater tendency to have diets higher in fat and consume fewer fresh fruits and vegetables. No literature exists about the changes in dietary habits and the effects on vitamin and mineral deficiencies among Egyptian Americans. Women may have more vitamin D deficiencies due to the conservative clothing they wear that does not allow them to be exposed to the sun (Henry Ford Hospital, 2009). Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy An Egyptian couple is not complete until they have a child and are usually under stress, fearing marriage REFLECTIVE EXERCISE 28.2 Jibade and Kakra Suleiman along with their teenage daughter and son have visited your health promotion and wellness informational booth at a community event. Mr. Suleiman (Jibade) has suffered from hypertension for several years. Mrs. Suleiman (Kakra) has been overweight for many years. They have asked advice about health eating, Egyptian style. They want their children to start eating more healthy as well. They tell the nutritionist, David Thomas, that they have accessed mypyramid.com, the U.S. Department of Agriculture (USDA) food pyramid, but this pyramid is not for them because they eat Egyptian cooking at home. 1. What is the first step the nurse should do to assess this family’s eating habits? 2. Do you consider a 3-day diary of food intake to be adequate for assessing food habits? 3. Do you think that weekend food patterns are different from weekday food patterns? 4. How might you assist this family in adapting the USDA food pyramid to Egyptian food patterns? instability caused by a lack of childbearing, until they conceive their first baby (Hattar-Pollara et al., 2000). Even if the husband is the cause of delayed or permanent infertility, women are threatened by the potential of divorce and are expected to conceive within their first year of marriage. Egyptian American families are under less stress and pressure to conceive because of the absence of extended family, although extended families continue to pressure their daughters and sons through letters and telephone calls. Pregnancies cement marriages, ensure a more lasting relationship, and are a way of getting men and women to mature in their relationship. Pregnancy brings women a sense of security and their husbands’ and in-laws’ respect. Giving birth, particularly to a son, considerably strengthens the status and power of women. Pregnancy gives women permission to decrease their responsibilities. Systematic and concerted efforts have been initiated to develop and implement birth control practices in Egypt, with birth control being far more apparent in urban Egypt. However, a very high proportion of unmet contraceptive needs still exist in Egypt (Sultan, Bakr, Ismail, & Arafa, 2010). Whereas Egyptian Americans may practice family planning and birth control, these are never advocated before conceiving the first child. Family planning is practiced through a variety of methods, including birth control pills, condoms, and early withdrawal. Abortion is used in Egypt, as in other countries, as a method of birth control. Desirable family size in urban Egypt is three or four children, whereas desirable family size in the United States among Egyptian Americans is two or three children. Women take an active role in limiting pregnancies; they are willing to use any method of birth control to achieve and maintain a small family size. Infertility is shrouded in secrecy and is attributed first and foremost to women. Among poor urban and rural families in Egypt Kabsa is considered to be the cause of infertility (Inhorn, 1994). Kabsa happens when vulnerable women come in contact with “polluted” individuals. Kabsa causes a threat to reproductive organs, a concept close to the way in which the “evil eye” affects an individual. It is unlikely that Egyptians who immigrate hold such a concept about infertility; however, assessing individuals who may be suffering from infertility nonetheless requires communication skills to uncover explanatory frameworks. This will lead to more compliance. It is also important to note that just like other underserved populations, Arab Americans tend to experience difficulties in accessing and receiving care in general, but infertility care in particular because of social marginalization especially after 9/11. Egyptian Americans, like Arab Americans, are also unlikely to accept donor sperm or adoption as options (Inhorn & Fakih, 2006). Since the health-care entry point for women is usually for reproductive health services, and since there is a relationship 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 15 People of Egyptian Heritage between exposure to violence and poor reproductive health outcomes, it is important that health-care providers assess any signs of intimate partner violence and manage it (Afifi, 2008). Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Women are expected and advised to curtail physical activities during pregnancy for fear of miscarriage (Meleis, 2002). Women are also advised to eat more because they are feeding two. Some Egyptian American women have strong cravings (waham) for certain foods that may extend to such scarce items as out-of-season strawberries. If these foods are not consumed, babies may be marked with the shape of foods that were craved. Therefore, every effort is made to provide the pregnant woman with the needed foods. Providing support during labor and delivery is reserved for the woman’s relatives, particularly her mother. Egyptian Americans invariably request that a female family member accompany the birthing mother. If an Egyptian American woman goes into labor with only her husband in attendance, it is considered an emergency. Acculturated Egyptian American men want to be included in the birthing experience, which may offend Egyptian newcomers. In Egypt, men are excluded from the birthing process because it is believed that men lack the ability to witness this highly emotional and painful process and lack the experience to support their wives. The cold-and-hot theory for health and illness prevents women from bathing during the postpartum period. Bathing or washing hair could expose them to colds and chills. Egyptian Americans respond well to a sound rationale for bathing in a hot tub or taking a shower that dispels beliefs about the potential for infection. Chicken and chicken broth are expected to help women during their postpartum transition. The postpartum period lasts 40 days, during which new mothers are expected to rest, eat well, be confined to the house with their babies, and not engage in any sexual activities. They are usually cared for by family members and are not expected to have any demands put on them. This practice is eroding, however, because of increasing demands on women and the migration of families. Information related to birth control is always welcomed after the first pregnancy, although it may not be sought during the postpartum period. Death Rituals Death Rituals and Expectations Among Muslims in Egypt, Islam calls for burial of the deceased as soon as possible. The burial ritual includes cleaning the body and wrapping it in a white cotton wrap. Verses from the Qur’an are read and a special prayer is recited at the mosque before the body is buried underground in a simple tomb. Islam prohibits 15 fancy tombstones; only a simple stone with the name of the deceased is placed above ground. The simple stone suggests that individuals are equal in death when meeting their creator. On the night of the burial, friends and family gather in a large tent outside the deceased’s home to give their condolences and respect to the grieving family. No food is served, but Turkish coffee is usually offered. Forty days after the burial, another mourning ritual takes place in the home of the deceased’s family. Family members listen while passages from the Qur’an are read by a religious man to console the family. Thereafter, a similar ritual takes place on the anniversary of the death. Egyptian Christian death rituals in Egypt and the United States are similar to American Christian death rituals. For Egyptian immigrants, some cultural rituals are followed. For instance, the Islamic burial rituals are carried out in designated cemeteries. The evening before the burial, the Qur’an is recited, and occasionally, the mourning ritual is observed for 40 days after burial. The annual death observance ritual is rarely carried out. Some Muslim families insist on having the deceased buried in Egypt, which is a very costly process involving approval from both countries and transporting the deceased in a special casket. Abdel-Khalek and Ahmed (1986) found that Egyptian Americans have slightly higher anxiety about death than Americans. Perhaps for observing Muslims this may be due to anticipating the judgment from heaven after death (Stadler, 2008). Health-care providers may be involved in and bewildered by the decision-making processes that Egyptian families go through on the death of family members. Plans for death are rarely made ahead of time, though a burial site is invariably selected in advance to protect families against being buried in non-Muslim burial places. Similar practices are observed among Christian Egyptian Americans. Responses to Death and Grief Egyptians in Egypt and the United States react vigorously and dramatically to the loss of a family member, expressing their grief outwardly. Wailing and public crying occur when first learning of death. This public reaction is an expected demonstration of their grief; otherwise, the community may regard them as lacking affection for the deceased. Death is seen as inevitable, although any loss brings shock and despair. Older people speak calmly about their own impending death. Egyptian Americans with a strong religious foundation do not fear the nearness of death but rather view it as a journey to the other world, which is believed to be better. Egyptian Muslims and Christians believe in an afterlife and expect rewards for good deeds accomplished in their first life. They anticipate reuniting with those who preceded them. 2780_BC_Ch28_001-022 03/07/12 9:54 AM Page 16 16 Aggregate Data for Cultural-Specific Groups Spirituality Spiritual Beliefs and Health-Care Practices Dominant Religion and Use of Prayer Most Egyptian Americans talk about their religious teachings during episodes of illness. They derive comfort, strength, and meaning from verses in the Qur’an and of prophets. Family members use these verses to remind them that they are at the mercy and under the control of God and that God may have a particular reason for their suffering. To lose hope may mean they are losing faith in God and His abilities. Religious practices for Egyptian Americans are performed during marriage, death, and religious holidays. Egyptian Americans participate in two wedding ceremonies: One is a religious and civil ceremony performed by the mosque’s imam(usually in place of Maazoon, who performs these rituals in Egypt), and the other a social ceremony in which friends and family gather for a gala evening. Both could be performed on the same day or days, months, or years apart. A separation after the religious ceremony is considered a divorce, but it is customary for brides and grooms to live together only after the social celebration has taken place. Egyptian American Christians have one religious marriage ceremony. Prayers, even for the nondevout Muslim or Christian, are significant during times of illness. Egyptian Americans may bring the Qur’an or the Bible to their hospital beds and usually put it under the pillow or on the bedside table. Prayers may be recited by the individual, in groups for Muslims, or in religious settings such as mosques or churches. Families and friends pray for each other, invoking good health, cure of illness, and peace. Prayers during holidays are enjoyed particularly in groups and in religious settings. Meaning of Life and Individual Sources of Strength Religious Egyptians achieve inner peace through practicing their respective religious rituals, including individual or collective prayers, reading from the Qur’an or Bible, and other religious texts written by religious scholars. Muslims who can afford the expense and are in good health make the pilgrimage to Mecca sometime during their lifetime. The journey is believed to provide Muslims with a source of inner fulfillment. Similar patterns of fulfillment through participation in religious activities are common in the United States. REFLECTIVE EXERCISE 28.3 Hosni Kanaan, age 34 years, has recently been diagnosed with diabetes mellitus. He is single but lives two houses away from his parents in a suburban neighborhood. Because Ramadan is approaching and he closely follows his parents’ wishes for fasting, he has asked the clinic nurse practitioner about his insulin regulation. 1. What is Ramadan? 2. What are the religious requirements for fasting during Ramadan? 3. What recommendations will you give Mr. Kanaan regarding his diet and fasting during Ramadan? Health-Care Practices Health-Seeking Beliefs and Behaviors The health-care practices of Egyptian Americans can best be understood by looking at the historical roots and the meanings of health and health care for Egyptians. The pharaohs are credited with introducing medicine to the world, as evidenced by the writings on papyri from 4000 B.C. The practice of mummification, perfected to ensure that the pharaohs’ bodies were preserved to wait for the return of the departed spirit, may have helped the pharaohs to understand the intricate anatomy of the body. Papyri writings have been found describing body organs, gynecological conditions, surgery, and signs and symptoms of illnesses. There are indications that the early Egyptians also had dental knowledge and had developed treatments for dental problems. Pharaonic writings introduced the idea of body parts and segmentation. Egyptian health care is also influenced by Greek, or unani, medicine. The most famous medical library in the world was built in Alexandria during the reign of Alexander the Great, housing almost all the medical knowledge of the ancient world. The books contained in this library, which was later bu…